Effective May 1, 2012 - instantbenefits.com · prescription drugs when prescribed for experimental,...
Transcript of Effective May 1, 2012 - instantbenefits.com · prescription drugs when prescribed for experimental,...
HCR-0414-050812 NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1800-458-4600, extension 300, from the neighbor islands.
Preferred Drug Listing
Effective May 1, 2012
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
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Table of Contents
UHA PREFERRED DRUG LISTING (PDL).............................................................................................................................................................. 1 COVERED MEDICATIONS ...................................................................................................................................................................................... 1 GENERIC MEDICATIONS ....................................................................................................................................................................................... 1 LEGEND ................................................................................................................................................................................................................... 1 ANALGESICS........................................................................................................................................................................................................... 2
NON-NARCOTIC ANALGESICS ................................................................................................................................................................... 2 NARCOTIC ANALGESICS ............................................................................................................................................................................. 2 NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (Over the counter strengths are not covered) ............................................................ 2 ANTIRHEUMATICS ....................................................................................................................................................................................... 2 DRUGS TO PREVENT AND TREAT GOUT ................................................................................................................................................. 2 FIBROMYALGIA............................................................................................................................................................................................. 3 MIGRAINE ...................................................................................................................................................................................................... 3 OTHER ........................................................................................................................................................................................................... 3
ANTI-INFECTIVES ................................................................................................................................................................................................... 3 PENICILLINS.................................................................................................................................................................................................. 3 CEPHALOSPORINS ...................................................................................................................................................................................... 3 MACROLIDES ................................................................................................................................................................................................ 3 TETRACYCLINES .......................................................................................................................................................................................... 3 QUINOLONES................................................................................................................................................................................................ 3 AMINOGLYCOSIDES .................................................................................................................................................................................... 3 SULFONAMIDES ........................................................................................................................................................................................... 4 ANTITUBERCULOSIS ................................................................................................................................................................................... 4 ANTIFUNGALS .............................................................................................................................................................................................. 4 ANTIVIRALS................................................................................................................................................................................................... 4 ANTIMALARIALS ........................................................................................................................................................................................... 5 AMEBICIDES ................................................................................................................................................................................................. 5 ANTHELMINTICS........................................................................................................................................................................................... 5 MISCELLANEOUS ANTI-INFECTIVES ......................................................................................................................................................... 5
ANTINEOPLASTICS AND IMMUNOSUPPRESSANTS .......................................................................................................................................... 5 ANTINEOPLASTICS AND IMMUNOSUPPRESSANTS ................................................................................................................................ 5
CARDIOVASCULAR ................................................................................................................................................................................................ 6 CARDIAC GLYCOSIDES ............................................................................................................................................................................... 6 NITRATES ...................................................................................................................................................................................................... 6 BETA-BLOCKERS ......................................................................................................................................................................................... 7 CALCIUM ANTAGONISTS ............................................................................................................................................................................ 7 ANTIDYSRHYTHMIC DRUGS ....................................................................................................................................................................... 7 ANGIOTENSIN CONVERTING ENZYME INHIBITOR .................................................................................................................................. 7 ANTIADRENERGIC AGENTS-CENTRALLY ACTING .................................................................................................................................. 8 ANTIADRENERGIC AGENTS-PERIPHERAL ACTING ................................................................................................................................. 8 ALPHA BLOCKERS ....................................................................................................................................................................................... 8 VASODILATORS............................................................................................................................................................................................ 8 DIURETICS .................................................................................................................................................................................................... 8 CHOLESTEROL LOWERING AGENTS ........................................................................................................................................................ 8 MISCELLANEOUS CARDIOVASCULAR DRUGS ........................................................................................................................................ 9
CENTRAL NERVOUS SYSTEM .............................................................................................................................................................................. 9 ANTIANXIETY DRUGS .................................................................................................................................................................................. 9 ANTIDEPRESSANTS .................................................................................................................................................................................... 9 ANTIMANIA AND MOOD STABILIZER DRUGS ........................................................................................................................................... 9 ANTIPSYCHOTICS ...................................................................................................................................................................................... 10 SEDATIVES & HYPNOTICS ........................................................................................................................................................................ 10 CNS STIMULANTS ...................................................................................................................................................................................... 10 OTHER CNS DRUGS .................................................................................................................................................................................. 10 SMOKING DETERRENTS ........................................................................................................................................................................... 11
EAR, NOSE, AND THROAT MEDICATIONS ........................................................................................................................................................ 11 OTIC STEROID - ANTI-INFECTIVE COMBINATIONS .............................................................................................................................. 11 THROAT MEDICATIONS/ORAL LESIONS/GINGIVITIS ............................................................................................................................. 11
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
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CORTICOSTEROIDS, INHALED NASAL .................................................................................................................................................... 11 MISCELLANEOUS NASAL .......................................................................................................................................................................... 11
ENDOCRINE AND METABOLIC ........................................................................................................................................................................... 11 SYSTEMIC CORTICOSTEROIDS ............................................................................................................................................................... 11 ANDROGENS .............................................................................................................................................................................................. 11 ESTROGENS ............................................................................................................................................................................................... 11 ESTROGENS/PROGESTIN COMBINATIONS ............................................................................................................................................ 12 ORAL CONTRACEPTIVES .......................................................................................................................................................................... 12 TRANSDERMAL CONTRACEPTIVES ........................................................................................................................................................ 12 VAGINAL CONTRACEPTIVES .................................................................................................................................................................... 12 PROGESTINS .............................................................................................................................................................................................. 12 ORAL HYPOGLYCEMICS ........................................................................................................................................................................... 12 INSULINS & INSULIN TYPE INJECTABLES .............................................................................................................................................. 13 GLUCOSE TEST STRIPS ............................................................................................................................................................................ 13 GLUCAGON ................................................................................................................................................................................................. 13 ANTITHYROID DRUGS ............................................................................................................................................................................... 13 THYROID HORMONES ............................................................................................................................................................................... 13 OTHER ENDOCRINE DRUGS .................................................................................................................................................................... 13
GASTROINTESTINAL ........................................................................................................................................................................................... 13 ANTIDIARRHEAL PREPARATIONS ........................................................................................................................................................... 13 ANTIULCER DRUGS ................................................................................................................................................................................... 13 ANTIEMETICS ............................................................................................................................................................................................. 14 DIGESTANTS............................................................................................................................................................................................... 14 ANTISPASMODICS & DRUGS AFFECTING GI MOTILITY ........................................................................................................................ 14 SULFONAMIDE/MESALAMINE PRODUCTS ............................................................................................................................................. 14 OTHER ......................................................................................................................................................................................................... 14
GENITOURINARY .................................................................................................................................................................................................. 14 VAGINAL ANTI-INFECTIVES ...................................................................................................................................................................... 14 ANTICHOLINERGIC-ANTISPASMODICS ................................................................................................................................................... 15 CHOLINERGIC DRUGS .............................................................................................................................................................................. 15 URINARY ANALGESICS ............................................................................................................................................................................. 15 MISCELLANEOUS GENITOURINARY ........................................................................................................................................................ 15
HEMATOLOGICAL AGENTS ................................................................................................................................................................................ 15 HEMATOPOIETIC ........................................................................................................................................................................................ 15 ANTICOAGULANT DRUGS ......................................................................................................................................................................... 15 ANTIPLATELET DRUGS ............................................................................................................................................................................. 15 OTHER AGENTS ......................................................................................................................................................................................... 15
NEUROMUSCULAR .............................................................................................................................................................................................. 15 ANTICONVULSANTS .................................................................................................................................................................................. 15 ANTIPARKINSON DRUGS .......................................................................................................................................................................... 16 SKELETAL MUSCLE RELAXANTS ............................................................................................................................................................. 16 ANTICHOLINESTERASE MUSCLE STIMULANTS .................................................................................................................................... 16
NUTRITIONAL PRODUCTS .................................................................................................................................................................................. 16 PRENATAL VITAMINS ................................................................................................................................................................................ 16 VITAMINS ..................................................................................................................................................................................................... 16 MINERALS ................................................................................................................................................................................................... 16 POTASSIUM SUPPLEMENTS .................................................................................................................................................................... 17 MISCELLANEOUS NUTRITIONAL .............................................................................................................................................................. 17
OPHTHALMIC MEDICATIONS .............................................................................................................................................................................. 17 ALPHA-ADRENOCEPTOR AGONISTS ...................................................................................................................................................... 17 ALPHA-ADRENOCEPTOR AGONISTS COMBINATIONS ......................................................................................................................... 17 ANTI-INFLAMMATORY AGENTS ................................................................................................................................................................ 17 ANTI-ALLERGIC AGENTS .......................................................................................................................................................................... 17 ANTIMICROBIAL AGENTS .......................................................................................................................................................................... 17 ARTIFICIAL TEAR PRODUCTS/LUBRICANTS .......................................................................................................................................... 18 BETA-ADRENORECEPTOR ANTAGONISTS ............................................................................................................................................ 18 CARBONIC ANHYDRASE INHIBITORS ..................................................................................................................................................... 18 DILATING AGENTS ..................................................................................................................................................................................... 18 MIOTICS ....................................................................................................................................................................................................... 18 PROSTAGLANDINS .................................................................................................................................................................................... 18
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
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SYMPATHOMIMETICS ................................................................................................................................................................................ 18 RESPIRATORY ...................................................................................................................................................................................................... 19
ANTIHISTAMINES ....................................................................................................................................................................................... 19 ANTITUSSIVES & EXPECTORANTS.......................................................................................................................................................... 19 ANTIASTHMATICS ...................................................................................................................................................................................... 19
TOPICAL ................................................................................................................................................................................................................ 20 ANTI-ACNE MEDICATIONS ........................................................................................................................................................................ 20 ANTIFUNGALS ............................................................................................................................................................................................ 20 ANTI-INFECTIVES ....................................................................................................................................................................................... 20 ANTIPSORIATICS ....................................................................................................................................................................................... 20 CORTICOSTEROIDS .................................................................................................................................................................................. 20 CORTICOSTEROID COMBINATIONS ........................................................................................................................................................ 21 RECTAL ....................................................................................................................................................................................................... 21 SCABICIDES/PEDICULICIDES ................................................................................................................................................................... 21 MISCELLANEOUS ....................................................................................................................................................................................... 21
INDEX ..................................................................................................................................................................................................................... 22
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
1
UHA PREFERRED DRUG LISTING (PDL)
We are pleased to present you with the UHA preferred drug listing. The preferred drug listing is the cornerstone for a progressive program of managed care pharmacotherapy. Prescription drug therapy is an integral component of your patient’s comprehensive treatment program. The preferred drug listing was created to ensure UHA members receive high quality, cost-effective, rational drug therapy.
UHA is responsible for developing and maintaining the preferred drug listing. In making its decisions, UHA utilizes local consultant physicians and pharmacists representing various medical specialties. In addition to clinical considerations, UHA evaluates the cost of treatment of therapeutically equivalent drugs and bioequivalency data provided by the Food and Drug Administration (FDA). With a primary consideration to provide a safe, effective, and comprehensive preferred drug listing, UHA evaluated all therapeutic categories and has selected the most cost effective agent(s) in each class.
The preferred drug listing development and maintenance is a dynamic process. UHA regularly reviews new and existing medications to ensure the preferred drug listing meets the needs of both members and providers.
We invite recommendations and comments on improving the content or format of the preferred drug listing. Physicians may request the addition of a new drug or a review of drugs for inclusion or exclusion from the UHA Preferred Drug Listing by submitting their request to:
UHA Health Care Services
700 Bishop St, Suite 300 Honolulu, HI 96813
COVERED MEDICATIONS
Unless otherwise limited by the plan, all dosage forms and strengths of a listed medication available at the time of printing are covered. In order to reduce the risk of adverse effects to our members, UHA will not cover prescription drugs when prescribed for experimental, investigational, or non-FDA approved indications unless they have sufficient peer-reviewed literature to support their use for the prescribed indication. Drugs that are newly introduced are subject to a review period. Prior to evaluation, these drugs may be not covered, or may be subject to a higher co-payment.
GENERIC MEDICATIONS
UHA encourages the use of generic medications whenever possible and our open formulary includes all generics unless the specific classification of medications is an excluded category, such as weight loss medications. Please note that this Preferred Drug Listing does not list all covered generics. In order to help the Prescriber, the generic medications are listed according to their generic/chemical name as well as their previous “Brand” name. Where only the generic is listed, the Brand has been discontinued, but the generic is available. Boldface type indicates generic availability. It is important to remember that this PDL’s intent is to cover only the generic form of the drugs (cephalexin or “generic of KEFLEX”) and not the Brand forms. There is a higher co-payment for brand-name drugs that have an approved generic available.
LEGEND
boldface Indicates generic availability; boldface may not apply to every strength or dosage form under the listed generic name
PA Prior Authorization required
**A generic $0 copay will apply to the Brand medications marked with an asterisk (*) under the Value Based Prescription Drug Plan, which can be found on page 19.**
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
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ANALGESICS
NON-NARCOTIC ANALGESICS
butalbital/acetaminophen/caffeine (generic of ESGIC-PLUS)
butalbital/acetaminophen/caffeine (generic of FIORICET)
butalbital/aspirin/caffeine (generic of FIORINAL)
tramadol HCL (generic of ULTRAM)
NARCOTIC ANALGESICS
acetaminophen/codeine (generic of TYLENOL w/CODEINE)
buprenorphine/naloxone (SUBOXONE)
butalbital/aspirin/caffeine/codeine (generic of FIORINAL/CODEINE)
fentanyl transdermal (generic of DURAGESIC patch)
hydrocodone/acetaminophen (generic of LORCET)
hydrocodone/acetaminophen (generic of LORCET PLUS)
hydrocodone/acetaminophen (generic of VICODIN)
hydrocodone/acetaminophen (generic of VICODIN ES)
hydromorphone (generic of DILAUDID)
methadone (generic of DOLOPHINE)
morphine sulfate
morphine sulfate ext-rel (generic of MS CONTIN)
oxycodone (generic of ROXICODONE)
PA oxycodone ext-rel (OXYCONTIN)
oxycodone/acetaminophen (generic of PERCOCET)
oxycodone/aspirin (generic of PERCODAN)
NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (Over the counter strengths are not covered)
celecoxib (CELEBREX)
diclofenac (generic of VOLTAREN)
diclofenac patch (FLECTOR)
diflunisal
flurbiprofen (generic of ANSAID)
ibuprofen (generic of MOTRIN)
indomethacin
ketoprofen
nabumetone
naproxen (generic of NAPROSYN)
naproxen sodium (generic of ANAPROX)
naproxen sodium (generic of ANAPROX DS)
oxaprozin (generic of DAYPRO)
piroxicam (generic of FELDENE)
sulindac
ANTIRHEUMATICS
hydroxychloroquine (generic of PLAQUENIL)
leflunomide (generic of ARAVA)
methotrexate
DRUGS TO PREVENT AND TREAT GOUT
allopurinol (generic of ZYLOPRIM)
PA febuxostat (ULORIC)
colchicine (COLCRYS)
probenecid
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
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FIBROMYALGIA
milnacipran (SAVELLA)
pregabalin (LYRICA)
MIGRAINE
almotriptan (AXERT)
butalbital/acetaminophen/caffeine (generic of ESGIC-PLUS)
butalbital/aspirin/caffeine (generic of FIORINAL)
eletriptan (RELPAX)
ergoloid mesylates
isometheptene/dichloralphenazone/acetaminophen
naratriptan (generic of AMERGE)
rizatriptan dispersible tabs (MAXALT-MLT)
sumatriptan (generic of IMITREX)
OTHER
lidocaine HCl patch (LIDODERM)
ANTI-INFECTIVES
PENICILLINS
amoxicillin
amoxicillin/potassium clavulanate (generic of AUGMENTIN)
ampicillin
cloxacillin (generic of CLOXAPEN)
dicloxacillin
oxacillin
penicillin VK
CEPHALOSPORINS
cefaclor
cefaclor ext-rel (CEFACLOR ER)
cefadroxil
cefuroxime (generic of CEFTIN)
cephalexin (generic of KEFLEX)
cephradine
MACROLIDES
azithromycin (generic of ZITHROMAX)
erythromycin base (enteric coated) (ERY-TAB)
erythromycin estolate
erythromycin ethylsuccinate (generic of E.E.S.)
erythromycin stearate (generic of ERYTHROCIN)
TETRACYCLINES
doxycycline (generic of VIBRAMYCIN)
minocycline (generic of MINOCIN)
tetracycline
QUINOLONES
ciprofloxacin (generic of CIPRO)
moxifloxacin (AVELOX)
AMINOGLYCOSIDES
neomycin
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
4
SULFONAMIDES
sulfamethoxazole/trimethoprim (generic of BACTRIM)
sulfamethoxazole/trimethoprim (generic of SEPTRA)
sulfisoxazole/erythromycin
ANTITUBERCULOSIS
ethambutol (generic of MYAMBUTOL)
isoniazid
pyrazinamide
rifampin (generic of RIFADIN)
ANTIFUNGALS
clotrimazole (generic of MYCELEX)
fluconazole (generic of DIFLUCAN)
griseofulvin ultramicrosize (GRIS-PEG)
ketoconazole (generic of NIZORAL)
nystatin (generic of MYCOSTATIN)
terbinafine tabs (generic of LAMISIL)
ANTIVIRALS Treatment of HIV
abacavir/lamivudine (EPZICOM)
abacavir/lamivudine/zidovudine (TRIZIVIR)
atazanavir (REYATAZ)
darunavir (PREZISTA)
delavirdine (RESCRIPTOR)
didanosine delayed-rel (generic of VIDEX EC)
didanosine soln (VIDEX soln)
efavirenz (SUSTIVA)
emtricitabine (EMTRIVA)
emtricitabine/rilpivirine/tenovir (COMPLERA)
emtricitabine/tenovir/efavirenz (ATRIPLA)
etravirine (INTELENCE)
fosamprenavir (LEXIVA)
indinavir (CRIXIVAN)
lamivudine (EPIVIR)
lamivudine/zidovudine (COMBIVIR)
lopinavir/ritonavir (KALETRA)
maraviroc (SELZENTRY)
nelfinavir mesylate (VIRACEPT)
nevirapine (VIRAMUNE)
raltegravir (ISENTRESS)
rilpivirine (EDURANT)
ritonavir (NORVIR)
saquinavir (INVIRASE)
stavudine (generic of ZERIT)
tenofovir (VIREAD)
tenofovir/emtricitabine (TRUVADA)
tipranavir (APTIVUS)
zidovudine (generic of RETROVIR)
Treatment of Hepatitis B
adefovir (HEPSERA)
entecavir (BARACLUDE)
lamivudine (EPIVIR HBV)
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
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PA telbivudine (TYZEKA)
Treatment of Hepatitis C
PA telaprevir (INCIVEK)
ribavirin (generic of COPEGUS/REBETOL)
Treatment of Herpes Simplex
acyclovir (generic of ZOVIRAX)
famciclovir (generic of FAMVIR)
valacyclovir (generic of VALTREX)
Treatment of Influenza
amantadine
oseltamivir (TAMIFLU)
rimantadine (generic of FLUMADINE)
zanamivir (RELENZA)
ANTIMALARIALS
atovaquone/proguanil (generic of MALARONE)
chloroquine (generic of ARALEN)
hydroxychloroquine (generic of PLAQUENIL)
mefloquine (generic of LARIAM)
AMEBICIDES
iodoquinol (YODOXIN)
tinidazole (TINDAMAX)
ANTHELMINTICS
mebendazole
praziquantel (BILTRICIDE)
MISCELLANEOUS ANTI-INFECTIVES
clindamycin (generic of CLEOCIN)
dapsone
metronidazole (generic of FLAGYL)
nitrofurantoin (generic of MACRODANTIN)
trimethoprim
ANTINEOPLASTICS AND IMMUNOSUPPRESSANTS
All FDA-Approved, non-injectable Antineoplastics and Immunosuppressants are eligible for coverage provided that they are listed in the Compendia-Based Drug Bulletin as an indication for treatment of a specific neoplasm. The listing can be found at http://www.nccn.org/professionals/drug_compendium/content/contents.asp ANTINEOPLASTICS AND IMMUNOSUPPRESSANTS
altretamine (HEXALEN)
anastrozole (generic of ARIMIDEX)
azathioprine (generic of IMURAN)
bexarotene caps (TARGRETIN caps)
bicalutamide (generic of CASODEX)
busulfan (MYLERAN)
capecitabine (XELODA)
chlorambucil (LEUKERAN)
PA crizotinib (XALKORI)
cyclophosphamide
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
6
dasatinib (SPRYCEL)
PA erlotinib (TARCEVA)
estramustine (EMCYT)
etoposide
PA everolimus (AFINITOR)
exemestane (generic of AROMASIN)
flutamide
hydroxyurea (generic of HYDREA)
PA imatinib (GLEEVEC)
PA lapatinib (TYKERB)
PA lenalidomide (REVLIMID)
letrozole (generic of FEMARA)
leucovorin CA tabs
lomustine (CEENU)
megestrol (generic of MEGACE)
melphalan (ALKERAN)
mercaptopurine (generic of PURINETHOL)
methotrexate (TREXALL)
mesna tabs (MESNEX)
mitotane (LYSODREN)
mycophenolate mofetil (generic of CELLCEPT)
PA nilotinib (TASIGNA)
nilutamide (NILANDRON)
PA pazopanib (VOTRIENT)
procarbazine (MATULANE)
PA sorafenib (NEXAVAR)
PA sunitinib (SUTENT)
tamoxifen
temozolomide (TEMODAR)
PA thalidomide (THALOMID)
thioguanine (TABLOID)
PA topotecan caps (HYCAMTIN caps)
toremifene citrate (FARESTON)
tretinoin
PA vandetanib (CAPRELSA)
PA vorinostat (ZOLINZA)
CARDIOVASCULAR
CARDIAC GLYCOSIDES
digoxin
NITRATES
isosorbide dinitrate (generic of ISORDIL, excluding TEMBIDS)
isosorbide monohydrate (generic of IMDUR)
isosorbide monohydrate (generic of ISMO)
isosorbide monohydrate (generic of MONOKET)
nitroglycerin (generic of NITROSTAT)
nitroglycerin ext-rel
nitroglycerin oint (NITRO-BID)
nitroglycerin patch (generic of NITRO-DUR)
nitroglycerin sublingual spray (NITROLINGUAL spray)
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
7
BETA-BLOCKERS Beta-1 Specific
atenolol (generic of TENORMIN)
atenolol/chlorthalidone (generic of TENORETIC)
bisoprolol (generic of ZEBETA)
bisoprolol/hydrochlorothiazide (generic of ZIAC)
metoprolol (generic of LOPRESSOR)
metoprolol ext-rel (generic of TOPROL-XL)
metoprolol tartrate/hydrochlorothiazide (generic of LOPRESSOR HCT)
Non-Selective
carvedilol (generic of COREG)
carvedilol phosphate ext-rel (COREG CR)
nadolol (generic of CORGARD)
pindolol
propranolol
propranolol ext-rel (generic of INDERAL LA)
CALCIUM ANTAGONISTS
amlodipine (generic of NORVASC)
diltiazem ext-rel (generic of DILACOR XR)
diltiazem ext-rel (generic of TIAZAC)
nifedipine ext-rel (generic of ADALAT CC)
verapamil (generic of CALAN)
verapamil ext-rel (generic of CALAN SR)
ANTIDYSRHYTHMIC DRUGS
amiodarone (generic of CORDARONE)
disopyramide (generic of NORPACE)
disopyramide ext-rel (generic of NORPACE CR)
dronedarone (MULTAQ)
flecainide (generic of TAMBOCOR)
propafenone (generic of RYTHMOL)
sotalol HCL (generic of BETAPACE AF)
ANGIOTENSIN CONVERTING ENZYME INHIBITOR Angiotensin Converting Enzyme Inhibitors
benazepril (generic of LOTENSIN)
captopril (generic of CAPOTEN)
enalapril (generic of VASOTEC)
fosinopril (generic of MONOPRIL)
lisinopril (generic of ZESTRIL)
moexipril (generic of UNIVASC)
perindopril (generic of ACEON)
quinapril (generic of ACCUPRIL)
ramipril (generic of ALTACE)
trandolapril (generic of MAVIK)
Angiotensin Converting Enzyme Inhibitor Combinations
benazepril/hydrochlorothiazide (generic of LOTENSIN HCT)
captopril/hydrochlorothiazide (generic of CAPOZIDE)
enalapril/hydrochlorothiazide (generic of VASERETIC)
fosinopril/hydrochlorothiazide (generic of MONOPRIL-HCT)
lisinopril/hydrochlorothiazide (generic of ZESTORETIC)
quinapril/hydrochlorothiazide (generic of ACCURETIC)
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
8
Angiotensin II Antagonists (ARBs)
irbesartan (AVAPRO)
losartan (generic of COZAAR)
olmesartan (BENICAR)
valsartan (DIOVAN)
Angiotensin II Antagonist Combinations
amlodipine/olmesartan (AZOR)
irbesartan/hydrochlorothiazide (AVALIDE)
losartan/hydrochlorothiazide (generic of HYZAAR)
olmesartan/hydrochlorothiazide (BENICAR HCT)
valsartan/hydrochlorothiazide (DIOVAN HCT)
ANTIADRENERGIC AGENTS-CENTRALLY ACTING
clonidine tabs (generic of CATAPRES)
guanabenz acetate
guanfacine (generic of TENEX)
methyldopa
ANTIADRENERGIC AGENTS-PERIPHERAL ACTING
prazosin (generic of MINIPRESS)
terazosin
ALPHA BLOCKERS
phenoxybenzamine (DIBENZYLINE)
VASODILATORS
hydralazine
DIURETICS Loop Diuretics
bumetanide
furosemide (generic of LASIX)
torsemide (generic of DEMADEX)
Thiazides and Related Diuretics
chlorthalidone
hydrochlorothiazide
indapamide
methyclothiazide
metolazone (generic of ZAROXOLYN)
Potassium Sparing Diuretics
amiloride/hydrochlorothiazide
spironolactone (generic of ALDACTONE)
spironolactone/hydrochlorothiazide (generic of ALDACTAZIDE)
triamterene/hydrochlorothiazide (generic of DYAZIDE)
triamterene/hydrochlorothiazide (generic of MAXZIDE)
Carbonic Anhydrase Inhibitors
acetazolamide
methazolamide
CHOLESTEROL LOWERING AGENTS HMG-CoA Reductase Inhibitors
atorvastatin (generic of LIPITOR)
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
9
lovastatin (generic of MEVACOR)
pravastatin (generic of PRAVACHOL)
rosuvastatin (CRESTOR)
simvastatin (generic of ZOCOR)
Other Cholesterol Lowering Agents
cholestyramine aspartame (generic of QUESTRAN LIGHT)
cholestyramine sucrose (generic of QUESTRAN)
ezetimibe (ZETIA)
gemfibrozil (generic of LOPID)
niacin timed release (NIASPAN)
MISCELLANEOUS CARDIOVASCULAR DRUGS
enoxaparin ( generic of LOVENOX)
pentoxifylline (generic of TRENTAL)
CENTRAL NERVOUS SYSTEM
ANTIANXIETY DRUGS
alprazolam (generic of XANAX)
buspirone (generic of BUSPAR)
chlordiazepoxide (generic of LIBRIUM)
clonazepam (generic of KLONOPIN)
clorazepate (generic of TRANXENE)
diazepam (generic of VALIUM)
lorazepam (generic of ATIVAN)
oxazepam
ANTIDEPRESSANTS
amitriptyline
amoxapine
bupropion (generic of WELLBUTRIN)
bupropion ext-rel (generic of WELLBUTRIN SR)
bupropion ext-rel (generic of WELLBUTRIN XL)
clomipramine (generic of ANAFRANIL)
desipramine (generic of NORPRAMIN)
doxepin
duloxetine HCL (CYMBALTA)
escitalopram (LEXAPRO)
fluoxetine (generic of PROZAC)
fluoxetine (generic of SARAFEM)
imipramine (generic of TOFRANIL)
maprotiline
mirtazapine (generic of REMERON)
nortriptyline (generic of PAMELOR)
paroxetine HCl ext-rel (generic of PAXIL CR)
protriptyline (generic of VIVACTIL)
sertraline (generic of ZOLOFT)
trazodone
venlafaxine (generic of EFFEXOR)
venlafaxine ext-rel (generic of EFFEXOR XR)
ANTIMANIA AND MOOD STABILIZER DRUGS
carbamazepine (generic of TEGRETOL)
carbamazepine ext-rel (generic of TEGRETOL-XR)
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
10
divalproex sodium delayed-rel (generic of DEPAKOTE)
divalproex sodium ext-rel (generic of DEPAKOTE ER)
lamotrigine (generic of LAMICTAL)
lithium
ANTIPSYCHOTICS
aripiprazole (ABILIFY)
chlorpromazine
fluphenazine
fluphenazine decanoate
haloperidol
haloperidol decanoate (generic of HALDOL DECANOATE)
olanzapine (ZYPREXA)
paliperidone ext-rel (INVEGA)
perphenazine
quetiapine (SEROQUEL)
quetiapine ER (SEROQUEL XR)
risperidone (generic of RISPERDAL)
risperidone orally disintegrating tab (generic of RISPERDAL- M)
thioridazine
thiothixene (generic of NAVANE)
trifluoperazine
ziprasidone (GEODON)
SEDATIVES & HYPNOTICS
estazolam
flurazepam
ramelteon (ROZEREM)
temazepam (generic of RESTORIL)
triazolam (generic of HALCION)
zaleplon (generic of SONATA)
zolpidem (generic of AMBIEN)
zolpidem CR (generic of AMBIEN CR)
CNS STIMULANTS
amphetamine/dextroamphetamine mixed salts (generic of ADDERALL)
amphetamine/dextroamphetamine mixed salts ext-rel (generic of ADDERALL XR)
dextroamphetamine (generic of DEXEDRINE)
dextroamphetamine ext-rel (generic of DEXEDRINE SPANSULE)
methylphenidate (generic of RITALIN)
methylphenidate HCL (CONCERTA)
methylphenidate HCL (METADATE CD)
OTHER CNS DRUGS
disulfiram (generic of ANTABUSE)
donepezil HCL 23 mg tabs ONLY (ARICEPT)
galantamine (generic of RAZADYNE)
galantamine ext-rel (generic of RAZADYNE ER)
memantine (NAMENDA)
rivastigmine tartrate caps (generic of EXELON caps)
rivastigmine tartrate (EXELON patch, soln)
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
11
SMOKING DETERRENTS Coverage for Nicotine Replacement Therapy, such as patches, gums, lozenges, etc. are based on plan design. Refer to the member benefit guide for more information.
bupropion ext-rel (generic of ZYBAN)
varenicline (CHANTIX)
EAR, NOSE, AND THROAT MEDICATIONS
OTIC STEROID-ANTI-INFECTIVE COMBINATIONS
acetic acid
ciprofloxacin/dexamethasone otic (CIPRODEX)
ciprofloxacin/hydrocortisone otic (CIPRO HC)
hydrocortisone/neo/polymyxin B (generic of CORTISPORIN OTIC)
ofloxacin otic (generic of FLOXIN OTIC)
THROAT MEDICATIONS/ORAL LESIONS/GINGIVITIS
chlorhexidine gluconate (generic of PERIDEX)
clotrimazole (generic of MYCELEX)
lidocaine viscous
nystatin suspension (generic of MYCOSTATIN)
triamcinolone paste
CORTICOSTEROIDS, INHALED NASAL
flunisolide (generic of NASAREL)
fluticasone (generic of FLONASE)
triamcinolone (generic of NASACORT AQ)
MISCELLANEOUS NASAL
azelastine (generic of ASTELIN nasal spray)
ipratropium bromide 0.03% nasal spray (generic of ATROVENT)
ENDOCRINE AND METABOLIC
SYSTEMIC CORTICOSTEROIDS Glucocorticosteroids
dexamethasone
hydrocortisone
methylprednisolone (generic of MEDROL)
prednisolone
prednisolone syrup (generic of PRELONE)
prednisone
Mineralocorticoids
fludrocortisone
ANDROGENS
PA fluoxymesterone (ANDROXY)
PA testosterone gel (ANDROGEL, TESTIM)
PA testosterone transdermal (ANDRODERM)
ESTROGENS
estradiol (generic of ESTRACE)
estradiol transdermal (generic of CLIMARA)
estradiol transdermal (ESTRADERM)
estrogens, conjugated (PREMARIN)
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
12
ESTROGENS/PROGESTIN COMBINATIONS
estrogens, conjugated/medroxyprogesterone (PREMPHASE)
estrogens, conjugated/medroxyprogesterone (PREMPRO)
ORAL CONTRACEPTIVES Monophasic Oral Contraceptives
drospirenone/ethinyl estradiol (generic of YASMIN)
ethinyl estradiol/desogestrel (generic of DESOGEN)
ethinyl estradiol/norethindrone (generic of LOESTRIN FE)
ethinyl estradiol/norethindrone (generic of ORTHO-NOVUM 1/35)
ethinyl estradiol/norethindrone (generic of ORTHO-NOVUM 1/50)
levonorgestrel/ethinyl estradiol (generic of NORDETTE)
Biphasic Oral Contraceptives
ethinyl estradiol/desogestrel (generic of MIRCETTE)
Triphasic Oral Contraceptives
norethindrone/ethinyl estradiol (generic of ORTHO-NOVUM 7/7/7)
norethindrone/ethinyl estradiol (generic of TRI-NORINYL)
Progestin Only Oral Contraceptives
levonorgestrel (generic of PLAN B)
norethindrone (generic of ORTHO-MICRONOR)
TRANSDERMAL CONTRACEPTIVES
norelgestromin-ethinyl estradiol (ORTHO EVRA)
VAGINAL CONTRACEPTIVES
estradiol (ESTRING)
etonogestrel-ethinyl estradiol (NUVARING)
PROGESTINS
medroxyprogesterone (generic of PROVERA)
progesterone, micronized (PROMETRIUM)
ORAL HYPOGLYCEMICS
acarbose (generic of PRECOSE)
glimepiride (generic of AMARYL)
glipizide (generic of GLUCOTROL)
glipizide/metformin (generic of METAGLIP)
glyburide (generic of GLYNASE)
metformin (generic of GLUCOPHAGE)
metformin ext-rel (generic of GLUCOPHAGE XR)
pioglitazone (ACTOS)
pioglitazone/glimepiride (DUETACT)
pioglitazone/metformin (ACTOPLUS MET)
repaglinide (PRANDIN)
saxagliptin (ONGLYZA)
saxagliptin/metformin (KOMBIGLYZE XR)
sitagliptin (JANUVIA)
sitagliptin/metformin (JANUMET)
tolazamide
tolbutamide
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
13
INSULINS & INSULIN TYPE INJECTABLES This includes the mix, pens & vials.
exenatide (BYETTA)
insulin aspart (NOVOLOG)
insulin glargine (APIDRA)
insulin glargine (LANTUS)
insulin lispro (HUMALOG)
insulin/recom (HUMULIN)
insulin/recom (NOVOLIN)
liraglutide (VICTOZA)
pramlintide acetate (SYMLIN)
GLUCOSE TEST STRIPS
glucose test strips ALL BRANDS OF GLUCOMETERS AND TEST STRIPS ARE PREFERRED
GLUCAGON
glucagon (GLUCAGON EMERGENCY KIT)
ANTITHYROID DRUGS
methimazole (generic of TAPAZOLE)
propylthiouracil
THYROID HORMONES
levothyroxine (generic of LEVOTHROID)
levothyroxine (generic of LEVOXYL)
levothyroxine (generic of SYNTHROID)
liothyronine (generic of CYTOMEL)
OTHER ENDOCRINE DRUGS
alendronate (generic of FOSAMAX)
bromocriptine (generic of PARLODEL)
cabergoline (generic of DOSTINEX)
desmopressin (generic of DDAVP)
ibandronate (BONIVA 150 mg tab only)
raloxifene (EVISTA)
risedronate (ACTONEL)
GASTROINTESTINAL
ANTIDIARRHEAL PREPARATIONS Consider OTC Imodium as first line therapy
diphenoxylate/atropine (generic of LOMOTIL)
ANTIULCER DRUGS H2 Antagonists (Over the counter strengths are not covered)
cimetidine (generic of TAGAMET)
famotidine (generic of PEPCID)
nizatidine (generic of AXID)
ranitidine (generic of ZANTAC)
H. pylori treatments
bismuth subcitrate potassium+ metronidazole + tetracycline (PYLERA)
lansoprazole + amoxicillin + clarithromycin (PREVPAC)
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
14
Other anti-ulcer products
misoprostol (generic of CYTOTEC)
omeprazole (generic of PRILOSEC)
sucralfate (generic of CARAFATE)
ANTIEMETICS
aprepitant (EMEND)
granisetron (generic of KYTRIL)
meclizine (generic of ANTIVERT)
ondansetron (generic of ZOFRAN)
ondansetron orally disintegrating tabs (generic of ZOFRAN ODT)
prochlorperazine
promethazine
trimethobenzamide (generic of TIGAN)
DIGESTANTS
lipase/protease/amylase (CREON)
lipase/protease/amylase (PANCREAZE)
lipase/protease/amylase (ZENPEP)
ANTISPASMODICS & DRUGS AFFECTING GI MOTILITY
belladonna alkaloids/phenobarbital (generic of DONNATAL)
chlordiazepoxide/clidinium (generic of LIBRAX)
constulose
dicyclomine (generic of BENTYL)
enulose
hyoscyamine sulfate (generic of LEVSIN)
hyoscyamine sulfate (generic of LEVSIN-SL)
lactulose
metoclopramide (generic of REGLAN)
osmotic laxative (generic of SORBITOL SOLUTION 70 %)
PEG Solution (generic of COLYTE)
SULFONAMIDE/MESALAMINE PRODUCTS
balsalazide
budesonide (generic of ENTOCORT EC)
mesalamine delayed-rel tabs (ASACOL)
mesalamine delayed-rel tabs 800 mg (ASACOL HD)
mesalamine ext-rel caps (PENTASA)
mesalamine rectal susp (generic of ROWASA)
olsalazine sodium (DIPENTUM)
sulfasalazine (generic of AZULFIDINE)
OTHER
ursodiol (generic of URSO)
GENITOURINARY
VAGINAL ANTI-INFECTIVES OTC products may be used as first line therapy
clindamycin (generic of CLEOCIN VAGINAL CREAM)
fluconazole susp and tabs (generic of DIFLUCAN)
metronidazole gel (generic of METROGEL-VAGINAL)
miconazole (generic of MONISTAT)
nystatin (generic of MYCOSTATIN)
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
15
terconazole vag cream (generic of TERAZOL 3)
ANTICHOLINERGIC-ANTISPASMODICS
flavoxate HCL (generic of URISPAS)
oxybutynin
oxybutynin ext-rel (generic of DITROPAN XL)
propantheline (generic of PRO-BANTHINE)
solifenacin succinate (VESICARE)
tolterodine ext-rel (DETROL LA)
CHOLINERGIC DRUGS
bethanechol (generic of URECHOLINE)
URINARY ANALGESICS
methylene blue (generic of PROSED)
phenazopyridine (generic of PYRIDIUM)
MISCELLANEOUS GENITOURINARY
alfuzosin HCl (generic of UROXATRAL)
doxazosin (generic of CARDURA)
dutasteride (AVODART)
finasteride (generic of PROSCAR)
imipramine (generic of TOFRANIL)
tamsulosin (generic of FLOMAX)
terazosin
HEMATOLOGICAL AGENTS
HEMATOPOIETIC
folic acid
B-12/vit C/folic acid/iron/succinic acid (FERREX 150 FORTE PLUS)
leucovorin calcium (folinic acid)
vitamin A caps
ANTICOAGULANT DRUGS
dabigatran (PRADAXA)
warfarin (generic of COUMADIN)
ANTIPLATELET DRUGS
clopidogrel (generic of PLAVIX)
dipyridamole (generic of PERSANTINE)
prasugrel (EFFIENT)
OTHER AGENTS
PA deferasirox (EXJADE)
PA eltrombopag (PROMACTA)
NEUROMUSCULAR
ANTICONVULSANTS
carbamazepine (generic of TEGRETOL)
carbamazepine ext-rel (generic of TEGRETOL-XR)
clonazepam (generic of KLONOPIN)
divalproex sodium delayed-rel (generic of DEPAKOTE)
divalproex sodium ext-rel (generic of DEPAKOTE ER)
ethosuximide (generic of ZARONTIN)
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
16
gabapentin (generic of NEURONTIN)
lacosamide (VIMPAT)
lamotrigine (generic of LAMICTAL)
levetiracetam (generic of KEPPRA)
oxcarbazepine (generic of TRILEPTAL)
phenobarbital
phenytoin (generic of DILANTIN)
pregabalin (LYRICA)
primidone (generic of MYSOLINE)
topiramate (generic of TOPAMAX)
valproic acid (generic of DEPAKENE)
zonisamide (generic of ZONEGRAN)
ANTIPARKINSON DRUGS
amantadine
benztropine
bromocriptine (generic of PARLODEL)
carbidopa/levodopa (generic of PARCOPA)
carbidopa/levodopa (generic of SINEMET)
carbidopa/levodopa ext-rel (generic of SINEMET CR)
carbidopa/levodopa/entacapone (STALEVO)
entacapone (COMTAN)
pramipexole (generic of MIRAPEX)
rasagiline mesylate (AZILECT)
ropinirole (generic of REQUIP)
selegiline (generic of ELDEPRYL)
trihexyphenidyl
SKELETAL MUSCLE RELAXANTS
baclofen
carisoprodol (generic of SOMA)
chlorzoxazone
cyclobenzaprine (generic of FLEXERIL)
metaxalone (generic of SKELAXIN)
methocarbamol (generic of ROBAXIN)
tizanidine (generic of ZANAFLEX)
ANTICHOLINESTERASE MUSCLE STIMULANTS
pyridostigmine (generic of MESTINON)
NUTRITIONAL PRODUCTS
PRENATAL VITAMINS
NEXA SELECT
PREFERA OB
PREFERA OB ONE
PREFEREA OB + DHA
PRENEXA
VITAMINS
multivitamins/fluoride
MINERALS
sodium fluoride drops (generic of LURIDE drops)
sodium fluoride tabs (generic of LURIDE tabs)
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
17
POTASSIUM SUPPLEMENTS
potassium chloride effervescent tablet
potassium chloride liquid
potassium chloride tablet
potassium chloride tablet (generic of K-TABS)
MISCELLANEOUS NUTRITIONAL
levocarnitine (generic of CARNITOR)
OPHTHALMIC MEDICATIONS
ALPHA-ADRENOCEPTOR AGONISTS
brimonidine 0.1% (ALPHAGAN P 0.1%)
brimonidine 0.15% (generic of ALPHAGAN P)
brimonidine 0.2%
ALPHA-ADRENOCEPTOR AGONISTS COMBINATIONS
brimonidine/timolol (COMBIGAN)
ANTI-INFLAMMATORY AGENTS Corticosteroids
dexamethasone
fluorometholone (FML)
fluorometholone (FML FORTE)
loteprednol etabonate (LOTEMAX)
prednisolone acetate 0.12% (PRED MILD)
prednisolone acetate 1% (generic of PRED FORTE)
rimexolone (VEXOL)
Non-steroidal Anti-inflammatory Drugs
diclofenac sodium (generic of VOLTAREN)
flurbiprofen (generic of OCUFEN)
ANTI-ALLERGIC AGENTS
loteprednol etabonate (ALREX)
olopatadine HCL (PATADAY, PATANOL)
ANTIMICROBIAL AGENTS Antibiotics and Antibiotic Combinations
azithromycin (AZASITE)
bacitracin 500 units/g
bacitracin/polymyxin B
chloramphenicol (generic of CHLOROPTIC)
ciprofloxacin ophth oint (CILOXAN ophth oint)
ciprofloxacin ophth soln (generic of CILOXAN)
erythromycin oint
gentamicin
moxifloxacin (VIGAMOX)
neomycin/polymyxin B/gramicidin (generic of NEOSPORIN)
sulfacetamide solution and ointment (generic of BLEPH-10)
tobramycin (generic of TOBREX)
trimethoprim/polymyxin B 10000 units/mL (generic of POLYTRIM)
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
18
Antibiotic-Corticosteroid Combinations
neomycin/dexamethasone
neomycin/polymyxin B/bacitracin/hydrocortisone (generic of CORTISPORIN)
neomycin/polymyxin B/bacitracin/hydrocortisone oint (generic of CORTISPORIN)
neomycin/polymyxin B/dexamethasone (generic of MAXITROL)
prednisolone acetate and sulfacetamide sodium 10% suspension and ointment (BLEPHAMIDE)
prednisolone and gentamicin sulfate ointment (PRED-G SOP)
tobramycin/dexamethasone oint (TOBRADEX oint)
tobramycin/dexamethasone susp (generic of TOBRADEX susp)
Antifungals
natamycin (NATACYN)
Antivirals
ganciclovir opthal (ZIRGAN)
trifluridine (generic of VIROPTIC)
ARTIFICIAL TEAR PRODUCTS/LUBRICANTS
cyclosporine, emulsion (RESTASIS)
BETA-ADRENORECEPTOR ANTAGONISTS
betaxolol solution
betaxolol suspension (BETOPTIC S)
levobunolol (generic of BETAGAN)
timolol maleate gel (generic of TIMOPTIC-XE)
timolol maleate solution (generic of TIMOPTIC)
CARBONIC ANHYDRASE INHIBITORS Note: Carbonic Anhydrase Inhibitors are not considered first-line agents for the treatment of glaucoma
dorzolamide (generic of TRUSOPT)
dorzolamide/timolol maleate (generic of COSOPT)
DILATING AGENTS Anticholinergic
atropine
cyclopentolate (generic of CYCLOGYL)
dipivefrin
homatropine (generic of ISOPTO HOMATROPINE)
tropicamide (generic of MYDRIACYL)
Sympathomimetic
phenylephrine (generic of NEO-SYNEPHRINE)
MIOTICS
carbachol (ISOPTO CARBACHOL)
pilocarpine hydrochloride opth
PROSTAGLANDINS
bimatoprost (LUMIGAN)
latanoprost (generic of XALATAN)
travoprost (TRAVATAN)
SYMPATHOMIMETICS
dipivefrin (generic of PROPINE)
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
19
epinephrine (generic of EPIFRIN)
RESPIRATORY
ANTIHISTAMINES Consider OTC products as first line therapy as prescription antihistamines are nonpreferred. Oral
cyproheptadine (generic of PERIACTIN)
hydroxyzine HCl
hydroxyzine pamoate (generic of VISTARIL)
ANTITUSSIVES & EXPECTORANTS
benzonatate
codeine/chlorpheniramine/pseudoephedrine
codeine/guaifenesin liquid
codeine/phenylephrine/promethazine
codeine/promethazine
dextromethorphan/brompheniramine/pseudoephedrine
dextromethorphan/chlorpheniramine/phenylephrine
dextromethorphan/promethazine
guaifenesin
phenylephrine/promethazine
ANTIASTHMATICS Adrenergic Stimulants-Inhalers
albuterol sulfate, CFC-free aerosol (VENTOLIN HFA, PROAIR HFA)*
formoterol (FORADIL)
pirbuterol (MAXAIR AUTOHALER)
salmeterol (SEREVENT)
Adrenergic Stimulants-Solutions
albuterol
Adrenergic Stimulants-Oral Tabs
albuterol
albuterol ext-rel (generic of VOSPIRE ER)
Xanthine Derivatives
theophylline (THEO-24)
theophylline ext-rel
theophylline ext-rel tabs (generic of UNIPHYL)
Corticosteroids for Inhalation
beclomethasone, CFC-free aerosol (QVAR)*
fluticasone (FLOVENT)*
mometasone (ASMANEX)*
Other Drugs for Asthma
albuterol/ipratropium (COMBIVENT)
budesonide/formoterol (SYMBICORT)
ipratropium, CFC-free aerosol (ATROVENT HFA)
montelukast (SINGULAIR)
salmeterol/fluticasone (ADVAIR)
tiotropium (SPIRIVA)
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
20
TOPICAL
ANTI-ACNE MEDICATIONS
adapalene cream and gel 0.1% (generic for DIFFERIN)
adapalene gel 0.3%, lotion 0.1% (DIFFERIN)
benzoyl peroxide gel (generic of DESQUAM-E)
clindamycin (generic of CLEOCIN T)
dapsone gel (ACZONE)
erythromycin topical solution (generic of ERYCETTE)
erythromycin topical solution (generic of T-STAT)
erythromycin/benzoyl peroxide gel (generic of BENZAMYCIN)
isotretinoin oral
tazarotene cream, gel (TAZORAC)
tretinoin topical (generic of RETIN-A)
ANTIFUNGALS
ciclopirox suspension (generic of LOPROX SUSPENSION)
clotrimazole
econazole
ketoconazole (generic of NIZORAL)
nystatin (generic of MYCOSTATIN)
terbinafine cream 1% (generic of LAMISIL AT)
ANTI-INFECTIVES
gentamicin
metronidazole gel 1% (METROGEL)
mupirocin cream (BACTROBAN cream)
mupirocin ointment (generic of BACTROBAN)
retapamulin (ALTABAX)
silver sulfadiazine (generic of SILVADENE)
ANTIPSORIATICS
anthralin (DRITHOCREME)
calcipotriene (generic of DOVONEX)
tazarotene gel (TAZORAC)
CORTICOSTEROIDS Low Potency
alclometasone crm, oint 0.05% (generic of ACLOVATE)
desonide crm, oint 0.05% (generic of TRIDESILON)
hydrocortisone crm 2.5%
Medium Potency
betamethasone valerate
betamethasone valerate foam 0.12% (LUXIQ)
desonide foam 0.05% (VERDESO)
desoximetasone cream 0.05% (generic of TOPICORT LP)
fluocinolone acetonide crm, oint 0.025%
fluticasone propionate crm 0.05%, oint 0.005% (generic of CUTIVATE)
hydrocortisone valerate crm, oint 0.2% (generic of WESTCORT)
mometasone crm, lotion, oint 0.1% (generic of ELOCON)
triamcinolone acetonide crm, lotion 0.025%
triamcinolone acetonide crm, lotion, oint 0.1%
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
21
High Potency
betamethasone dipropionate (generic of DIPROSONE)
betamethasone dipropionate augmented crm 0.05% (generic of DIPROLENE AF)
betamethasone dipropionate augmented lotion 0.05% (generic of DIPROLENE)
desoximetasone crm, oint 0.25%, gel 0.05% (generic of TOPICORT)
fluocinonide crm, gel, oint, soln 0.05% (generic of LIDEX)
halcinonide crm, oint 0.1% (HALOG)
Very High Potency
betamethasone dipropionate augmented gel, oint 0.05% (generic of DIPROLENE)
clobetasol propionate crm, gel, lotion, oint 0.05% (generic of TEMOVATE)
clobetasol propionate foam 0.05% (generic of OLUX)
clobetasol propionate lotion, shampoo, spray 0.05% (CLOBEX)
halobetasol propionate crm, oint 0.05% (generic of ULTRAVATE)
CORTICOSTEROID COMBINATIONS
hydrocortisone/pramoxine (EPIFOAM)
RECTAL
hydrocortisone (generic of ANUSOL-HC 2.5%)
hydrocortisone acetate supp (generic of ANUSOL-HC)
hydrocortisone intrarectal foam (CORTIFOAM)
hydrocortisone retention enema (generic of CORTENEMA)
hydrocortisone/pramoxine (generic of ANALPRAM-HC)
hydrocortisone/pramoxine (PROCTOFOAM-HC)
SCABICIDES/PEDICULICIDES Treatment of choice is OTC Nix
ivermectin (STROMECTOL)
permethrin (generic of ELIMITE)
MISCELLANEOUS
aluminum chloride (generic of DRYSOL)
fluorouracil (generic of EFUDEX)
imiquimod (generic of ALDARA)
pimecrolimus (ELIDEL)
podofilox gel ONLY (CONDYLOX)
urea cream
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
22
INDEX
A abacavir/lamivudine, abacavir/lamivudine/zidovudine, 4 ABILIFY, 10 acarbose, 12 ACCU-CHEK, 13 ACCUPRIL, 7 ACCURETIC, 7 ACEON, 7 acetaminophen/codeine, 2 acetazolamide, 8 acetic acid, 11 ACLOVATE, 20 ACTONEL, 13 ACTOPLUS MET, 12 ACTOS, 12 acyclovir, 5 ACZONE, 20 ADALAT CC, 7 adapalene, 20 ADDERALL, 10 ADDERALL XR, 10 adefovir, 4 ADVAIR, 19 AFINITOR, 6 albuterol, 19 albuterol ext-rel, 19 albuterol sulfate, CFC-free aerosol, 18 albuterol/ipratropium, 19 alclometasone crm, oint 0.05%, 20 ALDACTAZIDE, 8 ALDACTONE, 8 ALDARA, 21 alendronate, 13 alfuzosin HCl, 15 ALKERAN, 6 allopurinol, 2 almotriptan, 3 ALPHAGAN P, 17 ALPHAGAN P 0.1%, 17 alprazolam, 9 ALREX, 17 ALTABAX, 20 ALTACE, 7 altretamine, 5 aluminum chloride, 21 amantadine, 5, 16 AMARYL, 12 AMBIEN, 10 AMBIEN CR, 10 AMERGE, 3 amiloride/hydrochlorothiazide, 8 amiodarone, 7 amitriptyline, 9 amlodipine, 7 amlodipine/olmesartan, 8 amoxapine, 9 amoxicillin, 3 amoxicillin/potassium clavulanate, 3 amphetamine/dextroamphetamine mixed salts, 10 amphetamine/dextroamphetamine mixed salts ext-rel, 10
ampicillin, 3 ANAFRANIL, 9 ANAPROX, 2 ANAPROX DS, 2 anastrozole, 5 ANDRODERM, 11 ANDROGEL, 11 ANDROXY, 11 ANSAID, 2 ANTABUSE, 10 anthralin, 20 ANTIVERT, 14 ANUSOL-HC, 21 APIDRA, 13 aprepitant, 14 APTIVUS, 4 ARALEN, 5 ARAVA, 2 ARICEPT, 10 ARIMIDEX, 5 aripiprazole, 10 AROMASIN, 6 ASACOL, 14 ASACOL HD, 14 ASMANEX, 19 ASTELIN nasal spray, 11 atazanavir, 4 atenolol, 7 atenolol/chlorthalidone, 7 ATIVAN, 9 atorvastatin, 8 atovaquone/proguanil, 5 atropine, 18 ATROVENT, 11 ATROVENT HFA, 19 AUGMENTIN, 3 AVALIDE, 8 AVAPRO, 8 AVELOX, 3 AVODART, 15 AXERT, 3 AXID, 13 AZASITE, 17 azathioprine, 5 azelastine, 11 AZILECT, 16 azithromycin, 3, 17 AZOR, 8 AZULFIDINE, 14
B B-12/vit c/folic acid/iron/succinic acid, 15 bacitracin 500 units/g, 17 bacitracin/polymyxin B, 17 baclofen, 16 BACTRIM, 4 BACTROBAN, 20 BACTROBAN cream, 20 balsalazide, 14
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
23
BARACLUDE, 4 beclomethasone, CFC-free aerosol, 19 belladonna alkaloids/phenobarbital, 14 benazepril, 7 benazepril/hydrochlorothiazide, 7 BENICAR, 8 BENICAR HCT, 8 BENTYL, 14 BENZAMYCIN, 20 benzonatate, 19 benzoyl peroxide gel, 20 benztropine, 16 BETAGAN, 18 betamethasone dipropionate, 21 betamethasone dipropionate augmented crm 0.05%, 21 betamethasone dipropionate augmented gel, oint 0.05%, 21 betamethasone dipropionate augmented lotion 0.05%, 21 betamethasone valerate, 20 betamethasone valerate foam 0.12%, 20 BETAPACE AF, 7 betaxolol solution, 18 betaxolol suspension, 18 bethanechol, 15 BETOPTIC S, 18 bexarotene caps, 5 bicalutamide, 5 BILTRICIDE, 5 bimatoprost, 18 bismuth subcitrate potassium/metronidazole/tetracycline, 13 bisoprolol, 7 bisoprolol/hydrochlorothiazide, 7 BLEPH-10, 17 BLEPHAMIDE, 18 BONIVA 150 mg tab only, 13 brimonidine 0.1%, 17 brimonidine 0.15%, 17 brimonidine 0.2%, 17 brimonidine/timolol, 17 bromocriptine, 13, 16 budesonide, 14 budesonide/formoterol, 19 bumetanide, 8 buprenorphine/naloxone, 2 bupropion, 9 bupropion ext-rel, 9, 11 BUSPAR, 9 buspirone, 9 busulfan, 5 butalbital/acetaminophen/caffeine, 2,3 butalbital/aspirin/caffeine, 2, 3 butalbital/aspirin/caffeine/codeine, 2 BYETTA, 13
C cabergoline, 13 CALAN, 7 CALAN SR, 7 calcipotriene, 20 capecitabine, 5 CAPOTEN, 7 CAPOZIDE, 7 CAPRELSA, 6 captopril, 7
captopril/hydrochlorothiazide, 7 CARAFATE, 14 carbachol, 18 carbamazepine, 9, 15 carbamazepine ext-rel, 9, 15 carbidopa/levodopa, 16 carbidopa/levodopa ext-rel, 16 carbidopa/levodopa/entacapone, 16 CARDURA, 15 carisoprodol, 16 CARNITOR, 17 carvedilol, 7 carvedilol phosphate ext-rel, 7 CASODEX, 5 CATAPRES, 8 CEENU, 6 cefaclor, 3 CEFACLOR ER, 3 cefaclor ext-rel, 3 cefadroxil, 3 CEFTIN, 3 cefuroxime, 3 CELEBREX, 2 celecoxib, 2 CELLCEPT, 6 cephalexin, 3 cephradine, 3 CHANTIX, 11 chlorambucil, 5 chloramphenicol, 17 chlordiazepoxide, 9 chlordiazepoxide/clidinium, 14 chlorhexidine gluconate, 11 CHLOROPTIC, 17 chloroquine, 5 chlorpromazine, 10 chlorthalidone, 8 chlorzoxazone, 16 cholestyramine aspartame, 9 cholestyramine sucrose, 9 ciclopirox suspension, 20 CILOXAN, 17 CILOXAN ophth oint, 17 cimetidine, 13 CIPRO, 3 CIPRO HC, 11 CIPRODEX, 11 ciprofloxacin, 3 ciprofloxacin ophth oint, 17 ciprofloxacin ophth soln, 17 ciprofloxacin/dexamethasone, 11 ciprofloxacin/hydrocortisone, 11 CLEOCIN, 5 CLEOCIN T, 20 CLEOCIN VAGINAL CREAM, 14 CLIMARA, 11 clindamycin, 5, 14, 20 clobetasol propionate crm, gel, lotion, oint 0.05%, 21 clobetasol propionate foam 0.05%, 21 clobetasol propionate lotion, shampoo, spray 0.05%, 21 CLOBEX, 21 clomipramine, 9 clonazepam, 9, 15
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
24
clonidine tabs, 8 clopidogrel, 15 clorazepate, 9 clotrimazole, 4, 11, 20 cloxacillin, 3 CLOXAPEN, 3 codeine/chlorpheniramine/pseudoephedrine, 19 codeine/guaifenesin liquid, 19 codeine/phenylephrine/promethazine, 19 codeine/promethazine, 19 colchicine, 2 COLCRYS, 2 COLYTE, 14 COMBIGAN, 17 COMBIVENT, 19 COMBIVIR, 4 COMPLERA, 4 COMTAN, 16 CONCERTA, 10 CONDYLOX, 21 constulose, 14 COPEGUS, 5 CORDARONE, 7 COREG, 7 COREG CR, 7 CORGARD, 7 CORTENEMA, 21 CORTIFOAM, 21 CORTISPORIN, 18 CORTISPORIN OTIC, 11 COSOPT, 18 COUMADIN, 15 COZAAR, 8 CREON, 14 CRESTOR, 9 CRIXIVAN, 4 crizotinib, 5 CUTIVATE, 20 cyclobenzaprine, 16 CYCLOGYL, 18 cyclopentolate, 18 cyclophosphamide, 5 cyclosporine, emulsion, 18 CYMBALTA, 9 cyproheptadine, 19 CYTOMEL, 13 CYTOTEC, 14
D dabigatran, 15 dapsone, 5 dapsone gel, 20 darunavir, 4 dasatinib, 6 DAYPRO, 2 DDAVP, 13 deferasirox, 15 delavirdine, 4 DEMADEX, 8 DEPAKENE, 16 DEPAKOTE, 10, 15 DEPAKOTE ER, 10, 15 desipramine, 9
desmopressin, 13 DESOGEN, 12 desonide crm, oint 0.05%, 20 desonide foam 0.05%, 20 desoximetasone cream 0.05%, 20 desoximetasone crm, oint 0.25%, gel 0.05%, 21 DESQUAM-E, 20 DETROL LA, 15 dexamethasone, 11, 17 DEXEDRINE, 10 DEXEDRINE SPANSULE, 10 dextroamphetamine, 10 dextroamphetamine ext-rel, 10 dextromethorphan/brompheniramine/pseudoephedrine, 19 dextromethorphan/chlorpheniramine/phenylephrine, 19 dextromethorphan/promethazine, 19 diazepam, 9 DIBENZYLINE, 8 diclofenac, 2 diclofenac patch, 2 diclofenac sodium, 17 dicloxacillin, 3 dicyclomine, 14 didanosine delayed-rel, 4 didanosine soln, 4 DIFFERIN, 20 DIFLUCAN, 4, 14 diflunisal, 2 digoxin, 6 DILACOR XR, 7 DILANTIN, 16 DILAUDID, 2 diltiazem ext-rel, 7 DIOVAN, 8 DIOVAN HCT, 8 DIPENTUM, 14 diphenoxylate/atropine, 13 dipivefrin, 18 DIPROLENE, 21 DIPROLENE AF, 21 DIPROSONE, 21 dipyridamole, 15 disopyramide, 7 disopyramide ext-rel, 7 disulfiram, 10 DITROPAN XL, 15 divalproex sodium delayed-rel, 10, 15 divalproex sodium ext-rel, 10, 15 DOLOPHINE, 2 donepezil HCL, 10 DONNATAL, 14 dorzolamide, 18 dorzolamide/timolol maleate, 18 DOSTINEX, 13 DOVONEX, 20 doxazosin, 15 doxepin, 9 doxycycline, 3 DRITHOCREME, 20 dronedarone, 7 drospirenone/ethinyl estradiol, 12 DRYSOL, 21 DUETACT, 12
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
25
duloxetine HCL, 9 DURAGESIC PATCH, 2 dutasteride, 15 DYAZIDE, 8
E E.E.S., 3 econazole, 20 EDURANT, 4 efavirenz, 4 EFFEXOR, 9 EFFEXOR XR, 9 EFFIENT, 15 EFUDEX, 21 ELDEPRYL, 16 eletriptan, 3 ELIDEL, 21 ELIMITE, 21 ELOCON, 20 eltrombopag, 15 EMCYT, 6 EMEND, 14 emtricitabine, 4 emtricitabine/rilpivirine/tenofovir, 4 EMTRIVA, 4 enalapril, 7 enalapril/hydrochlorothiazide, 7 enoxaparin, 9 entacapone, 16 entecavir, 4 ENTOCORT EC, 14 enulose, 14 EPIFOAM, 21 EPIFRIN, 19 epinephrine, 19 EPIVIR, 4 EPIVIR HBV, 4 EPZICOM, 4 ergoloid mesylates, 3 erlotinib, 6 ERYCETTE, 20 ERY-TAB, 3 ERYTHROCIN, 3 erythromycin base (enteric coated), 3 erythromycin estolate, 3 erythromycin ethylsuccinate, 3 erythromycin oint, 17 erythromycin stearate, 3 erythromycin topical solution, 20 erythromycin/benzoyl peroxide gel, 20 escitalopram, 9 ESGIC-PLUS, 2, 3 estazolam, 10 ESTRACE, 11 ESTRADERM, 11 estradiol, 11, 12 estradiol transdermal, 11 estradiol vaginal, 12 estramustine, 6 ESTRING, 12 estrogens, conjugated, 11 estrogens, conjugated/medroxyprogesterone, 12 ethambutol, 4
ethinyl estradiol/desogestrel, 12 ethinyl estradiol/norethindrone, 12 ethosuximide, 15 etonogestrel/ethinyl estradiol vaginal, 12 etoposide, 6 etravirine, 4 everolimus, 6 EVISTA, 13 EXELON, all forms, 10 exemestane, 6 exenatide, 13 EXJADE, 15 ezetimibe, 9
F famciclovir, 5 famotidine, 13 FAMVIR, 5 FARESTON, 6 febuxostat, 2 FELDENE, 2 FEMARA, 6 fentanyl transdermal, 2 FERREX 150 FORTE PLUS, 15 finasteride, 15 FIORICET, 2 FIORINAL, 2, 3 FIORINAL/CODEINE, 2 FLAGYL, 5 flavoxate HCL, 15 flecainide, 7 FLECTOR, 2 FLEXERIL, 16 FLOMAX, 15 FLONASE, 11 FLOVENT, 19 FLOXIN OTIC, 11 fluconazole, 4 fluconazole susp and tabs, 14 fludrocortisone, 11 FLUMADINE, 5 flunisolide, 11 fluocinolone acetonide crm, oint 0.025%, 20 fluocinonide crm, gel, oint, soln 0.05%, 21 fluorometholone, 17 fluorouracil, 21 fluoxetine, 9 fluoxymesterone, 11 fluphenazine, 10 fluphenazine decanoate, 10 flurazepam, 10 flurbiprofen, 2, 17 flutamide, 6 fluticasone, 11, 19 fluticasone propionate crm 0.05%, oint 0.005%, 20 FML, 17 FML FORTE, 17 folic acid, 15 FORADIL, 19 formoterol, 19 FOSAMAX, 13 fosamprenavir, 4 fosinopril, 7
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
26
fosinopril/hydrochlorothiazide, 7 furosemide, 8
G gabapentin, 16 galantamine, 10 galantamine ext-rel, 10 ganciclovir opthal, 18 gatifloxacin, 17 gemfibrozil, 9 gentamicin, 17, 20 GEODON, 10 GLEEVEC, 6 glimepiride, 12 glipizide, 12 glipizide/metformin, 12 glucagon, 13 GLUCAGON EMERGENCY KIT, 13 GLUCOPHAGE, 12 GLUCOPHAGE XR, 12 glucose test strips, 13 GLUCOTROL, 12 glyburide, 12 GLYNASE, 12 granisetron, 14 griseofulvin ultramicrosize, 4 GRIS-PEG, 4 guaifenesin, 19 guanabenz acetate, 8 guanfacine, 8
H halcinonide crm, oint 0.1%, 21 HALCION, 10 HALDOL DECANOATE, 10 halobetasol propionate crm, oint 0.05%, 21 HALOG, 21 haloperidol, 10 haloperidol decanoate, 10 HEPSERA, 4 HEXALEN, 5 homatropine, 18 HUMALOG, 13 HUMULIN, 13 HYCAMTIN caps, 6 hydralazine, 8 HYDREA, 5 hydrochlorothiazide, 8 hydrocodone/acetaminophen, 2 hydrocortisone, 11, 21 hydrocortisone acetate supp, 21 hydrocortisone crm 2.5%, 20 hydrocortisone intrarectal foam, 21 hydrocortisone retention enema, 21 hydrocortisone valerate crm, oint 0.2%, 20 hydrocortisone/neo/polymyxin B, 11 hydrocortisone/pramoxine, 21 hydromorphone, 2 hydroxychloroquine, 2, 5 hydroxyurea, 6 hydroxyzine HCl, 19 hydroxyzine pamoate, 19 hyoscyamine sulfate, 14
HYZAAR, 8
I ibandronate, 13 ibuprofen, 2 imatinib, 6 IMDUR, 6 imipramine, 9, 15 imiquimod, 21 IMITREX, 3 IMURAN, 5 INCIVEK, 5 indapamide, 8 INDERAL LA, 7 indinavir, 4 indomethacin, 2 insulin aspart, 13 insulin glargine, 13 insulin lispro, 13 insulin/recom, 13 INTELENCE, 4 INVEGA, 10 INVIRASE, 4 iodoquinol, 5 ipratropium bromide 0.03% nasal spray, 11 ipratropium, CFC-free aerosol, 19 irbesartan, 8 irbesartan/hydrochlorothiazide, 8 ISENTRESS, 4 ISMO, 6 isometheptene/dichloralphenazone/acetaminophen, 3 isoniazid, 4 ISOPTO CARBACHOL, 18 ISOPTO HOMATROPINE, 18 ISORDIL, excluding TEMBIDS, 6 isosorbide dinitrate, 6 isosorbide monohydrate, 6 isotretinoin oral, 20 ivermectin, 21
J JANUMET, 12 JANUVIA, 12
K KALETRA, 4 KEFLEX, 3 KEPPRA, 16 ketoconazole, 4, 20 ketoprofen, 2 KLONOPIN, 9, 15 KOMBIGLYZE XR, 12 K-TABS, 17 KYTRIL, 14
L lacosamide, 16 lactulose, 14 LAMICTAL, 10, 16 LAMISIL, 4 LAMISIL AT 1% cream, 20 lamivudine, 4
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
27
lamivudine/zidovudine, 4 lamotrigine, 10, 16 lansoprazole + amoxicillin + clarithromycin, 13 LANTUS, 13 lapatinib, 6 LARIAM, 5 LASIX, 8 latanoprost, 18 leflunomide, 2 lenalidomide, 6 letrozole, 6 leucovorin CA tabs, 6 leucovorin calcium (folinic acid), 15 LEUKERAN, 5 levetiracetam, 16 levobunolol, 18 levocarnitine, 17 levonorgestrel, 12 levonorgestrel/ethinyl estradiol, 12 LEVOTHROID, 13 levothyroxine, 13 LEVOXYL, 13 LEVSIN, 14 LEVSIN-SL, 14 LEXAPRO, 9 LEXIVA, 4 LIBRAX, 14 LIBRIUM, 9 LIDEX, 21 lidocaine HCl patch, 3 lidocaine viscous, 11 LIDODERM, 3 liothyronine, 13 lipase/protease/amylase, 14 LIPITOR, 8 liraglutide, 13 lisinopril, 7 lisinopril/hydrochlorothiazide, 7 lithium, 10 LOESTRIN FE, 12 LOMOTIL, 13 lomustine, 6 LOPID, 9 lopinavir/ritonavir, 4 LOPRESSOR, 7 LOPRESSOR HCT, 7 LOPROX SUSPENSION, 20 lorazepam, 9 LORCET, 2 LORCET PLUS, 2 losartan, 8 losartan/hydrochlorothiazide, 8 LOTEMAX, 17 LOTENSIN, 7 LOTENSIN HCT, 7 loteprednol etabonate, 17 lovastatin, 9 LOVENOX, 9 LUMIGAN, 18 LURIDE drops, 16 LURIDE tabs, 16 LUXIQ, 20 LYRICA, 3, 16
LYSODREN, 6
M MACRODANTIN, 5 MALARONE, 5 maprotiline, 9 maraviroc, 4 MATULANE, 6 MAVIK, 7 MAXAIR AUTOHALER, 19 MAXALT-MLT, 3 MAXITROL, 18 MAXZIDE, 8 mebendazole, 5 meclizine, 14 MEDROL, 11 medroxyprogesterone, 12 mefloquine, 5 MEGACE, 6 megestrol, 6 melphalan, 6 memantine, 10 mercaptopurine, 6 mesalamine delayed-rel tabs, 14 mesalamine ext-rel caps, 14 mesalamine rectal susp, 14 mesna tabs, 6 MESNEX, 6 MESTINON, 16 METADATE CD, 10 METAGLIP, 12 metformin, 12 metformin ext-rel, 12 methadone, 2 methazolamide, 8 methimazole, 13 methocarbamol, 16 methotrexate, 2, 6 methyclothiazide, 8 methyldopa, 8 methylene blue, 15 methylphenidate, 10 methylphenidate HCL, 10 methylprednisolone, 11 metoclopramide, 14 metolazone, 8 metoprolol, 7 metoprolol ext-rel, 7 metoprolol tartrate/hydrochlorothiazide, 7 METROGEL, 20 METROGEL-VAGINAL, 14 metronidazole, 5 metronidazole gel, 14 metronidazole gel 1%, 20 MEVACOR, 9 miconazole, 14 milnacipran, 3 MINIPRESS, 8 MINOCIN, 3 minocycline, 3 MIRAPEX, 16 MIRCETTE, 12 mirtazapine, 9
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
28
misoprostol, 14 mitotane, 6 moexipril, 7 mometasone, 19 mometasone crm, lotion, oint 0.1%, 20 MONISTAT, 14 MONOKET, 6 MONOPRIL, 7 MONOPRIL-HCT, 7 montelukast, 19 morphine sulfate, 2 morphine sulfate ext-rel, 2 MOTRIN, 2 moxifloxacin, 3, 17 MS CONTIN, 2 MULTAQ, 7 multivitamins/fluoride, 16 mupirocin cream, 20 mupirocin ointment, 20 MYAMBUTOL, 4 MYCELEX, 4, 11 mycophenolate mofetil, 6 MYCOSTATIN, 4, 11, 14, 20 MYDRIACYL, 18 MYLERAN, 5 MYSOLINE, 16
N nabumetone, 2 nadolol, 7 NAMENDA, 10 NAPROSYN, 2 naproxen, 2 naproxen sodium, 2 naratriptan, 3 NASACORT AQ, 11 NASAREL, 11 NATACYN, 18 natamycin, 18 NAVANE, 10 nelfinavir mesylate, 4 neomycin, 3 neomycin/dexamethasone, 18 neomycin/polymyxin B/bacitracin/hydrocortisone, 18 neomycin/polymyxin B/bacitracin/hydrocortisone oint, 18 neomycin/polymyxin B/dexamethasone, 18 neomycin/polymyxin B/gramicidin, 17 NEOSPORIN, 17 NEO-SYNEPHRINE, 18 NEURONTIN, 16 nevirapine, 4 NEXAVAR, 6 NEXA SELECT, 16 niacin timed release, 9 NIASPAN, 9 nifedipine ext-rel, 7 NILANDRON, 6 nilotinib, 6 nilutamide, 6 NITRO-BID, 6 NITRO-DUR, 6 nitrofurantoin, 5 nitroglycerin, 6
nitroglycerin ext-rel, 6 nitroglycerin oint, 6 nitroglycerin patch, 6 nitroglycerin sublingual spray, 6 NITROLINGUAL SPRAY, 6 NITROSTAT, 6 nizatidine, 13 NIZORAL, 4, 20 NORDETTE, 12 norelgestromin-ethinyl estradiol transdermal, 12 norethindrone, 12 norethindrone/ethinyl estradiol, 12 NORPACE, 7 NORPACE CR, 7 NORPRAMIN, 9 nortriptyline, 9 NORVASC, 7 NORVIR, 4 NOVOLIN, 13 NOVOLOG, 13 NUVARING, 12 nystatin, 4, 14, 20 nystatin suspension, 11
O OCUFEN, 17 ofloxacin otic, 11 olanzapine, 10 olmesartan, 8 olmesartan/hydrochlorothiazide, 8 olopatadine HCL, 17 olsalazine sodium, 14 OLUX, 21 omeprazole, 14 ondansetron, 14 ondansetron orally disintegrating tabs, 14 ONGLYZA, 12 ORTHO EVRA, 12 ORTHO-MICRONOR, 12 ORTHO-NOVUM 1/35, 12 ORTHO-NOVUM 1/50, 12 ORTHO-NOVUM 7/7/7, 12 oseltamivir, 5 osmotic laxative, 14 oxacillin, 3 oxaprozin, 2 oxazepam, 9 oxcarbazepine, 16 oxybutynin, 15 oxybutynin ext-rel, 15 oxycodone, 2 oxycodone ext-rel, 2 oxycodone/acetaminophen, 2 oxycodone/aspirin, 2 OXYCONTIN, 2
P paliperidone ext-rel, 10 PAMELOR, 9 PANCREAZE, 14 PARCOPA, 16 PARLODEL, 13, 16 paroxetine HCl ext-rel, 9
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
29
PATADAY, 17 PATANOL, 17 PAXIL CR, 9 pazopanib, 6 PEG Solution, 14 penicillin VK, 3 PENTASA, 14 pentoxifylline, 9 PEPCID, 13 PERCOCET, 2 PERCODAN, 2 PERIACTIN, 19 PERIDEX, 11 perindopril, 7 permethrin, 21 perphenazine, 10 PERSANTINE, 15 phenazopyridine, 15 phenobarbital, 16 phenoxybenzamine, 8 phenylephrine, 18 phenylephrine/promethazine, 19 phenytoin, 16 pimecrolimus, 21 pindolol, 7 pioglitazone, 12 pioglitazone/glimepiride, 12 pioglitazone/metformin, 12 pirbuterol, 19 piroxicam, 2 PLAN B, 12 PLAQUENIL, 2, 5 PLAVIX, 15 podofilox gel, 21 POLYTRIM, 17 potassium chloride effervescent tablet, 17 potassium chloride liquid, 17 potassium chloride tablet, 17 PRADAXA, 15 pramipexole, 16 pramlinitide acetate, 13 PRANDIN, 12 prasugrel, 15 PRAVACHOL, 9 pravastatin, 9 praziquantel, 5 prazosin, 8 PRECOSE, 12 PRED FORTE, 17 PRED MILD, 17 PRED-G SOP, 18 prednisolone, 11 prednisolone acetate 0.12%, 17 prednisolone acetate 1%, 17 prednisolone acetate and sulfacetamide sodium 10%
suspension and ointment, 18 prednisolone and gentamicin sulfate ointment, 18 prednisolone syrup, 11 prednisone, 11 PREFERA OB, 16 PREFERA OB ONE, 16 PREFERA OB + DHA, 16 pregabalin, 3, 16
PRELONE, 11 PREMARIN, 11 PREMPHASE, 12 PREMPRO, 12 prenatal vitamins, 16 PRENEXA, 16 PREVPAC, 13 PREZISTA, 4 PRILOSEC, 14 primidone, 16 PRO-BANTHINE, 15 probenecid, 2 procarbazine, 6 prochlorperazine, 14 PROCTOFOAM-HC, 21 progesterone, micronized, 12 PROMACTA, 15 promethazine, 14 PROMETRIUM, 12 propafenone, 7 propantheline, 15 PROPINE, 18 propranolol, 7 propranolol ext-rel, 7 propylthiouracil, 13 PROSCAR, 15 PROSED, 15 protriptyline, 9 PROVERA, 12 PROZAC, 9 PURINETHOL, 6 PYLERA, 13 pyrazinamide, 4 PYRIDIUM, 15 pyridostigmine, 16
Q QUESTRAN, 9 QUESTRAN LIGHT, 9 quetiapine, 10 quinapril, 7 quinapril/hydrochlorothiazide, 7 QVAR, 19
R raloxifene, 13 raltegravir, 4 ramelteon, 10 ril, 7 ranitidine, 13 rasagiline mesylate, 16 RAZADYNE, 10 RAZADYNE ER, 10 REBETOL, 5 REGLAN, 14 RELENZA, 5 RELPAX, 3 REMERON, 9 repaglinide, 12 REQUIP, 16 RESCRIPTOR, 4 RESTASIS, 18 RESTORIL, 10
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
30
retapamulin, 20 RETIN-A, 20 RETROVIR, 4 REVLIMID, 6 REYATAZ, 4 ribavirin, 5 RIFADIN, 4 rifampin, 4 rilpivirine, 4 rimantadine, 5 rimexolone, 17 risedronate, 13 RISPERDAL, 10 risperidone, 10 RITALIN, 10 ritonavir, 4 rivastigmine tartrate, 10 rizatriptan dispersible, 3 ROBAXIN, 16 ropinirole, 16 rosuvastatin, 9 ROWASA, 14 ROXICODONE, 2 ROZEREM, 10 RYTHMOL, 7
S salmeterol, 19 salmeterol/fluticasone, 19 saquinavir, 4 SARAFEM, 9 SAVELLA, 3 saxagliptin, 12 saxagliptin/metformin, 12 selegiline, 16 SELZENTRY, 4 SEPTRA, 4 SEREVENT, 19 SEROQUEL, 10 sertraline, 9 SILVADENE, 20 silver sulfadiazine, 20 simvastatin, 9 SINEMET, 16 SINEMET CR, 16 SINGULAIR, 19 sitagliptin, 12 sitagliptin/metformin, 12 sodium fluoride drops, 16 sodium fluoride tabs, 16 solifenacin succinate, 15 SOMA, 16 SONATA, 10 sorafenib, 6 SORBITOL SOLUTION 70 %, 14 sotalol HCL, 7 SPIRIVA, 19 spironolactone, 8 spironolactone/hydrochlorothiazide, 8 SPRYCEL, 6 STALEVO, 16 stavudine, 4 STROMECTOL, 21
SUBOXONE, 2 sucralfate, 14 sulfacetamide solution and ointment, 17 sulfamethoxazole/trimethoprim, 4 sulfasalazine, 14 sulfisoxazole/erythromycin, 4 sulindac, 2 sumatriptan, 3 sunitinib, 6 SUSTIVA, 4 SUTENT, 6 SYMBICORT, 19 SYMLIN, 13 SYNTHROID, 13
T TABLOID, 6 TAGAMET, 13 TAMBOCOR, 7 TAMIFLU, 5 tamoxifen, 6 tamsulosin, 15 TAPAZOLE, 13 TARCEVA, 6 TARGRETIN caps, 5 TASIGNA, 6 tazarotene cream, gel, 20 tazarotene gel, 20 TAZORAC, 20 TEGRETOL, 9, 15 TEGRETOL-XR, 9, 15 telaprevir, 5 telbivudine, 5 temazepam, 10 TEMODAR, 6 TEMOVATE, 21 temozolomide, 6 TENEX, 8 tenofovir, 4 TENORETIC, 7 TENORMIN, 7 TERAZOL, 15 terazosin, 8, 15 terbinafine tabs, 4 terconazole vag cream, 15 TESTIM, 11 testosterone gel, 11 testosterone transdermal, 11 tetracycline, 3 thalidomide, 6 THALOMID, 6 THEO-24, 19 theophylline, 19 theophylline ext-rel, 19 theophylline ext-rel tabs, 19 thioguanine, 6 thioridazine, 10 thiothixene, 10 TIAZAC, 7 TIGAN, 14 timolol maleate gel, 18 timolol maleate solution, 18 TIMOPTIC, 18
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
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TIMOPTIC-XE, 18 TINDAMAX, 5 tinidazole, 5 tiotropium, 20 tipranavir, 4 tizanidine, 16 TOBRADEX, 18 tobramycin, 17 tobramycin/dexamethasone, 18 TOBREX, 17 TOFRANIL, 9, 15 tolazamide, 12 tolbutamide, 12 tolterodine ext-rel, 15 TOPAMAX, 16 TOPICORT, 21 TOPICORT LP, 20 topiramate, 16 topotecan caps, 6 TOPROL-XL, 7 toremifene citrate, 6 torsemide, 8 tramadol HCL, 2 trandolapril, 7 TRANXENE, 9 TRAVATAN, 18 travoprost, 18 trazodone, 9 TRENTAL, 9 tretinoin, 6 tretinoin topical, 20 TREXALL, 6 triamcinolone, 11 triamcinolone acetonide crm, lotion 0.025%, 20 triamcinolone acetonide crm, lotion, oint 0.1%, 20 triamcinolone paste, 11 triamterene/hydrochlorothiazide, 8 triazolam, 10 TRIDESILON, 20 trifluoperazine, 10 trifluridine, 18 trihexyphenidyl, 16 TRILEPTAL, 16 trimethobenzamide, 14 trimethoprim, 5 trimethoprim/polymyxin B 10000 units/mL, 17 TRI-NORINYL, 12 TRIZIVIR, 4 tropicamide, 18 TRUERESULT, 13 TRUETEST, 13 TRUETRACK, 13 TRUSOPT, 18 T-STAT, 20 TYKERB, 6 TYLENOL w/CODEINE, 2 TYZEKA, 5
U ULORIC, 2 ULTRAM, 2 ULTRAVATE, 21 UNIPHYL, 19
UNIVASC, 7 urea cream, 21 URECHOLINE, 15 URISPAS, 15 UROXATRAL, 15 URSO, 14 ursodiol, 14
V valacyclovir, 5 valsartan, 8 valsartan/HCTZ, 8 VALIUM, 9 valproic acid, 16 VALTREX, 5 vandetanib, 6 varenicline, 11 VASERETIC, 7 VASOTEC, 7 venlafaxine, 9 venlafaxine ext-rel, 9 VENTOLIN HFA, 19 verapamil, 7 verapamil ext-rel, 7 VERDESO, 20 VESICARE, 15 VEXOL, 17 VIBRAMYCIN, 3 VICODIN, 2 VICODIN ES, 2 VICTOZA, 13 VIDEX EC, 4 VIDEX soln, 4 VIGAMOX, 17 VIMPAT, 16 VIRACEPT, 4 VIRAMUNE, 4 VIREAD, 4 VIROPTIC, 18 VISTARIL, 19 vitamin A, 15 VIVACTIL, 9 VOLTAREN, 2, 17 vorinostat, 6 VOSPIRE ER, 19 VOTRIENT, 6
W warfarin, 15 WELLBUTRIN, 9 WELLBUTRIN SR, 9 WELLBUTRIN XL, 9 WESTCORT, 20
X XALATAN, 18 XALKORI, 5 XANAX, 9 XELODA, 5
Effective 05/01/2012
NOTE: This list may be updated and drugs may be added or deleted as deemed necessary. For the most updated listing, please contact UHA Health Care Services at 532-4006, or 1-800-458-4600, extension 300, from the neighbor islands
32
Y YASMIN, 12 YODOXIN, 5
Z zaleplon, 10 ZANAFLEX, 16 zanamivir, 5 ZANTAC, 13 ZARONTIN, 15 ZAROXOLYN, 8 ZEBETA, 7 ZENPEP, 14 ZERIT, 4 ZESTORETIC, 7 ZESTRIL, 7 ZETIA, 9 ZIAC, 7 zidovudine, 4 ziprasidone, 10 ZIRGAN, 18 ZITHROMAX, 3 ZOCOR, 9 ZOFRAN, 14 ZOFRAN ODT, 14 ZOLINZA, 6 ZOLOFT, 9 zolpidem, 10 zolpidem ER, 10 ZONEGRAN, 16 zonisamide, 16 ZOVIRAX, 5 ZYBAN, 11 ZYLOPRIM, 2 ZYPREXA, 10