Dermatologicals

BRAND GENERIC BRAND
Antifungal Agents. . . . . . . . . . . . . . . . . . . . . . . . . .
EXPECTORANT AND COUGH PRODUCTS---------
Griseofulvin Microsize Susp generics only INTRODUCTION
ANTIVIRALS ---------------------------------------------------
This condensed formulary is designed to serve as Promethazine/Codeine or DM generics only Promethazine/Phenylephrine generics only a reference guide and assist in the selection of Promethazine/Phenylephrine/ generics only cost-effective pharmaceutical products. This is not a complete list of drugs on the Formulary and Triprolidine/Pseudoephedrine/ generics only listing is not a guarantee of coverage. Formulary listings are subject to change. Drug designation NASAL CORTICOSTEROIDS ----------------------------
by category is for reference only and not clinical comparison. This formulary is not intended to be a substitute for the clinical knowledge and judgment NASAL ANTIHISTAMINES --------------------------------
of the medical practitioner in their choice of drug therapy. In all cases, the prescriber is expected to OTHER NASAL AGENTS ---------------------------------
select appropriate drug therapy for the individual patient and provide high quality healthcare. Self-administered oral antiretroviral products will be ANTI-INFECTIVE AGENTS (ORAL)
added to the formulary as they come to market. Therapeutics Committee will regularly review the ANTHELMINTICS --------------------------------------------
AUTONOMIC & CENTRAL NERVOUS SYSTEM
formulary to ensure it meets the needs of both patients and providers. Thank you in advance for ALZHEIMER’S AGENTS -----------------------------------
ANTIBIOTICS--------------------------------------------------
Cephalosporins. . . . . . . . . . . . . . . . . . . . . . . . . . . .
ANALGESICS, NARCOTIC -------------------------------
ANTIDIABETIC AGENTS
INSULINS ------------------------------------------------------
Rapid-Acting Insulins . . . . . . . . . . . . . . . . . . . . . . .
Ketolides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Macrolides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Intermediate-Acting Insulins . . . . . . . . . . . . . . . . .
Erythromycin Ethylsuccinate generics only Long-Acting Insulins . . . . . . . . . . . . . . . . . . . . . . . .
Penicillins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ORAL --------------------------------------------------------------
ANALGESICS, NONSTEROIDAL ANTI-
Quinolones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
INFLAMMATORY ------------------------------------------
Sulfonamides . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tetracyclines . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other Anti-Infectives. . . . . . . . . . . . . . . . . . . . . .
*Arthrotec, Celebrex, and Flector are available at OTHER ANTIDIABETIC AGENTS ------------------------
ANALGESICS, OTHER --------------------------
*Lidoderm is available at the highest brand copay. ANALGESICS, SALICYLATES --------------------------
ANTIHISTAMINE / DECONGESTANTS
BRAND GENERIC BRAND GENERIC BRAND
ANTICONVULSANTS -------------------------------------
ANTILIPEMICS ---------------------------------------------------
Antimanic Agent . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Antipsychotic Agents . . . . . . . . . . . . . . . . . . . . . . . .
CALCIUM CHANNEL BLOCKERS -------------------------
ANTIPARKINSON AGENTS ------------------------------
COMBINATION ANTIHYPERTENSIVES ------------------
CARDIOVASCULAR AGENTS
ANXIOLYTICS, SEDATIVES, AND HYPNOTICS
ALDOSTERONE ANTAGONISTS -------------------------
ANGIOTENSIN II ANTAGONISTS -------------------------
DIRECT RENIN INHIBITORS--------------------------------
ANGIOTENSIN CONVERTING ENZYME INHIBITORS DIURETICS -------------------------------------------------------
CEREBRAL STIMULANTS ------------------------------
ANTI-ADRENERGIC AGENTS – BETA-BLOCKERS --
VASODILATORS -------------------------------------------------
*Provigil and Nuvigil are available at the highest ANTI-ADRENERGIC BLOCKERS – CENTRALLY
DMARDS --------------------------------------------------------
ACTING -------------------------------------------------------------
ANTI-ADRENERGIC BLOCKERS – PERIPHERALLY
ACTING-------------------------------------------------------------
MIGRAINE AGENTS------------------------------------------
ANTIARRHYTHMICS ------------------------------------------
CONTRACEPTIVES
MONOPHASIC --------------------------------------------------
OBSESSIVE COMPULSIVE DISORDER AGENTS---
PSYCHOTHERAPEUTIC AGENTS -----------------------
Antidepressants . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ANTICOAGULANTS/ANTITHROMBOTICS ------------
BRAND GENERIC BRAND GENERIC BRAND
Alclometasone Dipropionate generics only OTHER GI PRODUCTS ----------------------------------------
High Potency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
BI-PHASIC ---------------------------------------------------------
Highest Potency . . . . . . . . . . . . . . . . . . . . . . . . . . . .
*Amitiza is available at the highest brand copay. GOUT AGENTS
TRI-PHASIC -------------------------------------------------------
Clobetasol Propionate/Emol Olux-E/ Olux-Olux-E OTHER DERMATOLOGICALS ------------------------------
HORMONES
ANDROGENS ----------------------------------------------------
PROGESTIN ONLY ----------------------------------------------
EMERGENCY CONTRACEPTION --------------------------
ANTIESTROGENS/ANTIANDROGENS -------------------
CONTRACEPTIVE DEVICES ---------------------------------
DIAGNOSTICS
ESTROGENS --------------------------------------------------
CORTICOSTEROIDS
Formulary glucose test strips and meters include brands from Johnson & Johnson and Roche, such Prednisolone Tablets/Liquid generic/Orapred ** Step Therapy Required for some plans. GASTROINTESTINAL AGENTS
DERMATOLOGICALS
ANTIEMETIC/ ANTIVERTIGO --------------------------------
ACNE ----------------------------------------------------------------
ESTROGEN AND ANDROGEN COMBINATIONS -----
Sodium sulfacetamide/Sulfur generics only ESTROGEN AND PROGESTERONE
COMBINATIONS -----------------------------------------------
ANTIBIOTICS -----------------------------------------------------
Estradiol/Norethindrone generic/Activella ANTISPASMODIC/ GI MOTILITY ----------------------------
FERTILITY REGULATORS -----------------------------------
ANTIVIRALS ------------------------------------------------------
FUNGICIDES ------------------------------------------------------
ANTIULCER -------------------------------------------------------
GROWTH HORMONE ------------------------------------------
PROGESTINS -----------------------------------------------------
TOPICAL ANTI-INFLAMMATORY AGENTS -------------
Low Potency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
BOWEL EVACUANTS ------------------------------------------
DIGESTANTS -----------------------------------------------------
SELECTIVE RECEPTOR MODULATORS ----------------
Intermediate Potency . . . . . . . . . . . . . . . . . . . . . . . . .
BRAND GENERIC BRAND GENERIC BRAND
IMMUNOLOGIC AGENTS
OSTEOPOROSIS AGENTS
URINARY AGENTS
* All of the following are available at the highest brand copay: Avonex, Betaseron, Copaxone, and VAGINAL PREPARATIONS
IMPOTENCE AGENTS
OPHTHALMICS
RESPIRATORY/ASTHMA
ANTI-ALLERGIC AGENTS ------------------------------------
MISCELLANEOUS AGENTS
ANTI-ASTHMATIC AGENTS ---------------------------------
Antileukotrienes . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Corticosteroids . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ANTI-GLAUCOMA AGENTS----------------------------------
Fluticasone Inhaler/Rotadisk Flovent HFA/Diskus Sympathomimetics . . . . . . . . . . . . . . . . . . . . . . . . .
ANTI-INFECTIVE/ANTIVIRAL AGENTS -------------------
Xanthine Derivatives . . . . . . . . . . . . . . . . . . . . . . . .
OTHER RESPIRATORY/ASTHMA AGENTS ------------
* All of the following are available at the highest brand copay: Leukine, Neulasta, and Neupogen. ** Self-administered oral immunosuppressants and ANTI-INFECTIVE AND ANTI-INFLAMMATORY
antineoplastics will be added to the formulary as COMBINATIONS -------------------------------------------------
SKELETAL MUSCLE RELAXANTS
Tobramycin/Dexamethasone generic/Tobradex ANTI-INFLAMMATORY AGENTS ---------------------------
_________________________________________ BETA-BLOCKERS ----------------------------------------------
Administered by:
THYROID AND ANTITHYROID AGENTS
WellPoint NextRx 8407 Fallbrook Avenue / West Hills, CA 91304 WellPoint NextRx is a division of WellPoint, Inc. and is also a VASOCONSTRICTORS ----------------------------------------
registered service mark of WellPoint, Inc. WellPoint NextRx Services are provided by a WellPoint PBM (either NextRx Services, Inc. or NextRx, LLC, as applicable). MISCELLANEOUS OPHTHALMIC AGENTS ------------

Source: http://www.scripformulary.com/clientpages/wellpoint.pdf