J-16 Medication Formulary.pdf

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WORLD TRADE CENTER MONITORING & TREATMENT PROGRAM

FORMULARY MEDICATION LIST

Generic Name Brand Name Dosage Form RESPIRATORY Cromolyn Inhaler Intal Inhaler

(Intal MDI - Metered Dos Inhaler) e

Inhaler

Metaproterenol Inhaler

Alupent Inhaler Inhaler

Albuterol Solution Proventil Unit dose by nebulizer

Arformoterol Brovana Formoterol Foradil Aerolizer Capsules

Pirbuterol Maxair Inhaler Albuterol Proventil HFA

Inhaler Inhaler

Salmeterol Serevent Diskus

Albuterol Proair HFA Albuterol Ventolin HFA Levalbuterol Xopenex Albuterol ER VoSpire ER Tablet Only brand ER tabs covered.

Budesonide/Formot ol er Symbicort

Fluticasone/Salmete l ro Advair

Albuterol/Ipratropium DuoNeb

Albuterol/Ipratropium Combivent Inhaler

Inhaler

Ipratropium Atrovent HFA

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Ipratropium Atrovent Nebulizers

Nebulizer

Tiotropium Spiriva Mometasone Asmanex

Twisthaler Triamcinolone Azmacort Inhaler Inhaler

Budesonide inhalation

Pulmicort Respule

Nebulizer

Fluticasone Flovent Diskus Fluticasone Flovent Fluticasone Flovent HFA

Inhaler Inhaler

Beclomethasone QVAR Budesonide Inhalation

Pulmicort Turbohaler

Inhaler

Theophylline Theo-24, Theocap, Theochron, Theodur, Uniphyl

Including sustained release versions.

Prednisone Prednisone Intensol®;

Sterapred®;

Medrol, Meprolone

Sterapred® DS

Methylprednisolone

Zafirlukast Accolate Monteleukast Singulair Duratuss Cough Med Tablet #60/month Guaifenesin/Pseudo phedrine SR tabs e Mucinex D Tablet

Guaifenesin SR tabs Mucinex Tablet

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Guaifenesin w/dextromethorphan

Mucinex DM All other Rx Versions Covered (OTC not covered).

Promethazine Phenergan Brand does not appear to be manufactured currently however open for coverage if available.

Lidocaine INJ Xylocaine Injection anesthetic or antiarrythmic

No indication for treatment of primary condition

Benzonatate Tessalon Pearles

Warfarin Coumadin Blood thinner, H blood clots,prop x of halaxis

No indication for treatment of primary condition

Hydroxychloroquine Plaquenil anti-rheumatic, malarial anti No indication for treatment of primary condition

Enoxaparin Lovenox Blood thinner, H blood clots,prop x of halaxis

No indication for treatment of primary condition

Epinephrine Epipen Methotrexate Rheumatrex®

Trexall® MTX anti-rheumatic, chemotherapy no indication for treatment of primary condition

Acetylcysteine (Mucomyst - Branded)

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Cyclophosphamide (Cytoxan - Branded) immunosuppres cancer, arthritis sion, No indication for treatment of primary condition

Interferon Roferon-A, Intron-A, Rebetron, Alferon-N, Peg- Intron, Avonex, Betaseron, Infergen, Actimmune, Pegasys antiviral, cancer hepatitis, warts

, No indication for treatment of primary condition

Miscellaneous Respiratory Aerochamber (Aerochamber w/mask -additional delivery method) Inspirease Home Oxygen

CPAP & BIPAP

CHRONIC Diphenhydramine Benadryl (diphenhydramin e)

RHINOSINUSITIS Desloratidine Clarinex

Loratidine Alavert Loratidine Claritin Cetirizine Zyrtec Levocetirizine Xyzal

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Fexofenadine Allegra (Allegra suspension -alternate delivery method)

Loratidine/Pseudoe edrine ph Claritin D

Desloratidine/Pseud ephedrine o Clarinex D

Fexofenadine/Pseud ephedrine o Allegra D

Cetirizine/Pseudoep edrine h Zyrtec D

Ipratropium Atrovent nasal spray

Azelastine Astelin Nasal Spray

Fluticasone Flonase nasal spray

Budesonide Rhinocort AQ Nasal Spray

Triamcinolone Nasacort AQ Nasal Spray

Flunisolide Nasarel Nasal Spray

Flunisolide Veramyst Mometasone Nasonex Nasal

Spray Nasal Saline Lavage/Irrigation Solution

Various

Miscellaneous Rhinosinusitis

Headache Caplets

Nonspecific OTC medication

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Strength Severe Allergy & Sinus

Nonspecific OTC medication

GERD Esomeprazole Nexium Omeprazole Zegerid Omeprazole Prilosec Lansoprazole Prevacid Pantoprazole Protonix

(Protonix Pak - Powder Formulation)

Rabeprazole Aciphex Famotidine Pepcid Cimetidine Tagamet Nizatidine Axid Ranitidine Zantac Bismuth Subsalicylate/Metro dazole/Tetracycline Hydrochloride ni

Helidac H. pylori stoma ulcers ch No indication for treatment of primary condition

Lansoprazole, Amoxicillin and Clarithromycin

Prevpak H. pylori stoma ulcers ch No indication for treatment of primary condition

Bismuth Subcitrate Potassium

Pylera H. pylori stoma ulcers ch No indication for treatment of primary condition

Sucralfate Carafate All forms Palonosetron Aloxi Nausea No indication for treatment of primary condition

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Dolasetron Anzemet Nausea No indication for treatment of primary condition

Granisetron Kytril Nausea No indication for treatment of primary condition

Ondansetron Zofran Nausea No indication for treatment of primary condition

Metoclopramide Reglan

ANTIBIOTICS Amoxicillin (Amoxil- Branded)

Amoxicillin- Potassium Clavulanate

Augmentin

Clarithromycin Biaxin Azithromycin Zithromax Levofloxacin Levaquin Moxifloxacin Avelox Ciprofloxacin Cipro Sulfamethoxazole 800mg /Trimethopr 150mg) im Bactim DS

Doxycycline Atridox™ Doryx® Doxy® Monodox® Periostat® Vibramycin®

Fluconazole Diflucan

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Metronidazole Flagyl (Flagyl ER - extended release formulation)

Clotrimazole Myclex Troche Yeast or fungal infections

No indication for treatment of primary condition

Ketoconazole (Nizoral- Branded)

All forms o and topical.

ral Yeast or fungal infections

No indication for treatment of primary condition

Nystatin (Mycostatin - Branded)

Yeast or fungal infections

No indication for treatment of primary condition

Cefadroxil Duricef Cefuroxime Ceftin Cefixime Suprax Cephalexin Keflex Acyclovir Zovirax Oral and to formulation both covere pical s d.

Herpes virus inf like shingles, ch pox cold sores, p y occur in the sett prednisone ther ections icken may

No indication for treatment of primary ing of apy p y condition

Gentamicin Sulfate Garamycin Antibiotic, gram negative bacteri a

Administered IV or IM

Tobramycin TOBI Nebs (Nebulized antibiotic)

May be indicated for lower respiratory tract infections.

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Isoniazid INH™ Nydrazid®

Tuberculosis therapy No indication for treatment of primary condition

Ganciclovir (Cyotvene - Branded)

Treatment of CM infections usual found in immunosuppres

V ly sed pt

No indication for treatment of primary condition

Foscarnet Sodium Foscavir® Treatment of CM infections usual found in immunosuppres

V ly sed pt

No indication for treatment of primary condition

Doxycycline (Vibramycin - Branded)

SMOKING Varenicline Chantix CESSATION Nicotine Patch Nicoderm or

Nicotrol Patch Patch

Nicotine Nasal Spray Nicotrol Nasa Spray l Spray

Nicotine Inhaler Nicotrol Inhaler Inhaler Nicotine Gum Nicorett Chew

Gum ing Gum

Nicotine Lozenge Nicotine Lozenge Commit

Lozenge

Welbutrin XL

MENTAL HEALTH Citalopram Celexa

Escitalopram Lexapro Nefazadone Serzone Paroxetine Paxil

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Fluoxetine Prozac (Prozac Weekly - Delayed Release Formulation)

Do not cover weekly delayed release medication

Sertraline Zoloft Venlafaxine Effexor / XR Duloxetine Cymbalta Buproprion Hydrochloride

Buproban™ Budeprion™ SR Wellbutrin® Wellbutrin® SR Wellbutrin® XL Zyban®

Budeprion XL Wellbutrin XL Zolpidem tartrate Ambien®

AmbienPak™ Ambien® CR

Zolpidem CR Ambien CR Eszopiclone Lunesta Zaleplon Sonata Ramelteon Rozerem Alprazolam Xanax Clonazepam Klonopin Lorazepam Ativan Diazepam Valium Temazepam Restoril

(Restoril 22.5mg)

MENTAL HEALTH Flurazepam Dalmane

Imipramine Tofranil Desipramine Norpramine Clomipramine Anafranil Amitriptyline Elavil Doxepin Sinequin

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Nortriptyline Pamelor Amphetamine/Dext amphetamine ro Adderall/XR commonly used

ADD

for No indication for treatment of primary condition

Methylphenidate Concerta commonly used

ADD

for No indication for treatment of primary condition

Dextroamphetamine Dexedrine SR commonly used

ADD

for No indication for treatment of primary condition

Modafinil Provigil Methylphenidate Ritalin commonly used

ADD

for No indication for treatment of primary condition

Atomoxetine Strattera commonly used

ADD

for No indication for treatment of primary condition

Tranycypromine Parnate Phenelzine Nardil Ziprasidone Geodon Haloperidol Haldol Risperidone Risperdal Quetiapine Seroquel Chlorpromazine Thorazine Olanzapine Zyprexa Perphenazine Trilafon Buspirone Buspar Divalproex Depakote Valproic Acid Depakene

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Lamotrigene Lamictal (Lamictal Starter Pack -additional dosing option)

Brand named Lamictal required PA.

Generic used in mental health treatment.

Lithium Eskalith, Lithobid, Lithonate)

Prazosin Minipress Carbamazepine Tegretol

(Tegretol XR - Extended Release Formulation)

Cover both daily and extended release

Propranolol Inderal Mirtazipine Remeron Trazadone hydrochloride

Deseryl

Acamprosate Campral®

Aripiprazole Abilify Aprazolam Xanex Buprenorphine (Subutex -

Branded) Liothyronine Cytomel thyroid medication No indication for treatment of primary condition

Risperdone Risperdal Trazodone Hydrochloride

Deseryl

Sildenafil Citrate Viagra Treatment of ED No indication for treatment of

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Gabapentin Neurontin, Gabarone®

Cyclosporine Gengraf Antirejection No indication for treatment of primary condition

Cyclosporine Neoral Antirejection No indication for treatment of primary condition

Cyclosporine Sandimmune Antirejection No indication for treatment of primary condition

Mycophenolate Myfortic Cellcept

Antirejection No indication for treatment of primary condition

Mycophenolate Antirejection No indication for treatment of primary condition

Sirolimus Rapamune Antirejection No indication for treatment of primary condition

Tacrolimus Prograf Antirejection No indication for treatment of primary condition

Azathioprine Immuran Antirejection No indication for treatment of

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MUSCULO-

SKELETAL

Fentanyl Lozenge Actiq Lozenge opioid Require prior authorization pending medical documentation of WTC related condition.

Codeine Too numerous to mention opioid Require prior authorization pending medical documentation of WTC related condition.

Propoxyphene/Acet minophen a Darvocet-N® (containing Acetaminophen and Propoxyphene) E-Lor® (containing Acetaminophen and Propoxyphene) Genagesic® (containing Acetaminophen and Propoxyphene) Wygesic® (containing Acetaminophen and Propoxyphene) opioid Require prior authorization pending medical documentation of WTC related condition.

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Propoxyphene Darvocet Darvon Darvon-N Dolene opioid Require prior authorization pending medical documentation of WTC related condition.

Hydromorphone Dilaudid opioid Require prior authorization pending medical documentation of WTC related condition.

Fentanyl Duragesic Patches opioid Require prior authorization pending medical documentation of WTC related condition.

Fentany Buccal Tab Fentora opioid Require prior authorization pending medical documentation of WTC related condition.

Morphine MS IR, MS Contin opioid Require prior authorization pending medical documentation of

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Oxycodone Oxy IR opioid Require prior authorization pending medical documentation of WTC related condition.

Oxycontin Oxycontin opioid Require prior authorization pending medical documentation of WTC related condition.

Oxycodone/APAP Percocet opioid Require prior authorization pending medical documentation of WTC related condition.

APAP w/codeine Tylenol #2, #3, #4 opioid Require prior authorization pending medical documentation of WTC related condition.

Tramadol Ultracet, Ultram /

ER

opioid Require prior authorization pending medical documentation of

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Tramadol opioid Require prior authorization pending medical documentation of WTC related condition.

Hydrocodone/APAP Vicodin opioid Require prior authorization pending medical documentation of WTC related condition.

Hydrocodone Lortab, Lorcet, Vicodin, Vicoprofen, Zydone, Norco and many others too numerous to mention opioid Require prior authorization pending medical documentation of WTC related condition.

opioid Require prior authorization pending medical documentation of WTC related condition.

Baclofen (Also available as Lioresal® Intrathecal) muscle relaxer & antispastic agen t.

Need pre authorization of Mus/Skel

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Cyclobenzaprine Flexeril muscle relaxant Require prior authorization pending medical documentation of WTC related condition.

Methocarbamol Robaxin muscle relaxant Require prior authorization pending medical documentation of WTC related condition.

Metaxalone Skelaxin muscle relaxant Require prior authorization pending medical documentation of WTC related condition.

Carisoprodol Soma muscle relaxant Require prior authorization pending medical documentation of WTC related condition.

Pentazocine Talwin opioid Require prior authorization pending medical documentation of

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Tizanidine Zanaflex muscle relaxant Require prior authorization pending medical documentation of WTC related condition.

Diclofenac/Misopro il/Voltaren st Arthrotec muscle relaxant Require prior authorization pending medical documentation of WTC related condition.

Diflunisal Dolobid Anti inflammatory Require prior authorization pending medical documentation of WTC related condition.

Ibuprofen Motrin, Nuprin Anti inflammatory Require prior authorization pending medical documentation of WTC related condition.

Indomethacin Indocin Anti inflammatory Require prior authorization pending medical documentation of

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Etodolac Lodine Anti inflammatory Require prior authorization pending medical documentation of WTC related condition.

Meloxicam Mobic Anti inflammatory Require prior authorization pending medical documentation of WTC related condition.

Naproxen Naprosyn Anti inflammatory Require prior authorization pending medical documentation of WTC related condition.

Nabumetone Relafen Anti inflammatory Require prior authorization pending medical documentation of WTC related condition.

Choline Magnesium Trisalicylate

Trilisale Anti inflammatory Require prior authorization pending medical documentation of

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Diclofenac Voltaren/XR Anti inflammatory Require prior authorization pending medical documentation of WTC related condition.

Celecoxib Celebrex Anti inflammatory Require prior authorization pending medical documentation of WTC related condition.

MISCELLANEOUS Aripiprazole Abilify

Testosterone Patch

(REMOVED)

Androderm Transdermal Patch(REMOVE D)

Testosterone replacemtn

No indication for treatment of primary condition

Docusate Colace Stool softener No indication for treatment of primary condition

Duloxetine Cymbalta Amitriptyline Elavil Sodium Hyaluronat Hyaluronic Acid

(REMOVED)

e, Knee injection f arthritis or No indication for treatment of primary condition

Euflexxa Hylan GF-20 Knee injection f arthritis or No indication for treatment of

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Lidocaine Lidoderm 5% pain Require prior authorization pending medical documentation of WTC related condition.

Lidocaine transdermal

Lidoderm Patches pain Require prior authorization pending medical documentation of WTC related condition.

Pregabalin Lyrica Gabapentin Neurontin (Neurontin solution -additional method of delivery)

Sodium Hyaluronat Hyaluronic Acid e, Hyalgan ®, Synvisc ®)Euflexxa )

Knee injection f arthritis or No indication for treatment of primary p y condition

Sodium Hyaluronate, Hyaluronic Acid

Knee injection f arthritis or No indication for treatment of primary condition

Hydroxychloroquine Plaquenil anti-rheumatic, malarial anti No indication for treatment of primary condition

Carbamazepine Tegretol Zolpidem Ambien

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Hyalgan Injections

Knee injection f arthritis or No indication for treatment of primary condition

Sennacot, Senokot

Laxative No indication for treatment of primary condition

Botox (Type A), Myobloc (Type B)

Botulinum Toxin Type B;Botulinum Toxin Type A used for cervica dystonia and ne l ck pain

No indication for treatment of primary condition

Acetaminophen, Butalbital, and Caffeine; Fiorinal, Fioricet

Amaphen® Anoquan® Butace® Endolor® Esgic® Fioricet® Medigesic® Repan®

Note: Fiorin a similar combinatio aspirin vs.

acetaminop al is n with hen tension H/A's No indication for treatment of primary condition

Hydrocodone Lortab, Lorcet,Zydone, Norco opioid Require prior authorization pending medical p g documentation of WTC related condition.

Dolophine, Methadose

Methadone opioid Require prior authorization pending medical documentation of

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Oxycodone Ocy-Contin, Oxy- Fast, Endocet, Percodan, Roxicodone, Roxicet and others too numerous to mention opioid Require prior authorization pending medical documentation of WTC related condition.

Too numerous to mention as alone or in combination opioid Require prior authorization pending medical documentation of WTC related condition.

Topamax Topiramate Kenalog Triamcinolone topical steroid, skin No indication for treatment of primary condition

Alendronate Fosamax, Fosamax w/ Vit D

Treatment of Osteoporosis

No indication for treatment of primary condition

Alendronate Fosamax w/ Vit D

Treatment of Osteoporosis

No indication for treatment of primary condition

Risedronate Actonel Treatment of Osteoporosis

No indication for treatment of primary condition

Ibandronate Boniva Treatment of Osteoporosis

No indication for treatment of

VACCINES Pre-transplant vaccines

No indication for treatment of primary condition

Flu Pneumovax

Add Xolair to the formulary

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