List of preferred medications Member formulary

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1 List of preferred medications 08 Member formulary

2 What is the GHP Family Formulary? A formulary is a list of drugs selected by GHP Family, which represents medications believed to be a necessary part of a quality treatment program. This formulary is up to date at the time of print. For the most up to date information, please go to our website at Can the Formulary change? The plan may add or remove drugs from the formulary. If we remove drugs from our formulary, or add restrictions on a drug such as a requirement for prior authorization, quantity limits and/or step therapy restrictions on a drug, we must notify affected members of the change at least 30 days before the change becomes effective. See section, Are there any requirements or limits on my drugs? for more information. How do I use the Formulary? There are two ways to find your drug within the formulary: Condition The formulary begins on page 8. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 8. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page I-. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. The first column of the formulary lists the formulary drug. Brand drugs are printed in all upper case letters (e.g. ADVAIR DISKUS). Generic drugs are printed in all lower case italic letters (e.g. simvastatin). names that appear in parenthesis after the generic covered drugs are the name of the brand medication. The brand name in parenthesis, appear for reference only to assist in identifying the generic medication and does NOT indicate that the brand name drug is on the formulary. The second column of the formulary lists the tier the drug is covered on. Tier contains generic medications. Tier contains brand name medications. s listed as are over-the-counter medications. See the section titled s for an explanation of drugs that are listed as.

3 The third and final column of the formulary lists any requirements or limits that may apply to the drug. See the section titled Are there any requirements or limits on my drugs below. Sometimes a drug comes in multiple forms (e.g., drops, liquid, tablet, syrup, etc.). If this column lists a specific drug form then only that form is included in the formulary. What if my drug is not on the Formulary? If your drug is not included in this formulary, you should first contact Member Services and confirm that your drug is not listed. What are generic drugs? GHP Family covers both brand name drugs and generic drugs. If your doctor prescribes a brand name drug and a generic is available, your pharmacist will give you the generic version of that drug. A generic drug is approved by the Federal Food & Administration (FDA) as having the same active ingredient as the brand name drug and is just as safe and effective. Generally, generic drugs cost less than brand name drugs. Prescriptions written as brand medically necessary by your doctor will require prior authorization. Are Over-the-Counter () drugs covered? Certain medications are listed on the formulary. drugs will require a prescription from your doctor. Dispensing Limits GHP Family will cover up to a 34-day supply of your medication unless the prescription is written for less by your physician or the medication is subject to a quantity limit restriction. A medication may be refilled when 85% has been used. If for some reason you need a refill before 85% of the medication has been used please call GHP Family Pharmacy Services at (855) or (570) for assistance. GHP Family will grant one early refill if you are traveling outside of Pennsylvania and will run out of medication before you return home. GHP Family will allow this once per medication per member per year. Your pharmacy should contact GHP Family Pharmacy Services at (855) or (570) to obtain a vacation supply. Any additional requests for a vacation supply will require prior authorization. Requests to replace medications that are lost, stolen, or destroyed must be reviewed by GHP Family Pharmacy Services. Members should contact GHP Family Pharmacy Services at (855) or (570) for more information. Blood Glucose Monitors Members are entitled to receive one new blood glucose monitor every two years. No prior authorization is required for formulary Blood Glucose Meters (Glucometers) and formulary

4 glucose test strips up to 00 strips per month. Larger quantities of test strips, non-formulary glucometers and non-formulary test strips require prior authorization. Prior authorization will also be required for members needing a new blood glucose monitor before two years have passed. Please contact GHP Family Pharmacy Services at (855) or (570) for more information. Formulary Blood Glucose Meters and Test Strips include: One Touch Basic One Touch Ultra One Touch Ultra One Touch Ultra Smart One Touch Ultramini One Touch Ultralink One Touch Verio IQ Sure Step Sure Step Pro s benefit drugs are drugs dispensed and administered in a physician s office. This formulary does not list all drugs available as a medical benefit. Several medical benefit drugs are listed in this formulary as in the Tier column but only for the purposes of alerting members, physicians, and pharmacies that prior authorization or other formulary restrictions may apply to these drugs. All medical benefit drugs that require a prior authorization are listed on this formulary. Any questions regarding the coverage of medical benefit drugs should be directed to GHP Family Member Services at (800) Vaccines Influenza (Flu) vaccines are available to members at a retail pharmacy without a prescription. The typhpoid vaccine (Vivotif) is also available at retail pharmacies but requires a prescription. Other vaccines are considered a medical benefit and should be administered by your physician. Are there any requirements or limits on my drugs? Some drugs may have additional requirements or limits. These requirements and limits may include: Prior Authorization: GHP Family requires your physician to get prior approval for certain drugs. This means that your prescriber will need to get approval from GHP Family before you fill prescriptions for these drugs. Without this approval, GHP Family will not pay for the drug. If GHP denies the prior authorization request, you can appeal the decision. Please see the GHP member handbook, section 5, Complaint, Appeal and Fair Hearing Processes, for information about filing an appeal. 3

5 Quantity Limits: For certain drugs, GHP Family has limits to the amount of the drug that you can get. If your prescriber wants you to have more than the limit, your prescriber must request prior authorization. Step Therapy: In some cases, GHP Family requires you to first try certain drugs to treat your medical condition before we will approve another drug for that condition. For example, if A and B both treat your medical condition, GHP Family may not approve B unless you try A first. If A does not work for you, GHP Family will then approve B. Your prescriber may request prior authorization if A does not work for you or if you cannot take A. Pharmacy: medications can only be filled by certain pharmacies in the GHP Family network. drugs are medications used to treat complex diseases. These medications usually require specialized handling and monitoring. If you are taking a specialty medicine or if you have a question about finding a specialty pharmacy, please call GHP Family Pharmacy Services at (855) or (570) medications have the words, next to them in the formulary. The following abbreviations are found within column three of this formulary and indicate the requirements and limits listed above: ABBREVIATION DESCRIPTION EXPLANATION Utilization Management Restrictions PA QL ST Prior Authorization Restriction Quantity Limit Restriction Step Therapy Restriction Your physician is required to get prior authorization from GHP Family before you fill your prescription for this drug. Without prior approval, GHP Family will not pay for this drug. GHP Family limits the amount of this drug that can be obtained per prescription, or within a specific time frame. Before GHP Family will approve this drug, you must first try another drug(s) to treat your medical condition. This drug may only be approved if the other drug(s) does not work for you. Some drugs are not available at your retail pharmacy. These drugs are called specialty drugs and can be obtained at specialty pharmacies. To find out how and where to obtain a specialty drug, please contact GHP Family Pharmacy Services at (855) or (570)

6 ABBREVIATION DESCRIPTION EXPLANATION NSO Prior Authorization Restriction for New Starts Only How much will I pay for my drugs? If you are a new member or if you have not taken this drug before, you (or your physician) are required to get prior authorization from GHP Family before you fill your prescription for this drug. Without prior approval, GHP Family will not pay for this drug. Pharmacy copays will apply to members 8 years of age and older unless otherwise listed below. Brand name prescription drugs have a $3 copayment. Generic prescription and over-the-counter drugs have a $ copayment. Services cannot be denied if the member is unable to afford the copay. There are no copays for: Pregnant women (including the postpartum period which ends 60 days after delivery) Children under 8 years of age benefit drugs Members in a nursing home Members in an Intermediate Care Facility for Mental Retardation or Intermediate Care Facility for Other Related Conditions Family planning drugs or supplies s, including immunizations, when dispensed and/or administered by a physician Title IV-B Foster Care and IV-E Foster Care and Adoption Assistance Members eligible under the Breast and Cervical Cancer Prevention and Treatment Programs There is no copay for the following groups of medications: o Antihypertensives (high blood pressure) o Antidiabetes (high blood sugar) o Anticonvulsants (seizure) o Cardiovascular preparations (heart disease) o Antipsychotics (except those that are controlled substance antianxiety drugs) o Antineoplastics (cancer drugs) o Antiglaucoma drugs o Anti-Parkinson s drugs o HIV/AIDS drugs Non-covered medications The following medications are not eligible for coverage under the Assistance Program: s that are designated by the FDA as less than effective (DESI) drugs Any drug marketed by a drug company that does not participate in the Medicaid Rebate Program s used for weight loss 5

7 s used for cosmetic purposes or hair growth s used for fertility s used for erectile dysfunction Cough and cold medications for members over years of age s and devices classified as experimental s ordered by a prescriber who has been barred or suspended from participating the MA program What if my drug requires prior authorization? If you learn that GHP Family requires prior authorization of your drug, you have two options: You can ask GHP Family Pharmacy Services for a list of similar drugs that are on the GHP Family formulary. You can call GHP Family Pharmacy Services at (855) or (570) When you receive the list, show it to your doctor and ask him or her if one of these drugs will work for you. Your physician can ask GHP Family for approval of your drug through a prior authorization. See below for information about how your physician can request a prior authorization. What if I need a drug that is not listed on the GHP Family Formulary? Your physician can ask us to approve your drug even if it is not on our formulary. What if I need an amount that exceeds the GHP Family Formulary limit? If your drug has a quantity limit, your physician can ask us to approve a higher amount. Generally, GHP Family will only approve your physician s request if the alternative drugs included on the plan s formulary would not be as effective in treating your condition and/or would cause you to have a negative medical effect. We must make our decision within 4 hours of getting your prescriber s request. If the pharmacy cannot fill your prescription because of the medication being non-formulary or requiring prior authorization, GHP Family will authorize a temporary supply of the medication. If your prescription is for an ongoing medication, a 5 day temporary supply will be authorized. If your prescription is for a new medication, a 5 day temporary or emergency supply of medication will be authorized. Members are limited to one emergency supply per medication every 80 days. A member whose prescription rejects for prior authorization or other utilization management criteria should not be turned away at the pharmacy without receiving a temporary or emergency supply of medication unless the dispensing pharmacist feels that dispensing the medication would jeopardize the health and safety of the member. 6

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10 Table of Contents Analgesics... 3 Anesthetics... 8 Anti-Addiction/Substance Abuse Treatment Agents... 9 Antianxiety Agents... 0 Antibacterials... Anticancer Agents... 4 Anticholinergic Agents... Anticonvulsants... Antidementia Agents... 4 Antidepressants... 4 Antidiabetic Agents... 6 Antifungals... 9 Antigout Agents... 3 Antihistamines... 3 Anti-Infectives (Skin And Mucous Membrane)... 3 Antimigraine Agents... 3 Antimycobacterials Antinausea Agents Antiparasite Agents Antiparkinsonian Agents Antipsychotic Agents Antivirals (Systemic) Blood Products/Modifiers/Volume Expanders Caloric Agents Cardiovascular Agents Central Nervous System Agents Contraceptives... 57

11 Cough And Cold Products Dental And Oral Agents Dermatological Agents Devices... 7 Enzyme Replacement/Modifiers Eye, Ear, Nose, Throat Agents Gastrointestinal Agents Genitourinary Agents Hormonal Agents, Stimulant/Replacement/Modifying Immunological Agents Inflammatory Bowel Disease Agents Irrigating Solutions Metabolic Bone Disease Agents Miscellaneous Therapeutic Agents Ophthalmic Agents... 0 Radioactive Agents... 0 Replacement Preparations... 0 Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Urine And Feces Contents Vasodilating Agents Vitamins And Minerals... 07

12 Analgesics Analgesics, Miscellaneous acephen rectal suppository 0 acetaminophen oral elixir 60 /5 ml (Non-Aspirin) acetaminophen rectal suppository 0, 650 (Acephen) acetaminophen-codeine oral solution 0- QL (66.67 per day) /5 ml, /5 ml (5 ml) acetaminophen-codeine oral tablet QL (3 per day) acetaminophen-codeine oral tablet (Tylenol-Codeine #3) QL ( per day) acetaminophen-codeine oral tablet (Tylenol-Codeine #4) QL (6 per day) alagesic lq oral solution /5 ml buprenorphine transdermal patch weekly (Butrans) QL (4 per 8 days) 0 mcg/hour, 5 mcg/hour, 0 mcg/hour, 5 mcg/hour, 7.5 mcg/hour butalbital-acetaminop-caf-cod oral capsule butalbital-acetaminophen oral tablet 50- (Marten-Tab) QL (6 per day) 35 butalbital-acetaminophen-caff oral (Fioricet) capsule butalbital-acetaminophen-caff oral (Capacet) capsule butalbital-acetaminophen-caff oral tablet (Esgic) butalbital-acetaminophen-caff oral tablet butalbital-aspirin-caffeine oral capsule (Fiorinal) butalbital-aspirin-caffeine oral tablet capacet oral capsule children's fever reducing rectal suppository 0 children's non-aspirin oral elixir 60 /5 ml children's non-aspirin oral liquid 60 /5 ml children's non-aspirin oral tablet,chewable 80 3 Geisinger Family 08 Formulary Effective: February, 08

13 children's pain reliever oral tablet,chewable 80 children's pain-fever relief oral liquid 60 /5 ml children's pain-fever relief oral tablet,chewable 80 children's tactinal oral tablet,chewable 80 CODEINE SULFATE ORAL SOLUTION 30 MG/5 ML codeine sulfate oral tablet 5, 30, QL (6 per day) 60 endocet oral tablet 0-35,.5-35 QL ( per day), 5-35, endodan oral tablet QL ( per day) fentanyl citrate buccal lozenge on a handle,00 mcg,,600 mcg, 00 mcg, (Actiq) PA; QL (0 per 30 days) 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 7 hour 00 (Duragesic) QL (0 per 30 days) mcg/hr, 75 mcg/hr fentanyl transdermal patch 7 hour (Duragesic) QL (0 per 30 days) mcg/hr, 5 mcg/hr, 50 mcg/hr hydrocodone-acetaminophen oral solution.5-67 /5 ml, 5-63 /7.5ml(7.5ml) hydrocodone-acetaminophen oral solution (Hycet) QL (90 per day) /5 ml hydrocodone-acetaminophen oral tablet (Vicodin HP) QL (3 per day) hydrocodone-acetaminophen oral tablet (Lorcet HD) QL ( per day) 0-35 hydrocodone-acetaminophen oral tablet 5- (Vicodin) QL (3 per day) 300 hydrocodone-acetaminophen oral tablet 5- (Lorcet (hydrocodone)) QL ( per day) 35 hydrocodone-acetaminophen oral tablet (Vicodin ES) QL (3 per day) hydrocodone-acetaminophen oral tablet (Lorcet Plus) QL ( per day) hydrocodone-ibuprofen oral tablet 0-00, 5-00 (Ibudone) QL (5 per day) hydrocodone-ibuprofen oral tablet.5-00 (Reprexain) QL (5 per day) hydrocodone-ibuprofen oral tablet QL (5 per day) 4 Geisinger Family 08 Formulary Effective: February, 08

14 hydromorphone oral tablet, 4 (Dilaudid) QL (6 per day) hydromorphone oral tablet 8 (Dilaudid) QL (8 per day) ibuprofen-oxycodone oral tablet QL (4 per day) levorphanol tartrate oral tablet QL (6 per day) margesic oral capsule marten-tab oral tablet QL (6 per day) masophen oral tablet 500 meperidine oral solution 50 /5 ml meperidine oral tablet 00 (Demerol) meperidine oral tablet 50 methadone oral concentrate 0 /ml (Methadone Intensol) QL ( per day) methadone oral solution 0 /5 ml, 5 QL (60 per day) /5 ml methadone oral tablet 0, 5 (Dolophine) QL ( per day) methadose oral tablet,soluble 40 QL (3 per day) morphine concentrate oral solution 00 QL (9 per day) /5 ml (0 /ml) morphine oral capsule,extend.release (Kadian) QL (4 per day) pellets 0, 0, 60, 80 morphine oral capsule,extend.release (Kadian) QL (3 per day) pellets 00, 30, 50 morphine oral solution 0 /5 ml QL (90 per day) morphine oral solution 0 /5 ml (4 QL (45 per day) /ml) MORPHINE ORAL TABLET 5 MG, 30 QL (6 per day) MG morphine oral tablet extended release 00 (MS Contin) QL (3 per day), 5, 30 morphine oral tablet extended release 00 (MS Contin) QL (4 per day), 60 morphine rectal suppository 0, 0, 30, 5 non-aspirin child rectal suppository 0 non-aspirin extra strength oral tablet 500 non-aspirin oral tablet,chewable 80 non-aspirin pain relief oral tablet 500 oxycodone oral capsule 5 QL (6 per day) oxycodone oral concentrate 0 /ml QL (6 per day) oxycodone oral solution 5 /5 ml QL (43.33 per day) oxycodone oral tablet 0, 0 QL (6 per day) oxycodone oral tablet 5, 30, 5 (Roxicodone) QL (6 per day) 5 Geisinger Family 08 Formulary Effective: February, 08

15 oxycodone-acetaminophen oral tablet 0- (Endocet) QL ( per day) 35,.5-35, 5-35, oxycodone-aspirin oral tablet QL ( per day) oxymorphone oral tablet 0, 5 (Opana) QL (6 per day) pain relief oral capsule 500 pain reliever extra strength oral tablet 500 PRIALT INTRATHECAL SOLUTION 00 MCG/ML, 5 MCG/ML PA - QL (5 per day) reprexain oral tablet 0-00,.5-00, 5-00 tension headache reliever oral tablet tramadol oral tablet 50 (Ultram) QL (40 per 30 days) tramadol oral tablet extended release 4 QL (90 per 30 days) hr 00 tramadol oral tablet extended release 4 QL (30 per 30 days) hr 00, 300 tramadol oral tablet, er multiphase 4 hr QL (90 per 30 days) 00 tramadol oral tablet, er multiphase 4 hr QL (30 per 30 days) 00, 300 tramadol-acetaminophen oral tablet (Ultracet) QL (40 per 30 days) 35 xylon 0 oral tablet 0-00 QL (5 per day) Nonsteroidal Anti-Inflammatory Agents aspirin oral tablet 35 (Bayer Aspirin) aspirin oral tablet,chewable 8 (Aspirin Childrens) aspirin oral tablet,delayed release (dr/ec) 35 aspirin oral tablet,delayed release (dr/ec) 8 aspirin rectal suppository 300, 600 aspir-low oral tablet,delayed release (dr/ec) 8 aspir-trin oral tablet,delayed release (dr/ec) 35 buffered aspirin oral tablet 35 celecoxib oral capsule 00, 00, 400, 50 (Aspir-Trin) (Adult Aspirin Regimen) 6 Geisinger Family 08 Formulary Effective: February, 08 (Celebrex) QL (60 per 30 days)

16 children's aspirin oral tablet,chewable 8 children's ibu-drops oral drops,suspension 50 /.5 ml children's ibuprofen oral suspension 00 /5 ml choline,magnesium salicylate oral liquid 500 /5 ml COMFORT PAC-IBUPROFEN KIT 800 MG COMFORT PAC-MELOXICAM KIT 5 MG COMFORT PAC-NAPROXEN KIT 500 MG diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended (Voltaren-XR) release 4 hr 00 diclofenac sodium oral tablet,delayed release (dr/ec) 5, 50, 75 diclofenac sodium topical gel % (Voltaren) QL (0 per day) diflunisal oral tablet 500 e.c. prin oral tablet,delayed release (dr/ec) 35 ecotrin oral tablet,delayed release (dr/ec) 35 etodolac oral capsule 00, 300 etodolac oral tablet 400 (Lodine) etodolac oral tablet 500 etodolac oral tablet extended release 4 hr 400, 500, 600 fenoprofen oral tablet 600 (ProFeno) flurbiprofen oral tablet 00, 50 ibuprofen jr strength oral tablet,chewable 00 ibuprofen oral suspension 00 /5 ml (Child Ibuprofen) ibuprofen oral tablet 00 (Advil) ibuprofen oral tablet 400, 600, 800 indomethacin oral capsule 5, 50 indomethacin oral capsule, extended release 75 infant's ibuprofen oral drops,suspension 50 /.5 ml 7 Geisinger Family 08 Formulary Effective: February, 08

17 infant's medi-profen oral drops,suspension 50 /.5 ml ketoprofen oral capsule 50, 75 ketorolac oral tablet 0 QL (0 per day) meclofenamate oral capsule 00, 50 mefenamic acid oral capsule 50 meloxicam oral suspension 7.5 /5 ml meloxicam oral tablet 5, 7.5 (Mobic) nabumetone oral tablet 500, 750 naproxen oral suspension 5 /5 ml (Naprosyn) naproxen oral tablet 50, 375 naproxen oral tablet 500 (Naprosyn) naproxen oral tablet,delayed release (EC-Naprosyn) (dr/ec) 375, 500 naproxen sodium oral tablet 0 (Aleve) naproxen sodium oral tablet 75 naproxen sodium oral tablet 550 (Anaprox DS) oxaprozin oral tablet 600 (Daypro) piroxicam oral capsule 0, 0 (Feldene) salsalate oral tablet 500, 750 (Disalcid) sulindac oral tablet 50, 00 tolmetin oral capsule 400 tolmetin oral tablet 00, 600 tri-buffered aspirin oral tablet 35 VOLTAREN TOPICAL GEL % PA Anesthetics Local Anesthetics CIDALEAZE TOPICAL CREAM 3 % glydo mucous membrane jelly in applicator % LIDO BDK KIT GAUGE X "-.5 %-.5 % lidocaine hcl mucous membrane jelly % lidocaine hcl mucous membrane solution 4 % (40 /ml) lidocaine hcl topical cream 3 % (CidalEaze) lidocaine hcl-hydrocortison ac rectal kit 3- % (7 gram) lidocaine hcl-hydrocortison ac topical cream % 8 Geisinger Family 08 Formulary Effective: February, 08

18 lidocaine topical adhesive (Lidoderm) PA; QL (90 per 30 days) patch,medicated 5 % lidocaine topical ointment 5 % lidocaine viscous mucous membrane solution % lidocaine-hydrocortisone-aloe rectal kit 3-.5 % (7 gram) lidocaine-prilocaine topical cream.5-.5 % lidocaine-prilocaine topical kit.5-.5 % (AgonEaze) oral pain relief mucous membrane gel 0 % pinnacaine otic (ear) drops 0 % Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) 333 buprenorphine hcl sublingual tablet, PA 8 buprenorphine-naloxone sublingual tablet PA -0.5, 8- buproban oral tablet extended release hr 50 bupropion hcl (smoking deter) oral tablet (Zyban) extended release hr 50 disulfiram oral tablet 50, 500 (Antabuse) naloxone injection syringe 0.4 /ml, /ml naltrexone oral tablet 50 NARCAN NASAL SPRAY,NON- AEROSOL MG/ACTUATION, 4 MG/ACTUATION nicorelief buccal gum, 4 nicotine (polacrilex) buccal gum, 4 nicotine (polacrilex) buccal lozenge, 4 nicotine transdermal patch 4 hour 4 /4 hr, /4 hr, 7 /4 hr SUBOXONE SUBLINGUAL FILM -3 MG, -0.5 MG, 4- MG, 8- MG (Nicorelief) (Nicorette) (Nicoderm CQ) PA 9 Geisinger Family 08 Formulary Effective: February, 08

19 VIVITROL INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 380 MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.5, 0.5, - (Xanax) QL (4 per day) alprazolam oral tablet (Xanax) QL ( per day) alprazolam oral tablet extended release 4 (Xanax XR) QL (4 per day) hr 0.5, alprazolam oral tablet extended release 4 (Xanax XR) QL ( per day) hr, 3 alprazolam oral tablet,disintegrating 0.5 QL (4 per day), 0.5, alprazolam oral tablet,disintegrating QL ( per day) chlordiazepoxide hcl oral capsule 0, 5, 5 QL (4 per day) clonazepam oral tablet 0.5, (Klonopin) QL (0 per day) clonazepam oral tablet (Klonopin) QL (0 per day) clonazepam oral tablet,disintegrating QL (0 per day) 0.5, 0.5, 0.5, clonazepam oral tablet,disintegrating QL (0 per day) diazepam intensol oral concentrate 5 QL (8 per day) /ml diazepam oral solution 5 /5 ml ( QL (40 per day) /ml) diazepam oral tablet 0,, 5 (Valium) QL (4 per day) diazepam rectal kit , 5- (Diastat AcuDial) QL (5 per 30 days) diazepam rectal kit.5 (Diastat) QL (5 per 30 days) flurazepam oral capsule 5 QL ( per day) flurazepam oral capsule 30 QL ( per day) lorazepam oral concentrate /ml (Lorazepam Intensol) QL (5 per day) lorazepam oral tablet 0.5, (Ativan) QL (0 per day) lorazepam oral tablet (Ativan) QL (5 per day) oxazepam oral capsule 0, 5, 30 QL (4 per day) temazepam oral capsule 5,.5, (Restoril) QL ( per day) 30, 7.5 triazolam oral tablet 0.5 QL (4 per day) triazolam oral tablet 0.5 (Halcion) QL ( per day) 0 Geisinger Family 08 Formulary Effective: February, 08

20 Antibacterials Aminoglycosides neomycin oral tablet 500 TOBI INHALATION SOLUTION FOR PA; NEBULIZATION 300 MG/5 ML tobramycin in 0.5 % nacl inhalation (Tobi) PA solution for nebulization 300 /5 ml Antibacterials, Miscellaneous clindamycin hcl oral capsule 50, 300 (Cleocin HCl), 75 clindamycin palmitate hcl oral recon soln (Cleocin Pediatric) 75 /5 ml DALVANCE INTRAVENOUS SOLUTION 500 MG PA linezolid oral suspension for reconstitution (Zyvox) PA 00 /5 ml linezolid oral tablet 600 (Zyvox) QL ( per day) methenamine hippurate oral tablet gram (Hiprex) methenamine mandelate oral tablet 0.5 g, gram METRONIDAZOLE (BULK) POWDER metronidazole oral capsule 375 (Flagyl) metronidazole oral tablet 50, 500 (Flagyl) nitrofurantoin macrocrystal oral capsule (Macrodantin) 00, 5, 50 nitrofurantoin monohyd/m-cryst oral capsule 00 (Macrobid) nitrofurantoin oral suspension 5 /5 ml (Furadantin) SIVEXTRO INTRAVENOUS RECON PA SOLN 00 MG SIVEXTRO ORAL TABLET 00 MG PA trimethoprim oral tablet 00 vancomycin in dextrose 5 % intravenous piggyback gram/00 ml vancomycin intravenous recon soln 5 gram vancomycin oral capsule 5, 50 (Vancocin) XIFAXAN ORAL TABLET 00 MG PA XIFAXAN ORAL TABLET 550 MG PA; QL (60 per 30 days) ZYVOX ORAL SUSPENSION FOR PA RECONSTITUTION 00 MG/5 ML ZYVOX ORAL TABLET 600 MG PA; QL ( per day) Cephalosporins Geisinger Family 08 Formulary Effective: February, 08

21 AVYCAZ INTRAVENOUS RECON SOLN.5 GRAM cefaclor oral capsule 50, 500 cefaclor oral suspension for reconstitution 5 /5 ml, 50 /5 ml, 375 /5 ml cefaclor oral tablet extended release hr 500 cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 50 /5 ml, 500 /5 ml cefadroxil oral tablet gram cefdinir oral capsule 300 cefdinir oral suspension for reconstitution 5 /5 ml, 50 /5 ml cefpodoxime oral suspension for reconstitution 00 /5 ml, 50 /5 ml cefpodoxime oral tablet 00, 00 cefuroxime axetil oral tablet 50, 500 cephalexin oral capsule 50, 500 (Keflex) cephalexin oral suspension for reconstitution 5 /5 ml, 50 /5 ml cephalexin oral tablet 50, 500 Macrolides azithromycin oral packet gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 00 /5 ml, 00 /5 ml azithromycin oral tablet 50, 500, (Zithromax) 600 clarithromycin oral suspension for reconstitution 5 /5 ml, 50 /5 ml clarithromycin oral tablet 50, 500 e.e.s. 400 oral tablet 400 ERYPED 00 ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML ERYPED 400 ORAL SUSPENSION FOR RECONSTITUTION 400 MG/5 ML ery-tab oral tablet,delayed release (dr/ec) 50, 500 erythrocin (as stearate) oral tablet 50 erythromycin ethylsuccinate oral (E.E.S. Granules) suspension for reconstitution 00 /5 ml PA Geisinger Family 08 Formulary Effective: February, 08

22 erythromycin ethylsuccinate oral tablet (E.E.S. 400) 400 erythromycin oral capsule,delayed release(dr/ec) 50 erythromycin oral tablet 50, 500 erythromycin-sulfisoxazole oral suspension for reconstitution /5 ml Penicillins amoxicillin oral capsule 50, 500 amoxicillin oral suspension for reconstitution 5 /5 ml, 00 /5 ml, 50 /5 ml, 400 /5 ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet,chewable 5, 50, 400 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml amoxicillin-pot clavulanate oral (Augmentin) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral (Augmentin ES-600) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral tablet 50-5 amoxicillin-pot clavulanate oral tablet (Augmentin) 500-5, amoxicillin-pot clavulanate oral tablet (Augmentin XR) extended release hr, amoxicillin-pot clavulanate oral tablet,chewable , ampicillin oral capsule 50, 500 ampicillin oral suspension for reconstitution 5 /5 ml, 50 /5 ml dicloxacillin oral capsule 50, 500 penicillin v potassium oral recon soln 5 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, 500 Quinolones ciprofloxacin hcl oral tablet 00, Geisinger Family 08 Formulary Effective: February, 08

23 ciprofloxacin hcl oral tablet 50, 500 (Cipro) ciprofloxacin oral (Cipro) suspension,microcapsule recon 50 /5 ml, 500 /5 ml levofloxacin oral solution 50 /0 ml levofloxacin oral tablet 50, 500, (Levaquin) 750 ofloxacin oral tablet 00, 300, 400 Sulfonamides sulfamethoxazole-trimethoprim oral (Sulfatrim) suspension /5 ml sulfamethoxazole-trimethoprim oral tablet (Bactrim) sulfamethoxazole-trimethoprim oral tablet (Bactrim DS) sulfasalazine oral tablet 500 (Azulfidine) sulfasalazine oral tablet,delayed release (Azulfidine EN-tabs) (dr/ec) 500 sulfatrim oral suspension /5 ml Tetracyclines doxycycline hyclate oral capsule 00, (Morgidox) 50 doxycycline hyclate oral tablet 00, 0 doxycycline hyclate oral tablet 50, 75 (Acticlate) doxycycline monohydrate oral capsule 00 (Mondoxyne NL), 50 doxycycline monohydrate oral suspension (Vibramycin) for reconstitution 5 /5 ml doxycycline monohydrate oral tablet 00 (Avidoxy) doxycycline monohydrate oral tablet 50, 50, 75 minocycline oral capsule 00, 50, (Minocin) 75 minocycline oral tablet 00, 50, 75 TETRACYCLINE HCL (BULK) POWDER tetracycline oral capsule 50, 500 Anticancer Agents 4 Geisinger Family 08 Formulary Effective: February, 08

24 Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 00 MG ADCETRIS INTRAVENOUS RECON SOLN 50 MG PA - PA AFINITOR ORAL TABLET 0 MG,.5 MG, 5 MG, 7.5 MG ALECENSA ORAL CAPSULE 50 MG PA; QL (8 per day) ALIQOPA INTRAVENOUS RECON PA SOLN 60 MG ALKERAN ORAL TABLET MG ALUNBRIG ORAL TABLET 30 MG PA; ; QL (6 per day) anastrozole oral tablet (Arimidex) ARRANON INTRAVENOUS SOLUTION 50 MG/50 ML ARZERRA INTRAVENOUS SOLUTION,000 MG/50 ML, 00 MG/5 ML AVASTIN INTRAVENOUS SOLUTION 5 MG/ML - BAVENCIO INTRAVENOUS PA SOLUTION 0 MG/ML BELEODAQ INTRAVENOUS RECON PA SOLN 500 MG BESPONSA INTRAVENOUS RECON PA SOLN 0.9 MG (0.5 MG/ML INITIAL) bexarotene oral capsule 75 (Targretin) PA bicalutamide oral tablet 50 (Casodex) BLINCYTO INTRAVENOUS KIT 35 PA MCG BOSULIF ORAL TABLET 00 MG, 400 PA; MG BOSULIF ORAL TABLET 500 MG PA; ; QL ( per day) CABOMETYX ORAL TABLET 0 MG, PA; QL ( per day) 40 MG, 60 MG capecitabine oral tablet 50, 500 (Xeloda) PA PA 5 Geisinger Family 08 Formulary Effective: February, 08

25 CAPRELSA ORAL TABLET 00 MG, PA; 300 MG carboplatin intravenous solution 0 /ml clofarabine intravenous solution 0 /0 (Clolar) PA ml CLOLAR INTRAVENOUS SOLUTION PA 0 MG/0 ML COMETRIQ ORAL CAPSULE 00 PA; MG/DAY(80 MG X-0 MG X), 40 MG/DAY(80 MG X-0 MG X3), 60 MG/DAY (0 MG X 3/DAY) COTELLIC ORAL TABLET 0 MG PA; QL (3 per day) CYCLOPHOSPHAMIDE ORAL CAPSULE 5 MG, 50 MG cyclophosphamide oral tablet 5, 50 CYRAMZA INTRAVENOUS PA SOLUTION 0 MG/ML DACOGEN INTRAVENOUS RECON PA SOLN 50 MG DARZALEX INTRAVENOUS PA SOLUTION 0 MG/ML EMCYT ORAL CAPSULE 40 MG EMPLICITI INTRAVENOUS RECON PA SOLN 300 MG, 400 MG ERIVEDGE ORAL CAPSULE 50 MG PA; ; QL (30 per 30 days) ERWINAZE INJECTION RECON SOLN PA 0,000 UNIT etoposide oral capsule 50 exemestane oral tablet 5 (Aromasin) FARYDAK ORAL CAPSULE 0 MG, 5 PA; QL (6 per days) MG, 0 MG flutamide oral capsule 5 GAZYVA INTRAVENOUS SOLUTION PA,000 MG/40 ML - GILOTRIF ORAL TABLET 0 MG, 30 PA; QL (30 per 30 days) MG, 40 MG GLEEVEC ORAL TABLET 00 MG, 400 PA MG GLEOSTINE ORAL CAPSULE 0 MG, 00 MG, 40 MG, 5 MG 6 Geisinger Family 08 Formulary Effective: February, 08

26 HALAVEN INTRAVENOUS PA SOLUTION MG/ ML (0.5 MG/ML) HEXALEN ORAL CAPSULE 50 MG HYCAMTIN ORAL CAPSULE 0.5 MG, MG hydroxyurea oral capsule 500 (Hydrea) IBRANCE ORAL CAPSULE 00 MG, 5 MG, 75 MG PA; ; QL ( per 8 days) ICLUSIG ORAL TABLET 5 MG, 45 PA MG IDHIFA ORAL TABLET 00 MG, 50 PA; QL ( per day) MG imatinib oral tablet 00, 400 (Gleevec) PA IMBRUVICA ORAL CAPSULE 40 MG PA; ; QL (4 per day) IMFINZI INTRAVENOUS SOLUTION PA 50 MG/ML IMLYGIC INJECTION SUSPENSION PA 0EXP6 ( MILLION) PFU/ML, 0EXP8 (00 MILLION) PFU/ML INLYTA ORAL TABLET MG, 5 MG PA; ISTODAX INTRAVENOUS RECON PA SOLN 0 MG/ ML IXEMPRA INTRAVENOUS RECON PA SOLN 5 MG, 45 MG JAKAFI ORAL TABLET 0 MG, 5 MG, 0 MG, 5 MG, 5 MG PA; ; QL (60 per 30 days) JEVTANA INTRAVENOUS SOLUTION 0 MG/ML (FIRST DILUTION) PA KADCYLA INTRAVENOUS RECON SOLN 00 MG, 60 MG KEYTRUDA INTRAVENOUS RECON SOLN 50 MG KEYTRUDA INTRAVENOUS SOLUTION 5 MG/ML KISQALI FEMARA CO-PACK ORAL TABLET 00 MG/DAY(00 MG X )-.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 400 MG/DAY(00 MG X )-.5 MG PA - PA PA PA; ; QL (49 per 8 days) PA; ; QL (70 per 8 days) 7 Geisinger Family 08 Formulary Effective: February, 08

27 KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY(00 MG X 3)-.5 MG KISQALI ORAL TABLET 00 MG/DAY (00 MG X ) KISQALI ORAL TABLET 400 MG/DAY (00 MG X ) KISQALI ORAL TABLET 600 MG/DAY (00 MG X 3) KYMRIAH INTRAVENOUS SUSPENSION KYPROLIS INTRAVENOUS RECON SOLN 30 MG, 60 MG LARTRUVO INTRAVENOUS SOLUTION 0 MG/ML LENVIMA ORAL CAPSULE 0 MG/DAY (0 MG X /DAY), 4 MG/DAY(0 MG X -4 MG X ), 8 MG/DAY (0 MG X -4 MG X), 0 MG/DAY (0 MG X ), 4 MG/DAY(0 MG X -4 MG X ), 8 MG/DAY (4 MG X ) PA; ; QL (9 per 8 days) PA; ; QL ( per 8 days) PA; ; QL (4 per 8 days) PA; ; QL (63 per 8 days) PA PA PA PA; QL (3 per day) letrozole oral tablet.5 (Femara) PA Required for age less than 44 years; AGE (Min 44 Years) LEUKERAN ORAL TABLET MG lomustine oral capsule 0, 00, 40 (Gleostine) LONSURF ORAL TABLET MG, MG PA LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT.5 MG,.5 MG LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG Geisinger Family 08 Formulary Effective: February, 08

28 LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG - LYNPARZA ORAL CAPSULE 50 MG PA; QL (448 per 8 days) LYNPARZA ORAL TABLET 00 MG, PA; QL (4 per day) 50 MG LYSODREN ORAL TABLET 500 MG MARQIBO INTRAVENOUS KIT 5 PA MG/3 ML(0.6 MG/ML) FINAL MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 0, 40 MEKINIST ORAL TABLET 0.5 MG PA; ; QL (90 per 30 days) MEKINIST ORAL TABLET MG PA; ; QL (30 per 30 days) melphalan oral tablet (Alkeran) mercaptopurine oral tablet 50 methotrexate sodium (pf) injection solution 5 /ml methotrexate sodium injection solution 5 /ml methotrexate sodium oral tablet.5 MYLERAN ORAL TABLET MG NERLYNX ORAL TABLET 40 MG PA; QL (6 per day) NEXAVAR ORAL TABLET 00 MG PA; ; QL (0 per 30 days) NILANDRON ORAL TABLET 50 MG nilutamide oral tablet 50 (Nilandron) NINLARO ORAL CAPSULE.3 MG, 3 MG, 4 MG PA; ; QL (3 per 8 days) ODOMZO ORAL CAPSULE 00 MG PA; QL ( per day) ONIVYDE INTRAVENOUS PA DISPERSION 4.3 MG/ML OPDIVO INTRAVENOUS SOLUTION 00 MG/0 ML, 40 MG/4 ML PA oxaliplatin intravenous recon soln 00, 50-9 Geisinger Family 08 Formulary Effective: February, 08

29 oxaliplatin intravenous solution 00 /0 ml, 50 /0 ml (5 /ml) PERJETA INTRAVENOUS SOLUTION 40 MG/4 ML (30 MG/ML) - - PA; POMALYST ORAL CAPSULE MG, MG, 3 MG, 4 MG PORTRAZZA INTRAVENOUS PA SOLUTION 800 MG/50 ML (6 MG/ML) REVLIMID ORAL CAPSULE 0 MG, 5 PA; ; QL MG,.5 MG, 0 MG, 5 MG, 5 MG (30 per 30 days) RITUXAN HYCELA SUBCUTANEOUS PA SOLUTION 400 MG/.7 ML (0 - MG/ML), 600 MG/3.4 ML (0 MG/ML) RITUXAN INTRAVENOUS PA CONCENTRATE 0 MG/ML - RUBRACA ORAL TABLET 00 MG, PA; ; QL 300 MG (4 per day) RUBRACA ORAL TABLET 50 MG PA; QL (4 per day) RYDAPT ORAL CAPSULE 5 MG PA; ; QL (56 per days) SPRYCEL ORAL TABLET 00 MG, 40 PA MG, 0 MG, 50 MG, 70 MG, 80 MG STIVARGA ORAL TABLET 40 MG PA; ; QL (0 per 30 days) SUTENT ORAL CAPSULE.5 MG, 5 PA; MG, 37.5 MG, 50 MG SYLVANT INTRAVENOUS RECON PA SOLN 00 MG, 400 MG SYNRIBO SUBCUTANEOUS RECON PA SOLN 3.5 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG PA; ; QL (0 per 30 days) TAGRISSO ORAL TABLET 40 MG, 80 MG PA; ; QL ( per day) tamoxifen oral tablet 0, 0 TARCEVA ORAL TABLET 00 MG, 50 MG PA NSO; ; QL ( per day) 0 Geisinger Family 08 Formulary Effective: February, 08

30 TARCEVA ORAL TABLET 5 MG PA NSO; ; QL (3 per day) TARGRETIN ORAL CAPSULE 75 MG PA TASIGNA ORAL CAPSULE 50 MG, PA 00 MG TECENTRIQ INTRAVENOUS SOLUTION,00 MG/0 ML (60 MG/ML) TEMODAR ORAL CAPSULE 00 MG, 40 MG, 80 MG, 50 MG, 5 MG TEMODAR ORAL CAPSULE 0 MG temozolomide oral capsule 00, 40, 80, 0, 50, 5 (Temodar) TEPADINA INJECTION RECON SOLN PA 00 MG, 5 MG TORISEL INTRAVENOUS RECON PA SOLN 30 MG/3 ML (0 MG/ML) (FIRST) tretinoin (chemotherapy) oral capsule 0 TYKERB ORAL TABLET 50 MG PA; UNITUXIN INTRAVENOUS SOLUTION 3.5 MG/ML PA VECTIBIX INTRAVENOUS SOLUTION 00 MG/5 ML (0 MG/ML), 400 MG/0 ML (0 MG/ML) VELCADE INJECTION RECON SOLN 3.5 MG PA VENCLEXTA ORAL TABLET 0 MG PA; QL ( per day) VENCLEXTA ORAL TABLET 00 MG PA; QL (4 per day) VENCLEXTA ORAL TABLET 50 MG PA; QL ( per day) VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 0 MG-50 MG- 00 MG PA PA PA; QL (4 per 8 days) VOTRIENT ORAL TABLET 00 MG PA; ; QL (0 per 30 days) XALKORI ORAL CAPSULE 00 MG, 50 MG PA; ; QL (60 per 30 days) XELODA ORAL TABLET 50 MG, 500 MG YERVOY INTRAVENOUS SOLUTION 00 MG/40 ML (5 MG/ML), 50 MG/0 ML (5 MG/ML) PA - Geisinger Family 08 Formulary Effective: February, 08

31 YONDELIS INTRAVENOUS RECON PA SOLN MG ZALTRAP INTRAVENOUS SOLUTION PA 00 MG/4 ML (5 MG/ML), 00 MG/8 ML (5 MG/ML) - ZEJULA ORAL CAPSULE 00 MG PA; ; QL (3 per day) ZELBORAF ORAL TABLET 40 MG PA; ; QL (40 per 30 days) ZEVALIN (Y-90) INTRAVENOUS KIT PA 3. MG/ ML ZOLINZA ORAL CAPSULE 00 MG PA ZYKADIA ORAL CAPSULE 50 MG PA; ; QL (5 per day) ZYTIGA ORAL TABLET 50 MG PA; ; QL (0 per 30 days) ZYTIGA ORAL TABLET 500 MG PA; QL (60 per 30 days) Anticholinergic Agents Antimuscarinics/Antispasmodics propantheline oral tablet 5 Anticonvulsants Anticonvulsants BANZEL ORAL SUSPENSION 40 PA MG/ML BANZEL ORAL TABLET 00 MG, 400 MG PA carbamazepine oral capsule, er (Carbatrol) multiphase hr 00, 00, 300 carbamazepine oral suspension 00 /5 (Tegretol) ml carbamazepine oral tablet 00 (Epitol) carbamazepine oral tablet extended (Tegretol XR) release hr 00, 00, 400 carbamazepine oral tablet,chewable 00 DILANTIN ORAL CAPSULE 30 MG divalproex oral capsule, delayed rel (Depakote Sprinkles) sprinkle 5 divalproex oral tablet extended release 4 (Depakote ER) hr 50, 500 divalproex oral tablet,delayed release (dr/ec) 5, 50, 500 (Depakote) Geisinger Family 08 Formulary Effective: February, 08

32 epitol oral tablet 00 ethosuximide oral solution 50 /5 ml (Zarontin) felbamate oral suspension 600 /5 ml (Felbatol) felbamate oral tablet 400, 600 (Felbatol) gabapentin oral capsule 00, 300, (Neurontin) 400 gabapentin oral solution 50 /5 ml (Neurontin) gabapentin oral tablet 600, 800 (Neurontin) GABITRIL ORAL TABLET MG, 6 MG lamotrigine oral tablet 00, 50, (Lamictal) 00, 5 lamotrigine oral tablet, chewable (Lamictal) dispersible 5, 5 lamotrigine oral tablets,dose pack 5 (Lamictal Starter (Blue) (35) Kit) levetiracetam oral solution 00 /ml (Keppra) levetiracetam oral tablet,000, 50 (Keppra), 500, 750 levetiracetam oral tablet extended release 4 hr 500, 750 (Keppra XR) LYRICA ORAL CAPSULE 00 MG, 50 PA; QL (90 per 30 days) MG, 00 MG, 5 MG, 50 MG, 75 MG LYRICA ORAL CAPSULE 5 MG, 300 MG PA; QL (60 per 30 days) oxcarbazepine oral suspension 300 /5 ml (60 /ml) (Trileptal) oxcarbazepine oral tablet 50, 300, (Trileptal) 600 phenobarbital oral elixir 0 /5 ml (4 /ml) phenobarbital oral tablet 00, 5, 6., 30, 3.4, 60, 64.8, 97. phenytoin oral suspension 5 /5 ml (Dilantin-5) phenytoin oral tablet,chewable 50 (Dilantin Infatabs) phenytoin sodium extended oral capsule (Dilantin Extended) 00 phenytoin sodium extended oral capsule (Phenytek) 00, 300 primidone oral tablet 50, 50 (Mysoline) tiagabine oral tablet, 4 (Gabitril) 3 Geisinger Family 08 Formulary Effective: February, 08

33 topiragen oral tablet 00, 00, 5, 50 topiramate oral capsule, sprinkle 5, 5 topiramate oral capsule,sprinkle,er 4hr 00, 50, 00, 5, 50 topiramate oral tablet 00, 00, 5, 50 valproic acid (as sodium salt) oral solution 50 /5 ml (Topamax) (Qudexy XR) PA (Topamax) (Depakene) valproic acid oral capsule 50 (Depakene) zonisamide oral capsule 00, 5 (Zonegran) zonisamide oral capsule 50 Antidementia Agents Antidementia Agents donepezil oral tablet 0, 5 (Aricept) PA Required for age less than 8 years; AGE (Min 8 Years) donepezil oral tablet,disintegrating 0, 5 PA Required for age less than 8 years; AGE (Min 8 Years) memantine oral solution /ml AGE (Min 8 Years) memantine oral tablet 0, 5 (Namenda) AGE (Min 8 Years) NAMENDA ORAL SOLUTION MG/ML PA Required for age less than 8 years; AGE (Min 8 Years) NAMENDA ORAL TABLET 0 MG, 5 MG rivastigmine tartrate oral capsule.5, 3, 4.5, 6 Antidepressants Antidepressants amitriptyline oral tablet 0, 00, 50, 5, 50, 75 amitriptyline-chlordiazepoxide oral tablet.5-5, 5-0 amoxapine oral tablet 00, 50, 5, 50 budeprion sr oral tablet extended release hr 50 bupropion hcl oral tablet 00, 75 PA Required for age less than 8 years; AGE (Min 8 Years) PA Required for age less than 8 years; AGE (Min 8 Years) 4 Geisinger Family 08 Formulary Effective: February, 08

34 bupropion hcl oral tablet extended release (Wellbutrin SR) hr 00, 50, 00 bupropion hcl oral tablet extended release 4 hr 50, 300 (Wellbutrin XL) citalopram oral solution 0 /5 ml QL (0 per day) citalopram oral tablet 0, 0 (Celexa) QL (.5 per day) citalopram oral tablet 40 (Celexa) QL ( per day) clomipramine oral capsule 5, 50, (Anafranil) 75 desipramine oral tablet 0, 5 (Norpramin) desipramine oral tablet 00, 50, 50, 75 desvenlafaxine succinate oral tablet (Pristiq) QL ( per day) extended release 4 hr 00, 5, 50 doxepin oral capsule 0, 00, 50, 5, 50, 75 doxepin oral concentrate 0 /ml duloxetine oral capsule,delayed (Cymbalta) QL ( per day) release(dr/ec) 0, 60 duloxetine oral capsule,delayed (Cymbalta) QL ( per day) release(dr/ec) 30 escitalopram oxalate oral solution 5 /5 QL (0 per day) ml escitalopram oxalate oral tablet 0, 0 (Lexapro) QL ( per day), 5 fluoxetine oral capsule 0 (Prozac) QL (3 per day) fluoxetine oral capsule 0 (Prozac) QL (4 per day) fluoxetine oral capsule 40 (Prozac) QL ( per day) fluoxetine oral solution 0 /5 ml (4 QL (0 per day) /ml) fluoxetine oral tablet 0 (Sarafem) QL (3 per day) fluoxetine oral tablet 0 (Sarafem) QL (4 per day) FLUOXETINE ORAL TABLET 60 MG QL ( per day) fluvoxamine oral tablet 00 QL (3 per day) fluvoxamine oral tablet 5 QL ( per day) fluvoxamine oral tablet 50 QL (.5 per day) imipramine hcl oral tablet 0, 5, (Tofranil) 50 imipramine pamoate oral capsule 00, 5, 50, 75 mirtazapine oral tablet 5, 30, 45 (Remeron) 5 Geisinger Family 08 Formulary Effective: February, 08

35 mirtazapine oral tablet 7.5 mirtazapine oral tablet,disintegrating 5 (Remeron SolTab), 30, 45 nefazodone oral tablet 00, 50, 00, 50, 50 nortriptyline oral capsule 0, 5, (Pamelor) 50, 75 nortriptyline oral solution 0 /5 ml paroxetine hcl oral tablet 0, 0, (Paxil) QL ( per day) 40 paroxetine hcl oral tablet 30 (Paxil) QL ( per day) paroxetine hcl oral tablet extended release (Paxil CR) QL ( per day) 4 hr.5 paroxetine hcl oral tablet extended release (Paxil CR) QL ( per day) 4 hr 5, 37.5 perphenazine-amitriptyline oral tablet - 0, -5, 4-0, 4-5, 4-50 sertraline oral concentrate 0 /ml (Zoloft) QL (0 per day) sertraline oral tablet 00 (Zoloft) QL ( per day) sertraline oral tablet 5, 50 (Zoloft) QL (.5 per day) trazodone oral tablet 00, 50, 300, 50 venlafaxine oral capsule,extended release (Effexor XR) QL ( per day) 4hr 50 venlafaxine oral capsule,extended release (Effexor XR) QL ( per day) 4hr 37.5 venlafaxine oral capsule,extended release (Effexor XR) QL (3 per day) 4hr 75 venlafaxine oral tablet 00, 5, 37.5, 50, 75 QL (3 per day) Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose oral tablet 00, 5, 50 GLYXAMBI ORAL TABLET 0-5 MG, 5-5 MG INVOKAMET ORAL TABLET 50-,000 MG, MG, 50-,000 MG, MG INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 4HR 50-,000 MG, MG, 50-,000 MG, MG (Precose) ST; QL ( per day) ST; QL ( per day) ST; QL ( per day) 6 Geisinger Family 08 Formulary Effective: February, 08

36 INVOKANA ORAL TABLET 00 MG, ST; QL ( per day) 300 MG JARDIANCE ORAL TABLET 0 MG, 5 ST; QL ( per day) MG JENTADUETO ORAL TABLET.5- ST; QL ( per day),000 MG, MG, MG JENTADUETO XR ORAL TABLET, IR - ST; QL ( per day) ER, BIPHASIC 4HR.5-,000 MG JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 4HR 5-,000 MG ST; QL ( per day) metformin oral tablet,000, 500, (Glucophage) 850 metformin oral tablet extended release 4 (Glucophage XR) hr 500, 750 nateglinide oral tablet 0, 60 (Starlix) pioglitazone oral tablet 5, 30, 45 (Actos) repaglinide oral tablet 0.5 repaglinide oral tablet, (Prandin) SYNJARDY ORAL TABLET.5-,000 ST; QL ( per day) MG, MG, 5-,000 MG, MG SYNJARDY XR ORAL TABLET, IR - ST; QL ( per day) ER, BIPHASIC 4HR 0-,000 MG, 5-,000 MG SYNJARDY XR ORAL TABLET, IR - ST; QL ( per day) ER, BIPHASIC 4HR.5-,000 MG, 5-,000 MG TANZEUM SUBCUTANEOUS PEN ST; QL (4 per 8 days) INJECTOR 30 MG/0.5 ML, 50 MG/0.5 ML TRADJENTA ORAL TABLET 5 MG ST; QL ( per day) VICTOZA SUBCUTANEOUS PEN ST; QL (9 per 30 days) INJECTOR 0.6 MG/0. ML (8 MG/3 ML) Insulins BASAGLAR KWIKPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (3 ML) LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (3 ML) LANTUS SUBCUTANEOUS SOLUTION 00 UNIT/ML 7 Geisinger Family 08 Formulary Effective: February, 08

37 LEVEMIR FLEXTOUCH SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (3 ML) LEVEMIR SUBCUTANEOUS SOLUTION 00 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION 00 UNIT/ML (70-30) NOVOLIN N SUBCUTANEOUS SUSPENSION 00 UNIT/ML NOVOLIN R INJECTION SOLUTION 00 UNIT/ML NOVOLOG FLEXPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML NOVOLOG MIX FLEXPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (70-30) NOVOLOG MIX SUBCUTANEOUS SOLUTION 00 UNIT/ML (70-30) NOVOLOG PENFILL SUBCUTANEOUS CARTRIDGE 00 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 00 UNIT/ML TOUJEO SOLOSTAR AGE (Min 8 Years) SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (.5 ML) TRESIBA FLEXTOUCH U-00 SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (3 ML) TRESIBA FLEXTOUCH U-00 SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (3 ML) XULTOPHY 00/3.6 SUBCUTANEOUS ST; QL (5 per 30 days) INSULIN PEN 00 UNIT-3.6 MG /ML (3 ML) Sulfonylureas glimepiride oral tablet,, 4 (Amaryl) glipizide oral tablet 0, 5 (Glucotrol) glipizide oral tablet extended release 4hr (Glucotrol XL) 0,.5, 5 glipizide-metformin oral tablet.5-50,.5-500, Geisinger Family 08 Formulary Effective: February, 08

38 glyburide micronized oral tablet.5, 3, 6 glyburide oral tablet.5,.5, 5 glyburide-metformin oral tablet.5-50 glyburide-metformin oral tablet.5-500, Antifungals Antifungals 3-day vaginal vaginal cream % af topical aerosol powder % antifungal (terbinafine) topical cream % antifungal (tolnaftate) topical powder % anti-fungal topical powder % baza antifungal topical cream % clotrimazole mucous membrane troche 0 clotrimazole topical cream % (Glynase) (Glucovance) (Antifungal (clotrimazole)) clotrimazole topical solution % clotrimazole vaginal cream % (Clotrimazole-7) clotrimazole vaginal tablet 00 clotrimazole-7 vaginal cream % clotrimazole-betamethasone topical cream (Lotrisone) % clotrimazole-betamethasone topical lotion % CRESEMBA INTRAVENOUS RECON SOLN 37 MG econazole topical cream % ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 00 MG, 50 MG fluconazole oral suspension for (Diflucan) reconstitution 0 /ml, 40 /ml fluconazole oral tablet 00, 50, (Diflucan) 00, 50 foot and sneaker topical aerosol powder % formula 3 topical solution % GRIFULVIN V ORAL TABLET 500 MG PA PA 9 Geisinger Family 08 Formulary Effective: February, 08

39 griseofulvin microsize oral suspension 5 /5 ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 5 (Gris-PEG, 50 (ultramicrosize)) itraconazole oral capsule 00 (Sporanox) PA jock itch (terbinafine) topical cream % ketoconazole oral tablet 00 ketoconazole topical cream % ketoconazole topical foam % (Extina) ketoconazole topical shampoo % (Nizoral) MICONAZOLE NITRATE (BULK) POWDER miconazole nitrate topical aerosol powder (Athlete's Foot) % miconazole-3 vaginal kit 00 - % (9 gram) miconazole-3 vaginal suppository 00 miconazorb af topical powder % myco nail a topical solution 5 % nyamyc topical powder 00,000 unit/gram nyata topical powder 00,000 unit/gram NYSTATIN (BULK) POWDER BILLION UNIT nystatin oral powder 50 million unit nystatin oral suspension 00,000 unit/ml nystatin oral tablet 500,000 unit nystatin topical cream 00,000 unit/gram nystatin topical ointment 00,000 unit/gram nystatin topical powder 00,000 unit/gram (Nyamyc) nystatin-triamcinolone topical cream 00, unit/g-% nystatin-triamcinolone topical ointment 00, unit/gram-% nystop topical powder 00,000 unit/gram odor control foot-sneaker topical aerosol powder % pedi-dri topical powder 00,000 unit/gram terbinafine hcl oral tablet 50 (Lamisil) terbinafine hcl topical cream % (Antifungal (terbinafine)) tolnaftate topical aerosol powder % (AF) 30 Geisinger Family 08 Formulary Effective: February, 08

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