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Printed formulary catalog basic


Scripps Health Formulary
April 2016 Foreword
Pharmacy and Therapeutics Committee. MedImpact approves such multi-
This document represents the efforts of the MedImpact Healthcare Systems
source drugs for addition to the MAC list based on the following criteria: Pharmacy and Therapeutics (P & T) and Formulary Committees to provide physicians • A multi-source drug product manufactured by at least one (1) nationally and pharmacists with a method to evaluate the safety, efficacy and cost-effectiveness marketed company. of commercially available drug products. A structured approach to the drug selection • At least one (1) of the generic manufacturer's products must have an "A" process is essential in ensuring continuing patient access to rational drug therapies. rating or the generic product has been determined to be unassociated with The ultimate goal of the Portfolio Formulary is to provide a process and framework to efficacy, safety or bioequivalency concerns by the MedImpact P & T
support the dynamic evolution of this document to guide prescribing decisions that reflect the most current clinical consensus associated with drug therapy decisions. • Drug product will be approved for generic substitution by the MedImpact
P & T Committee. This is accomplished through the auspices of the MedImpact P & T and Formulary
Committees. These committees meet quarterly and more often as warranted to ensure This list is reviewed and updated periodically based on the clinical literature and clinical relevancy of the Formulary. To accommodate changes to this document, pharmacokinetic characteristics of currently available versions of these drug updates are made accessible as necessary. As you use this Formulary, you are encouraged to review the information and provide If a member or physician requests a brand name product in lieu of an approved your input and comments to the MedImpact P & T and Formulary Committees.
generic, the member, based upon their coverage, will typically be required to pay the difference in cost between the brand and the generic. If a physician The MedImpact P & T and Formulary Committees use the following criteria in the
determines that there is a documented medical need for the brand equivalent, a evaluation of drug selection for the Portfolio Formulary: request for coverage may be made using the medication request process. Drug safety profile • Drug efficacy 2. Three Tier Benefit
• Comparison of relevant therapeutic benefits to current formulary agents of The Formulary may be applied to a three tier benefit design, where the member similar use, and to minimize therapeutic duplication where possible shares the cost of prescription drug therapy at three levels of copayment. In • Cost-effectiveness relative to comparable therapies most instances, generically available drugs will be covered under the first or lowest copay tier, branded drugs listed on the Formulary will be covered under How to Use the Formulary
the second copay tier, and branded drugs not on the Formulary will be covered The Formulary is a list of medications available to MedImpact members under their
under the third or highest copay tier. pharmacy benefit. All drugs are listed by their generic names and most common 3. Medication Request Process
proprietary (branded) name. The Formulary may be accessed by using the index, Depending upon plan benefit design, a medication request process may apply either by generic or proprietary name (in capital letters) and by therapeutic drug category. In situations where an FDA approved generic equivalent is available, brand A. Formulary Agents
names are listed for reference purposes only, and do not denote coverage for the Drugs that are listed in the Formulary with associated Prior Authorization brand, unless specifically noted. Any drug not found in this Formulary listing, or any (PA) require evaluation, per MedImpact P & T Committee Prior
Formulary updates published by MedImpact shall be considered a Non-Formulary
Authorization guidelines prior to dispensing at a network pharmacy. Each request will be reviewed on an individual patient need basis. If the request does not meet the guidelines established by the P & T Committee, the All drugs are listed in each category in alphabetical order by generic name. Where an request will not be approved and alternative therapy may be FDA approved generic is available for the listed generic name, the generic name is B. Non-Formulary Agents
For certain agents within the Formulary, a recommended prescribing guideline may Any drug not found in the Formulary listing, or any Formulary updates apply. These are denoted throughout the document using the following symbols: published by MedImpact, shall be considered a Non-Formulary drug.
Coverage for non-formulary agents may be applied for in advance. When Coverage may depend on patient age a member gives a prescription order for a non-formulary drug to a Coverage or lack thereof may depend upon pharmacist, the pharmacist will evaluate the patient's drug history and concurrent use of another drug contact the physician to determine if there is a reasonable medical need Coverage may depend on patient gender for a non-formulary drug. Each request will be reviewed on an individual Coverage may depend on prescribing physician's patient need basis. Approval will be given if a documented medical need specialty or board certification exists. The following basic guidelines are used: • The use of Formulary Drugs is contraindicated in the patient. Requires specific physician request process • The patient has failed an appropriate trial of Formulary or related • The choices available in the Formulary are not suited for the present Coverage may be limited to specific quantities patient care need, and the drug selected is required for patient per prescription and/or time period Coverage may depend on previous use of another • The use of a Formulary drug may provoke an underlying condition, which would be detrimental to patient care. Please refer to the prescribing guideline appendix within this document for details If the request does not meet the guidelines established by the P & T regarding specific agents. Committee, the request will not be approved and alternative therapy may Benefit Coverage and Limitations
C. Obtaining Coverage
This printed Formulary does not provide information regarding the specific coverage Coverage, questions or information regarding the medication request or and limitations an individual member may be subject to. Many members have specific formulary process may be obtained by: benefit inclusions, exclusions, copays, or a lack of coverage, which are not reflected in 1. Faxing a completed Medication Request Form to MedImpact at
2. Contacting MedImpact at (800) 788-2949 and providing all
The Formulary applies only to outpatient drugs provided to members, and does not necessary information requested. apply to medications used in inpatient settings. If a member has any specific questions regarding their coverage, they should contact their Plan Sponsor or MedImpact will provide an authorization number, specific for the medical
MedImpact at (800) 788-2949.
need, for all approved requests. Non-approved requests may be appealed. The prescriber must provide information to support the appeal Depending upon a member's specific benefit parameters, the following topics
on the basis of medical necessity. Prior Authorization is generally not may apply:
available for drugs that are specifically excluded by benefit design. 1. Generic Substitution
When available, FDA approved generic drugs are to be used in all situations, 4. General Exclusions
regardless of the brand name indicated. The generic names are bolded in the
A. Over the Counter (OTC) medications or their equivalents, unless otherwise formulary listing wherever an FDA approved generic drug product is available. specified in the Formulary listing. Greater economy is realized through the use of generic equivalents. This policy B. Nicotine Smoking Cessation products (i.e., transdermal nicotine, nicotine is not meant to preclude or supplant any state statutes that may exist. All drugs gum, nicotine inhaler). that are or become available generically are subject to review by MedImpact's
C. Drugs specifically listed as not covered. 804 Portfolio High Formulary – April 2016 Scripps Health Formulary
D. Any drug products used for cosmetic purposes. E. Experimental drug products or any drug product used in an experimental F. Replacement of lost or stolen medication. G. Non self-administered injectable drug products unless otherwise specified in the Formulary listing. H. Foreign sourced drugs or drugs not approved by the United States Food & Drug Administration. The P & T and Formulary Committees recognize that not all medical needs can be met with this document and encourage inquiries about alternative therapies. 5. Pharmacist and Physician Communication
The Formulary is a tool to promote cost-effective prescription drug use. The P &
T and Formulary Committees have made every attempt to create a document
that meets all therapeutic needs; however, the art of medicine makes this a
formidable task. MedImpact welcomes the participation of physicians,
pharmacists, and ancillary medical providers, in this dynamic process.
Physicians and pharmacists are highly encouraged to direct any suggestions,
comments or formulary additions to MedImpact at the following address:
Chairperson, Pharmacy & Therapeutics Committee MedImpact Healthcare Systems, Inc.
10181 Scripps Gateway Court San Diego, CA 92131 Portfolio High Formulary – April 2016 Scripps Health Formulary
Antihyperlipidemic - MTP Inhibitors . 8 Generic Substitution . i Bile Salt Sequestrants . 8 Three Tier Benefit . i Medication Request Process . i Niacin Preparations . 9 General Exclusions . i CARDIOVASCULAR DISEASE - MISCELLANEOUS AGENTS . 9 Pharmacist and Physician Communication . ii Adrenergic Vasopressor Agents . 9 Antianginal & Anti-Ischemic Agents, Non-Hemodynamic . 9 Allergenic extracts . 6 Antihyperlipidemia - HMG-CoA & Calcium Channel Blocker Combinations . 9 2nd Geneneration Antihistamine & Decongestant Combinations . 6 Heart Rate Reducing, Selective I(F) Current Inhib. 9 Antihistamines - 1st Generation . 6 CARDIOVASCULAR DISEASE - VASODILATION . 9 Antihistamines - 2nd Generation . 6 Vasodilators, Combination . 9 Nasal Anti-Inflammatory Steroids . 6 Vasodilators, Coronary . 9 Nasal Antihistamine . 6 CONTRACEPTION/OXYTOCICS . 9 ANTIEMESIS/ANTIVERTIGO . 6 Contraceptives, Intravaginal, Systemic . 9 Antiemetic/Antivertigo Agents . 6 Contraceptives, Oral . 9 Contraceptives, Transdermal . 9 Beta-Adrenergic Agents . 6 Beta-Adrenergic & Anticholinergic Combinations . 6 COUGH AND COLD . 9 Beta-Adrenergic & Glucocorticoid Combinations . 6 1st Generation Antihistamine & Decongestant Combinations. 9 General Bronchodilator Agents . 6 Narcotic Antitussive-1st Geneneration Antihistamine-Decongestants . 9 Leukotriene Receptor Antagonists . 6 Narcotic Antitussive-1st Generation Antihistamines . 9 Mast Cell Stabilizers . 6 Narcotic Antitussive-Anticholinergic Comb. 9 Oral Inhaled Corticosteroids . 6 Non-Narcotic Antitussive-1st Generation Antihistamine Combinations . 9 Phosphodiesterase-4 (PDE4) Inhibitors . 6 DERMATOLOGY - ACNE . 9 Acne Agents, Systemic . 9 AUTONOMIC NERVOUS SYSTEM DISORDERS . 6 Acne Agents, Topical . 9 Alzheimer's Therapy, Nmda Receptor Antagonists . 6 Keratolytic-Glucocorticoid Combinations . 9 Alzheimer's Therapy, Nmda Receptor Antagonists & Cholines Inhibitors . 6 Keratolytics . 9 Cholinesterase Inhibitors . 6 Rosacea Agents, Topical . 9 BEHAVIORAL HEALTH - ANTIDEPRESSANTS . 6 Vitamin A Derivatives . 9 Alpha-2 Receptor Antagonist Antidepressants . 6 DERMATOLOGY - ANTIINFECTIVE . 9 Maois - Non-Selective & Irreversible . 6 Topical Antibiotics . 9 Norepinephrine & Dopamine Reuptake Inhibitors (NDRIs) . 6 Topical Antifungals . 10 Selective Serotonin Reuptake Inhibitors (SSRIs) . 6 Topical Antiparasitics . 10 SSRI & Antipsycho, Atyp, Dopamine & Serotonin Antag Comb . 6 Topical Antivirals . 10 Serotonin-2 Antagonist/Reuptake Inhibitors (SARIs). 6 Topical Sulfonamides . 10 Serotonin-Norepinephrine Reuptake-Inhib (SNRIs) . 6 DERMATOLOGY - ANTIINFLAMMATORY . 10 Tricyclic Antidepressants & Rel. Non-Sel. Ru-Inhib . 7 Topical Anti-Inflammatory Steroidal . 10 BEHAVIORAL HEALTH - OTHER . 7 Topical Anti-Inflammatory, NSAIDs . 10 Adrenergics, Aromatic, Non-Catecholamine . 7 Topical Antibiotics/Antiinflammatory, Steroidal . 10 Anti-Alcoholic Preparations . 7 DERMATOLOGY - MISCELLANEOUS . 10 Anti-Anxiety Drugs . 7 Antiperspirants . 10 Anti-Mania Drugs . 7 Antiseborrheic Agents . 10 Antipsychotics, Phenothiazines . 7 Topical Antineoplastic & Premalignant Lesion Agents . 10 Antipsychotics, Atypical, D2 Partial Agonist/5HT Mixed . 7 Topical Local Anesthetics . 10 Antipsychotics, Dopamine & Serotonin Antagonists . 7 DERMATOLOGY - PIGMENTATION DISORDERS . 10 Antipsychotics, Atypical, Dopamine, & Serotonin Antagonists . 7 Topical Hyperpigmentation Agents . 10 Antipsychotics, Dopamine Antagonists, Thioxanthenes . 7 DERMATOLOGY - PSORIASIS/ECZEMA . 10 Antipsychotics, Dopamine Antagonists, Butyrophenones . 7 Antipsoriatic Agents, Systemic . 10 Barbiturates . 7 Antipsoriatics Agents . 10 Narcolepsy and Sleep Disorder Therapy Agents . 7 Topical Immunosuppressive Agents . 10 Narcotic Antagonists . 7 Sedative-Hypnotics, Non-Barbiturate . 7 Antihyperglycemic, Alpha-Glucosidase Inhibitors (Non-Sulfonylurea) . 10 Treatment for Attention Deficit-Hyperactivity (ADHD)/Narcolepsy . 7 Antihyperglycemic, Amylin Analog-Type . 10 Treatment for Attention Deficit-Hyperactivity (ADHD), Nri-Type . 7 Antihyperglycemic, DPP-4 Inhibitors . 10 CARDIOVASCULAR DISEASE - ARRHYTHMIA . 7 Antihyperglycemic, DPP-4 Inhibitor & Biguanide Combinations . 10 Antiarrhythmics . 7 Antihyperglycemic, Incretin Mimetic (GLP-1 Receptor Agonists) . 10 CARDIOVASCULAR DISEASE - CARDIAC STIMULANTS . 7 Antihyperglycemic, Insulin-Release Stimulant Type . 10 Digitalis Glycosides . 7 Antihyperglycemic, Insulin-Response Enhancer (Non-Sulfonylurea) . 11 CARDIOVASCULAR DISEASE - HYPERTENSION . 7 Antihyperglycemic, Biguanide Type (Non-Sulfonylurea) . 11 ACE Inhibitor/Calcium Channel Blocker Combinations . 7 Antihyperglycemic, Insulin-Rel Stim.& Biguanide Combinations . 11 ACE Inhibitor/Thiazide & Thiazide-Like Diuretics . 7 Antihyperglycemic, Insulin-Response & Release Combinations . 11 Alpha-Adrenergic Blocking Agents . 8 Antihyperglycemic Insul-Resp. Enhancer & Biguanide Combinations . 11 Alpha/Beta-Adrenergic Blocking Agents . 8 Antihyperglycemic-Glucocorticoid Receptor Blockers. 11 Angiotensin Receptor Antagonist/Calcium Channel Blocker/Thiazide Antihyperglycemic-Sod/Gluc Cotransport2 (SGLT2) Inhibitors . 11 Combinations . 8 Antihyperglycemic, Sodium/Glucose Cotransport-2 (SGLT2) Inhibitor and Angiotensin Receptor Antagonist/Thiazide Diuretic Combinations . 8 Biguanide Combination . 11 Angiotensin Receptor Antagonist & Calcium Channel Blockers . 8 Antihyperglycemic, SGLT-2 & DPP-4 Inhibitor Combination . 11 Antihypertensives, ACE Inhibitors . 8 Diabetic Supplies . 11 Antihypertensives, Angiotensin Receptor Antagonist . 8 Diabetic Ulcer Preparations, Topical . 11 Antihypertensives, Sympatholytic . 8 Hyperglycemics . 11 Antihypertensives, Vasodilators . 8 Beta-Adrenergic Blocking Agents . 8 Syringes & Accessories . 11 Beta-Adrenergic Blocking Agents/Thiazide & Related . 8 EAR - GENERAL DISORDERS . 11 Calcium Channel Blocking Agents . 8 Ear Preparations, Misc. Anti-Infectives . 11 Loop Diuretics . 8 Ear Preparations, Antibiotics . 11 Potassium Sparing Diuretics . 8 Otic Preparations, Anti-Inflammatory-Antibiotics . 11 Potassium Sparing Diuretics in Combination . 8 Otic Preparations, Local anesthetics . 11 Pulmonary Anti-HTN, Sel. C-GMP Phosphodiesterase T5 Inhibitors . 8 ELECTROLYTE REGULATION . 11 Pulmonary Anti-HTN, Endothelin Receptor Antagonists . 8 Electrolyte Depleters . 11 Pulmonary Anti-HTN, Prostacyclin-Type . 8 Potassium Replacement . 11 Pulmonary Anti-HTN, Soluble Guanylate Cyclase Stimulators . 8 ENDOCRINE DISORDER - FERTILITY . 11 Thiazide & Related Diuretics . 8 Drugs to Treat Impotency . 11 CARDIOVASCULAR DISEASE - LIPID IRREGULARITY . 8 Fertility Stimulating Preparations, Non-FSH . 11 Antihyperlipidemic - APO B-100 Synthesis Inhibitor . 8 Follicle Stimulating / Luteinizing Hormones . 11 Antihyperlipidemic - HMG CoA Reductase Inhibitors . 8 Pregnancy Facilitating/Maintaining Agents, Hormonal. 11 Antihyperlipidemic - HMG CoA Reductase Inhibitors & Niacin . 8 ENDOCRINE DISORDER - OTHER . 11 Portfolio High Formulary – April 2016 Scripps Health Formulary
Antineoplastic LHRH (GNRH) Agonists, Pituitary Suppressants . 11 Antivirals, HIV-Specific, CCR5 Co-Receptor Antag. 14 Antidiuretic & Vasopressor Hormones . 11 Antivirals, HIV-Specific, Fusion Inhibitors . 14 Bone Formation Stim. Agents - Parathyroid Hormone . 11 Antivirals, HIV-Specific, Non-Nucleoside, RTI . 14 Bone Resorption Inhibitor & Vitamin D Combinations . 11 Antivirals, HIV-Specific, Nucleoside Analog, RTI . 14 Bone Resorption Inhibitors . 11 Antivirals, HIV-Specific, Nucleotide Analog, RTI . 15 Growth Hormone Receptor Antagonists . 12 Antivirals, HIV-Specific, Protease Inhibitor Comb . 15 Growth Hormones . 12 Antivirals, HIV-Specific, Protease Inhibitors . 15 Hyperparathyroid Tx Agent, Vitamin D Analog-Type . 12 Antivirals, HIV-1 Integrase Strand Transfer Inhibtors. 15 LHRH (GnRH) Antagonist, Pituitary Suppressant Agents . 12 Antiviral Combination Nucleoside, Nucleotide & Non-Nucleoside RTI . 15 Luteinizing Hormone Releasing Hormone –LHRH (GnRH) . Error! Bookmark
Cytochrome P450 Inhibitors . 15 not defined.
Hepatitis B Treatment Agents . 15 Pituitary Suppressive Agents . 12 Hepatitis C Combination Agents. 15 ENDOCRINE DISORDER - THYROID . 12 Hepatitis C Treatment Agents . 15 Antithyroid Preparations . 12 INFLAMMATORY DISEASE . 15 Iodine Containing Agents . 12 Anti-Arthritic & Chelating Agents . 15 Thyroid Hormones . 12 Anti-Arthritic, Folate Antagonist Agents . 15 EYE - GENERAL DISORDERS . 12 Anti-Inflammatory Tumor Necrosis Factor Inhibitor . 15 Eye Antibiotic-Corticoid Combinations . 12 Anti-Inflammatory, Pyrimidine Synthesis Inhibitors . 15 Eye Antihistamines . 12 Bradykinin B2 Receptor Antagonists . 15 Eye Antiinflammatory Agents . 12 Glucocorticoids . 15 Eye Antivirals . 12 Mineralocorticoids . 15 Eye Sulfonamides . 12 Monoclonal antibody-human interleukin . 15 EYE - MISCELLANEOUS . 12 NSAIDs, Cyclooxygenase Inhibitor-Type . 15 Ophthalmic Cystine Delpleting Agents . 12 LOCAL ANESTHESIA . 15 Ophthalmic Anti-Inflammatory Immunomodulator-Type . 12 Local Anesthetics . 15 Ophthalmic Antibiotics . 12 LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMAT . 15 Ophthalmic Mast Cell Stabilizers . 12 Bowel Antiinflamatory Agents . 15 EYE - GLAUCOMA . 12 Chronic Inflam. Colon Dx, 5-A-Salicylat, Rectal Tx . 15 Carbonic Anhydrase Inhibitors . 12 Drug Tx-Chronic Inflam. Colon Dx, 5-Aminosalicylat . 15 Miotics/Other Intraoccula Pressure Reducers . 12 Hemorrhoidal Preparations . 15 Rectal Preparations . 15 GOUT AND RELATED DISEASES . 13 Rectal/Lower Bowel Prep., Glucocort. (Non-Hemorr) . 15 LOWER GASTROINTESTINAL DISORDERS - OTHER . 15 Hyperuricemia Treatment - Purine Inhibitors . 13 Ammonia Inhibitors . 15 Uricosuric Agents . 13 Antidiarrheals . 15 HEMATOLOGICAL DISORDERS . 13 Anticoagulants, Coumarin Type . 13 Laxatives & Cathartics . 16 Hematinics, Other . 13 Narcotic Antagonists, Peripherally-Acting . 16 Hemorrheologic Agents . 13 MISCELLANEOUS AGENTS . 16 Heparin & Related Preparations . 13 Anaphylaxis Therapy Agents . 16 Leukocyte (WBC) Stimulants . 13 Parasympathetic Agents . 16 Platelet Aggregation Inhibitors . 13 Pku Tx Agent-Cofactor Of Phenylalanine Hydroxylase. 16 Platelet Reducing Agents . 13 NEOPLASTIC DISEASE . 16 Thrombopoietin Receptor Agonists . 13 Alkylating Agents. 16 Vitamin K Preparations . 13 Antiandrogenic Agents . 16 HORMONAL DEFICIENCY. 13 Antimetabolites . 16 Androgenic Agents . 13 Antineoplastic - Aromatase Inhibitors . 16 Estrogen/Androgen Combinations . 13 Antineoplastic – Hedgehog Pathway Inhibitors. 16 Estrogenic Agents . 13 Antineoplastic – Janus Kinase (JAK) Inhibitors . 16 Progestational Agents . 13 Antineoplastic - MEK1 and MEK2 Kinase Inhibitors . 16 IMMUNOSUPPRESSION/MODULATION. 13 Antineoplastic - Topoisomerase I Inhibitors . 16 Immunomodulators . 13 Antineoplastic - Immunomodulator Agents . 16 Immunosuppressives . 13 Antineoplastic - Systemic Enzyme Inhibitors . 16 INFECTIOUS DISEASE - BACTERIAL . 13 Antineoplastic, Histone Deacetylase Inhibitors, HDIS . 16 Absorbable Sulfonamides . 13 Antineoplastics, Miscellaneous . 16 Betalactams . 13 Chemotherapy Rescue/Antidote Agents . 16 Cephalosporins - 1st Generation . 13 Selective Estrogen Receptor Modulators (SERM) . 16 Cephalosporins - 2nd Generation . 13 Selective Retinoid X Receptor Agonists (RXR) . 16 Cephalosporins - 3rd Generation . 13 Steroid Antineoplastics . 16 Chemotherapeutics, Antibacterial, Miscellaneous . 13 NEUROLOGICAL DISEASE - MISCELLANEOUS . 16 Agents to Treat Multiple Sclerosis . 16 Lincosamides . 13 Fibromyalgia Agents, Serotonin-Norepineph RU Inhibitor . 17 Movement Disorders (Drug Therapy) . 17 Nitrofuran Derivatives . 14 ORAL/PHARYNGEAL DISORDERS . 17 Oxazolidinones . 14 Dental Aids & Preparations . 17 Penicillins . 14 Nose Preparations, Antibiotics . 17 Nose Preparations, Miscellaneous (Rx) . 17 Tetracyclines . 14 OTHER DRUGS . 17 INFECTIOUS DISEASE - FUNGAL . 14 Appetite Stimulators for Anorexia, Cachexia, Wasting Syndrome . 17 Antifungal Agents . 14 General Inhalation Agents . 17 Antifungal Antibiotics . 14 Metabolic disease enzyme replace, hypophosphatasia . 17 INFECTIOUS DISEASE - MISCELLANEOUS . 14 Needles/Needleless Devices . 17 Aminoglycosides . 14 Somatostatic Agents . 17 Anti-Mycobacterium Agents . 14 OTHER RESPIRATORY DISORDERS . 17 Antileprotics . 14 Antifibrotic Therapy – Pyridone Analogs . 17 Antitubercular Antibiotics . 14 Cystic Fibrosis-Cftr Potentiator & Corrector Comb. 17 Rifamycins and Related Derivative Antibiotics . 14 Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Potentiators Vancomycin & Derivatives . 14 INFECTIOUS DISEASE - PARASITIC . 14 Pulmonary Fibrosis – Systemic Enzyme Inhibitors . 17 Anaerobic Antiprotozoal-Antibacterial Agents . 14 PAIN MANAGEMENT - ANALGESICS . 17 Anthelmintics . 14 Analgesic, Non-Salicylate & Barbiturate Combinations . 17 Antimalarial Drugs . 14 Analgesic, Salicylate, Barbiturate & Xanthine Combinations . 17 Antiprotozoal Drugs, Miscellaneous . 14 Analgesic, Non-Salicylate, Barbiturate & Xanthine Combinations . 17 INFECTIOUS DISEASE - VIRAL . 14 Analgesic/Antipyretics, Salicylates . 17 Antivirals, HIV-Spec, Non-Peptidic Protease Inhib . 14 Analgesics, Narcotics . 17 Antivirals, HIV-Spec, Nucleoside-Nucleotide Analog . 14 Antimigraine Preparations . 17 Antivirals, HIV-Spec., Nucleoside Analog, RTI Comb . 14 Narcotic & Non-Salicylate Analgesic, Barbiturate & Xanthine Combinations . 17 Portfolio High Formulary – April 2016 Scripps Health Formulary
Narcotic & Salicylate Analgesics, Barbiturates & Xanthines . 17 Narcotic Analgesic & Non-Salicylate Analgesic Combinations . 17 PARKINSON'S DISEASE . 17 Antiparkinsonism Drugs, Anticholinergic . 17 Antiparkinsonism Drugs, Other . 17 Decarboxylase Inhibitors . 18 SEIZURE DISORDER . 18 Anticonvulsants. 18 SKELETAL MUSCLE DISORDER . 18 Agents To Treat Periodic Paralysis . 18 Skeletal Muscle Relaxants . 18 UPPER GASTROINTESTINAL DISORDERS - DIGESTIVE . 18 Pancreatic Enzymes . 18 UPPER GASTROINTESTINAL DISORDERS - SPASTIC DISEASE . 18 Anticholinergics/Antispasmodics . 18 Belladonna Alkaloids . 18 UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE . 18 Anti-Ulcer Preparations . 18 Anti-Ulcer-H.pylori Agents . 18 Anticholinergics, Quaternary Ammonium . 18 Histamine H2-Receptor Inhibitors . 18 Intestinal Motility Stimulants . 18 Proton-Pump Inhibitors . 18 URINARY TRACT - FUNCTIONAL DISORDERS . 18 Benign Prostatic Hypertrophy/Micturition Agents . 18 Benign Prostatic Hypertrophy, 5-alpha red. Inhib & alpha-1 antag comb agents . 18 Kidney Stone Agents . 18 Overactive Bladder Agents, Beta-3 Adrenergic Recep . 18 Urinary Tract Analgesic Agents . 18 Urinary Tract Anesthetic/Analgesic Agents (Azo-Dye) . 18 Urinary Tract Antispasmodic, M(3) Selective Antagonists . 18 Urinary Tract Antispasmodic/Antiincontinence Agents . 18 VAGINAL DISORDERS . 18 Vaginal Antibiotics . 18 Vaginal Antifungals . 18 Vaginal Estrogen Preparations . 18 Vaginal Sulfonamides . 18 VITAMIN AND/OR MINERAL DEFICIENCY . 18 Fluoride Preparations . 18 Folic Acid Preparations . 19 Multivitamin Preparations . 19 Pediatric Vitamin Preparations . 19 Prenatal Vitamin Preparations . 19 Vitamin B Preparations . 19 Vitamin D Preparations . 19 SPECIALTY INJECTABLE CROSS REFERENCE LISTING . 19 Portfolio High Formulary – April 2016 Scripps Health Formulary
ipratropium bromide Allergenic extracts
tiotropium bromide 5-grass pollen extract tiotropium bromide SPIRIVA RESPIMAT short ragweed pollen extract Leukotriene Receptor Antagonists
timothy grass pollen extract montelukast sodium
2nd Geneneration Antihistamine & Decongestant Combinations
Mast Cell Stabilizers
p-ephed hcl/cetirizine hcl (OTC) ZYRTEC-D (OTC)
cromolyn sodium
p-ephed sul/loratadine (OTC)
CLARITIN-D 12 HOUR Oral Inhaled Corticosteroids
budesonide
PULMICORT RESPULES CLARITIN-D 24 HOUR beclomethasone dipropionate Antihistamines - 1st Generation
hydroxyzine hcl
mometasone furoate hydroxyzine pamoate
promethazine hcl
Phosphodiesterase-4 (PDE4) Inhibitors
Antihistamines - 2nd Generation
QL + roflumilast cetirizine hcl (OTC)
levocetirizine dihydrochloride
Xanthines
loratadine (OTC)
Nasal Anti-Inflammatory Steroids
theophylline anhydrous
flunisolide
theophylline anhydrous fluticasone propionate
AUTONOMIC NERVOUS SYSTEM DISORDERS
triamcinolone acetonide
Alzheimer's Therapy, Nmda Receptor Antagonists
QL + betamethasone dipropionate memantine hcl
Alzheimer's Therapy, Nmda Receptor Antagonists & Cholines
Inhibitors
mometasone furoate QL + memantine hcl/donepezil hcl Nasal Antihistamine
azelastine hcl
Cholinesterase Inhibitors
donepezil hcl
galantamine hydrobromide
Antiemetic/Antivertigo Agents
QL + dronabinol
pyridostigmine bromide
meclizine hcl
rivastigmine tartrate
ondansetron
neostigmine bromide ondansetron hcl (QL on
BEHAVIORAL HEALTH - ANTIDEPRESSANTS
solution)
Alpha-2 Receptor Antagonist Antidepressants
prochlorperazine maleate
mirtazapine
promethazine hcl
Maois - Non-Selective & Irreversible
netupitant/palonosetron hcl tranylcypromine sulfate
phenelzine sulfate prochlorperazine edisylate Norepinephrine & Dopamine Reuptake Inhibitors (NDRIs)
bupropion hcl
Beta-Adrenergic Agents
albuterol sulfate
ALBUTEROL SULFATE metaproterenol sulfate
Selective Serotonin Reuptake Inhibitors (SSRIs)
terbutaline sulfate
citalopram hydrobromide
albuterol sulfate escitalopram oxalate
PROAIR RESPICLICK fluoxetine hcl
fluoxetine er
formoterol fumarate paroxetine hcl
STRIVERDI RESPIMAT sertraline hcl
salmeterol xinafoate SSRI & Antipsycho, Atyp, Dopamine & Serotonin Antag Comb
Beta-Adrenergic & Anticholinergic Combinations
ipratropium/albuterol sulfate
Serotonin-2 Antagonist/Reuptake Inhibitors (SARIs)
ipratropium/albuterol sulfate trazodone hcl
COMBIVENT RESPIMAT Serotonin-Norepinephrine Reuptake-Inhib (SNRIs)
tiotropium br/olodaterol hcl STIOLTO RESPIMAT duloxetine hcl
Beta-Adrenergic & Glucocorticoid Combinations
venlafaxine hcl
fluticasone/salmeterol QL + desvenlafaxine ER (Ranbaxy) DESVENLAFAXINE ER fluticasone/vilanterol mometasone/formoterol QL + desvenlafaxine succinate General Bronchodilator Agents
ipratropium bromide
Portfolio High Formulary – April 2016 Scripps Health Formulary
Tricyclic Antidepressants & Rel. Non-Sel. Ru-Inhib
Antipsychotics, Dopamine Antagonists, Thioxanthenes
amitriptyline hcl
thiothixene
amoxapine
Antipsychotics, Dopamine Antagonists, Butyrophenones
clomipramine hcl
haloperidol
desipramine hcl
haloperidol lactate
HALDOL ORAL CONC. doxepin hcl
imipramine hcl
maprotiline hcl
Narcolepsy and Sleep Disorder Therapy Agents
nortriptyline hcl
modafinil
BEHAVIORAL HEALTH - OTHER
Narcotic Antagonists
Adrenergics, Aromatic, Non-Catecholamine
naltrexone hcl
amphet asp/amphet/d-amphet
Sedative-Hypnotics, Non-Barbiturate
dextroamphetamine sulfate
chloral hydrate
dextroamphetamine capsule
DEXEDRINE SPANSULE estazolam
dextroamphetamine tablet (5mg, ZENZEDI
eszopiclone
flurazepam hcl
QL + dextroamphetamine tablet (2.5mg, ZENZEDI temazepam
dextroamphetamine tablet (15mg, ZENZEDI triazolam
zaleplon
QL + lisdexamfetamine dimesylate zolpidem tartrate
Anti-Alcoholic Preparations
Treatment for Attention Deficit-Hyperactivity (ADHD)/Narcolepsy
Anti-Anxiety Drugs
dexmethylphenidate hcl
alprazolam
XANAX ALPRAZOLAM QL + methylphenidate hcl
buspirone hcl
chlordiazepoxide hcl
METHYLIN CHEW TAB clorazepate dipotassium
diazepam
lorazepam
LORAZEPAM INTENSOL meprobamate
oxazepam
QL + methylphenidate ER Susp Anti-Mania Drugs
Treatment for Attention Deficit-Hyperactivity (ADHD), Nri-Type
lithium carbonate
ESKALITH LITHOBID lithium citrate
CARDIOVASCULAR DISEASE - ARRHYTHMIA
Antipsychotics, Phenothiazines
chlorpromazine hcl
amiodarone hcl
fluphenazine hcl
disopyramide phosphate
flecainide acetate
thioridazine hcl
mexiletine hcl
trifluoperazine hcl
procainamide hcl
Antipsychotics, Atypical, D2 Partial Agonist/5HT Mixed
propafenone hcl
ST + aripiprazole
ABILIFY SOLUTION quinidine gluconate
quinidine sulfate
disopyramide phosphate ST + aripiprazole
ABILIFY DISCMELT Antipsychotics, Dopamine & Serotonin Antagonists
CARDIOVASCULAR DISEASE - CARDIAC STIMULANTS
loxapine succinate
Digitalis Glycosides
Antipsychotics, Atypical, Dopamine, & Serotonin Antagonists
clozapine
DIGOXIN ORAL SOLN. olanzapine
CARDIOVASCULAR DISEASE - HYPERTENSION
olanzapine ODT
ACE Inhibitor/Calcium Channel Blocker Combinations
quetiapine fumarate
amlodipine besylate/benazepril LOTREL
risperidone
ACE Inhibitor/Thiazide & Thiazide-Like Diuretics
risperidone ODT
benazepril/hydrochlorothiazide LOTENSIN HCT
ziprasidone hcl
Portfolio High Formulary – April 2016 Scripps Health Formulary
diltiazem hcl
Alpha-Adrenergic Blocking Agents
DILACOR XR TIAZAC doxazosin mesylate
felodipine
phenoxybenzamine hcl
isradipine IR capsules
prazosin hcl
nicardipine hcl
terazosin hcl
nifedipine
Alpha/Beta-Adrenergic Blocking Agents
carvedilol
labetalol hcl
nimodipine
carvedilol phosphate Angiotensin Receptor Antagonist/Calcium Channel
verapamil hcl
Blocker/Thiazide Combinations
verapamil hcl ER
Angiotensin Receptor Antagonist/Thiazide Diuretic Combinations
Loop Diuretics
bumetanide
furosemide
torsemide
Potassium Sparing Diuretics
Angiotensin Receptor Antagonist & Calcium Channel Blockers
eplerenone
amlodipine bes/olmesartan med Potassium Sparing Diuretics in Combination
Antihypertensives, ACE Inhibitors
benazepril hcl
captopril
enalapril maleate
Pulmonary Anti-HTN, Sel. C-GMP Phosphodiesterase T5
fosinopril sodium
Inhibitors
lisinopril
sildenafil citrate
moexipril hcl
Pulmonary Anti-HTN, Endothelin Receptor Antagonists
quinapril hcl
ramipril
Antihypertensives, Angiotensin Receptor Antagonist
Pulmonary Anti-HTN, Prostacyclin-Type
irbesartan
losartan potassium
Pulmonary Anti-HTN, Soluble Guanylate Cyclase Stimulators
valsartan
olmesartan medoxomil Thiazide & Related Diuretics
Antihypertensives, Sympatholytic
clonidine hcl
guanfacine hcl
indapamide
methyldopa
metolazone
reserpine
Antihypertensives, Vasodilators
CARDIOVASCULAR DISEASE - LIPID IRREGULARITY
hydralazine hcl
Antihyperlipidemic - APO B-100 Synthesis Inhibitor
Beta-Adrenergic Blocking Agents
mipomersen sodium acebutolol hcl
Antihyperlipidemic - HMG CoA Reductase Inhibitors
atenolol
atorvastatin calcium
bisoprolol fumarate
lovastatin
metoprolol succinate
pravastatin sodium
metoprolol tartrate
simvastatin
simvastatin (80mg only)
pindolol
QL + rosuvastatin calcium propranolol hcl
sotalol hcl
Antihyperlipidemic - HMG CoA Reductase Inhibitors & Niacin
QL + niacin/simvastatin timolol maleate
Antihyperlipidemic - MTP Inhibitors
Beta-Adrenergic Blocking Agents/Thiazide & Related
Bile Salt Sequestrants
bisoprolol fumarate/hctz
Calcium Channel Blocking Agents
WELCHOL POWDER PACKETS amlodipine besylate
Portfolio High Formulary – April 2016 Scripps Health Formulary
COLESTID GRANULES Lipotropics
norethindrone a-e estradiol
fenofibrate
norethindrone-ethinyl estrad
fenofibrate, micronized
fenofibrate nanocrystallized
gemfibrozil
norgestimate-ethinyl estradiol
ORTHO TRI-CYCLEN omega-3 acid ethyl esters
norgestrel-ethinyl estradiol
norgestimate-ethinyl estradiol
ORTHO TRI-CYCLEN LO noreth a-et estra/fe fumarate Contraceptives, Transdermal
Niacin Preparations
ST + norelgestromin/ethin.estradiol
Oxytocics
CARDIOVASCULAR DISEASE - MISCELLANEOUS AGENTS
methylergonovine maleate
Adrenergic Vasopressor Agents
COUGH AND COLD
midodrine hcl
1st Generation Antihistamine & Decongestant Combinations
Antianginal & Anti-Ischemic Agents, Non-Hemodynamic
phenylephrine hcl/prometh hcl
Narcotic Antitussive-1st Geneneration Antihistamine-
Antihyperlipidemia - HMG-CoA & Calcium Channel Blocker
phenylephrine hcl/cod/prometh PHENERGAN VC
Heart Rate Reducing, Selective I(F) Current Inhib.
Narcotic Antitussive-1st Generation Antihistamines
PA + ivabradine hcl codeine/promethazine hcl
CARDIOVASCULAR DISEASE - VASODILATION
hydrocodone/chlorphen p-stirex TUSSIONEX
Vasodilators, Combination
Narcotic Antitussive-Anticholinergic Comb.
isosorb dinit/hydralazine hcl hydrocodone/homatrop me-br
Vasodilators, Coronary
Non-Narcotic Antitussive-1st Generation Antihistamine
isosorbide dinitrate
d-methorphan hb/prometh hcl
ISORDIL TITRADOSE DEXTROMETHORPHAN isosorbide mononitrate
DERMATOLOGY - ACNE
Acne Agents, Systemic
Acne Agents, Topical
Contraceptives, Intravaginal, Systemic
clindamycin phos/benzoyl perox BENZACLIN
QL + etonogestrel/ethinyl estradiol sulfacetamide sodium
clindamycin phos/benzoyl perox Contraceptives, Oral
clindamycin/tretinoin desog-et estra/ethin estra
desogestrel-ethinyl estradiol
benzoyl peroxide/hydrocortison benzoyl peroxide
ethinyl estradiol/drospirenone
podofilox
Rosacea Agents, Topical
Vitamin A Derivatives
ethynodiol d-ethinyl estradiol
AGE adapalene
AGE tazorotene foam DERMATOLOGY - ANTIINFECTIVE
Topical Antibiotics
levonorgestrel-eth estra
clindamycin phosphate
SEASONALE AVIANE-28 erythromycin base/benz per
erythromycin base/ethanol
gentamicin sulfate
mupirocin ointment
noreth a-et estra/fe fumarate
Portfolio High Formulary – April 2016 Scripps Health Formulary
mupirocin calcium cream
Topical Anti-Inflammatory, NSAIDs
clindamycin phosphate diclofenac sodium erythromycin base/benz per Topical Antibiotics/Antiinflammatory, Steroidal
Topical Antifungals
neomy sulf/polymyx b sulf/hc CORTISPORIN CREAM ciclopirox olamine
CORTISPORIN OINT ciclopirox 8% solution
DERMATOLOGY - MISCELLANEOUS
clotrimazole/betamet diprop
aluminum chloride
Antiseborrheic Agents
naftifine hcl 1% cream
selenium sulfide
naftifine hcl 1% gel, 2%
sulfacetamide sodium
cream/gel
Topical Antineoplastic & Premalignant Lesion Agents
nystatin
sulconazole nitrate mechlorethamine gel Topical Antiparasitics
Topical Local Anesthetics
hc acetate/pramoxine hcl
malathion
DERMATOLOGY - PIGMENTATION DISORDERS
permethrin
Topical Hyperpigmentation Agents
Topical Antivirals
DERMATOLOGY - PSORIASIS/ECZEMA
acyclovir
ZOVIRAX OINTMENT Antipsoriatic Agents, Systemic
acitretin
Topical Sulfonamides
methoxsalen, rapid
silver sulfadiazine
secukinumab
DERMATOLOGY - ANTIINFLAMMATORY
Antipsoriatics Agents
Topical Anti-Inflammatory Steroidal
alclometasone dipropionate
amcinonide
betamet diprop/prop gly
Topical Immunosuppressive Agents
betamethasone dipropionate
DEL-BETA DIPROSONE AGE tacrolimus
betamethasone valerate
DIABETES
clobetasol propionate
Antihyperglycemic, Alpha-Glucosidase Inhibitors (Non-
clobetasol propionate
acarbose
clobetasol propionate/emoll
TEMOVATE EMOLLIENT Antihyperglycemic, Amylin Analog-Type
desonide
DESOWEN TRIDESILON pramlintide acetate SYMLIN SYMLINPEN 120 Antihyperglycemic, DPP-4 Inhibitors
diflorasone diacetate
fluocinolone acetonide
sitagliptin phosphate Antihyperglycemic, DPP-4 Inhibitor & Biguanide Combinations
linagliptin/metformin hcl fluticasone propionate
sitagliptin phos/metformin hcl halobetasol propionate
sitagliptin phos/metformin hcl Antihyperglycemic, Incretin Mimetic (GLP-1 Receptor Agonists)
QL + dulaglutide hydrocortisone acetate/urea
QL + liraglutide hydrocortisone butyrate
hydrocortisone valerate
Antihyperglycemic, Insulin-Release Stimulant Type
mometasone furoate
triamcinolone acetonide
glimepiride
glipizide
diflorasone diacetate/emoll glipizide/metformin hcl
glyburide
hydrocort/sal acid/sulf/shmp#1 nateglinide
repaglinide
hydrocortisone butyrate/emoll LOCOID LIPOCREAM tolazamide
hydrocortisone probutate tolbutamide
Portfolio High Formulary – April 2016 Scripps Health Formulary
Antihyperglycemic, Insulin-Response Enhancer (Non-
HUMALOG MIX 75-25 insulin regular, human pioglitazone hcl
Syringes & Accessories
Antihyperglycemic, Biguanide Type (Non-Sulfonylurea)
syringes & needles ALL COMMERCIALLY metformin hcl
AVAILABLE SYRINGES EAR - GENERAL DISORDERS
Antihyperglycemic, Insulin-Rel Stim.& Biguanide Combinations
Ear Preparations, Misc. Anti-Infectives
glyburide, micro/metformin hcl GLUCOVANCE
acetic acid
repaglinide/metformin hcl
acetic acid/aluminum acetate
Antihyperglycemic, Insulin-Response & Release Combinations
acetic acid/hydrocortisone
Ear Preparations, Antibiotics
Antihyperglycemic Insul-Resp. Enhancer & Biguanide
neomy sulf/polymyx b sulf/hc
CORTISPORIN OTIC pioglitazone hcl/metformin hcl
ofloxacin
pioglitazone hcl/metformin hcl Otic Preparations, Anti-Inflammatory-Antibiotics
Antihyperglycemic-Glucocorticoid Receptor Blockers
ciprofloxacin hcl/dexameth Otic Preparations, Local anesthetics
Antihyperglycemic-Sod/Gluc Cotransport2 (SGLT2) Inhibitors
antipyrine/benzocaine otic QL + canagliflozin ELECTROLYTE REGULATION
Electrolyte Depleters
QL + empagliflozin calcium acetate
sodium polystyrene sulfonate
Antihyperglycemic, Sodium/Glucose Cotransport-2 (SGLT2)
sevelamer carbonate Inhibitor and Biguanide Combination
QL + canagliflozin/metformin hcl Potassium Replacement
QL + empagliflozin/metformin hcl potassium chloride
Antihyperglycemic, SGLT-2 & DPP-4 Inhibitor Combination
ENDOCRINE DISORDER - FERTILITY
QL + empagliflozin/linagliptin Drugs to Treat Impotency
Diabetic Supplies
G + sildenafil citrate blood-glucose calib. control ALL ABBOTT CONTROL Fertility Stimulating Preparations, Non-FSH
clomiphene citrate
CONTROL PRODUCTS Follicle Stimulating / Luteinizing Hormones
(e.g., ONETOUCH) follitropin alpha, recomb blood-glucose meter follitropin beta, recomb gonadotropin,chorionic, human ALL LIFESCAN METERS (e.g., ONETOUCH) hcg alpha, recombinant blood sugar diagnostics urofollitropin (fsh) Pregnancy Facilitating/Maintaining Agents, Hormonal
ALL LIFESCAN TEST progesterone, micronized lancing device/lancets ENDOCRINE DISORDER - OTHER
Antineoplastic LHRH (GNRH) Agonists, Pituitary Suppressants
ONETOUCH) LANCETS Diabetic Ulcer Preparations, Topical
Antidiuretic & Vasopressor Hormones
desmopressin (nonrefrigerated) DDAVP
Bone Formation Stim. Agents - Parathyroid Hormone
glucagon,human recombinant Bone Resorption Inhibitor & Vitamin D Combinations
Insulins
alendronate sodium/vitamin d3 insulin glargine,hum.rec.anlog Bone Resorption Inhibitors
alendronate sodium tablet
alendronate sodium solution
FOSAMAX SOLUTION insulin nph hum/reg insulin hm etidronate disodium
insulin nph human isophane ibandronate
insulin npl/insulin lispro HUMALOG MIX 50-50 raloxifene hcl
Portfolio High Formulary – April 2016 Scripps Health Formulary
Growth Hormone Receptor Antagonists
Eye Antivirals
Growth Hormones
Eye Sulfonamides
na sulfacetm/prednis sp
sulfacetamide sodium
na sulfacetm/prednisol ac BLEPHAMIDE S.O.P. EYE - MISCELLANEOUS
Hyperparathyroid Tx Agent, Vitamin D Analog-Type
Ophthalmic Cystine Delpleting Agents
LHRH (GnRH) Antagonist, Pituitary Suppressant Agents
Ophthalmic Anti-Inflammatory Immunomodulator-Type
cetrorelix acetate ganirelix acetate GANIRELIX ACETATE Ophthalmic Antibiotics
bacitracin
bacitracin/polymyxin b sulfate
Pituitary Suppressive Agents
ciprofloxacin hcl
cabergoline
erythromycin base
ENDOCRINE DISORDER - THYROID
gentamicin sulfate
Antithyroid Preparations
neomycin/bacitracin/polymyxin NEOSPORIN OPHTH
methimazole
propylthiouracil PROPYLTHIOURACIL Iodine Containing Agents
potassium iodide
POTASSIUM IODIDE ofloxacin
Thyroid Hormones
polymyxin b sulfate/tmp
levothyroxine sodium
tobramycin sulfate
besifloxacin hcl drops susp 0.6% moxifloxacin hcl liothyronine sodium
Ophthalmic Mast Cell Stabilizers
cromolyn sodium
lodoxamide tromethamine nedocromil sodium EYE - GENERAL DISORDERS
pemirolast potassium Eye Antibiotic-Corticoid Combinations
EYE - GLAUCOMA
neo/polymyx b sulf/dexameth
Carbonic Anhydrase Inhibitors
neomy sulf/bacitrac zn/poly/hc
CORTISPORIN OPHTH neomy sulf/polymyx b sulf/hc
CORTISPORIN OPHTH SUSPENSION Miotics/Other Intraoccula Pressure Reducers
neomycin sulfate/dex na ph
betaxolol hcl
tobramycin sulfate/dexameth
bimatoprost 0.03%
neomy sulf/polymyx b sulf/pred brimonidine tartrate
tobramycin/lotepred etab carteolol hcl
Eye Antihistamines
dorzolamide hcl
azelastine hcl
dorzolamide hcl/timolol maleat
ketotifen fumarate (OTC)
latanoprost
olopatadine hcl
levobunolol hcl
Eye Antiinflammatory Agents
pilocarpine hcl
diclofenac sodium
timolol maleate
TIMOPTIC (Except Ocudose) TIMOPTIC-XE flurbiprofen sodium
travoprost (benzalkonium)
ketorolac tromethamine
ACULAR ACULAR LS prednisolone acetate
bimatoprost 0.01% bimonidine/timolol prednisolone sod phosphate
ISOPTO CARBACHOL fluorometholone acetate loteprednol etabonate Mydriatics
atropine sulfate
cyclopentolate hcl
homatropine hbr
ISOPTO HOMATROPINE prednisolone acetate Portfolio High Formulary – April 2016 Scripps Health Formulary
GOUT AND RELATED DISEASES
estradiol/noreth ac Colchicine
estrogens, conj/bazedoxifene colchicine
estrogen, con/m-progest acet Hyperuricemia Treatment - Purine Inhibitors
estrogens, conjugated allopurinol
estrogens, esterified QL + febuxostat Progestational Agents
medroxyprogesterone acet
Uricosuric Agents
norethindrone acetate
probenecid
progesterone, micronized
HEMATOLOGICAL DISORDERS
Anticoagulants, Coumarin Type
warfarin sodium
imiquimod
Direct Factor XA Inhibitors
interferon alfa-2b, recomb. Hematinics, Other
cyclosporine, modified
Hemorrheologic Agents
mycophenolate mofetil
sirolimus
Heparin & Related Preparations
tacrolimus anhydrous
enoxaparin sodium
heparin sodium, porcine
INFECTIOUS DISEASE - BACTERIAL
Absorbable Sulfonamides
heparin sodium, porcine/pf
dalteparin sodium, porcine sulfamethoxazole/trimethoprim BACTRIM DS
fondaparinux sodium Leukocyte (WBC) Stimulants
sulfisoxazole acetyl Betalactams
aztreonam lysine Platelet Aggregation Inhibitors
Cephalosporins - 1st Generation
cilostazol
cefadroxil hydrate
clopidogrel bisulfate
cephalexin monohydrate
clopidogrel bisulfate 300mg
Cephalosporins - 2nd Generation
cefaclor
cefprozil
cefuroxime axetil
Platelet Reducing Agents
Cephalosporins - 3rd Generation
anagrelide hcl
cefdinir
Thrombopoietin Receptor Agonists
cefpodoxime proxetil
PA + eltrombopag olamine Chemotherapeutics, Antibacterial, Miscellaneous
Vitamin K Preparations
meth/meth blue/ba/salicy/hyos
HORMONAL DEFICIENCY
mth/me blue/salicy/na phos/hyo Androgenic Agents
Ketolides
testosterone 1%
PA + testosterone cypionate
DEPO-TESTOSTERONE clindamycin hcl capsules
clindamycin palmitate
CLEOCIN PALMITATE testosterone enanthate
Macrolides
methyltestosterone ZITHROMAX TRI-PAK testosterone gel 1.62% testosterone solution Estrogen/Androgen Combinations
ery e-succ/sulfisoxazole
estrogen, ester/me-testosterone ESTRATEST H.S.
erythromycin base
Estrogenic Agents
erythromycin ethylsuccinate
estradiol
erythromycin stearate
estropipate
norethindrone ac-eth estradiol
erythromycin base Portfolio High Formulary – April 2016 Scripps Health Formulary
erythromycin ethylsuccinate Vancomycin & Derivatives
vancomycin hcl
QL + fidaxomicin INFECTIOUS DISEASE - PARASITIC
Amebacides
Nitrofuran Derivatives
paromomycin sulfate
nitrofurantoin macrocrystal
nitrofurantoin/nitrofuran mac
Anaerobic Antiprotozoal-Antibacterial Agents
linezolid
mebendazole
tedizolid phosphate tablet Penicillins
Antimalarial Drugs
amox tr/potassium clavulanate
chloroquine phosphate
ARALEN PHOSPHATE AUGMENTIN ES-600 hydroxychloroquine sulfate
mefloquine hcl
amoxicillin trihydrate
quinine sulfate
ampicillin trihydrate
primaquine phosphate dicloxacillin sodium
penicillin v potassium
Quinolones
Antiprotozoal Drugs, Miscellaneous
CIPRO ORAL SUSPENSION pentamidine isethionate ciprofloxacin hcl
INFECTIOUS DISEASE - VIRAL
All oral, non-experimental antiviral agents used for the treatment
of AIDS or HIV-related diseases are considered a formulary

moxifloxacin hcl
Antiretroviral Combination, Integrase Inhibitors
ofloxacin
elvitegravir/cobicistat/emtricitabine/ STRIBILD QL + doxycycline hyclate
tenofovir disoproxil fumarate elviteg/cobi/emtric/tenofo ala doxycycline monohydrate
Antivirals, General
doxycycline monohydrate
VIBRAMYCIN ORAL SUSPENSION acyclovir
minocycline hcl
ganciclovir
valacyclovir hcl
tetracycline hcl
oseltamivir phosphate doxycycline calcium VIBRAMYCIN SYRUP INFECTIOUS DISEASE - FUNGAL
Antivirals, HIV-Spec, Non-Peptidic Protease Inhib
Antifungal Agents
darunavir ethanolate darunavir/cobicistat fluconazole
tipranavir/vitamin e tpgs Antivirals, HIV-Spec, Nucleoside-Nucleotide Analog
terbinafine hcl
emtricitabine/tenofovir Antivirals, HIV-Spec., Nucleoside Analog, RTI Comb
LAMISIL GRANULES Antifungal Antibiotics
abacavir sulfate/lamivudine griseofulvin ultramicrosize
lamivudine/zidovudine nystatin
Antivirals, HIV-Specific, CCR5 Co-Receptor Antag.
griseofulvin suspension INFECTIOUS DISEASE - MISCELLANEOUS
Antivirals, HIV-Specific, Fusion Inhibitors
QL + enfuvirtide neomycin sulfate
tobramycin in 0.225% nacl
Antivirals, HIV-Specific, Non-Nucleoside, RTI
nevirapine
Anti-Mycobacterium Agents
nevirapine ER
ethambutol hcl
delavirdine mesylate isoniazid
Antivirals, HIV-Specific, Nucleoside Analog, RTI
abacavir sulfate
Antitubercular Antibiotics
didanosine
rifampin
lamivudine
stavudine
Rifamycins and Related Derivative Antibiotics
zidovudine
Portfolio High Formulary – April 2016 Scripps Health Formulary
Antivirals, HIV-Specific, Nucleotide Analog, RTI
tenofovir disoproxil fumarate fludrocortisone acetate
FLORINEF ACETATE Antivirals, HIV-Specific, Protease Inhibitor Comb
Monoclonal antibody-human interleukin
lopinavir/ritonavir ustekinumab
Antivirals, HIV-Specific, Protease Inhibitors
NSAIDs, Cyclooxygenase Inhibitor-Type
atazanavir sulfate celecoxib
atazanavir sulfate/cobicistat diclofenac sodium
fosamprenavir calcium indinavir sulfate etodolac
nelfinavir mesylate fenoprofen calcium
QL + saquinavir mesylate ibuprofen
Antivirals, HIV-1 Integrase Strand Transfer Inhibtors
ketoprofen
QL + elvitegravir ketorolac tromethamine
meclofenamate sodium
raltegravir potassium meloxicam
Antiviral Combination Nucleoside, Nucleotide & Non-Nucleoside
nabumetone
naproxen
naproxen sodium
Cytochrome P450 Inhibitors
oxaprozin
Hepatitis B Treatment Agents
piroxicam
adefovir dipivoxil
sulindac
entecavir
tolmetin sodium
lamivudine
EPIVIR HBV TABLET fenoprofen calcium EPIVIR HBV SOLUTION INDOCIN ORAL SUSP. Hepatitis C Combination Agents
LOCAL ANESTHESIA
ledipasvir/sofosbuvir Local Anesthetics
Hepatitis C Treatment Agents
lidocaine hcl
ribavirin 200mg
LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMAT
Bowel Antiinflamatory Agents
peginterferon alfa-2a PEGASYS PROCLICK Chronic Inflam. Colon Dx, 5-A-Salicylat, Rectal Tx
REBETOL SOLUTION mesalamine
mesalamine w/cleansing wipes ROWASA
INFLAMMATORY DISEASE
Anti-Arthritic & Chelating Agents
Drug Tx-Chronic Inflam. Colon Dx, 5-Aminosalicylat
balsalazide disodium
Anti-Arthritic, Folate Antagonist Agents
methotrexate sodium
Hemorrhoidal Preparations
hc acetate/pramoxine hcl
Anti-Inflammatory Tumor Necrosis Factor Inhibitor
Irritable Bowel Agents, Guanylate Cylase-C Agonists
Rectal Preparations
Anti-Inflammatory, Pyrimidine Synthesis Inhibitors
leflunomide
PROCTOCORT CREAM Bradykinin B2 Receptor Antagonists
icatibant acetate hydrocortisone acetate
budesonide
hc acetate/pramoxine hcl cortisone acetate
Rectal/Lower Bowel Prep., Glucocort. (Non-Hemorr)
dexamethasone tablet, elixir
LOWER GASTROINTESTINAL DISORDERS - OTHER
Ammonia Inhibitors
lactulose
sodium phenylbutyrate
prednisolone sod phosphate
sodium phenylbutyrate prednisone
DELTASONE PREDNISONE diphenoxylate hcl/atrop sulf
Bile Salts
Portfolio High Formulary – April 2016 Scripps Health Formulary
ursodiol
Antineoplastic - Topoisomerase I Inhibitors
Antineoplastic - Immunomodulator Agents
Laxatives & Cathartics
PA + lenalidomide peg 3350/na sulf,bicarb,cl/kcl
COLYTE WITH FLAVOR polyethylene glycol 3350
Antineoplastic - Systemic Enzyme Inhibitors
sod chloride/nahco3/kcl/peg's
imatinib mesylate
PA+ alectinib hydrochloride peg 3350/na sulf,bicarb,cl/kcl Narcotic Antagonists, Peripherally-Acting
naloxegol oxalate methylnaltrexone bromide Glucagon-Like Peptide (GLP-2) Analogs
teduglutide [rDNA origin] MISCELLANEOUS AGENTS
Anaphylaxis Therapy Agents
epinephrine
Parasympathetic Agents
bethanechol chloride
cevimeline hcl
ixazomib citrate pilocarpine hcl
lapatinib ditosylate Pku Tx Agent-Cofactor Of Phenylalanine Hydroxylase
lenvatinib mesylate sapropterin dihydrochloride nilotinib hydrochloride NEOPLASTIC DISEASE
Alkylating Agents
PA + osimertinib mesylate hydroxyurea
pazopanib hydrochloride lomustine
sorafenib tosylate sunitinib malate trametinib dimethyl sulfoxide Antiandrogenic Agents
Antineoplastic, Histone Deacetylase Inhibitors, HDIS
flutamide
panobinostat lactate abiraterone acetate Antineoplastics, Miscellaneous
etoposide
procarbazine hcl methotrexate sodium
AFINITOR DISPERZ methotrexate sodium
METHOTREXATE VIAL Chemotherapy Rescue/Antidote Agents
thioguanine
leucovorin calcium
LEUCOVORIN CALCIUM fludarabine phosphate Selective Estrogen Receptor Modulators (SERM)
tamoxifen citrate
methotrexate sodium toremifene citrate trifluridine/tipiracil hcl Selective Retinoid X Receptor Agonists (RXR)
Antineoplastic - Aromatase Inhibitors
bexarotene
anastrozole
Steroid Antineoplastics
exemestane
megestrol acetate
letrozole
estramustine phosphate sodium Antineoplastic – Hedgehog Pathway Inhibitors
NEUROLOGICAL DISEASE - MISCELLANEOUS
Agents to Treat Multiple Sclerosis
sonidegib phosphate glatiramer acetate
Antineoplastic – Janus Kinase (JAK) Inhibitors
dimethyl fumarate Antineoplastic - MEK1 and MEK2 Kinase Inhibitors
interferon beta-1a PA + cobimetinib fumarate interferon beta-1a/albumin ADMINISTRATION PACK Portfolio High Formulary – April 2016 Scripps Health Formulary
(300mg/15ml) oral solution
hydrocodone bit/acetaminophen HYCET
peginterferon beta-1a oral elixir (325mg/15ml)
hydromorphone hcl
Fibromyalgia Agents, Serotonin-Norepineph RU Inhibitor
methadone hcl
morphine sulfate
Movement Disorders (Drug Therapy)
morphine sulfate
morphine sulfate
ORAL/PHARYNGEAL DISORDERS
Dental Aids & Preparations
chlorhexidine gluconate
oxycodone hcl
triamcinolone acetonide
KENALOG IN ORABASE ROXICODONE INTENSOL Nose Preparations, Antibiotics
oxycodone hcl/acetaminophen
mupirocin calcium Nose Preparations, Miscellaneous (Rx)
oxycodone hcl/acetaminophen
ipratropium bromide
(325mg/5ml)
OTHER DRUGS
oxycodone hcl/aspirin
Appetite Stimulators for Anorexia, Cachexia, Wasting Syndrome
tramadol hcl
megestrol acetate
tramadol hcl/acetaminophen
General Inhalation Agents
CU + buprenorphine hcl/naloxone hcl sodium chloride for inhalation Metabolic disease enzyme replace, hypophosphatasia
hydrocodone bit/acetaminophen Needles/Needleless Devices
hydrocodone bit/acetaminophen needles, insulin disp., safety Somatostatic Agents
hydromorphone hcl octreotide acetate
OTHER RESPIRATORY DISORDERS
Antifibrotic Therapy – Pyridone Analogs
tapentadol hcl ER Antimigraine Preparations
Cystic Fibrosis-Cftr Potentiator & Corrector Comb.
ergotamine tartrate/caffeine
lumacaftor/ivacaftor Cystic Fibrosis Transmembrane Conductance Regulator (CFTR)
naratriptan
QL rizatriptan benzoate
Mucolytics
sumatriptan
IMITREX NASAL SPRAY sumatriptan succinate
Pulmonary Fibrosis – Systemic Enzyme Inhibitors
IMITREX INJECTION nintedanib esylate QL + zolmitriptan
PAIN MANAGEMENT - ANALGESICS
Analgesic, Non-Salicylate & Barbiturate Combinations
Narcotic & Non-Salicylate Analgesic, Barbiturate & Xanthine
Analgesic, Salicylate, Barbiturate & Xanthine Combinations
Narcotic & Salicylate Analgesics, Barbiturates & Xanthines
Analgesic, Non-Salicylate, Barbiturate & Xanthine Combinations
FIORINAL WITH CODEINE #3 butalb/acetaminophen/caffeine ESGIC
Narcotic Analgesic & Non-Salicylate Analgesic Combinations
Analgesic/Antipyretics, Salicylates
acetaminophen with codeine
TYLENOL-CODEINE NO.3 diflunisal
salsalate
Analgesics, Narcotics
acetaminophen and codeine CAPITAL AND CODEINE CU + buprenorphine hcl
PARKINSON'S DISEASE
Antiparkinsonism Drugs, Anticholinergic
codeine phos/carisoprodol/asa SOMA COMPOUND
benztropine mesylate
trihexyphenidyl hcl
fentanyl
Antiparkinsonism Drugs, Other
fentanyl citrate lozenge
amantadine hcl
hydrocodone bit/acetaminophen VICODIN
(300mg)
bromocriptine mesylate
hydrocodone bit/acetaminophen LORCET
entacapone
hydrocodone bit/acetaminophen LORTAB ELIXIR
pramipexole di-hcl
Portfolio High Formulary – April 2016 Scripps Health Formulary
ropinirole hcl
sucralfate
Anti-Ulcer-H.pylori Agents
lansoprazole/amox tr/clarith
selegiline hcl
Anticholinergics, Quaternary Ammonium
rasagiline mesylate chlordiazepoxide/clidinium br QL + rotigotine Histamine H2-Receptor Inhibitors
cimetidine hcl
Decarboxylase Inhibitors
famotidine
carbidopa
nizatidine
SEIZURE DISORDER
ranitidine hcl
Intestinal Motility Stimulants
metoclopramide hcl
TEGRETOL TEGRETOL XR Proton-Pump Inhibitors
clonazepam
QL + esomeprazole magnesium
diazepam
divalproex sodium
omeprazole capsules (RX)
PRILOSEC CAPSULES DEPAKOTE SPRINKLE omeprazole magnesium tablets PRILOSEC OTC
(OTC)
gabapentin
pantoprazole sodium
lamotrigine
PREVACID SOLUTABS pantoprazole sodium suspension URINARY TRACT - FUNCTIONAL DISORDERS
phenytoin
DILANTIN-125 DILANTIN CHEW TAB Benign Prostatic Hypertrophy/Micturition Agents
phenytoin sodium extended
alfuzosin
G + dutasteride
primidone
topiramate
finasteride
TOPAMAX SPRINKLE tamsulosin hcl
valproate sodium
Benign Prostatic Hypertrophy, 5-alpha red. Inhib & alpha-1 antag
valproic acid
DEPAKENE CAPSULES comb agents
zonisamide
G + dutasteride/tamsulosin hcl
Kidney Stone Agents
SKELETAL MUSCLE DISORDER
cysteamine bitartrate Agents To Treat Periodic Paralysis
Overactive Bladder Agents, Beta-3 Adrenergic Recep
dichlorphenamide Skeletal Muscle Relaxants
Urinary Tract Analgesic Agents
baclofen
pentosan polysulfate sodium Urinary Tract Anesthetic/Analgesic Agents (Azo-Dye)
phenazopyridine hcl
PARAFON FORTE DSC Urinary Tract Antispasmodic, M(3) Selective Antagonists
cyclobenzaprine hcl
solifenacin succinate dantrolene sodium
Urinary Tract Antispasmodic/Antiincontinence Agents
metaxalone
oxybutynin chloride
ROBAXIN ROBAXIN-750 trospium chloride
orphenadrine citrate
tolterodine tartrate
fesoterodine fumarate tizanidine hcl
VAGINAL DISORDERS
UPPER GASTROINTESTINAL DISORDERS - DIGESTIVE
Vaginal Antibiotics
Pancreatic Enzymes
METROGEL-VAGINAL PANCRELIPASE 5,000 amylase/lipase/protease Vaginal Antifungals
ULTRASE ULTRASE MT miconazole nitrate
butoconazole nitrate UPPER GASTROINTESTINAL DISORDERS - SPASTIC DISEASE
Vaginal Estrogen Preparations
dicyclomine hcl
Belladonna Alkaloids
estrogens, conjugated belladonna alkaloids/phenobarb DONNATAL
Vaginal Sulfonamides
hyoscyamine sulfate
VITAMIN AND/OR MINERAL DEFICIENCY
Fluoride Preparations
UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE
sodium fluoride
Anti-Ulcer Preparations
misoprostol
Portfolio High Formulary – April 2016 Scripps Health Formulary
< 12 years old Folic Acid Preparations
• Epaned (Step Therapy applies) ≥ 12 years old folic acid
≤ 25 years old Multivitamin Preparations
• Epiduo Forte ≤ 25 years old folic acid/mu-vits-min th
≥ 18 years old ≤ 25 years old Pediatric Vitamin Preparations
≤ 25 years old fluoride ion/iron/vit a,c&d
TRI-VI-FLOR W/IRON ≤ 25 years old fluoride ion/multivitamins
• Retin-A Micro ≤ 25 years old fluoride ion/multivits w-fe
POLY-VI-FLOR W/IRON • Retin-A Micro Pump ≤ 25 years old fluoride ion/vit a,c&d
≥ 12 years old Prenatal Vitamin Preparations
≤ 25 years old prenatal vit 15/iron cb/fa/dss
3. QUANTITY RESTRICTIONS (FORMULARY)
prenatal vit 16/iron cb/fa/dss
prenatal vit 18/iron cb/fa/dss
30 tablets per 30 days 900mL per 30 days prenatal vit 95/fe fum/fa
• Abilify Discmelt Vitamin B Preparations
90 tablets per 30 days 60 tablets per 30 days Vitamin D Preparations
60 tablets per 30 days calcitriol
30 capsules per 30 days 20mg, 25mg, 30mg 60 capsules per 30 days dihydrotachysterol • Advair Diskus 60 units per 30 days 12g (1 inhaler) per 30 days 1 capsule per 28 days SPECIALTY INJECTABLE CROSS REFERENCE LISTING
24 packets per 30 days 240 capsules per 30 days The following cross reference is being provided as a guide to
• Alendronate solution 300mL per 28 days formulary choices within prominent "specialty" injectable drug
categories. General specialty categories are cross referenced to
Ambien / Ambien CR 30 tablets per 30 days their corresponding formulary classification status and page
18 tablets per 30 days number. This cross reference is not meant to be all-inclusive.
60 capsules per 30 days Please refer to the Table of Contents or Index to determine
120 tablets per 30 days formulary status of injectable medications not listed in this cross
• Anoro Ellipta 60 blister packs per 30 days reference (e.g., Antineoplastics, Leukocyte Stimulants, etc.).
5mL (10 syringes) per 30 days 4mL (10 syringes) per 30 days Hematinics, Other 6mL (10 syringes) per 30 days 8mL (10 syringes) per 30 days HEPATITIS C
1 inhaler per 30 days Hepatitis C Treatment Agents 13 grams per 30 days 60mL (2 bottles) per 30 days HUMAN GROWTH FACTORS
60mL (2 bottles) per 30 days 30 tablets per 30 days • Atrovent HFA 2 inhalers per 28 days LOW MOLECULAR WEIGHT HEPARINS
Heparin and Related Preparations 30mg, 45mg, 60mg, 1 capsule per day MULTIPLE SCLEROSIS
2 capsules per day Agents to Treat Multiple Sclerosis 30 tablets per 30 days • Breo Ellipta 60 units per 30 days RHEUMATOID ARTHRITIS
60 tablets per 30 days Anti-Inflammatory, Pyrimidine Synthesis Inhibitors 4 patches per 28 days MEDICATION PRESCRIBING LIMITATIONS
30 tablets per 30 days 40 tablets 28 days 1. AGE RESTRICTIONS (FORMULARY)- Covered for ages:
≤ 18 years old 30 tablets per 30 days 6 tablets per 30 days ≤ 25 years old ≥ 12 years old 4 patches per 28 days ≤ 18 years old 90 tablets per 30 day 120 tablets per 30 days 8 patches per 30 days ≥ 15 years old 60 tablets per 30 days • Ritalin LA 60mg ≤ 18 years old ≤ 18 years old 18mg, 27mg, 54mg 30 tablets per 30 days 2. AGE RESTRICTIONS (NON FORMULARY)- Covered for ages:
60 tablets per 30 days • All carbinoxamine containing 60 tablets per 30 days products (i.e., Palgic, Tussafed, 30 tablets per 30 days 60 capsules per 30 days ≤ 18 years old 30 tablets per 30 days ≤ 25 years old • Depo-Testosterone 10mL per 30 days ≤ 25 years old • Desvenlavaxine ER 30 tablets per 30 days Portfolio High Formulary – April 2016 Scripps Health Formulary
injection (kits and • Dexedrine Spansule 4 vials per 30 days 60 capsules per 30 days 2 kits per 30 days 120 capsules per 30 days 6mg/0.5ml kit/refill kit 2 kits per 30 days 4mg/0.5ml kit/refill kit 20 tablets per 30 days 13g (1 inhaler) per 30 days 300 capsules per 30 days 10 patches per 30 days 120 tablets per 30 days 30 tablets per 30 days 60 tablets per 30 days 60 tablets per 30 days 30 tablets per 30 days 60 tablets per 30 days 1 capsules per 21 days 2 capsules per 21 days 30 tablets per 30 days 1 capsule per 21 days 60 tablets per 30 days • Emend Trifold Pack 1 packet per 21 days 60 tablets per 30 days 30 tablets per 30 days 10mg/mL oral solution 720mL per 30 days 60 tablets per 30 days 30 capsules per 30 days 30 tablets per 30 days 30 capsules per 30 days 10mg/mL oral solution 900mL per 30 days 60 tablets per 30 days 390mL per 30 days 30 tablets per 30 days 100/25mg tablets 300 tablets per 30 days 30 tablets per 30 days 200/50mg tablets 120 tablets per 30 days 30 tablets per 30 days 30 tablets per 30 days 40mL (4 vials) per 28 days • Exelon patch 30 patches per 30 days 30mL (10 pens) per 28 days 16gm (1 bottle) per 30 days 30 capsules per 30 days 25mL (1 bottle) per 30 days 120 capsules per 30 days 60 tablets per 30 days 30 capsules per 30 days 6mL (20 syringes) per 30 days 8mL (20 syringes) per 30 days 2.4mL (1 pen) per 28 days with a max duration of 2 years per 12mL (20 syringes) per 30 16mL (20 syringes) per 30 2500 units/0.2mL 2mL (10 syringes) per 30 days 20mL (20 syringes) per 30 5000 units/0.2mL 2mL (10 syringes) per 30 days 7500 units/0.3mL 3mL (10 syringes) per 30 days 16mL (20 syringes) per 30 10,000 units/1mL 10mL (10 syringes) per 30 12,500 units/0.5mL 20mL (20 syringes) per 30 15,000 units/0.6mL 5mL (10 syringes) per 30 days 18,000 units/0.72mL 6mL (10 syringes) per 30 days 30mL (10 vials) per 30 days 25,000 units/ml 7.2mL (10 syringes) per 30 days 2.5ml per 30 days 7.6mL (2 vials) per 30 days 30 tablets per 30 days 1 kit per 30 days 16 capsules per day 30 tablets per 30 days 60 capsules per 30 days • Geodon (oral) 60 capsules per 30 days 18 tablets per 30 days 30 tablets per 30 days 40mL (4 vials) per 28 days 60 tablets per 30 days 30mL (10 pens) per 28 days 10mg, 20mg, 40mg, 30 tablets per 30 days 40mL (4 vials) per 28 days 90 tablets per 30 days 40mL (2 vials) per 28 days • Methylin chewable tablet 90 tablets per 30 days • Humulin 70/30 20 units per 28 days 40mL (4 vials) per 28 days 30 tablets per 30 days 30mL (10 pens) per 28 days 90 tablets per 30 days 40mL (4 vials) per 28 days 60 tablets per 30 days 30mL (10 pens/cartridges) per 49 tablets per 28 days 300mLper 30 days • Humalog Mix 50/50 / 40mL (4 vials) per 28 days 30 capsules per 30 days 30mL (10 pens) per 28 days 28 capsules per 28 days 30 capsules per 30 days • Hydrocodone bit/acetaminophen (maximum of 4gm of • Narcan Nasal 2 boxes (4 nasal sprays per 30 acetaminophen per day): 16 tablets per 1 day supply 16.5g (1 canister) per 30 days 13 tablets per 1 day supply 25ml (1 bottle) per 30 days 12 tablets per 1 day supply 17g (1 canister) per 30 days 200ml per 1 day supply 30 patches per 30 days 325mg/15ml elixir 184ml per 1 day supply 30 capsules per 30 days tablets (all strengths) 18 tablets per 30 days 30 packets per 30 days 12 units per 30 days • Nilandron 150mg tablet 60 tablets for first 30 days, Portfolio High Formulary – April 2016 Scripps Health Formulary
then 30 tablets per 30 days 30 capsules per 30 days • Spiriva Respimat 1 inhaler per 30 days 30 capsules per 30 days • Stiolto Respimat 4g (60 inhalations) per 30 days 450mL per 30 days capsules/tablets 360 capsules/tablets per 30 10mg, 18mg, 25mg, 60 capsules per 30 days 180 tablets per 30 days 60mg, 80mg, 100mg 30 capsules per 30 days 60 tablets per 30 days 30 tablets per 30 days 1 ring per 28 days • Striverdi Respimat 4g (60 inhalations) per 30 days 3 patches per 28 days 30 capsules per 30 days 1.6mL per 28 days 60 capsules per 30 days • Oxycodone hcl/acetaminophen (maximum of 4gm 1 tablet per day acetaminophen per day): 12 tablets per 1 day supply 40 tablets per 183 days 61mL per 1 day supply 45mg, 75mg tablets 20 tablets per 183 days 360mL per 183 days 10mg, 15mg, 20mg, NOTE: The FDA recommends a maximum of 5 days of 30mg, 40mg, 60mg 60 tablets per 30 days therapy with this drug 120 tablets per 30 days 20 tablets per fill 120mL per 30 days 30 tablets per 30 days • Travatan/Travatan Z 2.5ml per 30 days 3 tubes per 56 days 30 tablets per 30 days 2 tubes per 56 days 2mL (4 pens) per 28 days • Plavix 300mg tablet 4 tablets per 30 days 30 tablets per 30 days 30 tablets per 30 days 7.5mL (5 pens) per 28 days 30 tablets per 30 days 240mL per 30 days 120 capsules per 30 days 180 capsules per 30 days • Vancocin Oral 480 tablets per 30 days 40 capsules per 30 days 240 tablets per 30 days 6 tablets per 30 days 60 tablets per 30 days 30 tablets per 30 days 60 capsules per 30 days 60 tablets per 30 days 30 tablets per 30 days 9mL (3 pens) per 30 days 30 tablets per 30 days 1200mL per 30 days Pulmicort Flexhaler 1 inhaler per 30 days 60 capsules per 30 days Pulmicort Respules 60mL (30 respules) per 30 days 1200mL per 30 days 8.7g (1 canister) per 30 days 60 tablets per 30 days 4.9g (1 canister) per 30 days 225g powder per 30 days 60mL (1 bottle) per 30 days 30 tablets per 30 days 240mL (2 bottles) per 30 days 300mL (2 bottles) per 30 days 8 patches per 30 days 360mL (2 bottles) per 30 days 30 tablets per 30 days 17.4g (2 inhalers) per 30 days 30 capsules per 30 days 120 tablets per 30 days 30 tablets per 30 days 60 tablets per 30 days 15mg loading dose 42 tablets per 21 days, followed by 30 tablets per 30 30 tablets per 30 days 64 vials per 30 days 2.5mg, 5mg, 7.5mg, 1800mL per 30 days 90 tablets per 30 days 180 capsules per 30 days 180 tablets per 30 days 60 tablets per 30 days 60 tablets per 30 days 60 tablets per 30 days 2400mL per 30 days 240ml per 30 days 60 tablets per 30 days 90 tablets per 30 days 30 tablets per 30 days 10mg, 20mg, 40mg, 30 capsules per 30 days 900mL per 30 days 60 tablets per 30 days 60 capsules per 30 days • Zofran oral solution 90 tablets per 30 days 4mg/5ml oral solution 50ml per 15 days 91 tablets per 84 days • Zomig/Zomig ZMT 60 doses (1 diskus) per 30 12 tablets per 30 days 12 units per 30 days 90 tablets per 30 days • Zyprexa/Zyprexa Zydis 30 tablets per 30 days 30 tablets per 30 days 4. QUANTITY RESTRICTIONS (NON FORMULARY)
120 tablets per 30 days 500/20mg, 500/40mg 30 tablets per 30 days 30 tablets per 30 days 30 tablets per 30 days • Aciphex Sprinkle 30 capsules per 30 days 60 tablets per 30 days 60 tablets per 30 days Portfolio High Formulary – April 2016 Scripps Health Formulary
30 tablets per 30 days 300ml per 30 days 30 tablets per 30 days • Clarinex-D 12 hour 60 tablets per 30 days 4 tablets per 28 days • Clarinex-D 24 hour 30 tablets per 30 days 1 tablet per 28 days 4 patches per 30 days 30 capsules per 30 days 50mg, 75mg, 100mg 60 tablets per 30 days 60 droperettes per 30 days 60 capsules per 30 days 30 patches per 30 days • Adoxa Pak 100mg, 60 tablets per 30 days 900mL per 30 days 180 tablets per 30 days 500/20mg, 1000/40mg 30 tablets per 30days • Depo-Provera 750/20mg, 100/20mg 60 tablets per 30 days • Depo-subQ Provera 104 0.65mL per 84 days 17.8g (2 inhalers) per 30 days • DermacinRx Silapak 1 kit per 30 days • DermasilkRx SDS 1 kit per 30 days 180 cartridges (2 kits) per 28 150 tablets per 30 days 30-4 unit + 60-8 unit • Desvenlafaxine ER 30 tablets per 30 days 60-4 unit + 30-8 unit 360 cartridges (4 kits) per 28 60-8 unit + 30-12 unit 30 capsules per 30 days 360 cartridges (4 kits) per 28 30 ampules per 28 days 360 cartridges (4 kits) per 28 120 tablets per 30 days 60 tablets per 30 days 60 tablets/capsules per 30 30mg/5ml oral susp 300ml per 30 days 4 units per 28 days 30 tablets per 30 days 30 tablets per 30 days 90 tablets per 30 days 12.2gms (2 inhalers) per 25 240mL per 30 days 23g (1 bottle) per 30 days 60 blister packs per 30 days 1 dose per 5 days 8 tablets per fill 30 tablets per 30 days 4 tablets per fill 10mL (2 bottles) per 30 days 40mL (4 vials) per 28 days 20-0.8mg, 30-1.2mg, Solostar/cartridge 30mL (10 pens/cartridges) per 50-2mg, 60-2.4mg, 2 capsules per day 30 tablets per 30 days 4 capsules per day 30 capsules per 30 days 30 patches per 30 days 60 tablets per 30 days 30 tablets per 30 days 1200mL per 30 days 60 tablets per 30 days 45g (1 tube) per 30 days 30 capsules per 30 days 45g (1 tube) per 30 days • Arnuity Ellipta 30 blister packs per 30 days 40 tablets per 28 days 4 tablets per 28 days • Esomeprazole Strontium 12 tablets per day 30 capsules per 30 days 60 tablets per 30 days 120 capsules per 30 days 1 kit per 30 days 1 ring per 90 days 12 tablets per 30 days 0.8mL (2 syringes) per 365 480 tablets per 30 days 60 tablets per 30 days 240 tablets per 30 days 1 pack per 28 days 40mg/ml suspension 2400ml per 30 days 30mL (10 pens) per 28 days 30 tablets per 30 days 30g (1 tube) per 30 days 90 tablets per 30 days 25g (1 bottle) per 30 days 270 tablets per 30 days 2 buccal films per day 180 tablets per 30 days 30 tablets per 30 days 600mg/5ml solution 900mL per 30 days 1 kit per 30 days 120 tablets per 30 days 10mL (1 bottle) per 30 days 30 capsules per 30 days 4 tablets per 28 days • Firmagon 80mg/vial 1 vial per 30 days 30 tablets per 30 days • Firmagon 120mg/vial 2 vials per 365 days 30 capsules per 30 days • Flovent Diskus 120mL per 30 days 60 units (1 diskus) per 30 days • Bydureon/Bydureon Pen 4 vials/pens per 28 days 120 units (2 diskus) per 30 1.2mL (1 pen) per 30 days 2.4mL (1 pen) per 30 days 21.2g (2 inhalers) per 30 days 9 packets per 30 days 12g (1 inhaler) per 30 days 1 dose per 5 days 24g (2 inhalers) per 30 days 180 capsules per 30 days 60 capsules per 30 days 56 tablets per 28 days 30 capsules per 30 days 18 tablets per 30 days 2.5mg, 5mg reditab 30 tablets per 30 days 60 tablets per 30 days Portfolio High Formulary – April 2016 Scripps Health Formulary
2 9 tablets per 1 day 120 tablets per 30 days 60 tablets per 30 days 8 tablets per 1 day 8mg, 10mg, 12mg 30 tablets per 30 days 4 tablets per 1 day 120 tablets per 30 days 90 tablets per 30 days 1 kit per 30 days 1 dose per 5 days 90 tablets per 30 days • Myalept 11.3mg vial 30 vials per 30 days 78 tablets per 30 days 30 tablets per 30 days • Granisol solution 60mL per 30 days • Nicotrol cartridge 1008 cartridges (6 inhalers) per 360mL (3 bottles) per 30 days 160mL (4 packs) per 90 days 30 tablets per 30 days • Novolin N/Novolin R/ 40mL (4 vials) per 28 days 60 tablets per 30 days • Hydrocodone bit/ (max 4gm per day) 40mL (4 vials) per 28 days 13 tablets per 1 day supply Flexpen/cartridge 30mL (10 pens/cartridges) per 184mL per 1 day supply • Novolog Mix 70/30 473mL (1 bottle) per 30 days 40mL (4 vials) per 28 days 30 tablets per 30 days 30mL (10 pens) per 28 days • Incruse Ellipta 30 blisters per 30 days 600mL per 10 days 30 tablets per 30 days 30 tablets per 30 days 45 tablets per 30 days 30 tablets per 30 days 30 tablets per 30 days 12.5g (1 bottle) per 30 days 60 tablets per 30 days 6 syringes per 30 days 60 tablets per 30 days 30 capsules per 30 days 480mL per 30 days 30 tablets per 30 days 10mg, 20mg, 30mg, 120 films per 30 days 40mg, 50mg, 60mg, 70mg, 80mg, 100mg, 5mg, 7.5mg, 10mg, 60 capsules per 30 days 60 tablets per 30 days 120 capsules per 30 days 120 tablets per 30 day 120 tablets per 30 days 30 capsules per 30 days 960mL (2 bottles) per 30 days 30 tablets per 30 days 60 tablets per 30 days 30 tablets per 30 days 30 tablets per 30 days • Oxycodone hcl/acetaminophen (maximum of 4gm • Kombiglyze XR acetaminophen per day): 60 tablets per 30 days 13 tablets per 1 day supply 5-500mg, 5-1000mg 30 tablets per 30 days 12 tablets per 1 day supply 8 tablets per 30 days • Lamictal ODT 30 tablets per 30 days 180 tablets per 30 days 120 tablets per 30 days 90 tablets per 30 days 30.5g (1 bottle) per 30 days 60 tablets per 30 days 2.5mL (1 bottle) per 30 days 2.5mL (1 bottle per 30 days) 180 tablets per 30 days 2.5mL (1 bottle per 30 days) 90 tablets per 30 days 30 tablets per 30 days 200mg, 250mg, 300mg 60 tablets per 30 days 3mL (1 bottle) per 30 days 270 tablets per 30 days 90 tablets per 30 days 20mg, 40mg, 60mg 30 tablets per 30 days 60 tablets per 30 days 60 capsules per 30 days 15 bottles per 30 days 30 tablets per 30 days 60 tablets per 30 days 1800mL per 30 days 30 tablets per 30 days 25mg, 50mg, 100mg 30 capsules per 30 days 40mL (4 vials) per 28 days 60 capsules per 30 days 30mL (10 pens) per 28 days 6 tablets per 30 days 1 tablet per day 30 tablets per 30 days 2 tablets per day 30 tablets per 30 days • LoSeasonique 91 tablets per 84 days 1.6mL (4 syringes) per 28 days 60 capsules per 30 days 0.8mL (4 syringes) per 28 days 60g (1 tube) per 28 days 1mL (4 syringes) per 28 days 4 patches per 30 days 1.2mL (4 syringes) per 28 days 1.4mL (4 syringes) per 28 days 8 vials per 28 days 1.8mL (4 syringes) per 28 days 30 tablets per 30 days 2mL (4 syringes) per 28 days 30g (1 tube) per 30 days 2.2mL (4 syringes) per 28 days 60 capsules per 30 days 2.4mL (4 syringes) per 28 days Portfolio High Formulary – April 2016 Scripps Health Formulary
30 capsules per 30 days 60 tablets per 30 days 60 tablets per 30 days 200mL (2 bottles) per 30 days 6.1g (1 bottle) per 30 days 30 capsules per 30 days 30 droperettes per 30 days 2 boxes (#20 diskhalers/box) 120 capsules per 30 days 60 capsules per 30 days 12 tablets per 30 days 7.7mL (1 pump) per 30 days 10mL (2 bottles) per 30 days 30 tablets per 30 days 30 tablets per 30 days 90 capsules per 30 days 3 capsules per 28 days • Rhinocort Aqua 17.2g (2 canisters) per 30 days 20 films per 30 days • Risperdal/Risperdal M- 60 tablets per 30 days 10 films per 30 days 2.5%: 7.5 grams (1 bottle) per 30 tablets per 30 days 300 capsules per 30 days 3.75% pump:7.5 grams (1 • Ryzodeg 70/30 30mL (10 pens) per 28 days bottle) per 28 days 180 tablets per 30 days 3.75% packet: 28 packets per 30 tablets per 365 days 60 tablets per 365 days 1 kit per 30 days 5. STEP THERAPY EDITS (FORMULARY)
4 patches per 28 days • Abilify tablets Trial of two preferred atypical antipsychotics (olanzapine, quetiapine 60 tablets per 30 days Abilify Discmelt IR, risperidone, ziprasidone) or SSRIs Abilify solution 30 tablets per 30 days (sertraline, fluoxetine, paroxetine, 91 tablets per 84 days citalopram, or escitalopram) or SNRIs • Seebri Neohaler 60 blister packs (1 Seebri (venlafaxine) within the past 365 days. inhaler) per 30 days • Actoplus Met Trial of metformin, metformin ER, 30 tablets per 30 days sulfonylurea (e.g., glyburide, glipizide) 30 tablets per 30 days or pioglitazone within the past 120 days 4 tablets per 365 days Trial of Ambien IR within the past 180 30 tablets per 30 days Trial of Astelin (azelastine) within the 2000mL (8 bottles) per 30 days 3840mL (8 bottles) per 30 days Trial of Proscar, alfuzosin, doxazosin, 5 bottles per 30 days prazosin, silodosin, tamsulosin or 6 tablets per 30 days terazosin within the past 120 days 6 tablets per 30 days Trial of ACE inhibitor, ACE inhibitor • Sumavel DosePro 4 units per 28 days combination, formulary generic ARB, or 120 sprays per 30 days formulary generic ARB combination 10.2g (1 inhaler) per 30 days within the past 120 days 4 pens per 28 days Trial of ACE inhibitor, ACE inhibitor 90 tablets per 30 days combination, formulary generic ARB, or 300g (60 x 5g tubes) per 30 formulary generic ARB combination within the past 120 days • Timoptic Ocudose 60 droperettes per 30 days Trial of two of the following: 90 capsules per 30 days atorvastatin, lovastatin, pravastatin or simvastatin within the past 365 days 30 mL (10 pens) per 28 days Trial of atorvastatin 40mg or Crestor 10mg, 20mg, 18 mL (6 pens) per 28 days atorvastatin 80mg within the past 120 10 capsules per day 9 tablets per 30 days Trial of Spiriva, Serevent,Breo Ellipta, Advair Diskus, or Dulera within the past 25mg, 50mg, 100mg 30 capsules per 30 days 60 capsules per 30 days • Desvenlafaxine ER Trial of two of the following: paroxetine, • Tudorza Pressair 1 inhaler per 30 days fluoxetine, citalopram, sertraline, 600mL per 30 days escitalopram, mirtazapine, • Utibron Neohaler 60 blister packs (Utibron bupropion, venlafaxine IR/ER within the Inhaler) per 30 days 2 tablets per 14 days Trial of oxybutynin or oxybutynin ER 10g (1 bottle) per 30 days within the past 120 days 540mL per 30 day Trial of vancomycin capsules within the 30 tablets per 30 days Trial of a topical corticosteroid within 60 tablets per 30 days the past 120 days 1200mL per 30 days • Drithocreme HP Trial of a topical corticosteroid within 1 capsule per day the past 120 days 30 tablets per 30 days Trial of metformin, metformin ER, 360 tablets per 30 days sulfonylurea (e.g., glyburide, glipizide) 10gm (2 tubes) per 365 days or pioglitazone within the past 120 days • Xifaxan 200mg 9 tablets per fill Trial of ACE inhibitor, ACE inhibitor 60 tablets per 30 days combination, formulary generic ARB, or formulary generic ARB combination 300mL per 30 days within the past 120 days 1 carton per 28 days Trial of gemifibrozil or generic fenofibrate within the past 120 days 30 packets per 30 days Portfolio High Formulary – April 2016 Scripps Health Formulary
Trial of any antiretroviral medication sertraline, escitalopram, mirtazapine, within the past 30 days bupropion, or venlafaxine IR/ER within Trial of two different non-drospirenone the past 365 days oral contraceptives (containing • Protonix Suspension Trial of Prilosec OTC or omeprazole levonorgestrel, norethindrone, within the past 120 days norgestimate, norgestrel, desogestrel, Trial of a topical corticosteroid within or ethinynodiol ace.) within the past the past 120 days Trial of mercaptopurine tablet within the Trial of metformin (IR/ER), a sulfonylurea, pioglitazone or a Trial of fluticasone or flunisolide within combination product containing any two the past 120 days of the three agents above within the • Qnasl Children Trial of fluticasone or flunisolide within the past 120 days Trial of Isentress, Reyataz, Prezista, • Quillivant XR Trial of Metadate CD or Ritalin LA Sustiva or Atripla within the past 120 within the past 120 days • Retin-A Micro Pump Trial of generic tretinoin microspheres Trial of metformin (IR/ER), a 0.04% AND tretinoin gel 0.10% within sulfonylurea, pioglitazone or a the past 365 days combination product containing any two Trial of pramipexole IR or ropinirole IR of the three agents above within the within the past 120 days Trial of oxybutynin or oxybutynin ER Trial of metformin (IR/ER), a within the past 120 days sulfonylurea, pioglitazone or a Trial of two of the following; combination product containing any two atorvastatin, lovastatin, pravastatin or of the three agents above within the simvastatin within the past 365 days Trial of two different non-drospirenone Trial of finasteride 5mg, alfuzosin, oral contraceptives (containing doxazosin, prazosin,tamsulosin or levonorgestrel, norethindrone, terazosin within the past 120 days norgestimate, norgestrel, desogestrel, Trial of metformin (IR/ER), a or ethinynodiol ace.) within the past sulfonylurea, pioglitazone, or a combination product containing any Trial of metformin (IR/ER), a two of the three agents above within sulfonylurea, pioglitazone, or a the past 120 days. combination product containing any two Trial of one generic contraceptive of the three agents above within the within the past 120 days • Loestrin FE24 Trial of two generic oral contraceptives Trial of ACE inhibitor, ACE inhibitor within the past 365 days combination, formulary generic ARB or • Lo Loestrin FE Trial of two generic oral contraceptives ARB combination within the past 120 within the past 365 days Trial of two different non-drospirenone Trial of oxybutynin or oxybutynin ER oral contraceptives (containing within the past 120 days levonorgestrel, norethindrone, Trial of gemifibrozil or generic norgestimate, norgestrel, desogestrel, fenofibrate within the past 120 days or ethinynodiol ace.) within the past Trial of metformin (IR/ER), a sulfonylurea, pioglitazone or a Trial of ondansetron, corticosteroids combination product containing any two and Emend within the past 365 days of the three agents above within the Trial of oxybutynin IR/ER within the Trial of allopurinol within the past 120 Trial of pramipexole IR or ropinirole IR within the past 120 days Trial of a topical corticosteroid within Trial of omeprazole, lansoprazole or the past 120 days Nexium Suspension pantoprazole within the past 120 days Trial of oxybutynin or oxybutynin ER Trial of donepezil and memantine within the past 120 days within the past 365 days Trial of two different non-drospirenone Trial of generic/multisource statin oral contraceptives (containing (atorvastatin, lovastatin, pravastatin, or levonorgestrel, norethindrone, simvastatin), or generic/multisource norgestimate, norgestrel, desogestrel, gemfibrozil or fenofibrate within the or ethinynodiol ace.) within the past Trial of a generic oral contraceptive • Vibramycin/Vibra-Tabs Trial of generic doxycycline within the past 120 days monohydrate capsules within the past Trial of two different non-drospirenone oral contraceptives (containing Trial of metformin (IR/ER), a levonorgestrel, norethindrone, sulfonylurea, pioglitazone or a norgestimate, norgestrel, desogestrel, combination product containing any two or ethinynodiol ace.) within the past of the three agents above within the Trial of a generic oral contraceptive Trial of previous HIV anti-retroviral within the past 120 days therapy within the past 120 days Trial of methotrexate tablet or solution Trial of one of the following: SSRI for injection within the past 120 days (sertraline, escitalopram, citalopram, • Prevacid Solutabs Trial of lansoprazole, omeprazole or fluoxetine, fluvoxamine, paroxetine), pantoprazole within the past 120 days topiramate, generic/multisource mixed Trial of two of the following: generic amphetamine salts (Adderall IR/XR), or paroxetine, fluoxetine, citalopram, methylphenidate (IR, ER, LA, CD) Portfolio High Formulary – April 2016 Scripps Health Formulary
within the past 120 days. divalproex, topiramate, or zonisamide Trial of two different non-drospirenone within the past 365 days oral contraceptives (containing Trial of Serevent Diskus or Striverdi levonorgestrel, norethindrone, Respimat within the past 120 days norgestimate, norgestrel, desogestrel, • Arnuity Ellipta Trial of at least two of the following: or ethinynodiol ace.) within the past Asmanex, Pulmicort, or QVAR within the past 365 days Trial of two different non-drospirenone Trial of balsalazide, Lialda, Pentasa or oral contraceptives (containing Apriso within the past 120 days levonorgestrel, norethindrone, Trial of alendronate and ibandronate norgestimate, norgestrel, desogestrel, within the past 365 days or ethinynodiol ace.) within the past Trial of Epipen within the past 120 Trial of two different non-drospirenone Trial of metformin (IR/ER), a oral contraceptives (containing sulfonylurea, pioglitazone, or a levonorgestrel, norethindrone, combination product containing any norgestimate, norgestrel, desogestrel, two of the three agents above within or ethinynodiol ace.) within the past the past 120 days. • Avidoxy/Avidoxy DK Trial of generic doxycycline • Zenzedi (2.5mg, 7.5mg) Trial of a multisource monohydrate 100mg capsules within dextroamphetamine sulfate tablet or the past 120 days dextroamphetamine solution within the Trial of sumatriptan or rizatriptan within the past 180 days • Zocor (80mg only) Trial of simvastatin 80mg or Vytorin Trial of lamotrigine, valproic acid or 10/80mg within the past 365 days topiramate within the past 120 days Trial of sumatriptan or rizatriptan within Trial of preferred long acting insulin the past 180 days within the past 120 days 6. STEP THERAPY EDITS (NON FORMULARY)
Trial of fluticasone or flunisolide within Trial of generic isotretinoin within the the past 365 days Trial of Butrans (buprenorphine Trial of two of the following; transdermal) patch within the past 120 omeprazole, lansoprazole or pantoprazole or rabeprazole within the Trial of zolpidem IR (Ambien), zaleplon (Sonata) or eszopiclone (Lunesta) • Aciphex Sprinkle Trial of two of the following; within the past 120 days omeprazole, lansoprazole, Trial of generic doxycycline pantoprazole or rabeprazole within the monohydrate 100mg capsules within the past 120 days Trial of generic doxycycline Trial of Kelo-cote or Recedo within the monohydrate tablets within the past • Benzaclin pump Trial of two preferred topical Trial of alendronate and ibandronate combination acne agents (Ziana and within the past 365 days Acanya) within the past 365 days Trial of Epipen within the past 120 Trial of generic ophthalmic antihistamine (epinastine, azelastine, Trial of two of the following; or olapatadine) AND Pataday atorvastatin, lovastatin, pravastatin or (olapatadine 0.2%) within the past 365 simvastatin within the past 365 days Trial of at least two of the following: Trial of two different non-drospirenone QVAR, Asmanex or Pulmicort within oral contraceptives (containing the past 365 days levonorgestrel, norethindrone, Trial of two of the following: norgestimate, norgestrel, desogestrel, atorvastatin, lovastatin, pravastatin or or ethinynodiol ace.) within the past simvastatin within the past 365 days Trial of at least two of the following: Trial of generic alendronate and QVAR, Asmanex or Pulmicort within ibandronate within the past 365 days the past 365 days Trial of two of the following • Anoro Ellipta Trial of Stiolto Respimat and one of the generic/multisource products: following: Spiriva, Striverdi or Serevent paroxetine, venlafaxine ER or IR, within the past 365 days fluoxetine, citalopram, sertraline, Trial of gemifibrozil or generic escitalopram, mirtazapine or bupropion fenofibrate within the past 120 days within the past 365 days Trial of ondansetron tablets or ODT Trial of paroxetine or venlafaxine within within the past 120 days the past 120 days Trial of Humalog within the past 120 Trial of metformin (IR/ER), a sulfonylurea, pioglitazone, or a Trial of bupropion hcl SR or XL within combination product containing any the past 120 days two of the three agents above and Trial of methylphenidate IR, Trulicity or Victoza within the past 365 generic/multisource mixed amphetamine salts (Adderall) or long- Trial of metformin (IR/ER), a acting formulation of methylphenidate sulfonylurea, pioglitazone, or a (ER, LA, CD) within the past 120 days combination product containing any Trial of two of the following; two of the three agents above and carbamazepine, gabapentin, Trulicity or Victoza within the past 365 lamotrigine, levetiracetam IR or ER, oxcarbazepine, valproic acid or Trial of ondansetron tablet or ODT Portfolio High Formulary – April 2016 Scripps Health Formulary
within the past 120 days Trial of generic ophthalmic • Clarinex Reditabs/ Trial of desloratadine or levocetirizine antihistamine (epinastine, azelastine, tablet within the past 120 days or olapatadine) AND Pataday (olapatadine 0.2%) within the past 365 Trial of tramadol ER (Ultram ER) within the past 120 days Trial of topical corticosteroid within the Trial of dorzolamide/timolol within the If age ≥ 12 years, trial of enalapril Trial of metformin (Glucophage), tablets within the past 120 days metformin ER, glyburide/metformin Trial of adapalene 0.1% gel within the (Glucovance), or glipizide/metformin (Metaglip) within the past 180 days • Epiduo Forte Trial of adapalene 0.1% gel within the Trial of methylphenidate CD, ER, or LA formulation or methylphenidate • Esomeprazole Strontium Trial of omeprazole, lansoprazole or suspension/solution within the past 120 pantoprazole within the past 120 days Trial of Narcan nasal spray within the Trial of balsalazide, Lialda, Pentasa or Apriso within the past 120 days Trial of two preferred atypical • DermacinRx Silapak Trial of all three individual ingredients: antipsychotics (olanzapine, quetiapine triamcinolone 0.1% (RX), dimethicone IR, risperidone, ziprasidone) within the 5% (OTC) and silicone tape (OTC) within the past 365 days Trial of metformin (IR/ER), a • DermasilkRx SDS Trial of all three individual ingredients: sulfonylurea, pioglitazone, or a triamcinolone 0.1% (RX), dimethicone combination product containing any 5% (OTC) and silicone tape (OTC) two of the three agents above and within the past 365 days Invokana, Invokamet, Jardiance or • Desvenlafaxine ER Trial of two of the following; generic Synjardy within the past 365 days paroxetine, fluoxetine, citalopram, Trial of two preferred atypical sertraline, escitalopram, venlafaxine antipsychotics (olanzapine, quetiapine ER or IR, mirtazapine or bupropion IR, risperidone, ziprasidone) within the within the past 365 days Trial of omeprazole, pantoprazole, or Trial of lamotrigine or topiramate within lansoprazole within the past 120 days the past 120 days • Diabetes blood glucose Trial of 1) one FreeStyle or Precision Trial of two of the following; paroxetine, test strips, Bayer brands brand test strip and 2) one OneTouch fluoxetine, citalopram, sertraline, (Contour, Breeze) test strip within the past 365 days escitalopram, mirtazapine, bupropion • Diabetes blood glucose Trial of 1) one FreeStyle or Precision or venlafaxine IR/ER within the past test strips, Roche brand test strip and 2) one OneTouch brands (Accu-chek, test strip within the past 365 days • Flovent Diskus/HFA Trial of two of the following: QVAR, Pulmicort or Asmanex within the past Trial of balsalazide, Lialda, Pentasa or Apriso within the past 120 days Trial of Serevent Diskus or Striverdi • Doryx 50mg tabs Trial of generic doxycycline Respimat within the past 120 days monohydrate 50mg capsules within the Trial of generic bupropion within the • Doryx 75mg tabs Trial of generic doxycycline Trial of generic metformin ER monohydrate 75mg tablets within the (Glucophage XR) within the past 120 • Doryx 100mg tabs/caps Trial of generic doxycycline Trial of sumatriptan or rizatriptan within monohydrate 100mg capsules within the past 180 days the past 120 day Trial of antiretroviral therapy within the • Doryx 150mg tabs Trial of generic doxycycline monohydrate 150mg tablets within the Trial of two of the following: carbamazepine, gabapentin, • Doryx 200mg tabs Trial of generic doxycycline lamotrigine, levetiracetam IR or ER, monohydrate 100mg capsules within oxcarbazepine, valproic acid, the past 120 days divalproex, topiramate or zonisamide Trial of generic oral NSAID within the within the past 365 days Trial of two of the following: Trial of extended-release carbamazepine, gabapentin, amphetamine/dextroamphetamine oral lamotrigine, levetiracetam IR or ER, capsules within the past 120 days oxcarbazepine, valproic acid, Trial of fluticasone or flunisolide within divalproex, topiramate or zonisamide the past 365 days within the past 365 days Trial of ACE inhibitor, ACE inhibitor Trial of balsalazide or Apriso within the combination, formulary generic ARB, or formulary generic ARB combination Trial of generic metformin ER within the past 120 days (Glucophage XR) within the past 120 Trial of ACE inhibitor, ACE inhibitor combination, formulary generic ARB, Trial of gabapentin (Neurontin) within or formulary generic ARB combination the past 120 days within the past 120 days For age over 1 year, trial of generic Trial of zolpidem immediate-release propranolol oral solution within the past tablets within the past 120 days Trial of a topical corticosteroid within Trial of pramiprexole (Mirapex), the past 120 days ropinirole IR (Requip) or generic gabapentin (Neurontin) within the past Portfolio High Formulary – April 2016 Scripps Health Formulary
• Monodox 75mg caps Trial of generic doxycycline monohydrate 75mg tabs within the within the past 120 days Trial of generic doxycycline • Incruse Ellipta Trial of preferred LAMA (Spiriva) within monohydrate 100mg cap within the the past 120 days Trial of Inderal LA within the past 120 Trial of two generic oral contraceptives within the past 365 days Trial of Inderal LA within the past 120 Trial of fluocinolone and bacitracin within the past 365 days Trial of zolpidem immediate-release Trial of a formulary DPP4 tablets within the past 120 days inhibitor(s)/combination (Januvia, Trial of two preferred atypical Janumet, Janumet XR, Tradjenta, or antipsychotics (olanzapine, quetiapine Jentadueto within the past 120 days IR, risperidone, ziprasidone) within the Trial of Humulin N within the past 120 Trial of generic duloxetine 20mg Trial of Humulin R within the past 120 capsules within the past 120 days Trial of a formulary DPP4 • Novolin 70/30 Trial of Humulin 70/30 within the past inhibitor(s)/combination (Januvia, Janumet, Janumet XR, Tradjenta, or Trial of Humalog within the past 120 Jentadueto within the past 120 days Trial of generic immediate-release • Novolog Mix 70/30 Trial of Humalog Mix 75/25 within the carbinoxamine maleate within the past Trial of hydrocodone/homatropine Trial of two of the following generic methylbromide within the past 120 products: paroxetine, venlafaxine ER/ IR, fluoxetine, citalopram, sertraline, Trial of immediate release trazodone escitalopram, mirtazapine or bupropion within the past 120 days within the past 365 days Trial of fluticasone or flunisolide within • Kombiglyze XR Trial of a formulary DPP4 the past 365 days inhibitor(s)/combination (Januvia, Trial of lamotrigine or topiramate within Janumet, Janumet XR, Tradjenta, or the past 120 days Jentadueto within the past 120 days Trial of a formulary DPP4 Trial of generic ophthalmic inhibitor(s)/combination (Januvia, antihistamine (epinastine, azelastine, Janumet, Janumet XR, Tradjenta, or or olapatadine) AND Pataday Jentadueto within the past 120 days (olapatadine 0.2%) within the past 365 Trial of generic doxycycline monohydrate 50mg capsule within the Trial of ondansetron tablets or ODT within the past 120 days Trial of a formulary DPP4 • Lamictal ODT/XR Trial of lamotrigine IR within the past inhibitor(s)/combination (Januvia, Janumet, Janumet XR, Tradjenta, or Trial of two preferred atypical Jentadueto within the past 120 days antipsychotics (olanzapine, quetiapine • Ovace Plus Lotion Trial of ketoconazole shampoo/cream IR, risperidone, ziprasidone) or SSRIs or ciclopirox shampoo/gel within the (sertraline, fluoxetine, paroxetine, citalopram, or escitalopram) or SNRIs Trial of two of the following: (venlafaxine) within the past 365 days carbamazepine, gabapentin, Trial of two of the following: lamotrigine, levetiracetam IR or ER, atorvastatin, lovastatin, pravastatin or oxcarbazepine, valproic acid, simvastatin within the past 365 days divalproex, topiramate, or zonisamide Trial of Lantus or Toujeo within the within the past 365 days Trial of Astelin (azelastine) within the Trial of Cialis and Viagra within the Trial of generic antihistamine and Pataday within the past 365 days Trial of 2 of the following: atorvastatin, Trial of Voltaren gel within the past 120 simvastatin, pravastatin or lovastatin within the past 365 days Trial of paroxetine IR within the past 10/20mg, 10/40mg, Trial of 40mg atorvastatin or 80mg atorvastatin within the past 120 days Trial of two of the following: Trial of two of the following: carbamazepine, gabapentin, atorvastatin, lovastatin, pravastatin or lamotrigine, levetiracetam IR or ER, simvastatin within the past 365 days oxcarbazepine, valproic acid, • Loestrin 24 Fe Trial of two generic oral contraceptives divalproex, topiramate, or zonisamide within the past 365 days within the past 365 days Trial of generic paroxetine, fluoxetine, Trial of Eliquis and Xarelto within the citalopram, sertraline, escitalopram, mirtazapine, or fluvoxamine IR within Trial of amlodipine and ACE inhibitor the past 120 days (quinapril hcl, perindopril erbumine, Trial of ketoconazole and clotrimazole ramipril, benazepril hcl, captopril, cream within the past 365 days enalapril maleate, fosinopril sodium, Trial of pramipexole IR or ropinirole IR lisinopril, trandolapril or moexipril hcl) within the past 120 days within the past 365 days • Moderiba Dosepak Trial of ribavirin 200mg capsule or Trial of topiramate immediate release tablet within the past 120 days within the past 120 days Portfolio High Formulary – April 2016 Scripps Health Formulary
Trial of Ritalin LA or Metadate CD (Imitrex or equivalent) within the past within the past 120 days Trial of finasteride 5mg, alfuzosin, Trial of Dulera, Advair or Breo Ellipta doxazosin, prazosin,tamsulosin or within the past 120 days terazosin within the past 120 days Trial of a topical corticosteroid within Trial of Otrexup and methotrexate the past 120 days tablet or solution for injection within the Trial of metformin (IR/ER), a sulfonylurea, pioglitazone, or a Trial of generic prednisone within the combination product containing any two of the three agents above and Trial of sumatriptan or rizatriptan within Trulicity or Victoza within the past 365 the past 180 days Trial of latanoprost and Lumigan or Trial of Comtan within the past 120 Travatan Z within the past 365 days Trial of two preferred atypical Trial of ACE inhibitor, ACE inhibitor antipsychotics (olanzapine, quetiapine combination, formulary generic ARB, IR, risperidone, ziprasidone) or SSRIs or formulary generic ARB combination (sertraline, fluoxetine, paroxetine, within the past 120 days citalopram, or escitalopram) or SNRIs • Timoptic Ocudose Trial of timolol drops within the past (venlafaxine) within the past 365 days • Rhinocort Aqua Trial of fluticasone or flunisolide within Trial of generic indomethacin within the the past 365 days • Ribasphere 400mg, Trial of ribavirin 200mg capsule or • Topicort Spray Trial of mometasone 0.1% ointment, tablet within the past 120 days fluocinonide 0.05% cream/ointment/ Trial of zolpidem IR (Ambien), zaleplon gel, desoximetasone 0.25% cream, or (Sonata) or eszopiclone (Lunesta) betamethasone dipropionate 0.05% within the past 120 days cream within the past 120 days Trial of Sinemet IR or CR within the Trial of preferred long-acting insulin within the past 120 days • Ryzodeg 70/30 Trial of preferred long acting insulin Trial of sumatriptan within the past 180 and preferred pre-mixed insulin) within the past 365 days Trial of topiramate IR within the past Trial of two different non-drospirenone oral contraceptives (containing • Tudorza Pressair Trial of Spiriva within the past 120 days levonorgestrel, norethindrone, • Utibron Neohaler Trial of preferred LAMA or LABA and norgestimate, norgestrel, desogestrel, LAMA/LABA(s) within the past 365 or ethinynodiol ace.) within the past Trial of promethazine with codeine Trial of Eliquis and Xarelto within the syrup within the past 120 days • Uceris rectal foam Trial of mesalamine enema within the Trial of all three individual ingredients: triamcinolone 0.1% (RX), dimethicone • Uceris tablet Trial of balsalazide within the past 120 5% (OTC) and silicone tape (OTC) within the past 365 days Trial of two preferred topical • Seebri Neohaler Trial of preferred LAMA within the past combination acne agents (Ziana and Acanya) within the past 365 days Trial of ondansetron tablet or ODT Trial of fluticasone or flunisolide within within the past 120 days the past 365 days Trial of two preferred atypical Trial of two preferred atypical antipsychotics (olanzapine, quetiapine antipsychotics (olanzapine, quetiapine IR, risperidone, ziprasidone) within the IR, risperidone, ziprasidone) within the Trial of two preferred atypical Trial of two of the following: paroxetine, antipsychotics (olanzapine, quetiapine fluoxetine, citalopram, sertraline, IR, risperidone, ziprasidone) or SSRIs escitalopram, mirtazapine, bupropion, (sertraline, fluoxetine, paroxetine, venlafaxine IR/ER within the past 365 citalopram, or escitalopram) or SNRIs (venlafaxine) within the past 365 days Trial of generic naproxen within the Trial of zolpidem IR (Ambien), zaleplon (Sonata) or eszopiclone (Lunesta) Trial of two of the following: within the past 120 days carbamazepine, gabapentin, Trial of oral acyclovir, valacyclovir or lamotrigine, levetiracetam IR or ER, famciclovir within the past 120 days oxcarbazepine, valproic acid, Trial of Cialis and Viagra within the divalproex, topiramate or zonisamide within the past 365 days Trial of Cialis and Viagra within the Trial of generic meloxicam within the Trial of generic minocycline immediate Trial of two of the following: release within the past 120 days atorvastatin, lovastatin, pravastatin or Trial of a topical corticosteroid within simvastatin within the past 365 days the past 120 days 10/20mg, 10/40mg Trial of atorvastatin 40mg or Trial of sotolol tablets within the past atorvastatin 80mg within the past 120 Trial of generic valproic acid or Trial of simvastatin 80mg or Vytorin divalproex within the past 120 days 10/80mg within the past 365 days • Sumavel Dose-Pro Trial of generic/multisource injectable Trial of oral acyclovir, valacyclovir or sumatriptan or nasal sumatriptan famciclovir within the past 120 days Portfolio High Formulary – April 2016 Scripps Health Formulary
Trial of metformin (IR/ER), a sulfonylurea, pioglitazone, or a combination product containing any two of the three agents above and Invokana, Invokamet, Jardiance or Synjardy within the past 365 days. • Xyzal Solution Trial of desloratadine or levocetirizine tablet within the past 120 days Trial of generic/multisource sumatriptan and nasal sumatriptan within the past 365 days Trial of omeprazole, lansoprazole or pantoprazole within the past 120 days Trial of fluticasone or flunisolide within the past 365 days Trial of latanoprost and Lumigan or Travatan Z within the past 365 days Trial of diclofenac sodium within the Trial of a topical corticosteroid within the past 120 days Trial of zolpidem immediate-release tablets within the past 120 days Trial of diclofenac sodium within the Trial of ondansetron tablet or ODT within the past 120 days 7. GENDER EDITS (FORMULARY)
8. GENDER EDITS (NON-FORMULARY)
9. PRIOR AUTHORIZATION RESTRICTIONS (FORMULARY)
Afinitor /Afinitor Disperz Avonex Admin Pack Revatio tablets Depo-Testosterone • Temodar capsules • Tobi Podhaler Portfolio High Formulary – April 2016 Scripps Health Formulary
Flebogamma DIF* Gammagard Liquid • Xifaxan 550mg 10. PRIOR AUTHORIZATION RESTRICTIONS (NON FORMULARY)
Carimune NF Nanofiltered* Neulasta Delivery Kit* Nutropin AQ NuSpin Portfolio High Formulary – April 2016 Scripps Health Formulary
Pegintron Redipen * = Dependent on plan benefit. If covered under pharmacy benefit, then non-formulary with prior authorization Revatio suspension 11. CONCURRENT USE EDITS (FORMULARY)
12. CONCURRENT USE EDITS (NON FORMULARY)
Simponi Aria IV* Portfolio High Formulary – April 2016 Scripps Health Formulary
5-grass pollen extract. 6 aminophylline . 6
amiodarone hcl . 7
abacavir sulfate . 14
abacavir sulfate/lamivudine . 14 amitriptyline hcl . 7
abacavir/dolutegravir/lamivudine . 14 amlodipine bes/olmesartan med . 8 azathioprine . 13
abacavir/lamivudine/zidovudine . 14
amlodipine besylate . 8
azelastine hcl . 6, 12
ABBOTT DIABETIC SUPPLIES . 11 amlodipine besylate/benazepril . 7
ABILIFY DISCMELT . 7 amlodipine/atorvast cal . 9
azithromycin . 13
ABILIFY SOLUTION . 7 amlodipine/valsartan . 8
ABILIFY TABLET . 7 amlodipine/valsartan/hctz . 8
abiraterone acetate . 16 aztreonam lysine . 13 amox tr/potassium clavulanate . 14
acarbose . 10
amoxapine . 7
bacitracin . 12
amoxicillin trihydrate . 14
bacitracin/polymyxin b sulfate . 12
baclofen . 18
acebutolol hcl . 8
amphet asp/amphet/d-amphet . 7
acetaminophen with codeine . 17
ampicillin trihydrate . 14
BACTROBAN . 9, 10 acetazolamide . 12
amylase/lipase/protease . 18
BACTROBAN NASAL . 17 acetic acid . 11
balsalazide disodium . 15
acetic acid/aluminum acetate . 11
anagrelide hcl . 13
acetic acid/hydrocortisone . 11
ANALPRAM HC . 15 becaplermin . 11 acetylcysteine . 17
beclomethasone dipropionate . 6 acitretin . 10
belladonna alkaloids/phenobarb . 18
benazepril hcl . 8
anastrozole . 16
benazepril/hydrochlorothiazide . 7
ACTOPLUS MET . 11 ACTOPLUS MET XR . 11 acyclovir . 10, 14
antipyrine/benzocaine otic . 11 BENZAMYCIN PAK . 10 benzoyl peroxide. 9
adapalene . 9
benzoyl peroxide/hydrocortison . 9 benztropine mesylate . 17
besifloxacin hcl drops susp 0.6% . 12 ADVAIR DISKUS . 6 betamet diprop/prop gly . 10
betamethasone dipropionate . 6, 10 ARALEN PHOSPHATE . 14 betamethasone valerate . 10
AFINITOR DISPERZ . 16 betaxolol hcl . 12
bethanechol chloride . 16
aripiprazole. 7
ARMOUR THYROID . 12 bexarotene . 10, 16 albuterol sulfate . 6
ALBUTEROL SULFATE . 6 bicalutamide . 16
alclometasone dipropionate . 10
asfotase alfa., STRENSIQ . 17 bimatoprost 0.01% . 12 bimatoprost 0.03% . 12 bimonidine/timolol . 12 alectinib hydrochloride . 16 bisoprolol fumarate . 8
alendronate sodium . 11
atazanavir sulfate . 15 bisoprolol fumarate/hctz . 8
alendronate sodium solution . 11
atazanavir sulfate/cobicistat . 15 alendronate sodium/vitamin d3 . 11 atenolol . 8
BLEPHAMIDE S.O.P. 12 alfuzosin . 18
atenolol/chlorthalidone . 8
blood sugar diagnostic . 11 allopurinol . 13
atomoxetine hcl . 7 blood-glucose calib. control . 11 atorvastatin calcium . 8
blood-glucose meter . 11 atropine sulfate . 12
ATROVENT . 6, 17 alprazolam . 7
ATROVENT HFA . 6 ALPRAZOLAM INTENSOL . 7 AUGMENTIN ES-600 . 14 BREO ELLIPTA . 6 AUGMENTIN XR . 14 altretamine . 16 aluminum chloride . 10
amantadine hcl . 17
brimonidine tartrate . 12
AVELOX ABC PACK . 14 brinzolamide . 12 brinzolamide/brimonidine . 12 bromocriptine mesylate. 17
budesonide . 6, 15
amcinonide . 10
bumetanide . 8
AMINOPHYLLIN . 6 AVONEX ADMINISTRATION PACK . 16 Portfolio High Formulary – April 2016 Scripps Health Formulary
BUPHENYL POWDER . 15 cholestyramine/sucrose . 8
cortisone acetate . 15
BUPHENYL TABLET . 15 CORTISPORIN CREAM . 10 buprenorphine . 17 CORTISPORIN OINTMENT . 10 buprenorphine hcl . 17
CORTISPORIN OPHTH OINTMENT . 12 buprenorphine hcl/naloxone hcl . 17 CORTISPORIN OPHTH SUSPENSION . 12 bupropion hcl . 6
ciclopirox 8% solution . 10
CORTISPORIN OTIC . 11 ciclopirox olamine . 10
CORTONE ACETATE . 15 buspirone hcl . 7
cilostazol . 13
butalb/acetaminophen/caffeine . 17
cimetidine hcl . 18
butalbital/acetaminophen . 17
butalbital/aspirin/caffeine . 17
CIPRO ORAL SUSPENSION . 14 butoconazole nitrate . 18 ciprofloxacin . 14
ciprofloxacin hcl . 12, 14
cabergoline . 12
ciprofloxacin hcl/dexameth . 11 cabozanitinib . 16 citalopram hydrobromide . 6
cromolyn sodium . 6, 12
clarithromycin . 13
CLARITIN (OTC) . 6 CLARITIN-D 12 HOUR . 6 calcipotriene. 10
CLARITIN-D 24 HOUR . 6 cyanocobalamin/fa/pyridoxine . 19 calcitriol . 19
CLEOCIN HCL . 13 calcium acetate . 11
CLEOCIN PALMITATE . 13 cyclobenzaprine hcl . 18
canagliflozin . 11 canagliflozin/metformin hcl . 11 clindamycin . 13
cyclopentolate hcl . 12
capecitabine . 16
clindamycin palmitate . 13
cyclophosphamide . 16
CAPITAL W-CODEINE . 17 clindamycin phos/benzoyl perox . 9
cyclosporine . 12, 13 clindamycin phosphate . 9, 10
cyclosporine, modified . 13
clindamycin/tretinoin . 9 captopril . 8
captopril/hydrochlorothiazide . 7
clobetasol propionate . 10
clobetasol propionate/emoll . 10
cysteamine bitartrate . 18 carbamazepine . 18
clomiphene citrate . 11
carbidopa . 18
clomipramine hcl . 7
carbidopa/levodopa . 17
clonazepam . 18
carbidopa/levodopa/entacapone . 17
clonidine hcl . 8
clopidogrel bisulfate . 13
clorazepate dipotassium . 7
dalteparin sodium,porcine . 13 clotrimazole . 14
danazol . 12
clotrimazole/betamet diprop . 10
carisoprodol . 18
clozapine . 7
carisoprodol/aspirin . 18
dantrolene sodium . 18
dapsone . 14
carteolol hcl. 12
cobimetinib fumarate . 16 carvedilol . 8
codeine phos/carisoprodol/asa . 17
darunavir ethanolate . 14 carvedilol phosphate . 8 codeine/butalbit/acetamin/caff . 17
darunavir/cobicistat . 14 codeine/butalbital/asa/caffein . 17
codeine/promethazine hcl . 9
COL-BENEMID . 13 DELATESTRYL . 13 cefaclor . 13
colchicine . 13
delavirdine mesylate . 14 cefadroxil hydrate . 13
colchicine/probenecid . 13
cefdinir . 13
colesevelam hcl . 8 cefpodoxime proxetil . 13
DEMULEN 1-50-21 . 9 cefprozil . 13
COLESTID GRANULES . 8 DEPAKENE CAPSULES . 18 DEPAKENE SYRUP . 18 cefuroxime axetil . 13
COLYTE WITH FLAVOR PACKETS . 16 DEPAKOTE ER . 18 DEPAKOTE SPRINKLE . 18 celecoxib . 15
COMBIVENT RESPIMAT . 6 DEPO-TESTOSTERONE . 13 desipramine hcl . 7
desmopressin (nonrefrigerated) . 11
cephalexin monohydrate . 13
COMPAZINE SYRUP . 6 desogestrel-ethinyl estradiol . 9
cetirizine hcl (OTC) . 6
desog-et estra/ethin estra . 9
cetrorelix acetate . 12 desonide . 10
cevimeline hcl . 16
desoximetasone . 10
chloral hydrate . 7
DESVENLAFAXINE ER (RANBAXY BRAND) . 6 chlorambucil . 16 desvenlafaxine ER (Ranbaxy) . 6 chlordiazepoxide hcl . 7
desvenlafaxine succinate . 6 chlordiazepoxide/clidinium br . 18 DESYREL 300MG . 6 chlorhexidine gluconate . 17
chloroquine phosphate . 14
chlorpromazine hcl . 7
dexamethasone . 15
chlorpropamide . 10
chlorthalidone . 8
DEXEDRINE SPANSULE . 7 chlorzoxazone . 18
dexmethylphenidate hcl . 7
cholestyramine/aspartame . 8
dextroamphetamine capsule . 7
Portfolio High Formulary – April 2016 Scripps Health Formulary
dextroamphetamine sulfate . 7
efavirenz/emtricitab/tenofovir . 15 etidronate disodium . 11
dextroamphetamine tablet . 7
etodolac . 15
etonogestrel/ethinyl estradiol . 9 etoposide . 16
DIAMOX SEQUELS . 12 diazepam . 7, 18
everolimus . 13, 16 dichlorphenamide . 18 diclofenac sodium .10, 12, 15 dicloxacillin sodium . 14
dicyclomine hcl . 18
eltrombopag olamine . 13 didanosine . 14
elviteg/cobi/emtric/tenofo ala . 14 elvitegravir . 15 EXELON PATCH . 6 elvitegravir/cobicistat/emtricitabine/ tenofovir exemestane . 16
disoproxil fumarate . 14 diflorasone diacetate . 10
diflorasone diacetate/emoll . 10 diflunisal . 17
empagliflozin . 11 famotidine. 18
difluprednate . 12 empagliflozin/linagliptin . 11 digoxin . 7
empagliflozin/metformin hcl . 11 DIGOXIN ORAL SOLN . 7 emtricitab/rilpivirine/tenofovir . 15 dihydrotachysterol . 19 emtricitabine . 15 emtricitabine/tenofovir . 14 felodipine . 8
DILANTIN CHEW TAB . 18 enalapril maleate . 8
DILANTIN-125 . 18 enalapril/hydrochlorothiazide . 7
fenofibrate . 9
fenofibrate nanocrystallized . 9
diltiazem hcl . 8
enfuvirtide . 14 fenofibrate, micronized. 9
dimethyl fumarate . 16 enoxaparin sodium . 13
fenoprofen calcium . 15
entacapone . 17
fentanyl . 17
entecavir . 15
fentanyl citrate lozenge . 17
diphenoxylate hcl/atrop sulf . 15
ENTOCORT EC . 15 dipivefrin hcl . 12 enzalutamide . 16 fesoterodine fumarate . 18 epinephrine . 16
fidaxomicin . 14 DIPROLENE AF . 10 finasteride. 18
dipyridamole . 13
fingolimod hcl . 16 EPIVIR HBV SOLUTION . 15 disopyramide phosphate . 7
EPIVIR HBV TABLET . 15 FIORICET WITH CODEINE . 17 eplerenone. 8
DITROPAN XL . 18 epoetin alfa . 13 FIORINAL WITH CODEINE . 17 divalproex sodium . 18
d-methorphan hb/prometh hcl . 9
ergocalciferol . 19
FIRST-HYDROCORTISONE . 10 ergotamine tartrate/caffeine . 17
DOLOPHINE HCL . 17 erlotinib hcl . 16 dolutegravir . 15 ery e-succ/sulfisoxazole . 13
flecainide acetate . 7
donepezil hcl . 6
ERYPED 200 . 13, 14 dornase alfa . 17 FLORINEF ACETATE . 15 dorzolamide hcl . 12
dorzolamide hcl/timolol maleat . 12
ERYTHROCIN STEARATE . 13 fluconazole . 14
erythromycin base . 12, 13
fludarabine phosphate . 16 erythromycin base/benz per . 9, 10
fludrocortisone acetate . 15
doxazosin mesylate . 8
erythromycin base/ethanol . 9
flunisolide . 6
doxepin hcl . 7
erythromycin ethylsuccinate . 13, 14
fluocinolone acetonide . 10
doxycycline calcium . 14 erythromycin stearate . 13
fluocinonide . 10
doxycycline hyclate . 14
fluocinonide/emollient . 10
doxycycline monohydrate . 14
escitalopram oxalate . 6
FLUORABON BASIC . 19 fluoride ion/iron/vit a,c&d . 19
DRITHOCREME HP . 10 fluoride ion/multivitamins . 19
DRITHO-SCALP . 10 esomeprazole magnesium . 18
fluoride ion/multivits w-fe . 19
dronabinol . 6
estazolam . 7
fluoride ion/vit a,c&d . 19
dronedarone hcl . 7 ESTRACE . 13, 18 fluorometholone. 12
estradiol . 13, 18
fluorometholone acetate . 12 estradiol/noreth ac . 13 fluorouracil . 10
estramustine phosphate sodium . 16 fluoxetine er . 6
duloxetine hcl . 6
ESTRATEST H.S. 13 fluoxetine hcl . 6
estrogen, con/m-progest acet . 13 fluoxymesterone . 13
estrogen, ester/me-testosterone. 13
fluphenazine hcl . 7
estrogens, conj/bazedoxifene . 13 FLURA-DROPS . 18 estrogens, conjugated . 13, 18 flurandrenolide . 10 dutasteride . 18
estrogens, esterified. 13 dutasteride/tamsulosin . 18
estropipate . 13
flurazepam hcl . 7
eszopiclone . 7
flurbiprofen . 15
flurbiprofen sodium . 12
ethambutol hcl . 14
flutamide . 16
EC-NAPROSYN . 15 ethinyl estradiol/drospirenone . 9
fluticasone propionate . 6, 10
ethosuximide . 18
fluticasone/salmeterol . 6 ethynodiol d-ethinyl estradiol . 9
fluticasone/vilanterol . 6 Portfolio High Formulary – April 2016 Scripps Health Formulary
irbesartan . 8
HUMALOG MIX 50-50 . 11 irbesartan/hydrochlorithiazide . 8
HUMALOG MIX 75-25 . 11 HUMULIN 70-30 . 11 folic acid . 19
isomethept/acetaminop/dichlphn . 17
isoniazid . 14
folic acid/mu-vits-min th . 19
ISOPTO ATROPINE . 12 FOLLISTIM AQ . 11 ISOPTO CARBACHOL . 12 follitropin alpha,recomb . 11 ISOPTO CARPINE . 12 follitropin beta,recomb . 11 hydralazine hcl . 8
ISOPTO HOMATROPINE . 12 fondaparinux sodium. 13 formoterol fumarate . 6 hydrochlorothiazide . 8
ISORDIL TITRADOSE . 9 hydrocodone bit/acetaminophen . 17
isosorb dinit/hydralazine hcl . 9 hydrocodone bit/acetaminophen oral elixir . 17
isosorbide dinitrate . 9
FOSAMAX PLUS D . 11 hydrocodone bit/acetaminophen oral solution
isosorbide mononitrate . 9
fosamprenavir calcium . 15 isotretinoin . 9
fosinopril sodium . 8
hydrocodone bit/homatrop me-br . 9
isradipine IR capsules . 8
fosinopril/hydrochlorothiazide . 7
hydrocodone/chlorphen p-stirex . 9
itraconazole . 14
hydrocort/sal acid/sulf/shmp#1 . 10 ivabradine hcl . 9 hydrocortisone . 10, 15
furazolidone . 14 hydrocortisone acetate . 15
ixazomib citrate . 16 furosemide . 8
hydrocortisone acetate/urea . 10
hydrocortisone butyrate . 10
hydrocortisone butyrate/emoll . 10 gabapentin . 18
hydrocortisone probutate . 10 galantamine hbr . 6
hydrocortisone valerate . 10
ganciclovir . 12, 14 hydromorphone hcl . 17
ganirelix acetate . 12 hydroxychloroquine sulfate . 14
GANIRELIX ACETATE . 12 hydroxyurea . 16
hydroxyzine hcl . 6
GARAMYCIN . 9, 12 hydroxyzine pamoate . 6
gatifloxacin . 12
hyoscyamine sulfate . 18
HYPER-SAL 7% . 17 gemfibrozil . 9
gentamicin sulfate . 9, 12
KENALOG IN ORABASE . 17 ibandronate . 11
ketoconazole . 10, 14
ibuprofen . 15
ketoprofen . 15
ketorolac tromethamine . 12, 15
glatiramer acetate . 16
ketotifen fumarate (OTC) . 12
icosapent ethyl . 9 glimepiride . 10
glipizide . 10
glipizide/metformin hcl . 10
imatinib mesylate . 16
GLUCAGON KIT . 11 imipramine hcl . 7
GLUCOPHAGE XR . 11 imiquimod . 13
IMITREX INJECTION . 17 GLUCOTROL XL . 10 IMITREX NASAL SPRAY . 17 IMITREX TABLET . 17 labetalol hcl . 8
glyburide . 10
LACTICARE-HC . 10 glyburide, micro/metformin hcl . 11
indapamide . 8
lactulose . 15, 16
INDERIDE-40/25 . 8 LAMISIL . 10, 14 gonadorelin acetate . 12 indinavir sulfate . 15 LAMISIL GRANULES . 14 gonadotropin,chorionic, human . 11 lamivudine . 14
INDOCIN ORAL SUSP. 15 lamivudine/zidovudine . 14 GONAL-F RFF . 11 lamotrigine . 18
INDOCIN SUPPOS . 15 lancing device/lancets . 11 griseofulvin suspension . 14 indomethacin . 15
griseofulvin ultramicrosize . 14
lansoprazole . 18
GRISEOFULVIN V . 14 lansoprazole/amox tr/clarith . 18
guanfacine hcl . 8
insulin glargine,hum.rec.anlog . 11 lapatinib ditosylate . 16 insulin lispro . 11 insulin nph hum/reg insulin hm . 11 insulin nph human isophane . 11 latanoprost . 12 HALDOL ORAL CONC . 7 insulin npl/insulin lispro . 11 ledipasvir/sofosbuvir . 15 halobetasol propionate . 10
insulin regular, human . 11 leflunomide . 15
haloperidol . 7
lenalidomide . 16 haloperidol lactate . 7
lenvatinib mesylate . 16 interferon alfa-2b, recomb. 13 hc acetate/pramoxine hcl . 10, 15
interferon beta-1a . 16 hcg alpha, recombinant . 11 interferon beta-1a/albumin . 16 HEPARIN LOCK . 13 letrozole . 16
heparin sodium, porcine . 13
leucovorin calcium . 16
heparin sodium, porcine/pf . 13
LEUCOVORIN CALCIUM . 16 ipratropium bromide . 6, 17
homatropine hbr . 12
ipratropium/albuterol sulfate . 6
Portfolio High Formulary – April 2016 Scripps Health Formulary
levetiracetam . 18
midodrine hcl . 9
levobunolol hcl . 12
levocetirizine . 6
mifepristone . 11 levofloxacin . 14
MACRODANTIN . 14 levonorgestrel . 9
malathion . 10
levonorgestrel-eth estra . 9
maprotiline hcl . 7
MILLIPRED DP . 15 milnacipran hcl . 17 levothyroxine sodium . 12
minocycline hcl . 14
mipomersen sodium . 8 MAXZIDE-25MG . 8 mebendazole . 14
lidocaine hcl . 15
mechlorethamine . 10 mirtazapine . 6
LIFESCAN DIABETIC SUPPLIES . 11 meclizine hcl . 6
misoprostol . 18
linaclotide . 15 meclofenamate sodium . 15
linagliptin . 10 linagliptin/metformin hcl . 10 modafinil . 7
lindane . 10
medroxyprogesterone acet . 13
moexipril hcl . 8
linezolid . 14
mefloquine hcl . 14
moexipril/hydrochlorothiazide . 8
mometasone furoate . 6, 10 megestrol acetate . 16, 17
mometasone/formoterol . 6 liothyronine sodium . 12
liraglutide . 10 meloxicam . 15
lisdexamfetamine dimesylate . 7 MONOPRIL HCT . 7 lisinopril . 8
memantine hcl . 6
montelukast sodium . 6
lisinopril/hydrochlorothiazide . 7
memantine hcl/donepezil hcl . 6 morphine sulfate . 17
lithium carbonate . 7
lithium citrate . 7
menotropins . 11 moxifloxacin hcl . 12, 14 LO LOESTRIN FE . 9 LO MINASTRIN FE . 9 meprobamate . 7
mth/me blue/salicy/na phos/hyo . 13 mercaptopurine . 16
MUCOMYST-10 . 17 LOCOID LIPOCREAM . 10 mesalamine . 15
mesalamine w/cleansing wipes . 15
mupirocin . 9
mupirocin calcium . 10, 17
lodoxamide tromethamine . 12 LOESTRIN FE24 . 9 metaproterenol sulfate . 6
metaxalone . 18
mycophenolate mofetil . 13
metformin hcl . 11
MYCOSTATIN . 10, 14 meth/meth blue/ba/salicy/hyos . 13 lomustine . 16
methadone hcl . 17
methazolamide . 12
methimazole . 12
na sulfacetm/prednis sp . 12
lopinavir/ritonavir . 15 na sulfacetm/prednisol ac . 12 METHLYIN SOLN . 7 nabumetone . 15
LOPRESSOR HCT . 8 methocarbamol . 18
nadolol . 8
methotrexate . 15
naftifine hcl . 10
loratadine (OTC) . 6
methotrexate sodium . 15, 16
lorazepam . 7
METHOTREXATE TABLET . 16 NALFON CAPSULE . 15 LORAZEPAM INTENSOL . 7 METHOTREXATE VIAL . 16 NALFON TABLET . 15 methoxsalen . 10 naloxegol oxalate . 16 LORCET PLUS . 17 methoxsalen, rapid . 10
naltrexone hcl . 7
methyldopa. 8
LORTAB ELIXIR . 17 methylergonovine maleate . 9
METHYLIN CHEW TAB . 7 losartan potassium . 8
methylnaltrexone bromide . 16 losartan/hydrochlorothiazide . 8
methylphenidate ER Susp . 7 naproxen . 15
methylphenidate hcl . 7
naproxen sodium . 15
methylprednisolone . 15
naratriptan . 17
LOTENSIN HCT . 7 methyltestosterone . 13
NARCAN NASAL . 7 loteprednol etabonate . 12 metipranolol . 12
metoclopramide hcl . 18
METOCLOPRAMIDE HCL INTENSOL . 18 lovastatin . 8
metolazone . 8
metoprolol succinate . 8
nateglinide . 10
metoprolol tartrate . 8
NATURE-THROID . 12 loxapine succinate . 7
metoprolol/hctz . 8
nebivolol hcl . 8 METROGEL-VAGINAL . 18 lubiprostone . 16 nedocromil sodium . 12 metronidazole . 9, 14, 18
needles, insulin disp., safety . 17 lumacaftor/ivacaftor . 17 nelfinavir mesylate . 15 mexiletine hcl . 7
neo/polymyx b sulf/dexameth . 12
miconazole nitrate . 18
neomy sulf/bacitrac zn/poly/hc . 12
neomy sulf/polymyx b sulf/hc . 10, 11, 12 neomy sulf/polymyx b sulf/pred . 12 Portfolio High Formulary – April 2016 Scripps Health Formulary
neomycin sulfate . 14
ofloxacin . 11, 12, 14
pegvisomant . 12 neomycin sulfate/dex na ph . 12
pemirolast potassium . 12 neomycin/bacitra/polymyxin/hc . 10 penicillamine . 15 neomycin/bacitracin/polymyxin . 12
olanzapine . 7
penicillin v potassium . 14
neomycin/polymyxn b/gramicidin . 12
olanzapine ODT . 7
pentamidine isethionate . 14 olanzapine/fluoxetine . 6
pentosan polysulfate sodium . 18 NEOSPORIN OPHTH DROPS . 12 pentoxifylline . 13
NEOSPORIN OPHTH OINTMENT . 12 olmesartan medoxomil . 8 neostigmine bromide. 6 olmesartan/amlodipin/hcthiazid . 8 p-ephed hcl/cetirizine hcl (OTC) . 6
olmesartan/hydrochlorothiazide . 8 p-ephed sul/loratadine . 6
olodaterol hcl . 6 netupitant/palonosetron hcl . 6 olopatadine hcl . 12
omega-3 acid ethyl esters . 9
omeprazole . 18
omeprazole magnesium . 18
permethrin . 10
nevirapine . 14
perphenazine . 7
nevirapine ER . 14
ondansetron . 6
phenazopyridine hcl . 18
ondansetron hcl . 6
phenelzine sulfate . 6 niacin . 9
niacin/simvastatin . 8 PHENERGAN VC . 9 OPTIPRANOLOL . 12 PHENERGAN VC W/CODEINE . 9 nicardipine . 8
PHENERGAN W/CODEINE . 9 nifedipine . 8
PHENERGAN W/DEXTROMETHORPHAN . 9 ORAMORPH SR . 17 phenobarbital . 7
nilotinib hydrochloride . 16 PHENOBARBITAL . 7 phenoxybenzamine hcl . 8
nimodipine . 8
phenylephrine hcl/cod/prometh . 9
orphenadrine citrate . 18
phenylephrine hcl/prometh hcl . 9
orphenadrine/aspirin/caffeine . 18
nintedanib esylate . 17 phenytoin. 18
phenytoin sodium extended . 18
ORTHO MICRONOR . 9 nitrofurantoin . 14 ORTHO TRI-CYCLEN . 9 nitrofurantoin macrocrystal . 14
ORTHO TRI-CYCLEN LO . 9 PHRENILIN FORTE . 17 nitrofurantoin/nitrofuran mac . 14
phytonadione . 13 nitroglycerin . 9
ORTHO-CYCLEN . 9 NITROLINGUAL . 9 pilocarpine hcl . 12, 16
pindolol . 8
nizatidine . 18
pioglitazone hcl . 11
NIZORAL . 10, 14 oseltamivir phosphate . 14 pioglitazone hcl/metformin hcl . 11 osimertinib mesylate . 16 pioglitazone/glimepiride . 11
pirfenidone . 17 piroxicam . 15
OVACE PLUS SUSPENSION . 10 PLAN B ONE-STEP . 9 NORDITROPIN . 12 NORDITROPIN FLEXPRO . 12 NORDITROPIN NORDIFLEX . 12 oxaprozin . 15
PLAVIX 300MG . 13 norelgestromin/ethin.estradiol . 9
oxazepam . 7
noreth a-et estra/fe fumarate . 9
oxcarbazepine . 18
PLEGRIDY PEN . 17 norethindrone . 9
norethindrone acetate . 13
OXSORALEN-ULTRA . 10 norethindrone ac-eth estradiol . 13
oxybutynin chloride . 18
norethindrone a-e estradiol . 9
oxycodone hcl . 17
podofilox . 9
norethindrone-ethinyl estrad . 9
oxycodone hcl/acetaminophen . 17
norethindrone-mestranol . 9
oxycodone hcl/aspirin . 17
polyethylene glycol 3350 . 16
NORGESIC FORTE. 18 palbociclib . 16 polymyxin b sulfate/tmp . 12
norgestimate-ethinyl estradiol . 9
norgestrel-ethinyl estradiol . 9
PANCRELIPASE 5,000 . 18 NORINYL 1+35 . 9 POLY-VI-FLOR . 19 NORINYL 1+50 . 9 panobinostat lactate . 16 POLY-VI-FLOR W/IRON . 19 pantoprazole sodium . 18
pomalidomide . 16 PARAFON FORTE DSC . 18 paricalcitol . 12
potassium chloride . 11
nortriptyline hcl . 7
potassium iodide . 12
POTASSIUM IODIDE . 12 paromomycin sulfate . 14
pramipexole di-hcl . 17
paroxetine hcl . 6
pramlintide acetate. 10 NULYTELY WITH FLAVOR PACKS . 16 prasugrel hcl . 13 pazopanib hydrochloride . 16 nystatin . 10, 14
pravastatin sodium . 8
nystatin/triamcin . 10
praziquantel . 14 prazosin hcl . 8
octreotide acetate . 17
peg 3350/na sulf,bicarb,cl/kcl . 16
PEGASYS PROCLICK . 15 pegfilgrastim . 13 peginterferon alfa-2a . 15 prednisolone . 15
peginterferon beta-1a . 17 prednisolone acetate . 12
Portfolio High Formulary – April 2016 Scripps Health Formulary
prednisolone sod phosphate . 12, 15
quetiapine fumarate . 7
salmeterol xinafoate . 6 prednisone . 15
QUILLIVANT XR . 7 salsalate . 17
PREDNISONE INTENSOL . 15 quinapril hcl . 8
SANDOSTATIN . 17 quinapril/hydrochlorothiazide . 8
sapropterin dihydrochloride . 16 PREMARIN . 13, 18 saquinavir mesylate . 15 quinidine gluconate . 7
sargramostim . 13 quinidine sulfate . 7
prenatal vit 15/iron cb/fa/dss . 19
quinine sulfate . 14
prenatal vit 16/iron cb/fa/dss . 19
SCALACORT DK . 10 prenatal vit 18/iron cb/fa/dss . 19
prenatal vit 95/fe fum/fa . 19
raloxifene hcl . 11
raltegravir potassium . 15 secukinumab . 10
ramipril . 8
selegiline hcl . 18
selenium sulfide . 10
PREVACID SOLUTABS . 18 ranitidine hcl . 18
rasagiline mesylate . 18 PRILOSEC OTC . 18 SEREVENT DISKUS . 6 primaquine phosphate . 14 primidone . 18
REBIF REBIDOSE . 16 sertraline hcl . 6
regorafenib . 16 sevelamer carbonate . 11 sevelamer hcl . 11 PROAIR RESPICLICK . 6 short ragweed pollen extract . 6 sildenafil citrate . 8, 11
probenecid . 13
procainamide hcl . 7
silver sulfadiazine . 10
procarbazine hcl . 16 repaglinide. 10
repaglinide/metformin hcl . 11
PROCARDIA XL . 8 simvastatin . 8
simvastatin (80mg only) . 8
prochlorperazine edisylate . 6 SINEMET 25-100 . 17 prochlorperazine maleate . 6
reserpine . 8
PROCTOCREAM-HC . 15 sirolimus . 13
PROCTOFOAM-HC . 15 sitagliptin phos/metformin hcl . 10 REVATIO TABLET. 8 sitagliptin phosphate . 10 progesterone, micronized . 11, 13 sod chloride/nahco3/kcl/peg's . 16
ribavirin . 14, 15 sodium chloride for inhalation . 17 sodium fluoride . 18
sodium phenylbutyrate . 15
promethazine hcl . 6
rifampin . 14
sodium polystyrene sulfonate . 11
rifampin/isoniazid . 14
propafenone hcl . 7
rilpivirine . 14 SOMA COMPOUND . 18 propranolol hcl . 8
SOMA COMPOUND WITH CODEINE . 17 propranolol/hydrochlorothiazid . 8
propylthiouracil . 12 RISPERDAL M-TAB . 7 PROPYLTHIOURACIL . 12 risperidone . 7
risperidone ODT . 7
sonidegib phosphate . 16 sorafenib tosylate . 16 sotalol hcl . 8
rivaroxaban . 13 rivastigmine . 6
rivastigmine tartrate . 6
SPIRIVA RESPIMAT . 6 rizatriptan benzoate . 17
spironolactone . 8
PROZAC WEEKLY . 6 PULMICORT FLEXHALER . 6 ROBAXIN-750 . 18 PULMICORT RESPULES . 6 STAGESIC-10 . 17 ropinirole hcl . 18
stavudine . 14
pyrazinamide . 14
rosuvastatin calcium . 8 PYRAZINAMIDE . 14 STIOLTO RESPIMAT . 6 pyridostigmine bromide . 6
pyrimethamine . 14 pyrimethamine/sulfadoxine . 14 ROXICODONE INTENSOL. 17 STRIVERDI RESPIMAT . 6 QNASL CHILDREN . 6 ruxolitinib . 16 sucralfate . 18
QUESTRAN LIGHT . 8 sulconazole nitrate . 10 Portfolio High Formulary – April 2016 Scripps Health Formulary
sulfacetamide sodium . 9, 10, 12
thyroid, pork . 12 sulfadiazine . 13
SULFADIAZINE . 13 sulfamethoxazole/trimethoprim . 13
sulfanilamide . 18 sulfasalazine . 15
timolol maleate . 8, 12
sulfisoxazole acetyl . 13 sulindac . 15
TIMOPTIC-XE . 12 sumatriptan . 17
timothy grass pollen extract . 6 sumatriptan succinate . 17
tiotropium br/olodaterol hcl . 6 sunitinib malate . 16 tiotropium bromide . 6 URETRON D-S . 13 tipranavir/vitamin e tpgs . 14 urofollitropin (fsh) . 11 tizanidine hcl . 18
ursodiol . 16
SYMLINPEN 120 . 10 tobramycin for inhalation . 14
ustekinumab . 15
SYMLINPEN 60 . 10 tobramycin sulfate . 12
tobramycin sulfate/dexameth . 12
valacyclovir hcl . 14
tobramycin/lotepred etab . 12 syringes & needles . 11 tolazamide . 10
valproate sodium . 18
tacrolimus . 10
tolbutamide . 10
valproic acid . 18
tacrolimus anhydrous . 13
TOLECTIN 600 . 15 valsartan . 8
tadalafil . 8, 11 valsartan/hydrochlorothiazide . 8
tolmetin sodium . 15
tolterodine tartrate . 18
VANCOCIN HCL . 14 vancomycin hcl . 14
TOPAMAX SPRINKLE . 18 TOPICORT LP . 10 topiramate . 18
tamoxifen citrate . 16
topotecan hcl . 16 tamsulosin hcl . 18
toremifene citrate . 16 tapentadol hcl ER . 17 torsemide . 8
TARGRETIN . 10, 16 vemurafenib . 16 venlafaxine hcl . 6
tramadol hcl . 17
VENTOLIN HFA . 6 tazorotene foam . 9 tramadol hcl/acetaminophen . 17
trametinib dimethyl sulfoxide . 16 verapamil hcl . 8
tedizolid phosphate . 14 verapamil hcl ER . 8
teduglutide [rDNA origin] . 16 trandolapril . 8
TRANXENE T-TAB . 7 TEGRETOL XR . 18 tranylcypromine sulfate . 6
telbivudine . 15 telithromycin . 13 temazepam . 7
travoprost (benzalkonium) . 12
trazodone hcl . 6
TEMOVATE EMOLLIENT . 10 VIBRAMYCIN ORAL SUSPENSION . 14 temozolomide . 16
VIBRAMYCIN SYRUP . 14 tenofovir disoproxil fumarate . 15 triamcinolone acetonide . 6, 10, 17
TENORETIC 100 . 8 triamterene/hydrochlorothiazid . 8
TENORETIC 50 . 8 triazolam . 7
VICON FORTE . 19 terazosin hcl . 8
terbinafine hcl . 10, 14 terbutaline sulfate . 6
teriparatide . 11 testosterone . 13
trifluoperazine hcl . 7
testosterone 1% . 13
trifluridine . 12
testosterone cypionate . 13
trifluridine/tipiracil hcl . 16 VIRAMUNE XR . 14 testosterone gel 1.62% . 13 TRIGLIDE 160MG . 9 testosterone solution . 13 trihexyphenidyl hcl . 17
tetrabenazine . 17 tetracycline hcl . 14
trimethoprim . 13
thalidomide . 14 TRI-VI-FLOR W/IRON . 19 VIVELLE-DOT . 13 VOLTAREN . 12, 15 VOLTAREN GEL . 10 theophylline anhydrous . 6
VOLTAREN-XR . 15 voriconazole . 14
thioguanine . 16
THIOGUANINE . 16 thioridazine hcl . 7
TYLENOL-CODEINE . 17 thiothixene . 7
Portfolio High Formulary – April 2016 Scripps Health Formulary
warfarin sodium . 13
WELCHOL POWDER PACKETS . 8 zolmitriptan . 17
WELLBUTRIN SR . 6 zolpidem tartrate . 7
WELLBUTRIN XL . 6 zonisamide . 18
ZOVIRAX CREAM . 10 ZOVIRAX OINTMENT . 10 XIFAXAN 550MG . 14 XODOL 10-300 . 17 zidovudine . 14
ziprasidone hcl . 7
ZYPREXA ZYDIS . 7 ZITHROMAX TRI-PAK . 13 ZYRTEC (OTC) . 6 ZYRTEC-D (OTC) . 6 zaleplon . 7
ZMAX PEDIATRIC . 13 Portfolio High Formulary – April 2016

Source: https://www.scripps.org/sparkle-assets/documents/scripps_health_formulary_april_2016_final.pdf

imcah.org.mx

Dr. Joel Rodríguez Saldaña Fecha de nacimiento:16 de Junio de 1953, México, D.F. Lugar de nacimiento: México, D.F. Página web: Act. 240815 Facultad de Medicina, U.N.A.M., México D.F. 1969-1974 Examen Profesional:11 de enero de 1974 Internado rotatorio de Pregrado: Clínica Hospital No. 1, I.M.S.S., Durango, Dgo., del16 de enero al 31 de diciembre de 1973.

Lizy4248 zydis anzjl_fp v3 fa_2.indd

ZYPREXA® NAME OF THE MEDICINE ZYPREXA® (olanzapine). ZYPREXA® Zydis® (olanzapine). Chemically, olanzapine is 2-methyl-4-(4-methyl-1-piperazinyl)-10H-thieno[2,3-b] [1,5]benzodiazepine and its empirical formula is C17H20N4S. Olanzapine is a yellow crystalline solid, practically insoluble in water with a molecular weight of 312.44. The CAS number for olanzapine is 132539-06-1.