Formulary Action and Date (Formulary additions become effective on the 1st
day of the following month.) |
Generic Name
(Trade Name) |
Dosage Form(s) and Strength(s) |
Therapeutic Classification |
Use
(comments) |
Added: 10/20/98 |
Albumin microspheres
(Optison) |
Injection:
3mL |
Diagnostic agent |
Left ventricle opacification during
echocardiograms |
Deleted: 6/16/98 |
Aminoglutethimide (Cytadren) |
Tablet:
250mg |
Antiadrenal; antineoplastic |
(Low usage agent) |
Addded: 1/99 |
Ammonium lactate (Lac-Hydrin) |
Lotion:
12% (400g) |
Emollient |
(Line-item extension) |
Manufacturer discontinuation: 1/99 |
Amoxicillin & clavulanate (Augmentin) |
Tablet:
250mg
Tablet, chewable:
250mg
(Note: other strengths
remain available) |
Antibiotic |
Various infections |
Added: 10/20/98 |
Amphotericin B lipid complex (Abelcet) |
Injection:
5mg/mL (20mL) |
Antifungal |
Invasive fungal infections in patients
refractory to conventional amphotericin B deoxycholate therapy or where
renal impairment or unacceptable toxicity precludes the use of the deoxycholate
formulation |
Addded: 1/99 |
Ascorbic acid (generic) |
Injection:
500mg/mL (50mL) |
Vitamin |
(Line-item extension) |
Added: 6/10/98 |
Atorvastatin (Lipitor) |
Tablet:
40mg |
HMG-CoA reductase inhibitor |
(Line item extension) |
Added: 7/21/98 |
Budesonide (Pulmicort Turbuhaler) |
Powder, inhalation: 200mcg/activation (200 inhalations) |
Corticosteroid |
Asthma |
Added: 10/20/98 |
Capecitabine
(Xeloda) |
Tablet:
150mg, 500mg |
Antimetabolite |
Metastatic breast cancer resistant
to paclitaxel and where anthracycline-containing regimens are not indicated
(due to resistance or maximum cumulative doses) |
Added: 10/20/98 |
Carbamide peroxide
(Debrox) |
Solution, otic: 6.5% (30mL) |
Ear wax emulsifier/dispersant |
Ear wax removal |
Added: 12/15/98 |
Carboxymethylcellulose (Celluvisc) |
Solution, ophthalmic: 1% (0.3mL) |
Ophthalmic lubricant |
Dry eyes |
Added: 12/15/98 |
Carboxymethylcellulose (Refresh Plus) |
Solution, ophthalmic: 0.5% (0.3mL) |
Ophthalmic lubricant |
Dry eyes |
Added: 4/21/98 |
Cefuroxime (Ceftin) |
Tablet:
125mg, 250mg, 500mg
Suspension: 25mg/mL
(50mL, 100mL, 200mL) |
2nd generation cephalosporin |
Pharyngitis, tonsillitis, otitis media,
UTIs, skin infections, impetigo (Replaces: cefpodoxime) |
Deleted: 4/21/98 |
Cefpodoxime (Vantin) |
Tablet:
100mg; 200mg
Suspension: 10mg/mL
(100mL); 20mg/mL (100mL) |
3rd generation cephalosporin |
(Replaced
by: oral
cefuroxime) |
Addded: 1/99 |
Cisatracurium (Nimbex) |
Injection:
10mg/mL (20mL) |
Neuromuscular blocker |
(Line-item extension) |
Added: 6/16/98 |
Cisplatin (Platinol) |
Injection, aqueous: 1mg/mL (50mL, 100mL) |
Antineoplastic |
(Line-item extension) |
Added: 12/15/98 |
Citalopram
(Celexa) |
Tablet:
20mg, 40mg |
SSRI |
Depression |
Added: 7/21/98 |
Clopidogrel (Pravix) |
Tablet:
75mg |
Anti-platelet agent |
Secondary prevention of atherosclerotic
events |
Manufacturer discontinuation: 1/99 |
Cyclopentolate (Cyclogyl) |
Solution, ophthalmic: 0.5% (2mL)
(Note: 1% and 2%
solutions remain available) |
Mydriatic |
Uveitis |
Added: 9/15/98 |
Daclizumab (Zenapax) |
Injection:
5mg/mL (5mL) |
Immunosuppressive |
Acute organ rejection in renal transplant
patients |
Addded: 1/99 |
Didanosine (Videx) |
Powder for oral solution: 4g |
Antiviral |
(Line-item extension) |
Manufacturer discontinuation: 1/99 |
Diethylstilbestrol (generic) |
Tablet:
1mg, 5mg |
Estrogen |
Prostate cancer |
Added: 6/16/98 |
Dihydroergotamine (Migranol) |
Nasal spray:
Kit (4 ampules containing 4mg/mL each) |
Ergot derivative |
Migraine |
Added: 7/21/98 |
Diphtheria & Tetanus Toxoids &
Acellular Pertussis Vaccine, Adsorbed (Tripedia) |
Injection:
0.5mL |
Immunization |
(Line-item extension) |
Added: 11/17/98 |
Efavirenz
(Sustiva) |
Capsule:
20mg |
Antiviral |
HIV infection |
Added: 6/16/98 |
Enoxaparin (Lovenox) |
Injection, syringe: 100mg/mL (0.6mL, 0.8mL, 1mL) |
Low molecular weight heparin |
(Line-item extension) |
Added: 5/19/98 |
Estramustine (Emcyt) |
Capsule: 140mg |
Combination estrogen/nitrogen mustard |
Metastatic/progressive prostate cancer |
Manufacturer discontinuation: 1/99 |
Etretinate (Tegison) |
Capsule:
10mg, 25mg |
Vitamin A derivative |
Psoriasis |
Added: 12/15/98 |
Fibrin sealant
(Tisseel) |
Solution, topical: 2mL |
Hemostatic |
Intra-operative bleeding |
Deleted: 7/21/98 |
Flunisolide (AeroBid-M) |
Spray:
250mcg/activation (7g ~ 50 inhalations) |
Corticosteroid |
(Replaced
by: budesonide and fluticasone) |
Added: 7/21/98 |
Fluticasone (Flovent Rotadisk) |
Powder, inhalation: 50mcg/activation, 100mcg/activation,
250mcg/activation (30 inhalations) |
Corticosteroid |
Asthma |
Added: 4/21/98 |
Follitropin alpha (Gonal-F) |
Injection: 75
units, 150 units |
Ovulation stimulant |
Infertility; assisted reproductive
technologies |
Manufacturer discontinuation: 1/99 |
Hepatitis B immune globulin (HyperHep) |
Injection:
0.5mL
(Note: 1mL and 2mL
volumes remain available) |
Immunizing agent |
Hepatitis B prophylaxis |
Added: 1/19/99 |
Hylan polymers (Symvisc) |
Injection:
8mg/mL (2mL) |
Hyaluronic acid derivative |
Osteoarthritis |
Added: 4/21/98 |
Imiquimod (Aldara) |
Cream: 5%
(250mg single-use packets) |
Immune response modifier |
Genital and perianal warts |
Manufacturer discontinuation: 1/99 |
Indocyanine green (Cardio-Green) |
Injection:
50mg
(Note: 25mg strength
remains available) |
Diagnostic |
Cardiac function |
Added: 7/21/98 |
Insulin
(Humulin R) |
Injection: 500
units/mL (20mL) |
Antidiabetic agent |
(Line-item extension) |
Addded: 1/99 |
Interferon Alpha 2-B (Intron A) |
Injection, auto-injector: 3 million units |
Interferon |
(Line-item extension) |
Added: 6/16/98 |
Iodixanol
(Visipaque) |
Injection: 55%
[27% iodine] (100mL); 62.5% [32% iodine] (50mL) |
Ionic contrast agent |
Contrast enhancement |
Added: 7/21/98 |
Iodixanol
(Visipaque) |
Injection: 62.5%
[32% iodine] 100mL |
Ionic contrast agent |
(Line-item extension) |
Addded: 1/99 |
Isoniazid & rifampin (Rifamate) |
Capsule:
isoniazid 150mg + rifampin 300mg |
Antituberculosis drug |
(Line-item extension) |
Added with a Level II Restriction: 12/15/98 |
Ketorolac
(Acular) |
Solution, ophthalmic: 0.5% (0.4mL) |
NSAID |
Seasonal allergic conjunctivitis;
Postoperative occular inflammation
(Limited to use for photorefractive keratectomy
(PRK) and phototherapeutic keratectomy (PTK)) |
Added: 6/16/98 |
Lactase
(Lactaid) |
Drops: 5000
units/mL (7mL) |
Dietary supplement |
(Line-item extension) |
Added: 6/16/98 |
Letrozole
(Femara) |
Tablet: 2.5mg |
Antineoplastic |
Breast cancer |
Addded: 1/99 |
Lidocaine (generic) |
Injection:
10mg/ml (5mL) |
Local anesthetic |
(Line-item extension) |
Addded: 1/99 |
Lidocaine & Prilocaine (EMLA) |
Transdermal patch: 1g |
Topical anesthetic |
(Line-item extension) |
Added: 7/21/98 |
Mafenide (Sulfamylon) |
Powder:
50g |
Topical antibacterial/antifungal |
(Line-item extension) |
Added: 9/15/98 |
Meropenem (Merrem) |
Injection:
500mg, 1g |
Carbapenem antibiotic |
Appendicitis; peritonitis; meningitis |
Manufacturer discontinuation: 1/99 |
Metocurine (Metubine) |
Injection:
2mg/mL (20mL) |
Neuromuscular blocking agent |
Adjunct to anesthesia and electroshock
therapy |
Addded: 1/99 |
Metrizamide (Amipaque) |
Injection:
3.75g [9.05% iodine] (20mL) |
Contrast agent |
(Line-item extension) |
Manufacturer discontinuation: 1/99 |
Metrizamide (Amipaque) |
Injection:
6.75g [6.52% iodine] (50mL) |
Contrast agent |
Contrast enhancement |
Addded: 1/99 |
Midazolam (Versed) |
Syrup:
2mg/mL (118mL) |
Benzodiazepine |
(Line-item extension) |
Added: 7/21/98 |
Montelukast (Singulair) |
Tablet, chewable: 5mg;
Tablet:
10mg |
Leukotriene receptor inhibitor |
Asthma |
Addded: 1/99 |
Mycophenolate (CellCept) |
Injection:
25mg/mL (20mL) |
Immunosuppressive |
(Line-item extension) |
Added: 6/16/98 |
Ofloxacin
(Floxin) |
Otic solution: 0.3% (5mL) |
Fluoroquinolone antibiotic |
Otitis media; otitis externa |
Added: 9/15/98 |
Oprelvekin (Neumega) |
Injection:
5mg |
Thrombopoietic growth factor (IL-11) |
Chemotherapy-induced thrombocytopenia |
Manufacturer discontinuation: 1/99 |
Oxidized cellulose, regenerated (Surgicel) |
Topical strip: 3x4"Nu Knit
(Note: other doage
forms remain available) |
Hemostatic |
Hemostasis |
Added: 9/15/98 |
Palivizumab (Synagis) |
Injection:
100mg |
Antiviral |
RSV (Replaces: respiratory syncytial virus immune globulin) |
Addded: 1/99 |
Paroxetine (Paxil) |
Suspension:
2mg/mL (250mL) |
SSRI |
(Line-item extension) |
Manufacturer discontinuation: 1/99 |
Pentagastrin
(Peptavlon) |
Injection:
0.25mg/mL (2mL) |
Gastric secretogogue |
Diagnostic agent |
Added: 7/21/98 |
Pergolide (Permax) |
Tablet:
0.05mg, 0.25mg, 1mg |
Dopamine agonist, ergot derivative |
Parkinson's disease |
Added: 11/17/98 |
Progesterone, micronized (Prometrium) |
Capsule:
100mg |
Progestin |
Hormone replacement therapy |
Manufacturer discontinuation: 1/99 |
Pyridoxine
(generic) |
Injection:
100mg/mL (10mL)
(Note: other doage
forms and volumes remain available) |
Vitamin B-6 |
Nutrient |
Added: 6/16/98 |
Raloxifene
(Evista) |
Tablet: 60mg |
Selective estrogen receptor modulator |
Postmenopausal osteoporosis |
Addded: 1/99 |
Ranitidine (generic) |
Tablet:
300mg |
Histamine H2-receptor antagonist |
(Line-item extension) |
Added: 5/19/98 |
Retinoic acid (Vesanoid) |
Capsule:
10mg |
Retinoid |
Acute promyelocytic leukemia |
Deleted: 9/15/98 |
Respiratory syncytial virus immune
globulin (RespiGam) |
Injection: 50mg/mL
(20mL, 50mL) |
Antiviral |
(Replaced
by: palivizumab) |
Addded: 8/18/98 |
Ribavirin & interferon alpha-2b
(Rebetron) |
Injection, auto-injector +
capsule: interferon
alfa-2b 3 million units/0.2mL (1.2mL) + ribavirin 200mg (#42, #70, #84) |
Antiviral |
Chronic hepatitis C |
Added: 7/21/98; 1/99 |
Risperidone
(Risperdal) |
Solution:
1mg/mL (30mL, 100mL) |
Antipsychotic |
(Line-item extension) |
Added: 5/19/98 |
Rituximab (Rituxan) |
Injection: 100mg,
500mg |
Anti-CD20 monoclonal antibody |
Non-Hodgkin's lymphoma |
Added: 7/21/98 |
Salmeterol
(Serevent Diskus) |
Powder, inhalation: 50mcg/activation (28 inhalations,
60 inhalations) |
Beta-adrenergic agonist |
Asthma |
Added: 6/16/98 |
Sildenafil
(Viagra) |
Tablet: 25mg,
50mg, 100mg |
Phosphodiesterase inhibitor |
Impotence |
Manufacturer discontinuation: 1/99 |
Sodium chloride
(generic) |
Solution, inhalation: 0.9% (1mL)
(Note: other doage
forms and volumes remain available) |
Saline |
Diluent |
Addded: 1/99 |
Sodium fluoride (Pediaflor) |
Drops:
1.1mg/mL (50mL) |
Mineral |
(Line-item extension) |
Added: 8/18/98 |
Tamsulosin (Flomax) |
Capsule:
0.4mg |
Alpha-1A receptor antagonist |
Benign prostatic hyperplasia |
Addded: 1/99 |
Testosterone (various) |
Transdermal patch (Androderm): 5mg/24h
Injection, cypionate (generic): 100mg/mL (10mL) |
Anabolic steroid |
(Line-item extension) |
Added: 11/17/98 |
Thalidomide
(Thalomid) |
Capsule:
50mg |
Immunomudulator |
Cutaneous erythema nodosum leprosum |
Added: 1/19/99 |
Timolol (Timoptic-XE) |
Gel, ophthalmic: 0.25% (5mL); 0.5% (2.5mL,
5mL) |
Beta-adrenergic blocking agent |
Glaucoma |
Added: 10/20/98 |
Tirofiban
(Aggrastat) |
Injection:
250mcg/mL (50mL) |
Antiplatelet agent |
Acute coronary syndrome |
Added: 4/21/98 |
Tobramycin (TOBI) |
Solution, inhalation:
60mg/mL (5mL) |
Aminoglycoside antibiotic |
Cystic fibrosis patients with P.
aeruginosa |
Added: 7/21/98 |
Tolcapone
(Tasmar) |
Tablet:
100mg, 200mg |
COMT inhibitor |
Parkinson's disease |
Added: 8/18/98 |
Tolterodine
(Detrol) |
Tablet:
1mg, 2mg |
Muscarinic receptor antagonist |
Overactive bladder |
Added: 12/15/98 |
Trastuzumab
(Herceptin) |
Injection: 440mg |
Monoclonal antibody against human
epidermal growth factor receptor 2 protein |
Breast cancer |
Deleted: 10/20/98 |
Triethanolamine polypeptide oleatecondensate
(Cerumenex) |
Solution, otic: 10% (12mL) |
Ear wax emulsifier/dispersant |
Ear wax removal
(Replaced by:
carbamide peroxide) |
Addded: 1/99 |
Tubocurarine (generic) |
Injection:
3mg/mL (20mL) |
Neuromuscular blocking agent |
(Line-item extension) |
Deleted effective: 4/21/99 |
Urofollitropin (Fertinex) |
Injection: 75units |
Ovulation stimulant |
Infertility; Assisted reproductive
technologies
(To be replaced by:
follitropin alpha) |
Added:
1/19/99 |
Varicella virus vaccine (Varivax) |
Injection:
1350 PFU/0.5mL (0.5mL)- (20mL) |
Vaccine |
Immunization against varicella infection |
Added: 6/16/98 |
Venlafaxine
(Effexor XR) |
Extended-release capsule:
37.5mg, 75mg, 150mg |
Antidepressant |
Depression |
Addded: 1/99 |
Vitamin E (generic) |
Capsule:
400units |
Vitamin |
(Line-item extension) |
Manufacturer discontinuation: 1/99 |
Vitamin K
(AquaMEPHYTON) |
Injection:
10mg/mL (5mL)
(Note: other strengths
and volumes remain available) |
Vitamin |
Nutrient |
