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Doxycycline hyclate* (Vibramycin)
GENERIC DRUGS
Minocycline* (Minocin, Dynacin)
Ascension Health endorses the use of FDA Tetracycline* (Sumycin)
ANTIFUNGAL AGENTS (ORAL) ________________
encourages the prescribing and dispensing of Clotrimazole* (Mycelex)
these generic medications whenever medically Fluconazole* (Diflucan) (QL)
Itraconazole* (Sporanox)
Ketoconazole* (Nizoral)
EXCLUDED DRUGS
Nystatin* (Mycostatin)
Terbinafine* (Lamisil)(QL)
Ascension Health has excluded the following Voriconazole* (Vfend)
drugs or drug classes from coverage under the ANTI-MALARIALS ___________________________
pharmacy benefit: cosmetic products (e.g. Egrifta, Latisse, Vaniqa), cough & cold Chloroquine* (Aralen)
combinations, allergy ophthalmics (e.g. Patanol), Hydroxychloroquine* (Plaquenil)
Mefloquine* (Lariam)
sedating antihistamines (e.g. Allegra, Clarinex), Quinine* (generic)
meperidine (Demerol), Lazanda/Subsys (fentanyl ANTI-TUBERCULOSIS AGENTS ________________
Ethambutol* (Myambutol)
ASCENSION (doxycycline), Duexis (ibuprofen/famotidine), Isoniazid* (Nydrazid)
Pyrazinamide* (pyrazinamide)
combinations and over-the-counter products. Rifampin* (Rifadin)
OTHER ANTI-INFECTIVES _____________________
professional (e.g. infused or vaccines) are Clindamycin* (Cleocin)
Iodoquinol* (iodoquinol)
Metronidazole* (Flagyl)
ORMULARY
PRIOR AUTHORIZATION / STEP THERAPY /
QUANTITY LIMITS
Trimethoprim* (Proloprim)
ANTI-VIRAL AGENTS
Select drugs require prior authorization (PA) of
benefits. Medication utilization must meet FDA approved indications as well as Ascension (CONDENSED VERSION)
Abacavir/Lamivudine/Zidovudine (Trizivir) Step Therapy Protocols (ST): Step therapy
Acyclovir* (Zovirax)
requires the use of one or more medications before benefits for the use of another medication Amantadine* (Symmetrel)
Quantity Limits (QL): Ascension Health has
January 2013
identified a number of select medications which Darunavir (Prezista) Delavirdine (Rescriptor) will be subject to quantity limits. A quantity limit Didanosine* (Videx EC)
Please note: This is not a comprehensive list of prescription medication Ascension Health will cover as a benefit within a defined period of time. Efavirenz/Emtricitabine/Tenofovir (Atripla) Quantity limits may be implemented on a per day basis (e.g. 1 tablet per day), per prescription or per 30 days. Enfuvirtide (Fuzeon)(SP)
SPECIALTY DRUGS
approved generic is available, the generic Ascension Health has specified certain specialty Famciclovir* (Famvir)
name is bolded and asterisked.
drugs are to be filled only through the in-house Foscarnet* (generic)
pharmacies or from Coram. These drugs are noted in the list below with (SP).
Ganciclovir* (Cytovene)
ANTI-INFECTIVE AGENTS
ANTIBIOTICS _______________________________
copayment. Example: Cefaclor* (Ceclor)
Cephalosporins .
means that the generic Cefaclor is Cefaclor* (Ceclor)
formulary and the brand is non-formulary Cefdinir* (Omnicef)
Cefditoren* (Spectracef)
Cefadroxil* (Duracef)
Ribavirin* (Rebetol)
Cefprozil* (Cefzil)
Rimantadine* (Flumadine)
active ingredient is only available as a Cefuroxime* (Ceftin)
Cefpodoxime* (Vantin)
Example: Tiotropium (Spiriva) means Cephalexin* (Keflex)
Stavudine* (Zerit)
that the brand, Spiriva is covered and Macrolides .
there is no generic available. Spiriva is Azithromycin* (Zithromax)(QL)
Clarithromycin XL* (Biaxin XL)
Erythromycin* (Eryc, PCE)
Valacyclovir* (Valtrex)
If the word 'generic' and the brand name Erythromycin/Sulfisoxazole* (Pediazole)
both appear within the parenthesis, both Penicillins .
Zidovudine* (Retrovir)
Amoxicillin* (Amoxil)
AUTONOMIC AND
Amoxicillin/Clavulanate* (Augmentin)
CENTRAL NERVOUS SYSTEM AGENTS
Example: Phenytoin (Dilantin / generic) Ampicillin* (Principen)
means that both the brand and generic Dicloxacillin* (Pathocil)
ANALGESICS, NARCOTIC _____________________
are available. Therefore, the brand Penicillin* (Veetids)
Acetaminophen/Codeine* (Tylenol w/codeine)
Dilantin and the generic phenytoin are on Quinolones .
Aspirin/Codeine* (Empirin w/codeine)
Ciprofloxacin/XR* (Cipro/XR) (QL)
Fentanyl* (Duragesic)(QL)
Levofoxacin* (Levaquin)(QL)
Fentanyl Citrate* (Actiq, Fentora)(PA/QL)
Ofloxacin* (Floxin)
Hydrocodone/Acetaminophen* (Lortab) (QL)
formulary listing shall be considered non- Sulfonamides .
Hydromorphone* (Dilaudid)
Morphine Sulfate* (MS Contin)(QL)
Erythromycin/Sulfisoxazole* (Pediazole)
Oxycodone/Acetaminophen* (Percocet) (QL)
Sulfamethoxazole/Trimethoprim* (Bactrim)
Oxycodone/Aspirin* (Percodan)
Sulfisoxazole* (generic)
Tetracyclines .
Oxycodone* (Oxycontin)(QL)
Analgesics, Non-Narcotic .
Antipsychotic Agents .
Simvastatin* (Zocor) (80mg requires PA)
APAP/Isometheptene/Dichlphen* (Midrin)
Chlorpromazine* (Thorazine)
BETA-ADRENERGIC BLOCKERS _______________
Acetaminophen/Caffeine/Butalbital* (Fioricet)
Clomipramine* (Anafranil)
Acebutolol* (Sectral))
Aspirin/Caffeine/Butalbital* (Fiorinal)
Clozapine* (Clozaril)
Atenolol/Chlorthalidone* (Tenoretic)
Ergotamine/Caffeine* (Cafergot)
Fluphenazine* (Prolixin)
Bisoprolol/HCTZ* (Zebeta)
Naratriptan* (Amerge) (QL)
Haloperidol* (Haldol)
Carvedilol* (Coreg/CR)
Sumatriptan* (Imitrex)(QL)
Loxapine* (Loxitane)
Labetalol* (Trandate)
Tramadol* (Ultram)
Olanzapine* (Zyprexa)
Metoprolol/HCTZ* (Lopressor)(QL)
ANALGESICS, NONSTEROIDAL
Perphenazine* (Trilafon)
Metoprolol ER* (Toprol XL) (QL)
ANTI-INFLAMMATORY ________________________
Prochlorperazine* (Compazine)
Nadolol* (Corgard)
Diclofenac* (Voltaren)
Quetiapine* (Seroquel)
Pindolol* (Viskin)
Etodolac* (etodolac)
Propranolol/XL/HCTZ* (Inderal)
Fenoprofen* (Nalfon)
Risperidone* (Risperdal)
Sotalol* (Betapace)
Flurbiprofen* (Ansaid)
Thioridazine* (Mellaril)
Timolol* (Blocadren)
Ibuprofen* (Motrin)
Thiothixene* (Navane)
CALCIUM CHANNEL BLOCKERS ______________
Indomethacin* (Indocin)
Trifluoperazine* (Stelazine)
Amlodipine* (Norvasc)(QL)
Ketoprofen* (ketoprofen)
Ziprasidone* (Geodon)
Diltiazem* (Cardizem)
Ketorolac* (Toradol)
SEDATIVES, HYPNOTICS AND ANTI-ANXIETY ____
Felodipine* (Plendil)
Meloxicam* (Mobic)
Alprazolam* (Xanax)
Nicardipine* (Cardene)
Nabumetone* (nabumetone)
Buspirone* (BuSpar)
Nifedipine* (Procardia/Adalat CC)
Naproxen* (Naprosyn)
Chloral Hydrate* (Noctec)
Nimodipine* (Nimotop)
Oxaprozin* (Daypro)
Chlordiazepoxide* (Librium)
Verapamil* (Calan,Verelan)
Piroxicam* (Feldene)
Clorazepate* (generic)
CENTRALLY ACTING ANTIHYPERTENSIVES _____
Sulindac* (Clinoril)
Diazepam* (Valium)
Clonidine* (Catapres)
Tolmetin* (Tolectin)
Estazolam* (generic)
Methyldopa* (generic)
ANALGESICS, SALICYLATES __________________
Flurazepam* (flurazepam)
DIURETICS _________________________________
Aspirin* (generic)
Lorazepam* (Ativan)
Acetazolamide* (Diamox Sequels)
Chol Sal/Magnesium Salicylate* (generic)
Meprobamate* (Miltown)
Chlorthalidone* (Hygroton)
Diflunisal* (Dolobid)
Oxazepam* (Serax)
Ethacrynic Acid* (Edecrin)
Salsalate* (Disalcid)
Temazepam* (Restoril)
Eplerenone* (Inspra)
ANTICONVULSANTS _________________________
Triazolam* (Halcion)
Zalpelon* (Sonata) (QL)
Furosemide* (Lasix)
Carbamazepine* (Tegretol XR/generic)
Zolpidem* (Ambien/CR) (QL)
HCTZ/Triamterene* (Dyazide/Maxzide)
Clonazepam* (Klonopin)
Hydrochlorothiazide* (generic)
Divalproex Sodium* (Depakote
CARDIOVASCULAR AGENTS
Indapamide* (generic)
Methazolamide* (generic)
Ethosuximide* (Zarontin)
ANGIOTENSIN CONVERTING ENZYME
Metolazone* (Zaroxolyn)
Gabapentin* (Neurontin)
INHIBITORS AND RECEPTOR BLOCKERS &
Spironolactone/HCTZ* (Aldactone)
Fosphenytoin*(Cerebyx)
COMBINATIONS _____________________________
Torsemide* (Demadex)
Lamotrigine* (Lamictal)
Benazepril/HCTZ* (Lotensin)
Triamterene* (Dyrenium)
Levetiracetam* (Keppra)
Benazepril/Amlodipine* (Lotrel)(QL)
VASODILATORS ____________________________
Phenobarbital* (generic)
Captopril/HCTZ* (Capoten/Capozide)
Hydralazine* (Apresoline)
Phenytoin* (Dilantin/generic)
Enalapril/HCTZ* (Vasotec/Vaseretic)
Isosorbide Dinitrate* (Isordil)
Primidone* (Mysoline)
Fosinopril/HCTZ* (Monopril)
Isosorbide Mononitrate* (Imdur, Monoket)
Oxcarbazepine* (Trileptal)
Irbesartan/HCTZ* (Avapro/Avalide)
Minoxidil* (generic)
Topiramate* (Topamax)
Lisinopril/HCTZ* (Zestril/Zestoretic)
Nitroglycerin* (generic)
Valproic Acid* (Depakene)
Losartan/HCTZ* (Cozaar/Hyzaar) (QL)
Zonisamide* (Zonegran)
Moexipril/HCTZ* (Univasc/Uniretic)
DERMATOLOGICALS
ANTIPARKINSON AGENTS ____________________
Olmesartan (Benicar/ Benicar HCT)(ST)(QL)
ACNE _____________________________________
Amantadine* (Symmetrel)
Quinapril/HCTZ* (Accupril/Accuretic)
Clindamycin* (Cleocin)
Benztropine* (Cogentin)
Ramipril* (Altace/generic)
Erythromycin* (Emgel)
Bromocriptine* (Parlodel)
Trandolapril* (Mavik)
Isotretinoin* (Accutane)
Carbidopa/Levodopa* (Sinemet/CR)
Trandolapril/verapamil* (Tarka)
Metronidazole* (MetroLotion,MetroGel)
Pramipexole* (Mirapex)
Valsartan/HCTZ (Diovan/Diovan HCT)(ST)(QL)
Minocycline* (Minocin/Solodyne)
Ropinirole* (Requip)
ANTI-ADRENERGIC BLOCKERS ________________
Sodium Sulfacetamide* (Sulfacet-R)
Selegiline*(Eldepryl)
Doxazosin* (Cardura)
Tretinoin* (Retin-A) (MAX AGE 34)
Trihexyphenidyl* (Artane)
Prazosin* (Minipress)
ANTIBIOTICS/ANTIVIRALS ____________________
CEREBRAL STIMULANTS _____________________
Terazosin* (Hytrin)
Acyclovir* (Zovirax/generic)
Amphet Asp/Amphet/D-Amphet*
ANTIARRHYTHMICS _________________________
Metronidazole* (MetroGel/MetroLotion)
(Adderall/Adderall XR)(QL)(MIN AGE 3/6)
Amiodarone* (Cordarone)
Mupirocin* (Bactroban)
Dexmethylphenidate* (Focalin)
Digoxin* (Lanoxin)
Sodium Sulfacetamide* (Sulfacet-R)
Dextroamphetamine* (Dexedrine)
Disopyramide* (Norpace)
FUNGICIDES ________________________________
Methylphenidate ER* (Concerta)
Flecainide* (Tambocor)
Ciclopirox* (Loprox)
Methylphenidate* (Ritalin)
Mexiletine* (Mexitil)
Clotrimazole/Betamethazone* (Lotrisone)
PSYCHOTHERAPEUTIC AGENTS _______________
Procainamide* (Pronestyl)
Ketoconazole* (Nizoral)
Antidepressants .
Propafenone* (Rythmol)
Nystatin/Triamcinolone* (Mycolog II)
Amitriptyline* (Elavil)
Quinidine Gluconate* (Quinidex)
TOPICAL ANTI-INFLAMMATORY AGENTS _______
Bupropion/-XL* (Wellbutrin/XL)(QL)
Sotalol* (Betapace AF)
Low Potency .
Citalopram* (Celexa)(QL)
ANTICOAGULANTS/ANTITHROMBOTICS ________
Desonide* (Desowen)
Desipramine* (Norpramin)
Anagrelide* (Agrylin)
Fluocinolone* (Synalar)
Doxepin* (Sinequan)
Cilostazol* (Pletal)
Hydrocortisone* (generic)
Escitalopram* (Lexapro)
Clopidogrel* (Plavix)(QL)
Fluoxetine* (Prozac)
Dipyridamole* (Persantine)
Medium Potency .
Fluvoxamine* (Luvox)
Pentoxifylline* (Trental)
Desoximetasone* (Topicort)
Imipramine* (Tofranil)
Ticlopidine* (Ticlid)
Fluocinolone* (Synalar)
Mirtazapine* (Remeron)
Warfarin* (generic/Coumadin)
Mometasone* (Elocon)
Nortriptyline* (Norpramin)
ANTILIPEMICS ______________________________
Prednicarbate* (Dermatop E)
Paroxetine* (Paxil /CR) (QL)
Atorvastatin* (Lipitor)
Triamcinolone* (Aristocort)
Sertraline* (Zoloft)
Cholestyramine* (Questran)
High Potency .
Trazodone* (trazodone)
Colestipol* (Colestid)
Betamethasone Dipropionate* (Diprosone)
Venlafaxine* (Effexor XR/Effexor)(QL)
Fenofibrate* (Lofibra)
Fluocinonide* (Lidex)
Antimanic Agents .
Gemfibrozil* (Lopid)
Ultra-High Potency .
Lithium Carbonate* (Eskalith)
Lovastatin* (Mevacor)
Augmented Betamethasone* (Diprolene)
Lithium Citrate* (Cibalith-S)
Niacin* (Niaspan/generic)
Clobetasol* (Temovate)
Pravastatin* (Pravachol)
Diflorasone* (Psorcon)
VAGINAL/RECTAL PREPARATIONS _____________
HORMONES
Corticosteroids .
Hydrocortisone* (Proctocort)
Mesalamine* (Rowasa)
ANTIESTROGENS ___________________________
Budesonide* (Pulmicort)
Metronidazole* (MetroGel Vaginal)
Tamoxifen* (Nolvadex)
Sulfanilamide* (AVC)
AROMATASE INHIBITORS _____________________
MISCELLANEOUS DERMATOLOGICALS _________
Anastrozole* (Arimidex)
Fluticasone/Salmeterol (Advair/Advair HFA) Calcipotriene* (Dovonex)
Exemestane* (Aromasin)
Sympathomimetics .
Fluorouracil* (Efudex)
Letrozole* (Femara)
Lindane* (Kwell)
ESTROGENS ________________________________
Metaproterenol* (Alupent)
Permethrin* (Elimite)
Podofilox* (Condylox)
Estradiol* (Estrace)
Terbutaline* (Brethine)
Selenium Sulfide* (Selsun RX)
Estradiol Patch* (Climara)
Xanthine Derivatives .
Silver Sulfadiazine* (Silvadene)
Estropipate* (Ogen)
Aminophylline* (generic)
ENDOCRINE AGENTS
PROGESTINS _______________________________
Theophylline* (Uniphyl)
ANTIDIABETIC AGENTS-INJECTABLE ___________
Medroxyprogesterone* (Provera)
OTHER AGENTS ____________________________
Megestrol* (Megace)
Insulin (Novolin/Novolog/Levemir)
ANTIDIABETIC AGENTS-ORAL _________________
Norethindrone* (Aygestin)
Albuterol/Ipratropium* (DuoNeb)
MISCELLANEOUS HORMONE PRODUCTS _______
Cromolyn* (Intal)
Acarbose* (Precose)
Flutamide* (generic)
Chlorpropamide* (Diabinese)
Montelukast* (Singulair)(QL)(PA)
Glimepiride* (Amaryl)
OPHTHALMICS
Glipizide* (Glucotrol)
ALPHA-AGONIST ____________________________
NASAL MEDICATIONS________________________
Glipizide/Metformin* (Metaglip)
Brimonidine Tartrate* (Alphagan P)
Azelastine* (Astelin) (QL)
Glyburide/Metformin* (Glucovance)
Fluticasone* (Flonase)
Glyburide/Micronized* (Glynase)
ANTI-INFECTIVE AGENTS _____________________
Flunisolide* (Nasarel)(QL)
Metformin* (Glucophage)
Chloramphenicol* (generic)
Nateglinide* (Starlix)
Ciprofloxacin* (Ciloxin)
SKELETAL AGENTS
Pioglitazone* (Actos)
Erythromycin* (Romycin)
ANTIRHEUMATICS ___________________________
Pioglitazone/Metformin* (ActoPlus Met)
Gentamicin* (Garamycin)
Tolazamide* (Tolinase)
Neomycin/Bacitracin/Polymyxin* (NeoSporin)
Azathioprine* (Imuran)
Tolbutamide* (Orinase)
Ofloxacin* (Ocuflox)
Hydroxychloroquine* (Plaquenil)
ANTIDIABETIC SUPPLIES _____________________
Polymyxin B/Trimethoprim* (Polytrim)
Methotrexate* (Rheumatrex)
Sulfacetamide* (Bleph-10)
BONE ENHANCING AGENTS __________________
Accu-Chek Meters and Test Strips (QL)
Tobramycin* (Tobrex)
One Touch Meters and Test Strips (QL)
Alendronate* (Fosamax)(QL)
ANTITHYROID _______________________________
ANTI-INFLAMMATORY AGENTS ________________
Calcitonin-Salmon* (Midrin)
Cromolyn* (Opticrom)
Etidronate* (Didronel)
Methimazole* (Tapazole)
Dexamethasone* (Maxidex)
Propylthiouracil* (generic)
THYROID ___________________________________
Diclofenac* (Voltaren)
SKELETAL MUSCLE RELAXANTS
Fluorometholone* (Flarex)
Levothyroxine* (Synthroid, Levothroid, Levoxyl,
Flurbiprofen* (Ocufen)
Baclofen* (Lioresal)
Prednisolone* (Inflamase Forte)
Carisoprodol* (Soma)
Thyroid* (Armour Thyroid)
ANTI-INFECTIVE AND
Cyclobenzaprine* (Amrix/Fexmid/Flexeril)
GASTROINTESTINAL AGENTS
ANTI-INFLAMMATORY COMBINATIONS _________
Diazepam* (Valium)
Methocarbamol* (Robaxin)
ANTIEMETIC/ANTIVERTIGO ___________________
Na Sulfacetm/Prednisolone* (Vasocidin)
Tizanidine* (Zanaflex)
Granisetron* (Kytril)
Neomy/Bacitracin/Polymyxin/Hydrocort*
Meclizine* (Antivert)
URINARY AGENTS
Metoclopramide* (Reglan)
Neomycin/Dexamethasone* (NeoDecadron)
ANTI-INFECTIVES ___________________________
Ondansetron* (Zofran)
Neomycin/Polymyx B/Dexamethasone*
Prochlorperazine* (Compazine)
Sulfadiazine* (generic)
Promethazine* (Phenergan)
ANTIVIRAL AGENTS _________________________
Sulfisoxazole* (Gantrisin)
Trimethobenzamide* (Tigan)
Trifluridine* (Viroptic)
Trimethoprim/Sulfamethoxazole* (Bactrim,
ANTISPASMODIC/GI MOTILITY _________________
BETA-BLOCKERS ___________________________
CHOLINERGIC AGENTS ______________________
Belladonna/Phenobarbital* (Donnatal)
Betaxolol* (Betoptic)
Clidinium/Chlordiazepoxide* (Librax)
Carteolol* (Ocupress)
Bethanechol* (Urecholine)
Dicyclomine* (Bentyl)
Levobunolol* (Betagan)
Flavoxate* (Urispas)
Hyoscyamine* (Levsin)
Metipranolol* (OptiPranolol)
OTHER URINARY AGENTS ____________________
Propantheline* (Pro-Banthine)
Timolol* (Timoptic)
Doxazosin* (generic)
ANTIULCER ________________________________
MIOTICS ___________________________________
Finasteride* (Proscar) (QL)
Misoprostol* (Cytotec)
Phenazopyridine* (Pyridium)
Dorzolamide* (Trusopt)
Prazosin* (generic)
OTHER GI PRODUCTS ________________________
Dorzolamide/timolol* (Cosopt)
Oxybutynin*/Ex rel* (Ditropan/XL) (QL)
Tamsulosin* (Flomax)
Balsalazide* (Colazal)
Latanoprost* (Xalatan)
Terazosin* (generic)
Lactulose* (Cephulac)
Pilocarpine* (Isopto Carbachol)
Tolterodine* (Detrol)
Mesalamine* (Asacol/Asacol HD/generic)
MYDRIATICS ________________________________
Trospium* (Sanctura) (QL)
Atropine* (Isopto Atropine)
Sulfasalazine* (Azulfidine)
Cyclopentolate* (Cyclogyl)
Ursodiol* (Actigall)
Homatropine* (Isopto Homatropine)
VITAMINS AND ELECTROLYTES
SYMPATHOMIMETICS ________________________
Prenatal Vitamins requiring prescription* GLUCOCORTICOIDS
Dipivefrin* (generic)
Dexamethasone* (Decadron)
Fludrocortisone* (Florinef)
GS REQUIRIN
Methylprednisolone* (generic)
ANTI-INFECTIVE AGENTS _____________________
Prednisolone* (Prelone)
Acetic Acid* (Vosol)
Prednisone* (generic)
Acetic Acid/Benzethonium* (generic)
Ofloxacin* (Floxin)
GOUT THERAPY
ANTI-INFECTIVE AND
Allopurinol* (Zyloprim)
ANTI-INFLAMMATORY COMBINATIONS _________
G STEP THERAPY UGS REQUIRING
Acetic acid/Hydrocortisone*(Vosol HC)
Colchicine/Probenecid* (generic)
Neomycin/Polymxin/HC* (Cortisporin)
Indomethacin* (Indocin)
Probenecid* (generic)
RESPIRATORY
ANTI-ASTHMATIC AGENTS ____________________

Source: http://www.lourdeshealth.net/assets-lhn/pdf/benefits/Rx%20Formulary%202013.pdf