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Microsoft word - trustplus.formulary 2004.07.01 wcaduet.doc

BRAND GENERIC BRAND
ANTIHISTAMINE / DECONGESTANTS
Other Anti-Infectives. . . . . . . . . . . . . . . . . . . . . .
Trust Plus
Pharmacy Benefit Consultants
EXPECTORANT AND COUGH PRODUCTS---------
July 2004
Antifungal Agents. . . . . . . . . . . . . . . . . . . . . . . . . .
INTRODUCTION
Promethazine/Codeine or DM generics only This condensed formulary is designed to serve as Promethazine/Phenylephrine generics only a reference guide and assist in the selection of Promethazine/Phenylephrine/ generics only cost-effective pharmaceutical products. The formulary is not intended to be a substitute for Triprolidine/Pseudoephedrine/ generics only your clinical knowledge and judgment. In all ANTIVIRALS ---------------------------------------------------
cases, the prescriber is expected to select NASAL CORTICOSTEROIDS ----------------------------
appropriate drug therapy for the individual patient Committee will regularly review the formulary to ensure it meets the needs of both patients and NASAL ANTIHISTAMINES --------------------------------
providers. Thank you in advance for your OTHER NASAL AGENTS ---------------------------------
ANTI-INFECTIVE AGENTS (ORAL)
ANTIDIABETIC AGENTS
Presently, all drugs specifically indicated for the ANTHELMINTICS --------------------------------------------
treatment of HIV and its opportunistic infections are INSULINS ------------------------------------------------------
Rapid-Acting Insulins . . . . . . . . . . . . . . . . . . . . . . .
ANTIBIOTICS--------------------------------------------------
ANTINEOPLASTIC AND IMMUNOSUPPRESSIVE
Cephalosporins. . . . . . . . . . . . . . . . . . . . . . . . . . . .
All oral FDA-approved antineoplastic and immunosuppressive agents are on Formulary. Coverage is determined by the member’s Plan. Intermediate-Acting Insulins . . . . . . . . . . . . . . . . .
AUTONOMIC & CENTRAL NERVOUS SYSTEM
Macrolides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ALZHEIMER’S AGENTS -----------------------------------
Erythromycin Ethylsuccinate generic/Eryped ANALGESICS, NARCOTIC -------------------------------
Long-Acting Insulins . . . . . . . . . . . . . . . . . . . . . . . .
Penicillins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ORAL --------------------------------------------------------------
Quinolones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sulfonamides . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tetracyclines . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
OTHER ANTIDIABETIC AGENTS ------------------------
BRAND GENERIC BRAND GENERIC BRAND
ANTI-ADRENERGIC BLOCKERS – CENTRALLY
ACTING -------------------------------------------------------------
Propoxyphene/APAP 325mg gen/Darvocet N-50 ANALGESICS, NONSTEROIDAL ANTI-
INFLAMMATORY ------------------------------------------
MIGRAINE AGENTS------------------------------------------
ANTI-ADRENERGIC BLOCKERS – PERIPHERALLY
ACTING-------------------------------------------------------------
ANTIARRHYTHMICS ------------------------------------------
OBSESSIVE COMPULSIVE DISORDER AGENTS---
PSYCHOTHERAPEUTIC AGENTS -----------------------
Antidepressants . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ANALGESICS, SALICYLATES --------------------------
ANTICONVULSANTS -------------------------------------
ANTICOAGULANTS/ANTITHROMBOTICS ------------
ANTILIPEMICS ---------------------------------------------------
Antimanic Agent . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Antipsychotic Agents . . . . . . . . . . . . . . . . . . . . . . . .
ANTIPARKINSON AGENTS ------------------------------
CALCIUM CHANNEL BLOCKERS -------------------------
COMBINATION ANTIHYPERTENSIVES ------------------
CARDIOVASCULAR AGENTS
ANXIOLYTICS, SEDATIVES, AND HYPNOTICS
ALDOSTERONE ANTAGONISTS -------------------------
ANGIOTENSIN II ANTAGONISTS -------------------------
ANGIOTENSIN CONVERTING ENZYME INHIBITORS
DIURETICS -------------------------------------------------------
CEREBRAL STIMULANTS --------------------------------
ANTI-ADRENERGIC AGENTS – BETA-BLOCKERS --
Methylphenidate CD/ER/LA Metadate CD/ER/ DMARDS --------------------------------------------------------
VASODILATORS -------------------------------------------------
BRAND GENERIC BRAND GENERIC BRAND
ANTIBIOTICS -----------------------------------------------------
ANTISPASMODIC/ GI MOTILITY ----------------------------
CONTRACEPTIVES
ANTIVIRALS ------------------------------------------------------
MONOPHASIC --------------------------------------------------
FUNGICIDES ------------------------------------------------------
ANTIULCER -------------------------------------------------------
TOPICAL ANTI-INFLAMMATORY AGENTS -------------
Low Potency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
BOWEL EVACUANTS ------------------------------------------
DIGESTANTS -----------------------------------------------------
Intermediate Potency . . . . . . . . . . . . . . . . . . . . . . . . .
OTHER GI PRODUCTS ----------------------------------------
BI-PHASIC ---------------------------------------------------------
High Potency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
TRI-PHASIC -------------------------------------------------------
GOUT AGENTS
Highest Potency . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HORMONES
OTHER DERMATOLOGICALS ------------------------------
PROGESTIN ONLY ----------------------------------------------
ANDROGENS ----------------------------------------------------
EMERGENCY CONTRACEPTION --------------------------
ANTIESTROGENS/ANTIANDROGENS -------------------
CONTRACEPTIVE DEVICES ---------------------------------
ESTROGENS --------------------------------------------------
CORTICOSTEROIDS
Methoxsalen Lotion/Capsule Oxsoralen/Ultra Prednisolone Tablets/Liquid generics only DIAGNOSTICS
DERMATOLOGICALS
ACNE ----------------------------------------------------------------
ESTROGEN AND ANDROGEN COMBINATIONS
GASTROINTESTINAL AGENTS
ESTROGEN AND PROGESTERONE
COMBINATIONS -----------------------------------------------
Sodium sulfacetamide/Sulfur generic/Plexion/TS ANTIEMETIC/ ANTIVERTIGO --------------------------------
BRAND GENERIC BRAND GENERIC BRAND
ANTI-INFLAMMATORY AGENTS ---------------------------
SKELETAL MUSCLE RELAXANTS
FERTILITY REGULATORS -----------------------------------
BETA-BLOCKERS ----------------------------------------------
GROWTH HORMONE ------------------------------------------
THYROID AND ANTITHYROID AGENTS
PROGESTINS -----------------------------------------------------
VASOCONSTRICTORS ----------------------------------------
MISCELLANEOUS OPHTHALMIC AGENTS ------------
OSTEOPOROSIS AGENTS
SELECTIVE RECEPTOR MODULATORS ----------------
URINARY AGENTS
IMMUNOLOGIC AGENTS
Oxybutynin Transdermal/XL Oxytrol/Ditropan XL VAGINAL PREPARATIONS
ANTI-INFECTIVE AND ANTI-INFLAMMATORY
COMBINATIONS -------------------------------------------------
IMPOTENCE AGENTS
RESPIRATORY/ASTHMA
OPHTHALMICS
ANTI-ASTHMATIC AGENTS ---------------------------------
MISCELLANEOUS AGENTS
Antileukotrienes . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ANTI-ALLERGIC AGENTS ------------------------------------
Corticosteroids . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ANTI-GLAUCOMA AGENTS----------------------------------
Sympathomimetics . . . . . . . . . . . . . . . . . . . . . . . . .
ANTI-INFECTIVE/ANTIVIRAL AGENTS -------------------
Xanthine Derivatives . . . . . . . . . . . . . . . . . . . . . . . .
OTHER RESPIRATORY/ASTHMA AGENTS ------------
ANTI-INFECTIVE AND ANTI-INFLAMMATORY
COMBINATIONS -------------------------------------------------
Administered on behalf of HealthTrans by:
WellPoint Pharmacy Management
8407 Fallbrook Avenue / West Hills, CA 91304 WellPoint Pharmacy Management is a Registered Mark of WellPoint Health Networks Inc. Services provided by Professional Claim Services Inc. doing business as WellPoint

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