Download diagnosis based formulary 2009

 DIAGNOSIS BASED
FORMULARY
2009
DIAGNOSIS BASED FORMULARY – 2009
Introduction
HospiScript Services is pleased to provide this Diagnosis Based Formulary (DBF) to serve as
a useful tool for physicians, nurses, and pharmacists in selecting the most appropriate and
cost-effective therapies that best meet the needs of the patient. This formulary reference
document lists the medications both alphabetically by generic drug name AND tiered by
symptom and therapeutic class.
The purpose of the system supported DBF is two-fold:
1. It serves as an educational tool that guides hospice clinical staff in medication
management of symptoms based on the patient’s terminal diagnosis.
2. It provides electronic safety nets to prevent unrelated medications from being billed to
the hospice.
How to Read the Diagnosis Based Formulary (DBF)
The DBF is made up of two components. The Base List includes medications that manage
symptoms common to all diagnoses, while the Diagnosis Specific Category medications are
used to manage conditions of a particular disease. Together, these two lists represent the
formulary for each terminal diagnosis. Upon admission to HospiScript, each patient is placed
on this electronically supported formulary.
(Base List + Diagnosis Specific Category = DBF)
The Base List addresses symptoms common in most terminal diagnoses and includes
medications to treat:
Agitation
Constipation
Depression
Dysphagia
Fever
Genitourinary symptoms
Infection (bacterial, viral, fungal)
Nausea & vomiting
Anorexia
Cough
Diarrhea
Dyspnes
Fluid retention
Hiccups
Insomnia
Neuropathic pain
Parkinsonism
Secretions
Xerostomia
Pruritus
Seizures
Anxiety
Delirium
Dry Eyes
Fatigue
Gastrointestinal symptoms
Hypokalemia
Muscle spasms
Pain
Respiratory (anti-inflammatory,
decongestant, humidifier)
Topicals
The Diagnosis Specific Categories include medications specific for:
Cancer
Pulmonary Disease
Stroke/Coma
Liver Disease
Neuromuscular Disease
HIV/AIDS
Failure to Thrive/Debility Unspecified (base only)
Heart Disease
Renal Disease (base only)
Dementia
The medications included in the Diagnosis Based Formulary are consistent with practice
standards in palliative care and are derived from current literature, including evidence based
information, where available. The DBF is regularly reviewed and updated by the HospiScript
Pharmacy & Therapeutics (P&T) Committee.
The Base List of medications is arranged by symptom in a tiered fashion. Under each tier, the
medications are listed by drug class and in recommended order of preference assuming there
are no specific criteria to warrant alternative drug therapy. You will note that a comment
section provides helpful information to assist the hospice team with drug selection. The
relative cost per patient day information helps guide prescribing towards cost effective choices,
when appropriate.
Many drugs are referenced as MST, or Multi-Symptom Therapy drugs. These drugs are useful
in the treatment of multiple symptoms and therefore will be listed in several sections of the
tiered DBF. It is important to become familiar with the utility of the MST drugs for several
reasons. If a drug is capable of accomplishing multiple symptom management goals, then it
should be utilized in order to reduce the number of medications that the patient must take or
have available in the home for anticipated symptoms (e.g. haloperidol for nausea and vomiting
may also be used if the patient develops agitation or delirium). In order to prevent duplication
of therapy, it is important to discontinue certain existing medications if a MST drug can replace
their therapeutic effect. This reduces the potential for adverse drug reactions associated with
polypharmacy (e.g. discontinue megestrol for appetite if prednisone is initiated for bone pain or
respiratory symptoms).
Sample Listing:
BASE LIST
BRAND
GENERIC
NAME
NAME
EXAMPLES
AGITATION/DELIRIUM
First line treatment
Haloperidol
Chlorpromazine
Haldol
Thorazine
SYMPTOM/INDICATION/
CLASSIFICATION
COMMENTS
RELATIVE
COST PER
DAY
Agitation-Typical
Antipsychotic
MST: Butyrophenone:
Avoid doses of > 2mg/day
in LTCF patients
¢
Agitation-Typical
Antipsychotic
MST: Phenothiazine:
Sedating, can cause
orthostatic hypotensionAvoid doses > 75mg/day in
LTCF
$
Formulary Exceptions
When a patient is enrolled in HospiScript, all the medication on the Base List and any
additional medications that fall under the Diagnosis Specific Category are automatically system
supported allowing these medications to be filled at the pharmacy and billed to the hospice.
You will need to contact HospiScript with any formulary exceptions. For example, if you
need to add any non-formulary medications or block any formulary medications so that
medications will be billed to the appropriate payer.
Blocking Unrelated Formulary Medications:
• If medications that are listed on the Base or Diagnosis Specific Category Lists (DBF)
are not related to a patient’s terminal diagnosis, the hospice must contact HospiScript to
inform them that those medications are not covered under the terminal diagnosis (e.g.
blocking the Base Formulary drug, furosemide, for the treatment of hypertension for a
patient who is on hospice for end-stage dementia).
Adding Non-Formulary Medications Related to the Terminal Diagnosis:
• HospiScript must also be notified by an authorized representative of the hospice if a
medication that is not on the Base or Diagnosis Specific Category Lists (DBF) is to be
paid for by hospice.
o This includes medications that are under a different disease state than the
patient’s designated diagnosis (e.g. adding risperidal which is not on the Base or
Cardiac add on formulary, for a cardiac patient).
The HospiScript Diagnosis Based Formulary (DBF) is a tool and is not intended to be a barrier
to providing timely, high quality patient care. We hope you find this information helpful. For
more in-depth information and algorithms on symptom management, refer to our GEMS
(Guidelines for the Effective Management of Symptoms) available in the client exclusive
section of our website, www.hospiscript.com.
Abbreviations Key
DBF
GEMS
MST
LTCF
SSRI
OTC
SC
TCA
BID
PRN
COPD
EPS
HP
Diagnosis Based Formulary
Guide for the Effective Management of Symptoms
Multi-Symptom Therapy
Long term care facility
Selective serotonin reuptake inhibitor
Over the counter
Subcutaneous
Tricyclic Antidepressant
Two times a day
As needed
Chronic obstructive pulmonary disease
Extrapyramidal symptoms
High potency
1-800-227-0848
www.hospiscript.com
HOSPISCRIPT DIAGNOSIS BASED FORMULARY - TIERED
The HospiScript Diagnosis Formulary is made up of two components. The Base List includes medications that manage symptoms common to all diagnoses,
while the Diagnosis Specific Category medications are used to manage conditions of a particular disease. Together, these two lists represent the formulary
for each terminal diagnosis.
The medications on the base list were selected to manage the following symptoms:
Agitation
Dry eyes
Gastrointestinal
Anorexia
Dry mouth
Hiccups
Anxiety
Dry skin
Infection
Chest congestion
Dysphagia
Insomnia
Constipation
Dyspnea
Muscle spasms
Cough
Dysuria
Nausea and Vomiting
Delirium
Fatigue
Oral candidiasis
Depression
Fever
Pain-Bone
Diarrhea
Fluid retention
Pain-Neuropathic
Pain-Nociceptive
Potassium depletion
Pruritus
Skin irritation
Terminal secretions
Topical infections
BASE LIST
GENERIC NAME
BRAND NAME EXAMPLES
SYMPTOM/INDICATION/
CLASSIFICATION
COMMENTS
RELATIVE
COST PER DAY
AGITATION/DELIRIUM
First line treatment
Haloperidol
Haldol
Agitation-Typical Antipsychotic
MST: Butyrophenone: Avoid
doses of > 2mg/day in LTCF
patients
¢
Chlorpromazine
Thorazine
Agitation-Typical Antipsychotic
MST: Phenothiazine: Sedating,
can cause orthostatic hypotensionAvoid doses > 75mg/day in LTCF
$
Phenobarbital
Luminal
Agitation-Barbiturate
MST: Used for it's sedating affects
¢
First line treatment
Prednisone
Deltasone
Anorexia-Corticosteroid
¢
Dexamethasone
Decadron
Anorexia-Corticosteroid
MST: Most cost effective
MST: More costly, less
mineralocorticoid activity/fluid
retention than prednisone.
Remeron
Anorexia-Antidepressant
MST: Beneficial if patient needs
antidepressant plus appetite
stimulation and have insomnia
ANOREXIA
$
Second line treatment
Mirtazapine
$
ANXIETY
First line treatment
Lorazepam
Ativan
Anxiety-Benzodiazepine
MST: Tablets
Alprazolam
Xanax
Anxiety-Benzodiazepine
MST: Tablets
Diazepam (No Diastat)
Valium
Anxiety-Benzodiazepine
MST: Long half-life-dose no more
frequently than q8h and avoid in
geriatrics unless bed bound
$
Clonazepam
Klonopin
Anxiety-Benzodiazepine
Also beneficial for seizure
prevention
$
Diazepam Concentrated Oral
Soln
Diazepam Intensol
Anxiety-Benzodiazepine
Lorazepam Concentrated Oral
Soln
Lorazepam Intensol
Anxiety-Benzodiazepine
$
$
Second line treatment
HSS Dx Based Tiered Formulary
MST: Intensol expensive-tablets
are well absorbed
sublingually/rectally
MST: Intensol expensive-tablets
are well absorbed
sublingually/rectally
$$$
$$$
2009
GENERIC NAME
BRAND NAME EXAMPLES
SYMPTOM/INDICATION/
CLASSIFICATION
COMMENTS
Third line treatment
Diphenhydramine
Benadryl
Anxiety-Antihistamine
MST: Use with caution in elderly
Hydroxyzine
Atarax, Vistaril
Anxiety-Antihistamine
MST: Use with caution in elderly
KlorCon
Cardiac-Potassium Supplement
Monitor potassium levels
RELATIVE
COST PER DAY
¢¢
$
HYPOKALEMIA
First line treatment
Potassium Chloride
¢
CONSTIPATION
First line treatment
Docusate Sodium
Colace
Senna/Docusate Sodium
Senokot S
Senna
Senokot
Bisacodyl
Dulcolax
Magnesium Citrate
Magnesium Hydroxide
Suspension
Second line treatment
Mag-Citrate
Not sufficient as a sole agent in
patients on opioids or who do not
have adequate fluid intake
Constipation-Stimulant and Softner Maximize dose before adding
Combination
additional agents (8 tabs/day)
Maximize dose before adding
Constipation-Stimulant Laxative
additional agents (8 tabs/day)
Maximize dose before adding
Constipation-Stimulant Laxative
additional agents (4 tabs/day)
Constipation-Osmotic Laxative
Saline Laxative
Milk of Magnesia
Constipation-Osmotic Laxative
Saline Laxative
¢
Constipation-Osmotic Laxative
More cost effective than lactulose
and as effective.Not sufficient as a
sole agent in patients on opioids
or who do not have adequate fluid
intake
$
Sorbitol 70% Soln
Sorbitol
Glycerin Suppository
Constipation-Osmotic Laxative
Don't use oral mineral oilp
aspiration
risk. Tryy Vaseline balls
if high impaction present
Saline Laxative
p
Constipation-Lubricant
Fleet Enema
¢¢
¢¢
¢
$
¢¢
$
Constipation-Osmotic Laxative
Mineral Oil Enema
Sodium Phosphate Enema
Constipation-Stool Softener
$$
$
COUGH
First line treatment
Guaifenesin Liq
¢¢
¢¢
Robitussin
Cough-Expectorant
Encourage fluid intake
Guaifenesin SR
Hydrocodone/Homatropine
Syrup
Guaifenesin/Dextromethorphan
Liq
Mucinex
Cough-Expectorant
Hycodan
Cough-Expectorant/Suppressant
Encourage fluid intake
Expectorant/Cough
Suppressant/Drying agent
Robitussin DM
Cough-Expectorant/Suppressant
Guaifenesin/Codeine Liq
Robitussin AC
Cough-Expectorant/Suppressant
Schedule V controlled substance
$$
Benzonatate
Tessalon Perles
Cough-Suppressant
Do not open or puncture capsules
$$$
Lidocaine Inj for Nebulization
Xylocaine
Cough-Suppressant
Do not use lidocaine with
epinephrine
$$$
Methylphenidate
Ritalin
Depression-Psychostimulant
Fluoxetine
Prozac
Depression-Selective Serotonin
Reuptake Inhibitor
Citalopram
Celexa
Sertraline
Zoloft
$$$$
$$
Second line treatment
DEPRESSION
First line treatment
Depression-Selective Serotonin
Reuptake Inhibitor
Depression-Selective Serotonin
Reuptake Inhibitor
MST: Drug of choice if patient has
< 4-6 weeks life expectancy
Least expensive SSRI:No
significant withdrawal symptoms
when discontinued abruptly
Good choice for depression
accompanied by anxiety
Good choice for depression
accompanied by anxiety
$
$
$$
$$
Second line treatment
Mirtazapine
Remeron
Depression-Atypical
MST: Sedating and increases
appetitite in doses of 7.5 and
15mg
Escitalopram
Lexapro
Depression-Selective Serotonin
Reuptake Inhibitor
Use citalopram as first line
HSS Dx Based Tiered Formulary
$
$$
2009
GENERIC NAME
BRAND NAME EXAMPLES
SYMPTOM/INDICATION/
CLASSIFICATION
COMMENTS
RELATIVE
COST PER DAY
DIARRHEA
First line treatment
Bismuth Subsalicylate
Kaopectate
Diarrhea-Absorbent
Loperamide
Imodium
Diarrhea-Hypermotility
Can get OTC
Diphenoxylate/Atropine
Lomotil
Diarrhea-Hypermotility
Prescription only
Psyllium
Metamucil
Diarrhea-Absorbent-Bulk Laxative
For bulking stool
$
$
$$
¢
DRY EYES
First line treatment
Artificial Tears
Lytears
Dry Eyes-Lubricant
Ophthalmic Lubricant
Lacrilube
Dry Eyes – Lubricant
Thick-it
Dysphagia
Morphine IR
Roxanol, MSIR
Dyspnea-Opioid
Lorazepam
Ativan
Dyspnea-Benzodiazepine
Alprazolam
Xanax
Dyspnea-Benzodiazepine
Diazepam (No Diastat)
Valium
Dyspnea-Benzodiazepine
Oxycodone
Oxyfast
Dyspnea-Opioid
Dyspnea Opioid
Hydromorphone
Dilaudid
Dyspnea-Opioid
Diazepam Intensol
Dyspnea-Benzodiazepine
Lorazepam Intensol
Dyspnea-Benzodiazepine
First line treatment
Methylphenidate
Ritalin
Fatigue-Psychostimulant
MST: Effect usually short term
$
Prednisone
Deltasone
Fatigue-Corticosteroid
MST: Multiple therapeutic actions
¢
Decadron
Fatigue-Corticosteroid
MST:Multiple therapeutic actions
$
Acetaminophen
Tylenol
Fever
Ibuprofen
Motrin
Fever-Nonsteroidal AntiInflammatory Drug
Lasix
Fluid Retention-Loop Diuretic
$
$
DYSPHAGIA
First line treatment
Thickening Agent
¢¢
DYSPNEA
First line treatment
MST: Start with low doses (2.55mg)
MST: Treats anxiety component
of dyspnea
MST: Treats anxiety component
of dyspnea
MST: Treats anxiety component
of dyspnea. Long half-life-dose no
more frequently than q8h and
avoid in geriatrics unless bed
bound.
$
$
$
$
Second line treatment
Diazepam Concentrated Oral
Soln
Lorazepam Concentrated Oral
Soln
p
MST: More expensive
than
morphine
HP injectable expensive but good
choice for SC since it is potent
based on mg/ml
MST: Expensive-tablets are well
absorbed sublingually/rectally
MST: Expensive-tablets are well
absorbed sublingually/rectally
$$
$$
$$$
$$$
FATIGUE
Second line treatment
Dexamethasone
FEVER
First line treatment
MST: Maximum dose = 4
gms/24hrs
MST: Maximum dose = 3200
mgs/24hrs
¢
¢
FLUID RETENTION
First line treatment
Furosemide
Oral absorption less than
bumetanide especially in fluid
overload; Monitor for hypokalemia
¢
Second line treatment
Spironolactone
Aldactone
Metolazone
Zaroxolyn
HSS Dx Based Tiered Formulary
Fluid Retention-Potassium Sparing
May cause hyperkalemia
Diuretic
Adjunct to loop diuretics. Monitor
Fluid Retention-Thiazide Diuretic
for hypo+A154kalemia
¢¢
$$
2009
GENERIC NAME
BRAND NAME EXAMPLES
SYMPTOM/INDICATION/
CLASSIFICATION
COMMENTS
RELATIVE
COST PER DAY
GASTROINTESTINAL
First line treatment
Aluminum/Magnesium
Hydroxide
Aluminum/Magnesium
Hydroxide/Simethicone
Pepcid
Gastrointestinal-Proton Pump
Inhibitor
Gastrointestinal-H2 Antagonist
For prn use. Can cause rebound
acid production with chronic use
For prn use. Can cause rebound
acid production with chronic use
If using local pharmacy, use OTC
omeprazole only- not RX
Can cause confusion in elderly
Zantac
Gastrointestinal-H2 Antagonist
Can cause confusion in elderly
Simethicone
Second line treatment
Mylicon
Gastrointestinal-Gas
For gas
$
$
¢
Sucralfate
Carafate
Gastrointestinal-Protectant
Take other medication 1 hour
before sucralfate
$
Levsin
Genitourinary-Bladder SpasmsAnticholinergic
MST
Bethanechol
Urecholine
Genitourinary-Urinary RetentionCholinergic
For urinary retension
$$$
Oxybutynin IR
Ditropan
Genitourinary-Bladder SpasmsAnticholinergic
For urinary frequency or spasms:
Use immediate release form
$$$
Phenazopyridine
Pyridium
Genitourinary-Urinary Analgesic
Urinary analgesic: Use for a
maximum of 3 days
Baclofen
Lioresal
Hiccups-Muscle Relaxant
Haloperidol
Haloperidol
Hiccups-Antipsychotic
Chlorpromazine
Thorazine
Hiccups- Antipsychotic
Phenothiazine Antipsychotic:
Avoid doses > 75mg/day in LTCF
Metoclopramide
Reglan
Hiccups-Prokinetic
Promotility agent
$$
¢¢
$
$
$
$
¢¢
Maalox, Mylanta
Gastrointestinal-Antacid
Maalox Plus
Gastrointestinal-Antacid
Omeprazole OTC
Prilosec OTC
Famotidine (No Oral Liq)
Ranitidine (No Oral Liq)
¢¢
¢¢
$
GENITOURINARY
First line treatment
Hyoscyamine
¢¢
Second line treatment
¢¢
HICCUPS
First line treatment
Antispasmodic: best evidence
based choice
Butyrophenone: Avoid doses of >
2mg/day in LTCF patients
$
¢
$
INFECTION-BACTERIAL
First line treatment
Amoxicillin
Amoxil
Infection-Bacterial
Penicillin
Cephalexin
Keflex
Infection-Bacterial
Cephalosporin
Doxycycline
Vibramycin
Infection-Bacterial
Tetracycline
Erythromycin
E-Mycin, Erytab
Infection-Bacterial
Macrolide
Metronidazole
Flagyl
Infection-Bacterial
Miscellaneous
Sulfamethoxazole/Trimethoprim Bactrim DS
Second line treatment
Ciprofloxacin
Cipro
Infection-Bacterial
Sulfonamide
Infection-Bacterial
Fluoroquinolone
Azithromycin
Zithromax
Infection-Bacterial
Macrolide
Nitrofurantoin
Third line treatment
Levofloxacin
Macrodantin
Infection-Bacterial
Miscellaneous
Levaquin
Infection-Bacterial
Fluoroquinolone
Mycostatin
Infection-Fungal
No systemic absorption
Diflucan
Infection-Fungal
Multiple drug interactions
$$$$
Zovirax (Oral Only)
Infection-Viral
Only oral form-topical is
nonformulary
$$$
$$$$
$$$$
$$$
$$$$$
INFECTION-FUNGAL
First line treatment
Nystatin Oral Suspension
Second line treatment
Fluconazole
$$
INFECTION-VIRAL
First line treatment
Acyclovir
HSS Dx Based Tiered Formulary
2009
GENERIC NAME
BRAND NAME EXAMPLES
SYMPTOM/INDICATION/
CLASSIFICATION
COMMENTS
RELATIVE
COST PER DAY
INSOMNIA
First line treatment
Temazepam
Restoril
Insomnia-Benzodiazepine
Excluding 7.5 & 22.5 mg strength
¢
Trazodone
Second line treatment
Lorazepam
Desyrel
Insomnia-Antidepressant
Atypical antidepressant
¢
Ativan
Insomnia-Benzodiazepine
Short duraation of action
Alprazolam
Xanax
Insomnia-Benzodiazepine
Short duraation of action
Diphenhydramine
Benadryl
Insomnia-Anticholinergic
Mirtazapine
Remeron
Insomnia-Antidepressant
Avoid in the elderly
MST: Atypical antidepressant:
Sedating in doses < 30mg.
Beneficial if patient is also
depressed.
$
$
¢¢
Chloral Hydrate
Somnote
Insomnia-Hypnotic,
Nonbenzodiazepine
Valium
Muscle Spasm-Benzodiazepine
Long half-life-dose no more
frequently than q8h and avoid in
geriatrics unless bed bound.
$
Baclofen
Lioresal
Muscle Spasm-Skeletal Muscle
Relaxant
For muscle spacticity
$
Diazepam Concentrated Oral
Soln
Diazepam Intensol
Muscle Spasm-Benzodiazepine
Intensol expensive-tablets are well
absorbed sublingually/rectally
$
¢¢
MUSCLE SPASM
First line treatment
Diazepam (No Diastat)
Second line treatment
$$$
NAUSEA & VOMITING
First line treatment
Haloperidol
Haldol
Prochlorperazine
Compazine
Metoclopramide
Reglan
Lorazepam
Ativan
Meclizine
Antivert
y p
MST: Butyrophenone:
Less
sedating than other antiemetics,
Nausea & Vomiting:
can use tablets or liquid
Chemoreceptor Trigger Zone
PO/Sl/PR. Multiple uses for
haloperidol. Avoid doses of >
2mg/day in LTCF patients
Phenothiazine: More sedating,
Nausea & Vomiting:
less versatile and less cost
Chemoreceptor Trigger Zone
effective than haloperidol
Promotility Agent: Drug of choice
Nausea & Vomiting-Gastric Stasis
for gastric stasis
MST: Benzodiazepine: For anxiety
Nausea & Vomiting-Anxiety
induced nausea
Antihistamine: For movement
Nausea & Vomiting, Secretions
induced nausea
¢
$
$$
$
¢¢
Second line treatment
Chlorpromazine
Thorazine
Promethazine
Phenergan
Hyoscyamine
Levsin
Alprazolam
Xanax
Diazepam (No Diastat)
HSS Dx Based Tiered Formulary
Valium
MST: Phenothiazine: More
sedating than haloperidol. Avoid
doses of > 75mg/day in LTCF
patients
More sedating and much less
Nausea & Vomitingeffective than haloperidol.
Chemoreceptor Trigger Zone
Suppositories expensive
MST: Anticholinergic: For gastric
Nausea & Vomiting-Antispasmodic
colic; constipating
Nausea & VomitingChemoreceptor Trigger Zone
$
$
¢¢
Nausea & Vomiting-Anxiety
MST: Benzodiazepine: For anxiety
induced nausea
$
Nausea & Vomiting-Anxiety
MST: Benzodiazepine:Treats
anxiety component of dyspnea.
Long half-life-dose no more
frequently than q8h and avoid in
geriatrics unless bed bound.
$
2009
GENERIC NAME
SYMPTOM/INDICATION/
CLASSIFICATION
BRAND NAME EXAMPLES
COMMENTS
RELATIVE
COST PER DAY
Third line treatment
Erythromycin
E-Mycin, Erytab
Macrolide Antibiotic: If patient
Nausea & Vomiting-Gastric Stasis can't tolerate metoclopramide for
gastric stasis
Glycopyrrolate injection
Robinul
Nausea & Vomiting-Antispasmodic MST:Tablets very expensive
Diazepam Concentrated Oral
Soln
Diazepam Intensol
Nausea & Vomiting-Anxiety
MST: Benzodiazepine:Expensivetablets are well absorbed
sublingually/rectally
$$$
Lorazepam Concentrated Oral
Soln
Lorazepam Intensol
Nausea & Vomiting-Anxiety
MST: Benzodiazepine:Expensivetablets are well absorbed
sublingually/rectally
$$$
Transderm Scop
Nausea & Vomiting, Secretions
MST: Anticholinergic: For
movement induced nausea.
Constipating; onset of action
about 4 hrs
$$$
Methadone
Dolophine, Methadose
Neuropathic Pain-Opioid
Desipramine
Norpramin
Nortriptyline
Pamelor
Gabapentin
Neurontin
Scopolamine Patch
$
$$$
NEUROPATHIC PAIN
First line treatment
Neuropathic pain-Tricyclic
Antidepressant
Neuropathic pain-Tricyclic
Antidepressant
Neuropathic Pain-Antiepileptic
MST: 1st line when opioid and
neuropathic analgesic required
Less severe side effects than
amitriptyline
Less severe side effects than
amitriptyline
Anticonvulsant of choice for
neuropathic pain
¢¢
¢
¢
$$$
Second line treatment
Divalproex Sodium/Valproic Acid Depakote/Depakene
Neuropathic Pain
Antiepileptic
Pain-Antiepileptic
MST: Good for behavior
management also
Doxepin
Sinequan
Neuropathic pain-Tricyclic
Antidepressant
MST: Sedating
¢
Elavil
Neuropathic pain-Tricyclic
Antidepressant
Most severe side effects of TCAs
¢
$$$
Third line treatment
Amitriptyline
Carbamazepine
Tegretol
Neuropathic Pain-Antiepileptic
Pregabalin
Lyrica
Neuropathic Pain-Antiepileptic
Tylenol
Pain
MST: IR form is well absorbed
rectally
Onset of action quicker than
gabapentin- more expensive in
lower doses
¢¢
$$$
PAIN
First line treatment
Acetaminophen
Ibuprofen
Motrin
Naproxen
Naprosyn
Pain-Nonsteroidal AntiInflammatory Drug
Pain-Nonsteroidal AntiInflammatory Drug
Nociceptive Pain-Combination
Product
Nociceptive Pain-Combination
Product
Hydrocodone/Acetaminophen
Lortab, Vicodin
Oxycodone/Acetaminophen
Percocet
Morphine
Roxanol, MS Contin
Pain-Opioid
Methadone
Dolophine, Methadose
Pain-Opioid
Lidocaine Oral
Xylocaine Viscous
Pain-Pharyngeal
HSS Dx Based Tiered Formulary
MST: Maximum 4gms of
acetaminophen/day
MST: Maximum daily dose =
3200mg
Maximum daily dose = 1500mg
Watch acetaminophen content:
maximum 4gms/24hrs
Watch acetaminophen content:
maximum 4gms/24hrs
MST: Start with low doses (2.55mg)
MST: Immediate release opioid
with long half life
Watch for aspiration; wait 30
minutes before eating or
¢
¢
¢¢
$$
$$
¢¢-$$
¢¢
$
2009
GENERIC NAME
BRAND NAME EXAMPLES
SYMPTOM/INDICATION/
CLASSIFICATION
COMMENTS
RELATIVE
COST PER DAY
Second line treatment
Choline Magnesium Trisalicylate Trilisate
Prednisone
Deltasone
Dexamethasone
Decadron
Oxycodone IR
(No Sustained Release)
Hydromorphone
Third line treatment
Pain-Salicylate anti-inflammatory
Pain-Corticosteroid antiinflammatory
Pain-Corticosteroid antiinflammatory
Less platelet inhibition than
traditional NSAIDs
MST: Less expensive than
dexamethasone
MST: Less mineralocorticoid
activity than prednisone
MST: Immediate release opioid:
More expensive than morphine
MST: Immediate release opioid
$$
¢
$
$
Roxicodone
Pain-Opioid
Dilaudid
Pain-Opioid
Indomethacin
Indocin
Pain-Nonsteroidal AntiInflammatory Drug
Propoxyphene/Acetaminophen
Darvocet N-100
Nociceptive Pain-Combination
Product
OxyContin
Pain-Opioid
Expensive: (Nonformulary
Requires Prior Authorization)
$$$$
Duragesic
Pain-Opioid
Expensive, variable absorption,
difficult to titrate: (Nonformulary
Requires Prior Authorization)
$$$$
Oxycodone SR
(Nonformulary Requires Prior
Auth)
Fentanyl Patch
(Nonformulary Requires Prior
Auth)
MST: Causes significant gastric
irritating
Opioid/non-opioid combination:
Weak opioid-watch
acetaminophen content
$$
¢¢
$$
PARKINSONISM/EXTRAPYRAMIDAL SYMPTOMS
First line treatment
Diphenhydramine
Benadryl
EPS-Anticholinergic
MST: Avoid in the elderly
Benztropine
Cogentin
EPS-Anticholinergic
Avoid in the elderly
¢
¢
p
y
Diphenhydramine
y
Benadryl
Pruritus-Antihistamine
g
MST: Sedating-avoid
in the elderlyy
¢
Hydroxyzine
Atarax, Vistaril
Pruritus-Antihistamine
MST: Sedating-avoid in the elderly
$
Prednisone
Deltasone
Pruritus-Corticosteroid
Dexamethasone
Decadron
Pruritus-Corticosteroid
Doxepin
Sinequan
Pruritus-Tricyclic Antidepressant
MST: Sedating-Dose daily or BID
Prednisone
Deltasone
Respiratory Anti-InflammatoryCorticosteroid
Dexamethasone
Decadron
Respiratory Anti-InflammatoryCorticosteroid
Albuterol
Proventil
Beta Agonist Bronchodilator
More cost effective than
dexamethasone
MST: More expensive than
prednisone but causes less fluid
retention in high doses
Only for wheezing related to
terminal diagnosis
Saline-Nebulized
Respiratory-Humidifier
Use PRN between bronchodilator
doses. Thins secretions &
moistens airways
For sublingual use-NOT in the
EYE
PRURITUS
First line treatment
MST: More cost effective than
dexamethasone
MST: Less mineralocorticoid
activity than prednisone
¢
$
¢
RESPIRATORY
First line treatment
¢
$
$$
Second line treatment
Saline-Nebulized
$
SECRETIONS-DRYING AGENT
First line treatment
Atropine 1% Ophthalmic Soln
Isopto Atropine
Secretions-Anticholinergic
Second line treatment
Hyoscyamine
Levsin
Secretions-Anticholinergic
Glycopyrrolate injection
Robinul
Secretions-Anticholinergic
Scopolamine Patch
Transderm Scop
Secretions-Anticholinergic
HSS Dx Based Tiered Formulary
MST: Liquid is expensive
MST: Does not cross blood-brain
barrier. Oral dosage form
expensive, injectable preferred
MST: Only for long term antisecretion
¢¢
¢¢
$$$
$$$
2009
GENERIC NAME
BRAND NAME EXAMPLES
SYMPTOM/INDICATION/
CLASSIFICATION
COMMENTS
RELATIVE
COST PER DAY
SEIZURES
First line treatment
Seizures-Maintenance and
Abortive Treatment
Seizures-Maintenance and
Abortive Treatment
Seizures-Maintenance and
Abortive Treatment
MST: Benzodiazepine: For
abortive therapy
MST: Benzodiazepine: For
abortive therapy
MST: Barbiturate: For
maintenance seizure control
MST: Benzodiazepine: For
maintenance seizure control
Antiepileptic: For maintenance
seizure control
MST: Antiepileptic: For
maintenance seizure control
MST: Antiepileptic: For
maintenance seizure control
MST:Seizures due to intracranial
pressure
$
Lorazepam
Ativan
Diazepam (No Diastat)
Valium
Phenobarbital
Phenobarbital
Clonazepam
Klonopin
Seizures-Maintenance
Phenytoin
Dilantin
Seizures-Maintenance
Valproic acid/Divalproex
Depakote/Depakene
Seizures-Maintenance
Carbamazepine
Tegretol
Seizures-Maintenance
Dexamethasone
Decadron
Seizures-Maintenance
Lorazepam Concentrated Oral
Soln
Lorazepam Intensol
Seizures-Maintenance and
Abortive Treatment
Diazepam Concentrated Oral
Soln
Diazepam Intensol
Seizures-Maintenance and
Abortive Treatment
First line treatment
Emollient
Eucerin
Topical-Emollient
Vitamin A & D Cream
Sween
Topical-Emollient
Skin barrier
Camphor/Menthol Lotion
Sarna
Topical-Antipruritic
Topical Antipruritic
Itching
Hydrocortisone Cream
Cortaid
Topical-Corticosteroid
Rash, Itching
Topical-Anti-infective
Antibiotic
¢¢
¢¢
$
¢¢
¢
Antibiotic
¢¢
$
¢
$
¢¢
$$$
¢¢
$
Second line treatment
MST: Benzodiazepine: Expensivetablets are well absorbed
sublingually/rectally
MST: Benzodiazepine: Expensivetablets are well absorbed
sublingually/rectally
$$$
$$$
TOPICAL
Bacitracin
Neomycin/Polymyxin/Bacitracin
Ointment
Nystatin
Neosporin
Topical-Anti-infective
Mycostatin
Topical Antifingal
Myconazole Cream, Powder
Baza, Zeasorb AF
Topical Antifingal
¢
¢
¢¢
¢
¢¢
¢¢
$
Nystatin/Triamcinolone Cream
Mycolog
Topical-Antifungal/Corticosteroid
Thymol/Menthol/Ointment
Calmoseptine
Topical-Protectant
Zinc Oxide Ointment
Desitin
Topical-Protectant
Zinc Oxide + Dimethicone
Baza Protect
Topical-Protectant
Lidocaine Ointment
Second line treatment
Silver Sulfadiazine Cream
Lidocaine Topical
Topical-Analgesics
Local anesthetic: Localized pain
Silvadene
Topical-Burn & Antibacterial
Anti-infective
Salivart
Xerostoma (dry mouth)
¢¢
Line Maintenance
$
¢¢
Skin barrier
$
XEROSTOMIA (Dry Mouth)
First line treatment
Artificial Saliva
MISCELLANEOUS
Heparin
Heparin Lock flush
Sodium Chloride 0.9%
Injection, Irrigation, Nasal Spray
Relative Cost Per Day Chart
¢ = <$0.50
¢¢ = $0.50-0.99
$= $1.00-1.99
$$= $2.00-2.99
$$$ = $3.00- 4.99
$$$$ = $5.00-9.99
$$$$$ = $10.00-20.00
Please Note: Unless otherwise noted, all strengths and dosage forms of listed medications are covered on both the Base List and Diagnosis
Specific Categories.
HSS Dx Based Tiered Formulary
2009
DIAGNOSIS SPECIFIC CATEGORIES - MEDICATION LIST
Hospice Diagnoses
10 = Cancer
20 = Pulmonary
30 = Heart Disease
40 = Stroke/Coma
50 = Liver Disease
60 = Renal Disease
70 = Neuromuscular Diseases (ALS, Parkinson's, etc)
80 = HIV-AIDS
90 = Dementia
95 = Unclassified Diagnoses/Debility Unspecified/Failure to Thrive
THERAPEUTIC CLASS
GENERIC NAME
BRAND EXAMPLE
COMMENTS
RELATIVE COST PER DAY
CANCER (10)
Anticoagulant
Warfarin
Coumadin
Hypercoagulation due to cancer
Mineralocorticoids
Fludrocortisone
Fludrocortisone
Orthostastatic hypotension
Pancreatic Enzymes
Pancrelipase
Pancrease
Pancreatic cancer
¢¢
¢¢
$$$$
PULMONARY DISEASE (20)
Anticholinergics
Ipratropium
Atrovent
Tiotropium
Spiriva
Beta Adrenergic Agonists Salmeterol Xinafoate
Serevent Diskus
Beta Adrenergic
Agonist/Corticosteroid
Advair
Salmeterol-Fluticasone
Nebulizer more effective in late stage
COPD
Nebulizer more effective in late stage
COPD
Nebulizer more effective in late stage
COPD
Consider changing to nebulized albuterol
+ oral prednisone
Beta Adrenergic Agonists/
Albuterol-Ipratropium
Anticholinergic
Combivent, Duo-Neb
Nebulizer more effective in late stage
COPD
Corticosteroids - Inhaled
Beclomethasone
Q Var
Consider changing to oral prednisone
Xanthines
Theophylline
Theo-Dur
Monitor theophylline blood levels
Benazepril
Lotensin
Captopril
Capoten
Enalapril
Vasotec
$
$$$
$$$
$$$$
$$$
$$$
¢¢
HEART DISEASE (30)
ACE Inhibitors
Lisinopril
Prinivil, Zestril
Quinapril
Accupril
Ramipril
Altace
Alpha Adrenergic
Agonists
Alpha Adrenergic
Clonidine
Catapres
Doxazosin
Cardura
Blockers
Terazosin
Hytrin
Angiotensin Receptor
Candesartan
Atacand
Blockers
Irbesartan
Avapro
Antianginal Agents
Losartan
Cozaar
Olmesartan
Benicar
Valsartan
Diovan
Isosorbide Dinitrate
Isordil
Isosorbide Mononitrate
Warfarin
Monoket, Imdur
Nitroguard, Nitro Paste,
NitroPatch
Coumadin
Heparin
Heparin
Nitroglycerin
Anticoagulants
Antiplatelet
Aspirin
Bayer
Beta Adrenergic
Atenolol
Tenormin
Blockers
Bisoprolol
Zebeta
Carvedilol
Coreg (NO Coreg CR)
Labetalol
Normodyne
Metoprolol
Lopressor, Toprol XL
Propranolol
Inderal
HSS Dx Based Formulary/Dx Specific Add On Medications
¢¢
¢¢
¢¢
¢¢
$
$$
Patch is expensive
¢
$
¢
$
$
$
$$
$$
$$
¢¢
Spray expensive
$
¢¢
$$$
¢
¢
$
$$$
$
¢
¢¢
2009
THERAPEUTIC CLASS
GENERIC NAME
BRAND EXAMPLE
Calcium Channel
Amlodipine
Norvasc
Blockers
Diltiazem
Cardizem
Nifedipine
Procardia
Felodipine
Plendil
Verapamil
Calan
Cardiac Glycosides
Digoxin
Lanoxin
Thiazide Diuretics
Chlorthalidone
Hygroton
Hydrochlorothiazide
Oretic
Loop Diuretic
Bumetanide
Bumex
Vasodilators
Hydralazine
Apresoline
Benazepril
Lotensin
Captopril
Capoten
Enalapril
Vasotec
COMMENTS
RELATIVE COST PER DAY
$
¢¢
$
$
$$
¢
¢
¢
¢¢
¢¢
STROKE/COMA (40)
ACE Inhibitors
Lisinopril
Prinivil, Zestril
Quinapril
Accupril
¢¢
¢¢
¢¢
¢¢
$
$$
Ramipril
Altace
Clonidine
Catapres
¢
Doxazosin
Cardura
Blockers
Terazosin
Hytrin
Angiotensin Receptor
Candesartan
Atacand
Blockers
Irbesartan
Avapro
Losartan
Cozaar, Hyzaar
Olmesartan
Benicar
$
¢
$
$
$
$$
$$
¢¢
$$$
¢
¢
$
$$$
$
¢
¢¢
$
¢¢
$
$
$$
$$
¢
¢
Alpha Adrenergic
Agonists
Alpha Adrenergic
Anticoagulants
Valsartan
Diovan
Warfarin
Coumadin
Heparin
Heparin
Antiplatelet
Aspirin
Bayer
Beta Adrenergic
Atenolol
Tenormin
Blockers
Bisoprolol
Zebeta
Calcium Channel
Blockers
Carvedilol
Coreg (No CR)
Labetalol
Normodyne
Metoprolol
Lopressor, Toprol XL
Propranolol
Inderal
Amlodipine
Norvasc
Diltiazem
Cardizem
Felodipine
Plendil
Nifedipine
Procardia
Nisoldipine
Sular
Verapamil
Calan
Chlorthalidone
Hygroton
Hydrochlorothiazide
Oretic
Beta Adrenergic
Nadolol
Corgard
Blockers
Propranolol
Inderal
Thiazide Diuretics
LIVER DISEASE (50)
Coagulants
Vitamin K
Mephyton, AquaMephyton
Vasodilators
Isosorbide Dinitrate
Isordil
Isosorbide Mononitrate
Monoket, Imdur
Bumetanide
Bumex
Loop Diuretic
¢¢
¢¢
¢¢
$$
¢¢
¢¢
RENAL DISEASE (60)
Base Formulary Only (No additional add on's)
NEUROMUSCULAR DISEASE (70) ALS - PARKINSONS
Antiemetics
Trimethobenzamide
Tigan Capsules
Parkinson's
Antiparkinson's Agents
Amantadine
Symmetrel
Parkinson's
Entacapone
Comtan
Parkinson's
Levodopa/Carbidopa
Levodopa/Carbidopa/
Entacapone
Pramipexole
Sinemet
Parkinson's
$$$
¢¢
$$
$
Stelevo
Parkinson's
$$$$$
Mirapex
Parkinson's
Ropinirole
Requip
Parkinson's
Selegiline
Trihexyphenidyl
Eldepryl
Trihexyphenidyl
Parkinson's
Parkinson's
$$$$
$$$$
¢¢
¢
HSS Dx Based Formulary/Dx Specific Add On Medications
2009
THERAPEUTIC CLASS
Antispasmodics
Atypical Antipsychotics
GENERIC NAME
BRAND EXAMPLE
COMMENTS
Cyclobenzaprine
Flexeril
Skeletal Muscle Relaxant
Tizanidine
Zanaflex
Skeletal Muscle Relaxant
Quetiapine
Seroquel
Parkinsons
RELATIVE COST PER DAY
¢¢
$$
$$$
HIV OR AIDS (80)
Base Formulary Only (No additional add on's)
DEMENTIA (90)
Atypical Antipsychotics
Quetiapine
Seroquel
Risperidone
Risperdal
$$$
$$$$
UNSPECIFIED DIAGNOSIS/DEBILITY UNSPECIFIED/FAILURE TO THRIVE (95)
Base Formulary Only (No additional add on's)
HSS Dx Based Formulary/Dx Specific Add On Medications
2009
HospiScript Diagnosis Based Formulary - Alphabetical Listing by Brand/Generic Name
Generic/Brand Drug Name
Generic/Brand Drug Name
Accupril
Acetaminophen
Acyclovir
Quinapril
Tylenol
Zovirax (Oral Only)
Advair
Salmeterol-Fluticasone
Albuterol
Proventil
Albuterol-Ipratropium
Combivent, Duo-Neb
Aldactone
Spironolactone
Alprazolam
Xanax
Altace
Aluminum/Magnesium
Amantadine
Ramipril
Maalox, Mylanta, Maalox Plus
Symmetrel
A it i t li
Amitriptyline
El il
Elavil
Amlodipine
Amoxicillin
Amoxil
Norvasc
Amoxil
Amoxicillin
Antivert
Meclizine
Apresoline
Artificial Saliva
Artificial Tears
Aspirin
Hydralazine
Salivart
Lytears
Bayer
Atacand
Candesartan
Atarax
Hydroxyzine
Vistaril
Hydroxyzine
Atenolol
Tenormin
Ativan
Lorazepam
Atropine 1% Ophthalmic
Soln
Atrovent
Formulary
Cost
ACE Inhibitors
Fever, Pain-Nonopioid
Infection-Viral
Beta Adrenergic
Agonist/Corticosteroid
Beta Agonist Bronchodilator
Beta Adrenergic Agonists/
Anticholinergic
Fluid Retention-Potassium
Sparing Diuretic
Anxiety, Dyspnea, Insomnia,
Nausea & VomitingBenzodiazepine
CARDIAC/STROKE
BASE
BASE
$
¢
$$$
PULMONARY
$$$$
BASE
$$
PULMONARY
$$$
BASE
¢¢
BASE
$
ACE Inhibitors
Gastrointestinal-Antacid
Antiparkinson's Agents
Neuropathic
p
Pain-Tricyclic
y
Antidepressant
Calcium Channel Blockers
Infection-Bacterial
Infection-Bacterial
Nausea & Vomiting,
Secretions-Antihistamine
Vasodilators
Xerostoma (dry mouth)
Dry Eyes-Lubricant
Antiplatelet
Angiotensin Receptor
Blockers
CARDIAC/STROKE
BASE
NEUROMUSCULAR
$$
¢¢
¢¢
BASE
¢
CARDIAC/STROKE
BASE
BASE
$
¢¢
¢¢
BASE
¢¢
CARDIAC
BASE
BASE
CARDIAC/STROKE
¢¢
¢¢
$
¢
CARDIAC/STROKE
$
BASE
$
BASE
$
CARDIAC/STROKE
¢
BASE
$
Anxiety, PruritusAntihistamine
Anxiety, PruritusAntihistamine
Beta Adrenergic Blockers
Anxiety, Dyspnea, Insomnia,
Nausea & Vomiting, SeizuresBenzodiazepine
Isopto Atropine
Secretions-Anticholinergic
BASE
¢¢
Ipratropium
Anticholinergics
Angiotensin Receptor
Blockers
Infection-Bacterial
Topical-Anti-infective
Hiccups, Muscle Spasms
Infection-Bacterial
Antiplatelet
Topical-Protectant
Topical Antifingal
PULMONARY
$
CARDIAC/STROKE
$
BASE
BASE
BASE
BASE
CARDIAC/STROKE
BASE
BASE
$$$$
¢
$
¢¢
¢
¢¢
¢
Avapro
Irbesartan
Azithromycin
Bacitracin
Baclofen
Bactrim DS
Bayer
Baza Protect
Baza, Zeasorb AF
Zithromax
HSS DBF / Alpha Generic
Drug Class/Indication
Lioresal
Sulfamethoxazole/Trimethoprim
Aspirin
Zinc Oxide + Dimethicone
Myconazole Cream, Powder
2009
Generic/Brand Drug Name
Generic/Brand Drug Name
Beclomethasone
Q Var
Benadryl
Diphenhydramine
Benazepril
Lotensin
Benicar
Olmesartan
Benzonatate
Benztropine
Bethanechol
Tessalon Perles
Cogentin
Urecholine
Bisacodyl
Dulcolax
Bismuth Subsalicylate
Bisoprolol
Bumetanide
Bumex
Calan
Calmoseptine
Camphor/Menthol Lotion
Kaopectate
Zebeta
Bumex
Bumetanide
Verapamil
Thymol/Menthol/Ointment
Sarna
Candesartan
Atacand
Capoten
Captopril
Carafate
Captopril
Capoten
Sucralfate
Carbamazepine
Tegretol
Cardizem
Cardura
Carvedilol
Catapres
Diltiazem
Doxazosin
Coreg (NO Coreg CR)
Clonidine
Celexa
Citalopram
Cephalexin
Keflex
Chloral Hydrate
Somnote
Chlorpromazine
Thorazine
Chlorthalidone
Choline Magnesium
Trisalicylate
Cipro
Ciprofloxacin
Hygroton
Trilisate
Ciprofloxacin
Cipro
Citalopram
Celexa
Clonazepam
Klonopin
Clonidine
Cogentin
Colace
Catapres
Benztropine
Docusate Sodium
Combivent
Albuterol-Ipratropium
Compazine
Prochlorperazine
Comtan
Coreg (NO Coreg CR)
Corgard
Cortaid
Coumadin
Entacapone
Carvedilol
Nadolol
Hydrocortisone Cream
Warfarin
HSS DBF / Alpha Generic
Drug Class/Indication
Formulary
Cost
Corticosteroids - Inhaled
Anxiety, Insomnia, EPS,
Pruritus-Antihistamine
ACE Inhibitors
Angiotensin Receptor
Blockers
Cough-Suppressant
EPS-Anticholinergic
Genitourinary-Cholinergic
Constipation-Stimulant
Laxative
Diarrhea-Absorbent
Beta Adrenergic Blockers
Loop Diuretic
Loop Diuretic
Calcium Channel Blockers
Topical-Protectant
Topical-Antipruritic
Angiotensin Receptor
Blockers
ACE Inhibitors
ACE Inhibitors
Gastrointestinal-Protectant
PULMONARY
$$$
BASE
¢¢
CARDIAC/STROKE
¢¢
CARDIAC/STROKE
$$
BASE
BASE
BASE
$$$
¢
$$$
BASE
$
BASE
CARDIAC/STROKE
CARDIAC/LIVER
CARDIAC/LIVER
CARDIAC/STROKE
BASE
BASE
$
$
¢¢
¢¢
$$
¢
$
CARDIAC/STROKE
$
CARDIAC/STROKE
CARDIAC/STROKE
BASE
¢¢
¢¢
$
BASE
¢¢
Neuropathic Pain, SeizuresAntiepileptic
Calcium Channel Blockers
CARDIAC/STROKE
Alpha Adrenergic Blockers
CARDIAC/STROKE
Beta Adrenergic Blockers
CARDIAC/STROKE
Alpha Adrenergic Agonists
CARDIAC/STROKE
Depression-Selective
BASE
Serotonin Reuptake Inhibitor
Infection-Bacterial
BASE
Insomnia-Hypnotic,
BASE
Nonbenzodiazepine
Agitation, Hiccups, Nausea &
BASE
Vomiting-Phenothiazine
Thiazide Diuretics
CARDIAC/STROKE
Pain-Salicylate antiBASE
inflammatory
Infection-Bacterial
BASE
Infection-Bacterial
BASE
Depression-Selective
BASE
Serotonin Reuptake Inhibitor
Anxiety, SeizuresBASE
Benzodiazepine
Alpha Adrenergic Agonists
CARDIAC/STROKE
EPS-Anticholinergic
BASE
Constipation-Stool Softener
BASE
Beta Adrenergic Agonists/
PULMONARY
Anticholinergic
Nausea & Vomiting:
Chemoreceptor Trigger ZoneBASE
Phenothiazine
Antiparkinson's Agents
NEUROMUSCULAR
Beta Adrenergic Blockers
CARDIAC/STROKE
Beta Adrenergic Blockers
LIVER
Topical-Corticosteroid
BASE
Anticoagulants
CANCER/CARDIAC/STROKE
¢¢
$
$$$
¢
$$
$
¢¢
$
¢
$$
$$$$
$$$$
$$
$
¢
¢
¢¢
$$$
$
$$
$$$
¢¢
¢¢
¢¢
2009
Generic/Brand Drug Name
Generic/Brand Drug Name
Cozaar, Hyzaar
Losartan
Cyclobenzaprine
Flexeril
Darvocet N-100
Propoxyphene/Acetaminophen
Drug Class/Indication
Angiotensin Receptor
Blockers
Antispasmodics
Nociceptive Pain-Combination
Opioid/Nonopioid
Anorexia, Fatigue, Pain,
Pruritus, Respiratory AntiInflammatory, SeizuresCorticosteroid
Anorexia, Fatigue, Pain,
Pruritus, Respiratory AntiInflammatory-Corticosteroid
Neuropathic Pain SeizuresAntiepileptic
Neuropathic Pain-Tricyclic
Antidepressant
Topical-Protectant
Insomnia-Antidepressant
Anorexia, Fatigue, Pain,
Pruritus, Respiratory AntiInflammatory, SeizuresCorticosteroid
Formulary
Cost
CARDIAC/STROKE
$
NEUROMUSCULAR
¢¢
BASE
$$
BASE
$
BASE
¢
BASE
$$$
BASE
¢
BASE
BASE
¢¢
¢
BASE
$
Decadron
Dexamethasone
Deltasone
Prednisone
Depakote/Depakene
Divalproex Sodium/Valproic Acid
Desipramine
Norpramin
Desitin
Desyrel
Zinc Oxide Ointment
Trazodone
Dexamethasone
Decadron
Diazepam (No Diastat)
Valium
Anxiety, Dyspnea, Muscle
Spasms, Nausea & Vomiting,
Seizures-Benzodiazepine
BASE
$
Diazepam Concentrated
Oral Soln
Diazepam Intensol
Anxiety, Dyspnea, Muscle
Spasms, Nausea & Vomiting,
Seizures-Benzodiazepine
BASE
$$$
Diazepam Intensol
Anxiety, Dyspnea, Muscle
Diazepam Concentrated Oral Soln Spasms, Nausea & Vomiting,
Seizures-Benzodiazepine
BASE
$$$
Diflucan
Digoxin
Fluconazole
Lanoxin
BASE
CARDIAC
$$$$
¢
Dilantin
Phenytoin
BASE
¢¢
Dilaudid
Diltiazem
Hydromorphone
Cardizem
BASE
CARDIAC/STROKE
$$
¢¢
Diovan
Valsartan
CARDIAC/STROKE
$$
Diphenhydramine
Benadryl
BASE
¢¢
Diphenoxylate/Atropine
Lomotil
BASE
$$
Ditropan
Oxybutynin IR
BASE
$$$
Neuropathic Pain-Antiepileptic
BASE
$$$
Constipation-Stool Softener
BASE
¢¢
Neuropathic Pain, Pain-Opioid
BASE
¢¢
Alpha Adrenergic Blockers
Neuropathic Pain, PruritusTricyclic Antidepressant
Infection-Bacterial
Constipation-Stimulant
Beta Adrenergic Agonists/
Anticholinergic
CARDIAC/STROKE
$
BASE
¢
BASE
BASE
$
$
PULMONARY
$$$
Divalproex
Sodium/Valproic Acid
Docusate Sodium
Depakote/Depakene
Colace
Dolophine, Methadose
Methadone
Doxazosin
Cardura
Doxepin
Sinequan
Doxycycline
Dulcolax
Vibramycin
Bisacodyl
Duo-Neb
Albuterol-Ipratropium
HSS DBF / Alpha Generic
Infection-Fungal
Cardiac Glycosides
Seizures-MaintenanceAntiepileptic
Dyspnea, Pain-Opioid
Calcium Channel Blockers
Angiotensin Receptor
Blockers
Anxiety, Insomnia, EPS,
Pruritus-Antihistamine
Diarrhea-Hypermotility
Genitourinary-Bladder
Spasms-Anticholinergic
2009
Generic/Brand Drug Name
Generic/Brand Drug Name
Duragesic
Fentanyl Patch
(Nonformulary Requires Prior
Authorization)
Elavil
Amitriptyline
Eldepryl
Emollient
E-Mycin, Erytab
Enalapril
Entacapone
Erythromycin
Selegiline
Eucerin
Erythromycin
Vasotec
Comtan
E-Mycin, Erytab
Escitalopram
Lexapro
Eucerin
Emollient
Famotidine (No Oral Liq)
Felodipine
Fentanyl Patch
(Nonformulary Requires
Prior Authorization)
Flagyl
Duragesic
Fleet Enema
Drug Class/Indication
Formulary
$$$$
Pain-Opioid
Neuropathic Pain-Tricyclic
Antidepressant
Cost
BASE
¢
Antiparkinson's Agents
Topical-Emollient
Infection, Nausea & Vomiting
ACE Inhibitors
Antiparkinson's Agents
Infection, Nausea & Vomiting
Depression-Selective
Serotonin Reuptake Inhibitor
Topical-Emollient
NEUROMUSCULAR
BASE
BASE
CARDIAC/STROKE
NEUROMUSCULAR
BASE
¢¢
¢¢
$
¢¢
$$
$
BASE
$$
BASE
¢¢
Pepcid
Gastrointestinal-H2 Antagonist
BASE
$
Plendil
Calcium Channel Blockers
CARDIAC/STROKE
$
$$$$
Pain-Opioid
Infection-Bacterial
BASE
$
Sodium Phosphate Enema
Constipation-Osmotic Laxative
BASE
$
Flexeril
Fluconazole
Fludrocortisone
Fludrocortisone
Cyclobenzaprine
Diflucan
Fludrocortisone
Fludrocortisone
NEUROMUSCULAR
BASE
CARDIAC/STROKE
CARDIAC/STROKE
¢¢
$$$$
¢¢
¢¢
Fluoxetine
Prozac
BASE
$
Furosemide
Lasix
Antispasmodics
Infection-Fungal
Mineralocorticoids
Mineralocorticoids
Depression-Selective
Serotonin Reuptake Inhibitor
Fluid Retention-Loop Diuretic
BASE
¢
Gabapentin
Neurontin
Neuropathic Pain-Antiepileptic
BASE
$$$
Constipation-Osmotic Laxative
BASE
$
BASE
$$$
BASE
¢¢
BASE
$$
BASE
$$
BASE
¢
BASE
¢
BASE
CARDIAC/STROKE
$
$$$
BASE
$$$$
CARDIAC
CARDIAC/STROKE
¢¢
¢
BASE
$$
BASE
$$$$
BASE
BASE
¢¢
$$
BASE
$
Metronidazole
Glycerin Suppository
Glycopyrrolate injection
Robinul
Guaifenesin
Robitussin, Mucinex
Guaifenesin/Codeine Liq
Robitussin AC
Guaifenesin/Dextromethorp
Robitussin DM
han Liq
Haldol
Haloperidol
Haloperidol
Haldol
Heparin Flush
Heparin
Heparin Lock flush
Heparin
Hycodan
Hydrocodone/Homatropine Syrup
Hydralazine
Hydrochlorothiazide
Apresoline
Oretic
Hydrocodone/
Acetaminophen
Lortab, Vicodin
Hydrocodone/ Homatropine
Hycodan
Syrup
Hydrocortisone Cream
Cortaid
Hydromorphone
Dilaudid
Hydroxyzine
HSS DBF / Alpha Generic
Atarax, Vistaril
Nausea & Vomiting,
Secretions-Anticholinergic
Cough-Expectorant
CoughExpectorant/Suppressant
CoughExpectorant/Suppressant
Agitation, Hiccups, Nausea &
Vomiting-Butyrophenone
Agitation, Hiccups, Nausea &
Vomiting-Butyrophenone
Line Maintenance
Anticoagulants
CoughExpectorant/Suppressant
Vasodilators
Thiazide Diuretics
Nociceptive Pain-Combination
Opioid/Nonopioid
CoughExpectorant/Suppressant
Topical-Corticosteroid
Dyspnea, Pain-Opioid
Anxiety, PruritusAntihistamine
2009
Generic/Brand Drug Name
Generic/Brand Drug Name
Hygroton
Chlorthalidone
Hyoscyamine
Levsin
Hytrin
Terazosin
Ibuprofen
Motrin
Imdur
Imodium
Inderal
Isosorbide Mononitrate
Loperamide
Propranolol
Indocin
Indomethacin
Indomethacin
Indocin
Ipratropium
Atrovent
Irbesartan
Avapro
Isopto Atropine
Isordil
Isosorbide Dinitrate
Isosorbide Mononitrate
Kaopectate
Keflex
Atropine 1% Ophthalmic Soln
Isosorbide Dinitrate
Isordil
Monoket, Imdur
Bismuth Subsalicylate
Cephalexin
Klonopin
Clonazepam
KlorCon
Potassium Chloride
Labetalol
Lacrilube
Lanoxin
Lasix
Levaquin
Levodopa/Carbidopa
Normodyne
Ophthalmic Lubricant
Digoxin
Furosemide
Levofloxacin
Sinemet
Levodopa/ Carbidopa/
Entacapone
Stelevo
Levofloxacin
Levaquin
Levsin
Hyoscyamine
Lexapro
Escitalopram
Lidocaine Inj for
Nebulization
Lidocaine Ointment
Lidocaine Oral
Lioresal
Lisinopril
Lomotil
Loperamide
Lopressor
Xylocaine
Lidocaine Topical
Xylocaine Viscous
Baclofen
Prinivil, Zestril
Diphenoxylate/Atropine
Imodium
Metoprolol
Lorazepam
Ativan
Lorazepam Concentrated
Oral Soln
Lorazepam Intensol
Lorazepam Intensol
Lorazepam Concentrated Oral
Soln
HSS DBF / Alpha Generic
Drug Class/Indication
Formulary
Cost
Thiazide Diuretics
Genitourinary, Nausea &
Vomiting, SecretionsAnticholinergic
Alpha Adrenergic Blockers
Fever, Pain-Nonsteroidal AntiInflammatory Drug
Vasodilators
Diarrhea-Hypermotility
Beta Adrenergic Blockers
Pain-Nonsteroidal AntiInflammatory Drug
Pain-Nonsteroidal AntiInflammatory Drug
Anticholinergics
Angiotensin Receptor
Blockers
Secretions-Anticholinergic
Vasodilators
Vasodilators
Vasodilators
Diarrhea-Absorbent
Infection-Bacterial
Anxiety, SeizuresBenzodiazepine
Cardiac-Potassium
S
Supplement
l
Beta Adrenergic Blockers
Dry Eyes-Lubricant
Cardiac Glycosides
Fluid Retention-Loop Diuretic
Infection-Bacterial
Antiparkinson's Agents
CARDIAC/STROKE
¢
BASE
¢¢
CARDIAC/STROKE
¢
BASE
¢
CARDIAC/LIVER
BASE
CARDIAC/STROKE/LIVER
¢¢
$
¢¢
BASE
¢¢
BASE
¢¢
PULMONARY
$
CARDIAC/STROKE
$
BASE
CARDIAC/LIVER
CARDIAC/LIVER
CARDIAC/LIVER
BASE
BASE
¢¢
$$
$$
¢¢
$
$
BASE
$
BASE
¢
CARDIAC/STROKE
BASE
CARDIAC
BASE
BASE
NEUROMUSCULAR
$
$
¢
¢
$$$$$
$
Antiparkinson's Agents
NEUROMUSCULAR
$$$$$
Infection-Bacterial
Genitourinary, Nausea &
Vomiting, SecretionsAnticholinergic
Depression-Selective
Serotonin Reuptake Inhibitor
BASE
$$$$$
BASE
¢¢
BASE
$$
Cough-Suppressant
BASE
$$$
Topical-Analgesics
Pain-Pharyngeal
Hiccups, Muscle Spasms
ACE Inhibitors
Diarrhea-Hypermotility
Diarrhea-Hypermotility
Beta Adrenergic Blockers
Anxiety, Dyspnea, Insomnia,
Nausea & Vomiting, SeizuresBenzodiazepine
Anxiety, Dyspnea, Insomnia,
Nausea & Vomiting, SeizuresBenzodiazepine
Anxiety, Dyspnea, Insomnia,
Nausea & Vomiting, SeizuresBenzodiazepine
BASE
BASE
BASE
CARDIAC/STROKE
BASE
BASE
CARDIAC/STROKE
$
$
$
¢¢
$$
$
¢
BASE
$
BASE
$$$
BASE
$$$
2009
Generic/Brand Drug Name
Generic/Brand Drug Name
Lortab
Hydrocodone/ Acetaminophen
Losartan
Cozaar, Hyzaar
Lotensin
Benazepril
Luminal
Drug Class/Indication
Formulary
Cost
Nociceptive Pain-Combination
Opioid/Nonopioid
BASE
$$
Angiotensin Receptor
Blockers
ACE Inhibitors
CARDIAC/STROKE
$
CARDIAC/STROKE
¢¢
Phenobarbital
Agitation, Seizures-Barbiturate
BASE
¢
Lyrica
Pregabalin
Neuropathic Pain-Antiepileptic
BASE
$$$
Lytears
Artificial Tears
Aluminum/Magnesium
Hydroxide/Simethicone
Dry Eyes-Lubricant
BASE
$
Gastrointestinal-Antacid
BASE
¢¢
Gastrointestinal-Antacid
BASE
¢¢
Infection-Bacterial
BASE
$$$
Maalox Plus
Maalox, Mylanta
Aluminum/Magnesium Hydroxide
Macrodantin
Nitrofurantoin
Magnesium Citrate
Mag-Citrate
Constipation-Osmotic Laxative
BASE
¢¢
Magnesium Hydroxide
Suspension
Milk of Magnesia
Constipation-Osmotic Laxative
BASE
¢
Meclizine
Antivert
Mephyton, AquaMephyton
Vitamin K
Metamucil
Psyllium
Methadone
Dolophine, Methadose
Methylphenidate
Ritalin
Metoclopramide
Reglan
Metolazone
Zaroxolyn
Metoprolol
Metronidazole
Lopressor, Toprol XL
Flagyl
Magnesium Hydroxide
Suspension
Milk of Magnesia
Mineral Oil Enema
Mirapex
Pramipexole
Mirtazapine
Remeron
Monoket
Morphine
Isosorbide Mononitrate
Roxanol, MS Contin, MSIR
Motrin
Ibuprofen
Mucinex
Guaifenesin SR
Mycolog
Nystatin/Triamcinolone Cream
Myconazole Cream,
Powder
Mycostatin
Mylicon
Nadolol
Baza, Zeasorb AF
Nystatin
Simethicone
Corgard
Naprosyn
Naproxen
Naproxen
Naprosyn
Neomycin/Polymyxin/Bacitr
Neosporin
acin Ointment
Neomycin/Polymyxin/Bacitracin
Neosporin
Ointment
HSS DBF / Alpha Generic
Nausea & Vomiting,
Secretions-Antihistamine
Coagulants
Diarrhea-Absorbent-Bulk
Laxative
BASE
¢¢
LIVER
¢¢
BASE
¢
Neuropathic Pain, Pain-Opioid
BASE
¢¢
BASE
$
BASE
$$
Depression, FatiguePsychostimulant
Hiccups, Nausea & Vomiting
Fluid Retention-Thiazide
Diuretic
Beta Adrenergic Blockers
Infection-Bacterial
BASE
$$
CARDIAC/STROKE
BASE
¢
$
Constipation-Osmotic Laxative
BASE
¢
Constipation-Lubricant
Antiparkinson's Agents
Anorexia, Depression,
Insomnia-Atypical
Antidepressant
Vasodilators
Pain,Dyspnea-Opioid
Fever, Pain-Nonsteroidal AntiInflammatory Drug
Cough-Expectorant
TopicalAntifungal/Corticosteroid
BASE
NEUROMUSCULAR
$$
$$$$
BASE
$
CARDIAC/LIVER
BASE
¢¢
¢¢-$$
BASE
¢
BASE
¢¢
BASE
¢¢
Topical Antifingal
BASE
¢
Infection-Fungal
Gastrointestinal-Gas
Beta Adrenergic Blockers
Pain-Nonsteroidal AntiInflammatory Drug
Pain-Nonsteroidal AntiInflammatory Drug
BASE
BASE
LIVER
¢-$$
¢
¢¢
BASE
¢¢
BASE
¢¢
Topical-Anti-infective
BASE
¢¢
Topical-Anti-infective
BASE
¢¢
2009
Generic/Brand Drug Name
Generic/Brand Drug Name
Neurontin
Gabapentin
Nifedipine
Nisoldipine
Nitrofurantoin
Nitroglycerin
Nitroguard, Nitro Paste,
NitroPatch
Normodyne
Procardia
Sular
Macrodantin
Nitroguard, Nitro Paste, NitroPatch
Norpramin
Desipramine
Nortriptyline
Pamelor
Norvasc
Nystatin
Nystatin Oral Suspension
Nystatin/Triamcinolone
Cream
Amlodipine
Mycostatin
Mycostatin
Olmesartan
Benicar
Omeprazole OTC
Prilosec OTC
Ophthalmic Lubricant
Oretic
Lacrilube
Hydrochlorothiazide
Oxybutynin IR
Ditropan
Oxycodone IR
(No Sustained Release)
Oxycodone SR
(Nonformulary Requires
Prior Authorization)
Oxycodone/
Acetaminophen
OxyContin
Oxyfast
Nitroglycerin
Labetalol
Mycolog
Oxyfast, Roxidone
OxyContin
Percocet
Oxycodone SR
(Nonformulary Requires Prior
Authorization)
Oxycodone IR
(No Sustained Release)
Pamelor
Nortriptyline
Pancrease
Pancrelipase
Pancrelipase
Pancrease
Pepcid
Famotidine (No Oral Liq)
Percocet
Oxycodone/Acetaminophen
Phenazopyridine
Pyridium
Phenergan
Promethazine
Phenobarbital
Luminal
Phenytoin
Plendil
Dilantin
Felodipine
Potassium Chloride
KlorCon
Pramipexole
Mirapex
HSS DBF / Alpha Generic
Drug Class/Indication
Formulary
Cost
Neuropathic Pain-Antiepileptic
BASE
$$$
Calcium Channel Blockers
Calcium Channel Blockers
Infection-Bacterial
Antianginal Agents
CARDIAC/STROKE
STROKE
BASE
CARDIAC
$
$$
$$$
$
Antianginal Agents
CARDIAC
$
Beta Adrenergic Blockers
Neuropathic Pain-Tricyclic
Antidepressant
Neuropathic Pain-Tricyclic
Antidepressant
Calcium Channel Blockers
Topical Antifingal
Infection-Fungal
TopicalAntifungal/Corticosteroid
Angiotensin Receptor
Blockers
Gastrointestinal-Proton Pump
Inhibitor
Dry Eyes-Lubricant
Thiazide Diuretics
Genitourinary-Bladder
Spasms-Anticholinergic
CARDIAC/STROKE
$
BASE
¢
BASE
¢
CARDIAC/STROKE
BASE
BASE
$
¢
$$
BASE
¢¢
CARDIAC/STROKE
$$
BASE
$
BASE
CARDIAC/STROKE
$
¢
BASE
$$$
Dyspnea, Pain-Opioid
BASE
$$
Pain-Opioid
BASE
$$$$
Nociceptive Pain-Combination
Opioid/Nonopioid
BASE
$$
Pain-Opioid
BASE
$$$$
Pain, Dyspnea-Opioid
BASE
$$
Neuropathic Pain-Tricyclic
Antidepressant
Pancreatic Enzymes
Pancreatic Enzymes
BASE
¢
CANCER
CANCER
$$$$
$$$$
Gastrointestinal-H2 Antagonist
BASE
$
BASE
$$
BASE
¢¢
BASE
$
Agitation, Seizures-Barbiturate
BASE
¢
Seizures-Maintenance
Calcium Channel Blockers
Cardiac-Potassium
Supplement
Antiparkinson's Agents
BASE
CARDIAC/STROKE
¢¢
$
BASE
¢
NEUROMUSCULAR
$$$$
Nociceptive Pain-Combination
Opioid/Nonopioid
Genitourinary-Urinary
Analgesic
Nausea & VomitingChemoreceptor Trigger ZonePhenothiazine
2009
Generic/Brand Drug Name
Generic/Brand Drug Name
Prednisone
Deltasone
Pregabalin
Lyrica
Prilosec OTC
Omeprazole OTC
Prinivil
Zestril
Procardia
Lisinopril
Lisinopril
Nifedipine
Prochlorperazine
Compazine
Promethazine
Phenergan
Drug Class/Indication
Formulary
Cost
Anorexia, Fatigue, Pain,
Pruritus, Respiratory AntiInflammatory-Corticosteroid
BASE
¢
Neuropathic Pain-Antiepileptic
BASE
$$$
BASE
$
CARDIAC/STROKE
CARDIAC/STROKE
CARDIAC/STROKE
¢¢
¢¢
$
BASE
$
BASE
$
BASE
$$
CARDIAC/STROKE/LIVER
BASE
¢¢
$$
BASE
$
BASE
¢
BASE
¢¢
PULMONARY
NEUROMUSCULAR
CARDIAC/STROKE
CARDIAC/STROKE
$$$
$$$
$
$$
Prozac
Fluoxetine
Psyllium
Metamucil
Pyridium
Phenazopyridine
Q Var
Quetiapine
Quinapril
Ramipril
Beclomethasone
Seroquel
Accupril
Altace
Gastrointestinal-Proton Pump
Inhibitor
ACE Inhibitors
ACE Inhibitors
Calcium Channel Blockers
Nausea & Vomiting:
Chemoreceptor Trigger ZonePhenothiazine
Nausea & VomitingChemoreceptor Trigger ZonePhenothiazine
Nociceptive Pain-Combination
Opioid/Nonopioid
Beta Adrenergic Blockers
Beta Agonist Bronchodilator
Depression-Selective
Serotonin Reuptake Inhibitor
Diarrhea-Absorbent-Bulk
Laxative
Genitourinary-Urinary
Analgesic
Corticosteroids - Inhaled
Atypical Antipsychotics
ACE Inhibitors
ACE Inhibitors
Ranitidine (No Oral Liq)
Zantac
Gastrointestinal-H2 Antagonist
BASE
$
Reglan
Metoclopramide
BASE
$$
Remeron
Mirtazapine
BASE
$
Requip
Restoril
Ropinirole
Temazepam
NEUROMUSCULAR
BASE
$$$$
¢
Ritalin
Methylphenidate
BASE
$
Robinul
Glycopyrrolate injection
BASE
$$$
Robitussin
Guaifenesin Liq
BASE
¢¢
Robitussin AC
Guaifenesin/Codeine Liq
Hiccups, Nausea & Vomiting
Anorexia, Depression,
Insomnia-Atypical
Antidepressant
Antiparkinson's Agents
Insomnia-Benzodiazepine
Depression, FatiguePsychostimulant
Nausea & Vomiting,
Secretions-Anticholinergic
Cough-Expectorant
CoughExpectorant/Suppressant
CoughExpectorant/Suppressant
Antiparkinson's Agents
Pain, Dyspnea-Opioid
Pain, Dyspnea-Opioid
BASE
$$
BASE
$$
NEUROMUSCULAR
BASE
BASE
$$$$
$$
$
Pain, Dyspnea-Opioid
BASE
$
Respiratory-Humidifier
Xerostoma (dry mouth)
Beta Adrenergic Agonists
Beta Adrenergic
Agonist/Corticosteroid
Topical-Antipruritic
Nausea & Vomiting,
Secretions-Anticholinergic
Antiparkinson's Agents
BASE
BASE
PULMONARY
$
¢¢
$$$
PULMONARY
$$$$
BASE
$
BASE
$$$
NEUROMUSCULAR
¢¢
Propoxyphene/
Acetaminophen
Propranolol
Proventil
Darvocet N-100
Inderal
Albuterol
Saline-Nebulized
Salivart
Salmeterol Xinafoate
Guaifenesin/Dextromethorphan
Liq
Requip
Morphine ER
Morphine IR
Oxycodone IR
(No Sustained Release)
Saline-Nebulized
Artificial Saliva
Serevent Diskus
Salmeterol-Fluticasone
Advair
Sarna
Camphor/Menthol Lotion
Scopolamine Patch
Transderm Scop
Selegiline
Eldepryl
Robitussin DM
Ropinirole
MS Contin
Roxanol
Roxicodone
HSS DBF / Alpha Generic
2009
Generic/Brand Drug Name
Generic/Brand Drug Name
Senna
Senokot
Senna/Docusate Sodium
Senokot S
Senokot
Senna
Senokot S
Senna/Docusate Sodium
Serevent Diskus
Seroquel
Salmeterol Xinafoate
Quetiapine
Sertraline
Zoloft
Silvadene
Silver Sulfadiazine Cream
Simethicone
Sinemet
Silver Sulfadiazine Cream
Silvadene
Mylicon
Levodopa/Carbidopa
Sinequan
Doxepin
Sodium Chloride 0.9%
Sodium Phosphate Enema Fleet Enema
Somnote
Chloral Hydrate
Sorbitol 70% Soln
Sorbitol
Spiriva
p
Tiotropium
p
Spironolactone
Aldactone
Stelevo
Levodopa/Carbidopa/
Entacapone
Carafate
Nisoldipine
Sucralfate
Sular
Sulfamethoxazole/
Trimethoprim
Sween
Symmetrel
Bactrim DS
Tegretol
Carbamazepine
Temazepam
Tenormin
Terazosin
Tessalon Perles
Theo-Dur
Theophylline
Thickening Agent
Thick-it
Restoril
Atenolol
Hytrin
Benzonatate
Theophylline
Theo-Dur
Thick-it
Thickening Agent
Thorazine
Chlorpromazine
Thymol/Menthol/Ointment
Tigan Capsules
Tiotropium
Tizanidine
Toprol XL
Calmoseptine
Trimethobenzamide
Spiriva
Zanaflex
Metoprolol
Transderm Scop
Scopolamine Patch
Trazodone
Trihexyphenidyl
Desyrel
Trihexyphenidyl
Trilisate
Choline Magnesium Trisalicylate
HSS DBF / Alpha Generic
Vitamin A & D Cream
Amantadine
Drug Class/Indication
Formulary
Cost
BASE
¢
BASE
¢¢
BASE
¢
BASE
¢¢
PULMONARY
NEUROMUSCULAR
$$$
$$$
BASE
$$
BASE
BASE
BASE
NEUROMUSCULAR
$
$
¢
$
BASE
¢
BASE
¢¢
Constipation-Osmotic Laxative
BASE
$
Insomnia-Hypnotic,
Nonbenzodiazepine
BASE
¢¢
Constipation-Osmotic Laxative
BASE
$
Pulmonary-Anticholinergic
y
g
Fluid Retention-Potassium
Sparing Diuretic
PULMONARY
$$$
BASE
¢¢
Antiparkinson's Agents
NEUROMUSCULAR
$$$$$
Gastrointestinal-Protectant
Calcium Channel Blockers
BASE
STROKE
$
$$
Infection-Bacterial
BASE
¢¢
Topical-Emollient
Antiparkinson's Agents
Neuropathic Pain, SeizuresAntiepileptic
Insomnia-Benzodiazepine
Beta Adrenergic Blockers
Alpha Adrenergic Blockers
Cough-Suppressant
Pulmonary-Xanthines
Pulmonary-Xanthines
Dysphagia
Dysphagia
Agitation, Hiccups, Nausea &
Vomiting-Phenothiazine
Topical-Protectant
Antiemetics-Antihistamine
Pulmonary-Anticholinergics
Antispasmodics
Beta Adrenergic Blockers
Nausea & Vomiting,
Secretions-Anticholinergic
Insomnia-Antidepressant
Antiparkinson's Agents
Pain-Salicylate antiinflammatory
BASE
NEUROMUSCULAR
¢¢
¢¢
BASE
¢¢
BASE
CARDIAC/STROKE
CARDIAC/STROKE
BASE
PULMONARY
PULMONARY
BASE
BASE
¢
¢
¢
$$$
¢¢
¢¢
¢¢
¢¢
BASE
$
BASE
NEUROMUSCULAR
PULMONARY
NEUROMUSCULAR
CARDIAC/STROKE
¢
$$$
$$$
$$
¢
BASE
$$$
BASE
NEUROMUSCULAR
¢
¢
BASE
$$
Constipation-Stimulant
Laxative
Constipation-Stimulant and
Softner Combination
Constipation-Stimulant
Laxative
Constipation-Stimulant and
Softner Combination
Beta Adrenergic Agonists
Atypical Antipsychotics
Depression-Selective
Serotonin Reuptake Inhibitor
Topical-Burn & Antibacterial
Topical-Burn & Antibacterial
Gastrointestinal-Gas
Antiparkinson's Agents
Neuropathic Pain, PruritusTricyclic Antidepressant
Injection, Irrigation, Nasal
Spray
2009
Generic/Brand Drug Name
Generic/Brand Drug Name
Trimethobenzamide
Tylenol
Urecholine
Tigan Capsules
Acetaminophen
Bethanechol
Valium
Diazepam (No Diastat)
Valproic acid/Divalproex
Depakene/Depakote
Valsartan
Diovan
Vasotec
Verapamil
Vibramycin
Enalapril
Calan
Doxycycline
Vicodin
Hydrocodone/Acetaminophen
Vitamin A & D Cream
Vitamin K
Warfarin
Sween
Mephyton, AquaMephyton
Coumadin
Xanax
Alprazolam
Xylocaine
Xylocaine Viscous
Zanaflex
Lidocaine Inj for Nebulization
Lidocaine Oral
Tizanidine
Zantac
Ranitidine (No Oral Liq)
Zaroxolyn
Metolazone
Zebeta
Zinc Oxide + Dimethicone
Zinc Oxide Ointment
Zithromax
Bisoprolol
Baza Protect
Desitin
Azithromycin
Zoloft
Sertraline
Zovirax (Oral Only)
Acyclovir
Drug Class/Indication
Formulary
Cost
Antiemetics-Antihistamine
Fever, Pain-Nonopioid
Genitourinary-Cholinergic
NEUROMUSCULAR
BASE
BASE
$$$
¢
$$$
Anxiety, Dyspnea, Muscle
Spasms, Nausea & Vomiting,
Seizures-Benzodiazepine
BASE
$
BASE
$$$
CARDIAC/STROKE
$$
CARDIAC/STROKE
CARDIAC/STROKE
BASE
¢¢
$$
$
BASE
$$
Seizures-MaintenanceAntiepileptic
Angiotensin Receptor
Blockers
ACE Inhibitors
Calcium Channel Blockers
Infection-Bacterial
Nociceptive Pain-Combination
Opioid/Nonopioid
Topical-Emollient
BASE
Coagulants
LIVER
Anticoagulants
CANCER/CARDIAC/STROKE
Anxiety, Dyspnea, Insomnia,
Nausea & VomitingBASE
Benzodiazepine
Cough-Suppressant
BASE
Pain-Pharyngeal
BASE
Antispasmodics
NEUROMUSCULAR
Gastrointestinal-H2 Antagonist
Fluid Retention-Thiazide
Diuretic
Beta Adrenergic Blockers
Topical-Protectant
Topical-Protectant
Infection-Bacterial
Depression-Selective
Serotonin Reuptake Inhibitor
Infection-Antiviral
¢¢
¢¢
¢¢
$
$$$
$
$$
BASE
$
BASE
$$
CARDIAC/STROKE
BASE
BASE
BASE
$
¢¢
¢¢
$$$$
BASE
$$
BASE
$$$
Relative Cost Per Day
Chart
¢ = <$0.50
¢¢ = $0.50-0.99
$= $1.00-1.99
$$= $2.00-2.99
$$$ = $3.00- 4.99
$$$$ = $5.00-9.99
$$$$$ = $10.00-20.00
Please Note: Unless otherwise noted, all strengths and dosage forms of listed medications are covered on both the Base List and
Diagnosis Specific Categories.
HSS DBF / Alpha Generic
2009