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Mysmarthealth.org

Tetracycline* (Sumycin)
GENERIC DRUGS
ANTIFUNGAL AGENTS (ORAL) ________________
Ascension Health endorses the use of FDA Clotrimazole* (Mycelex)
Fluconazole* (Diflucan) (QL)
encourages the prescribing and dispensing of Itraconazole* (Sporanox)
these generic medications whenever medically Ketoconazole* (Nizoral)
Nystatin* (Mycostatin)
Terbinafine*
(Lamisil)(QL)
EXCLUDED DRUGS
Voriconazole* (Vfend)
ANTI-MALARIALS ___________________________
Ascension Health has excluded the following drugs or drug classes from coverage under the Chloroquine* (Aralen)
pharmacy benefit: cosmetic products (e.g. Hydroxychloroquine* (Plaquenil)
Egrifta, Latisse, Vaniqa), cough & cold Mefloquine* (Lariam)
combinations, allergy ophthalmics (e.g. Patanol), Quinine* (generic)
ANTI-TUBERCULOSIS AGENTS ________________
sedating antihistamines (e.g. Allegra, Clarinex), Ethambutol* (Myambutol)
Duexis, Lazanda/Subsys, meperidine, Oracea, Isoniazid* (Nydrazid)
Rayos, Solodyn, Suprenza ODT, medical foods Pyrazinamide* (pyrazinamide)
ASCENSION and drug/medical food combinations and over-
Rifampin* (Rifadin)
the-counter products. Drugs that must be given OTHER ANTI-INFECTIVES _____________________
by a medical professional (e.g. infused products) Clindamycin* (Cleocin)
Iodoquinol* (iodoquinol)
PRIOR AUTHORIZATION / STEP THERAPY /
Metronidazole* (Flagyl)
QUANTITY LIMITS
Trimethoprim* (Proloprim)
FORMULARY
Select drugs require prior authorization (PA) of
ANTI-VIRAL AGENTS
benefits. Medication utilization must meet FDA Abacavir* (Ziagen)
approved indications as well as Ascension Abacavir/Lamivudine/Zidovudine (Trizivir) Step Therapy Protocols (ST): Step therapy
Acyclovir* (Zovirax)
(CONDENSED VERSION)
requires the use of one or more medications before benefits for the use of another medication Amantadine* (Symmetrel)
Quantity Limits (QL): Ascension Health has
identified a number of select medications which will be subject to quantity limits. A quantity limit January 2014
Didanosine* (Videx EC)
Didanosine (Videx)
prescription medication Ascension Health will cover as a benefit within a defined period of time. Efavirenz/Emtricitabine/Tenofovir (Atripla) Please note: This is not a comprehensive list of Quantity limits may be implemented on a per day basis (e.g. 1 tablet per day), per prescription or Enfuvirtide (Fuzeon)(SP)
SPECIALTY DRUGS
Ascension Health has specified certain specialty Famciclovir* (Famvir)
drugs are to be filled only through the in-house Foscarnet* (generic)
approved generic is available, the generic pharmacies or from Coram. These drugs are name is bolded and asterisked.
noted in the list below with (SP).
Ganciclovir* (Cytovene)
ANTI-INFECTIVE AGENTS
Indinavir (Crixivan)
Lamivudine* (Epivir)
ANTIBIOTICS _______________________________
Lamivudine/Zidovudine* (Combivir)
Cephalosporins .
Cefaclor* (Ceclor)
copayment. Example: Cefaclor* (Ceclor)
Cefdinir* (Omnicef)
Nevirapine* (Viramune)
means that the generic Cefaclor is Cefditoren* (Spectracef)
formulary and the brand is non-formulary Cefadroxil* (Duracef)
Cefprozil* (Cefzil)
Ribavirin* (Rebetol)
Cefuroxime* (Ceftin)
Rimantadine* (Flumadine)
Cefpodoxime* (Vantin)
active ingredient is only available as a Cephalexin* (Keflex)
Macrolides .
Stavudine* (Zerit)
Example: Tiotropium (Spiriva) means Azithromycin* (Zithromax)(QL)
that the brand, Spiriva is covered and Clarithromycin XL* (Biaxin XL)
there is no generic available. Spiriva is Erythromycin* (Eryc, PCE)
Erythromycin/Sulfisoxazole* (Pediazole)
Valacyclovir* (Valtrex)
Penicillins .
If the word 'generic' and the brand name Amoxicillin* (Amoxil)
Zidovudine* (Retrovir)
both appear within the parenthesis, both Amoxicillin/Clavulanate* (Augmentin)
AUTONOMIC AND
Ampicillin* (Principen)
CENTRAL NERVOUS SYSTEM AGENTS
Dicloxacillin* (Pathocil)
Example: Phenytoin (Dilantin / generic) Penicillin* (Veetids)
ANALGESICS, NARCOTIC _____________________
means that both the brand and generic Quinolones .
Acetaminophen/Codeine* (Tylenol w/codeine)
are available. Therefore, the brand Ciprofloxacin/XR* (Cipro/XR) (QL)
Aspirin/Codeine* (Empirin w/codeine)
Dilantin and the generic phenytoin are on Levofoxacin* (Levaquin)(QL)
Fentanyl* (Duragesic)(QL)
Ofloxacin* (Floxin)
Fentanyl Citrate* (Actiq, Fentora)(PA/QL)
Sulfonamides .
Hydrocodone/Acetaminophen* (Lortab) (QL)
Hydromorphone* (Dilaudid)
Erythromycin/Sulfisoxazole* (Pediazole)
formulary listing shall be considered non- Morphine Sulfate* (MS Contin)(QL)
Sulfamethoxazole/Trimethoprim* (Bactrim)
Oxycodone/Acetaminophen* (Percocet) (QL)
Sulfisoxazole* (generic)
Tetracyclines .

Oxycodone/Aspirin* (Percodan)
Oxycodone* (Oxycontin)(QL)
Doxycycline hyclate* (Vibramycin)
Analgesics, Non-Narcotic .
Minocycline* (Minocin, Dynacin)
APAP/Isometheptene/Dichlphen* (Midrin)
Antipsychotic Agents .
Pravastatin* (Pravachol)
Acetaminophen/Caffeine/Butalbital* (Fioricet)
Chlorpromazine* (Thorazine)
Simvastatin* (Zocor) (80mg requires PA)
Aspirin/Caffeine/Butalbital* (Fiorinal)
Clomipramine* (Anafranil)
BETA-ADRENERGIC BLOCKERS _______________
Ergotamine/Caffeine* (Cafergot)
Clozapine* (Clozaril)
Acebutolol* (Sectral))
Naratriptan* (Amerge) (QL)
Fluphenazine* (Prolixin)
Atenolol/Chlorthalidone* (Tenoretic)
Sumatriptan* (Imitrex)(QL)
Haloperidol* (Haldol)
Bisoprolol/HCTZ* (Zebeta)
Rizatriptan (Maxalt/MLT) (QL)
Loxapine* (Loxitane)
Carvedilol* (Coreg/CR)
Tramadol* (Ultram)
Olanzapine* (Zyprexa)
Labetalol* (Trandate)
Zolmitriptan* (Zomig/Zomig ZMT)
Perphenazine* (Trilafon)
Metoprolol/HCTZ* (Lopressor)(QL)
ANALGESICS, NONSTEROIDAL
Prochlorperazine* (Compazine)
Metoprolol ER* (Toprol XL) (QL)
ANTI-INFLAMMATORY ________________________
Quetiapine* (Seroquel)
Nadolol* (Corgard)
Diclofenac* (Voltaren)
Pindolol* (Viskin)
Etodolac* (etodolac)
Risperidone* (Risperdal)
Propranolol/XL/HCTZ* (Inderal)
Fenoprofen* (Nalfon)
Thioridazine* (Mellaril)
Sotalol* (Betapace)
Flurbiprofen* (Ansaid)
Thiothixene* (Navane)
Timolol* (Blocadren)
Ibuprofen* (Motrin)
Trifluoperazine* (Stelazine)
CALCIUM CHANNEL BLOCKERS ______________
Indomethacin* (Indocin)
Ziprasidone* (Geodon)
Amlodipine* (Norvasc)(QL)
Ketoprofen* (ketoprofen)
SEDATIVES, HYPNOTICS AND ANTI-ANXIETY ____
Diltiazem* (Cardizem)
Ketorolac* (Toradol)
Alprazolam* (Xanax)
Felodipine* (Plendil)
Meloxicam* (Mobic)
Buspirone* (BuSpar)
Nicardipine* (Cardene)
Nabumetone* (nabumetone)
Chloral Hydrate* (Noctec)
Nifedipine* (Procardia/Adalat CC)
Naproxen* (Naprosyn)
Chlordiazepoxide* (Librium)
Nimodipine* (Nimotop)
Oxaprozin* (Daypro)
Clorazepate* (generic)
Verapamil* (Calan,Verelan)
Piroxicam* (Feldene)
Diazepam* (Valium)
CENTRALLY ACTING ANTIHYPERTENSIVES _____
Sulindac* (Clinoril)
Estazolam* (generic)
Clonidine* (Catapres)
Tolmetin* (Tolectin)
Flurazepam* (flurazepam)
Methyldopa* (generic)
ANALGESICS, SALICYLATES __________________
Lorazepam* (Ativan)
DIURETICS _________________________________
Aspirin* (generic)
Meprobamate* (Miltown)
Acetazolamide* (Diamox Sequels)
Chol Sal/Magnesium Salicylate* (generic)
Oxazepam* (Serax)
Chlorthalidone* (Hygroton)
Diflunisal* (Dolobid)
Temazepam* (Restoril)
Ethacrynic Acid* (Edecrin)
Salsalate* (Disalcid)
Triazolam* (Halcion)
Eplerenone* (Inspra)
ANTICONVULSANTS _________________________
Zalpelon* (Sonata) (QL)
Zolpidem*
(Ambien/CR) (QL)
Furosemide* (Lasix)
Carbamazepine* (Tegretol XR/generic)
HCTZ/Triamterene* (Dyazide/Maxzide)
Clonazepam* (Klonopin)
CARDIOVASCULAR AGENTS
Hydrochlorothiazide* (generic)
Divalproex Sodium* (Depakote
Indapamide* (generic)
ANGIOTENSIN CONVERTING ENZYME
Methazolamide* (generic)
Ethosuximide* (Zarontin)
INHIBITORS AND RECEPTOR BLOCKERS &
Metolazone* (Zaroxolyn)
Gabapentin* (Neurontin)
COMBINATIONS _____________________________
Spironolactone/HCTZ* (Aldactone)
Fosphenytoin*(Cerebyx)
Benazepril/HCTZ* (Lotensin)
Torsemide* (Demadex)
Lamotrigine* (Lamictal)
Benazepril/Amlodipine* (Lotrel)(QL)
Triamterene* (Dyrenium)
Levetiracetam* (Keppra)
Candesartan/HCTZ* (Atacand)
VASODILATORS ____________________________
Phenobarbital* (generic)
Captopril/HCTZ* (Capoten/Capozide)
Hydralazine* (Apresoline)
Phenytoin* (Dilantin/generic)
Enalapril/HCTZ* (Vasotec/Vaseretic)
Isosorbide Dinitrate* (Isordil)
Primidone* (Mysoline)
Fosinopril/HCTZ* (Monopril)
Isosorbide Mononitrate* (Imdur, Monoket)
Oxcarbazepine* (Trileptal)
Irbesartan/HCTZ* (Avapro/Avalide)
Minoxidil* (generic)
Topiramate* (Topamax)
Lisinopril/HCTZ* (Zestril/Zestoretic)
Nitroglycerin* (generic)
Valproic Acid* (Depakene)
Losartan/HCTZ* (Cozaar/Hyzaar) (QL)
Zonisamide* (Zonegran)
Moexipril/HCTZ* (Univasc/Uniretic)
DERMATOLOGICALS
ANTIPARKINSON AGENTS ____________________
Olmesartan (Benicar/ Benicar HCT)(ST)(QL)
ACNE _____________________________________
Amantadine* (Symmetrel)
Quinapril/HCTZ* (Accupril/Accuretic)
Clindamycin* (Cleocin)
Benztropine* (Cogentin)
Ramipril* (Altace/generic)
Erythromycin* (Emgel)
Bromocriptine* (Parlodel)
Trandolapril* (Mavik)
Isotretinoin* (Accutane)
Carbidopa/Levodopa* (Sinemet/CR)
Trandolapril/verapamil* (Tarka)
Metronidazole* (MetroLotion,MetroGel)
Pramipexole* (Mirapex)
Valsartan/HCTZ (Diovan/Diovan HCT)(ST)(QL)
Minocycline* (Minocin/Solodyne)
Ropinirole* (Requip)
ANTI-ADRENERGIC BLOCKERS ________________
Sodium Sulfacetamide* (Sulfacet-R)
Selegiline*(Eldepryl)
Doxazosin* (Cardura)
Tretinoin* (Retin-A) (MAX AGE 34)
Trihexyphenidyl* (Artane)
Prazosin* (Minipress)
ANTIBIOTICS/ANTIVIRALS ____________________
CEREBRAL STIMULANTS _____________________
Terazosin* (Hytrin)
Acyclovir* (Zovirax/generic)
Amphet Asp/Amphet/D-Amphet*
ANTIARRHYTHMICS _________________________
Metronidazole* (MetroGel/MetroLotion)
(Adderall/Adderall XR)(QL)(MIN AGE 3/6)
Amiodarone* (Cordarone)
Mupirocin* (Bactroban)
Dexmethylphenidate* (Focalin)
Digoxin* (Lanoxin)
Sodium Sulfacetamide* (Sulfacet-R)
Dextroamphetamine* (Dexedrine)
Disopyramide* (Norpace)
FUNGICIDES ________________________________
Methylphenidate ER* (Concerta)
Flecainide* (Tambocor)
Ciclopirox* (Loprox)
Methylphenidate* (Ritalin)
Mexiletine* (Mexitil)
PSYCHOTHERAPEUTIC AGENTS _______________
Clotrimazole/Betamethazone* (Lotrisone)
Procainamide* (Pronestyl)
Ketoconazole* (Nizoral)
Antidepressants .
Propafenone* (Rythmol)
Nystatin/Triamcinolone* (Mycolog II)
Amitriptyline* (Elavil)
Quinidine Gluconate* (Quinidex)
TOPICAL ANTI-INFLAMMATORY AGENTS _______
Bupropion/-XL* (Wellbutrin/XL)(QL)
Sotalol* (Betapace AF)
Low Potency .
Citalopram* (Celexa)(QL)
ANTICOAGULANTS/ANTITHROMBOTICS ________
Desonide* (Desowen)
Desipramine* (Norpramin)
Anagrelide* (Agrylin)
Fluocinolone* (Synalar)
Doxepin* (Sinequan)
Cilostazol* (Pletal)
Hydrocortisone* (generic)
Escitalopram* (Lexapro)
Clopidogrel* (Plavix)(QL)
Fluoxetine* (Prozac)
Dipyridamole* (Persantine)
Medium Potency .
Fluvoxamine* (Luvox)
Pentoxifylline* (Trental)
Desoximetasone* (Topicort)
Imipramine* (Tofranil)
Ticlopidine* (Ticlid)
Fluocinolone* (Synalar)
Mirtazapine* (Remeron)
Warfarin* (generic/Coumadin)
Mometasone* (Elocon)
Nortriptyline* (Norpramin)
ANTILIPEMICS ______________________________
Prednicarbate* (Dermatop E)
Paroxetine* (Paxil /CR) (QL)
Atorvastatin* (Lipitor)
Triamcinolone* (Aristocort)
Sertraline* (Zoloft)
Cholestyramine* (Questran)
High Potency .
Trazodone* (trazodone)
Colestipol* (Colestid)
Betamethasone Dipropionate* (Diprosone)
Venlafaxine* (Effexor XR/Effexor)(QL)
Fenofibrate* (Antara/Lofibra/Tricor)
Fluocinonide* (Lidex)
Antimanic Agents .
Gemfibrozil* (Lopid)
Ultra-High Potency .
Lithium Carbonate* (Eskalith)
Lovastatin* (Mevacor)
Augmented Betamethasone* (Diprolene)
Lithium Citrate* (Cibalith-S)
Niacin* (Niaspan/generic)
Clobetasol* (Temovate)
Diflorasone* (Psorcon)
HORMONES
Corticosteroids .
VAGINAL/RECTAL PREPARATIONS _____________
Hydrocortisone* (Proctocort)
ANTIESTROGENS ___________________________
Budesonide* (Pulmicort Respules)
Mesalamine* (Rowasa)
Tamoxifen* (Nolvadex)
Metronidazole* (MetroGel Vaginal)
AROMATASE INHIBITORS _____________________
Sulfanilamide* (AVC)
Anastrozole* (Arimidex)
Fluticasone/Salmeterol (Advair/Advair HFA) MISCELLANEOUS DERMATOLOGICALS _________
Exemestane* (Aromasin)
Sympathomimetics .
Calcipotriene* (Dovonex)
Letrozole* (Femara)
Fluorouracil* (Efudex)
ESTROGENS ________________________________
Metaproterenol* (Alupent)
Lindane* (Kwell)
Permethrin* (Elimite)
Estradiol* (Estrace)
Terbutaline* (Brethine)
Podofilox* (Condylox)
Estradiol Patch* (Climara)
Xanthine Derivatives .
Selenium Sulfide* (Selsun RX)
Estropipate* (Ogen)
Aminophylline* (generic)
Silver Sulfadiazine* (Silvadene)
PROGESTINS _______________________________
Theophylline* (Uniphyl)
ENDOCRINE AGENTS
Medroxyprogesterone* (Provera)
OTHER AGENTS ____________________________
ANTIDIABETIC AGENTS-INJECTABLE ___________
Megestrol* (Megace)
Norethindrone* (Aygestin)
Albuterol/Ipratropium* (DuoNeb)
MISCELLANEOUS HORMONE PRODUCTS _______
Cromolyn* (Intal)
ANTIDIABETIC AGENTS-ORAL _________________
Flutamide* (generic)
Acarbose* (Precose)
Montelukast* (Singulair)(QL)(PA)
Chlorpropamide* (Diabinese)
OPHTHALMICS
Glimepiride* (Amaryl)
ALPHA-AGONIST ____________________________
NASAL MEDICATIONS________________________
Glipizide* (Glucotrol)
Brimonidine Tartrate* (Alphagan P)
Azelastine* (Astelin) (QL)
Glipizide/Metformin* (Metaglip)
ANTI-INFECTIVE AGENTS _____________________
Fluticasone* (Flonase)
Glyburide/Metformin* (Glucovance)
Flunisolide* (Nasarel)(QL)
Glyburide/Micronized* (Glynase)
Chloramphenicol* (generic)
Metformin* (Glucophage)
Ciprofloxacin* (Ciloxin)
SKELETAL AGENTS
Nateglinide* (Starlix)
Erythromycin* (Romycin)
ANTIRHEUMATICS ___________________________
Pioglitazone* (Actos)
Gentamicin* (Garamycin)
Azathioprine* (Imuran)
Pioglitazone/Metformin* (ActoPlus Met)
Neomycin/Bacitracin/Polymyxin* (NeoSporin)
Hydroxychloroquine* (Plaquenil)
Tolazamide* (Tolinase)
Ofloxacin* (Ocuflox)
Methotrexate* (Rheumatrex)
Tolbutamide* (Orinase)
Polymyxin B/Trimethoprim* (Polytrim)
BONE ENHANCING AGENTS __________________
ANTIDIABETIC SUPPLIES _____________________
Sulfacetamide* (Bleph-10)
Tobramycin* (Tobrex)
Alendronate* (Fosamax)(QL)
Accu-Chek Meters and Test Strips (QL)
ANTI-INFLAMMATORY AGENTS ________________
Calcitonin-Salmon* (Midrin)
One Touch Meters and Test Strips (QL)
Etidronate* (Didronel)
ANTITHYROID _______________________________
Cromolyn* (Opticrom)
Dexamethasone* (Maxidex)
Methimazole* (Tapazole)
Diclofenac* (Voltaren)
SKELETAL MUSCLE RELAXANTS
Propylthiouracil* (generic)
Fluorometholone* (Flarex)
THYROID ___________________________________
Flurbiprofen* (Ocufen)
Baclofen* (Lioresal)
Levothyroxine* (Synthroid, Levothroid, Levoxyl,
Prednisolone* (Inflamase Forte)
Carisoprodol* (Soma)
ANTI-INFECTIVE AND
Cyclobenzaprine* (Amrix/Fexmid/Flexeril)
Thyroid* (Armour Thyroid)
ANTI-INFLAMMATORY COMBINATIONS _________
Diazepam* (Valium)
Methocarbamol* (Robaxin)
GASTROINTESTINAL AGENTS
Na Sulfacetm/Prednisolone* (Vasocidin)
Tizanidine* (Zanaflex)
ANTIEMETIC/ANTIVERTIGO ___________________
Neomy/Bacitracin/Polymyxin/Hydrocort*
Granisetron* (Kytril)
URINARY AGENTS
Neomycin/Dexamethasone* (NeoDecadron)
Meclizine* (Antivert)
Neomycin/Polymyx B/Dexamethasone*
ANTI-INFECTIVES ___________________________
Metoclopramide* (Reglan)
Sulfadiazine* (generic)
Ondansetron* (Zofran)
ANTIVIRAL AGENTS _________________________
Sulfisoxazole* (Gantrisin)
Prochlorperazine* (Compazine)
Trimethoprim/Sulfamethoxazole* (Bactrim,
Promethazine* (Phenergan)
Trifluridine* (Viroptic)
Trimethobenzamide* (Tigan)
BETA-BLOCKERS ___________________________
ANTISPASMODIC/GI MOTILITY _________________
Betaxolol* (Betoptic)
CHOLINERGIC AGENTS ______________________
Bethanechol*
(Urecholine)
Belladonna/Phenobarbital* (Donnatal)
Carteolol* (Ocupress)
Flavoxate* (Urispas)
Clidinium/Chlordiazepoxide* (Librax)
Levobunolol* (Betagan)
Dicyclomine* (Bentyl)
Metipranolol* (OptiPranolol)
OTHER URINARY AGENTS ____________________
Hyoscyamine* (Levsin)
Timolol* (Timoptic)
Doxazosin* (generic)
Propantheline* (Pro-Banthine)
MIOTICS ___________________________________
Finasteride* (Proscar) (QL)
ANTIULCER ________________________________
Phenazopyridine* (Pyridium)
Prazosin* (generic)
Misoprostol* (Cytotec)
Dorzolamide* (Trusopt)
Oxybutynin*/Ex rel* (Ditropan/XL) (QL)
Dorzolamide/timolol* (Cosopt)
Tamsulosin* (Flomax)
OTHER GI PRODUCTS ________________________
Latanoprost* (Xalatan)
Pilocarpine* (Isopto Carbachol)
Terazosin* (generic)
Balsalazide* (Colazal)
MYDRIATICS ________________________________
Tolterodine* (Detrol)
Lactulose* (Cephulac)
Trospium* (Sanctura) (QL)
Mesalamine* (Asacol/Asacol HD/generic)
Atropine* (Isopto Atropine)
Cyclopentolate* (Cyclogyl)
VITAMINS AND ELECTROLYTES
Sulfasalazine* (Azulfidine)
Homatropine* (Isopto Homatropine)
Ursodiol* (Actigall)
SYMPATHOMIMETICS ________________________
Prenatal Vitamins requiring prescription* Dipivefrin* (generic)
GLUCOCORTICOIDS
Dexamethasone* (Decadron)
GS REQUIRIN
Fludrocortisone* (Florinef)
ANTI-INFECTIVE AGENTS _____________________
Methylprednisolone* (generic)
Acetic Acid* (Vosol)
Prednisolone* (Prelone)
Acetic Acid/Benzethonium* (generic)
Prednisone* (generic)
Ofloxacin* (Floxin)
ANTI-INFECTIVE AND
GOUT THERAPY
ANTI-INFLAMMATORY COMBINATIONS _________
G STEP THERAPY UGS REQUIRING
Allopurinol* (Zyloprim)
Acetic acid/Hydrocortisone*(Vosol HC)
Neomycin/Polymxin/HC* (Cortisporin)
Colchicine/Probenecid* (generic)
Indomethacin* (Indocin)
RESPIRATORY
Probenecid* (generic)
ANTI-ASTHMATIC AGENTS ____________________

Source: http://mysmarthealth.org/documents/ASCformulary2014.pdf

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INTERNATIONAL CENTRE FOR ECONOMIC RESEARCH WORKING PAPER SERIES G. Crespi, P. D’Este, R. Fontana, A Geuna THE IMPACT OF ACADEMIC PATENTING ON UNIVERSITY RESEARCH AND ITS TRANSFER The impact of academic patenting on university research and its transfer International Development Research Centre, Ottawa, Canada INGENIO (CSIC-UPV), Valencia, Spain & SPRU-Univers

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