Pdl_011908.xls

A
Drug Name
Generic Name
FSC Description
Adult Strength/Dose/Form
Restricted to DERM. Must have 'yellow sticker'.
A topical immune stimulator for warts. Restricted to Infections Disease, Dermatology, and OB/GYN departments. Reserved for immunocompromised patients and cases refractory to standard therapies.
Limit: 2 Inhalers or 50 vials neb sol per copay.
2nd line agent for Rheumatoid arthritis (RA) 250/125, 500/125, 875/125; 125/31.25, 200/28.5, 250/62.5, 400/57 CH; 125/31.25/5 mL, 200/28.5/5 mL, 250/62.5/5 mL, 2nd line agent. Must have tried/failed sulfasalazine B
Drug Name
Generic Name
FSC Description
Adult Strength/Dose/Form
Limit: 22 grams/copay. Note: ONLY stock ointment.
Limit: 80 grams oint/cream or 60mls lotion.
Limit: 80 grams oint/cream or 60mls lotion.
Generic (qty limited to 14 day treatment/30days) Restricted for patients who are not candidates for C
Drug Name
Generic Name
FSC Description
Adult Strength/Dose/Form
Restricted to ID/Ortho for pseudomonas specific or resistant organisms. For UTI's, Levaquin (levofloxacin) QL: 30 tablets per copay/month. Loratidine liquid not 150,200 Must fail Tier 1 NSAIDS (ibuprofen, naproxen).
2nd line agent. For patients with COPD on a regular aerosol bronchodilator who continue to have evidence of bronchospasm and require a second bronchodilator. D
Drug Name
Generic Name
FSC Description
Adult Strength/Dose/Form
Limit: 1 month supply. 30 caps per copay Limit: 100 tabs per copay; Only stock Darvon 65mg Must fail Tier 1 Depakote tablets before using IM; IV; intra-articular; intra-lesional Stock: 4mg/ml #30ml MDV Limit: 100 tabs per copay; Restricted to Cancer center, 250 2nd line agent. For patients intolerant to sulfasalzaine.
E
Drug Name
Generic Name
FSC Description
Adult Strength/Dose/Form
Limit: 80 grams/copay. Note: do not stock gel F
Drug Name
Generic Name
FSC Description
Adult Strength/Dose/Form
Must fail Tier 1 NSAIDS (ibuprofen, naproxen).
2nd line agent. Must have failed Cardura (doxazosin) Must fail Tier 1 Nasarel. QL 1 container per copay per G
Drug Name
Generic Name
FSC Description
Adult Strength/Dose/Form
H
Drug Name
Generic Name
FSC Description
Adult Strength/Dose/Form
Restricted to GI and Infectious Disease. Oral agent for Limit: 80 grams/copay. Note: 2.5% is restricted to I
Drug Name
Generic Name
FSC Description
Adult Strength/Dose/Form
Limit: 2 injections or 1 box/copay/month. Note: Do NOT stock Imitrex tablets. see Relpax.
Must fail Tier 1 NSAIDS (ibuprofen, naproxen).
Limit: 2 MDI's or #120 ampules for nebulization K
Drug Name
Generic Name
FSC Description
Adult Strength/Dose/Form
0.1%,0.5% crm; 0.025%,0.1% lot; Limit: 80gm per copay Note: 0.1% tier 1, 0.025% tier 2 L
Drug Name
Generic Name
FSC Description
Adult Strength/Dose/Form
Limit: 2 bottles of 946mls or 1,892mls.
Limit: 1 pack per copay Formulary alternative(s): M
Drug Name
Generic Name
FSC Description
Adult Strength/Dose/Form
Limit: 100 tabs/copay. Rx must indicate "for pain" to be filled at UNMH OP Pharmacy. For Methadone maintenance, take Rx to a licensed Methadone Limit: 100 tabs per copay; Criteria: Diagnosis of ADHD Limit: 100 tabs per copay; Criteria: Diagnosis of ADHD 15,30; 10,15,30 sol tab; 15,30,60,100,200 ER; 2,4,20/mL Stock: suspension. DO NOT STOCK the troches N
Drug Name
Generic Name
FSC Description
Adult Strength/Dose/Form
bacitracin/neomycin/polymyxin B topical Y ferrous bis-glycinate chelate/polysaccharide iron complex/calcium ascorbate and ferrous bis-glycinate chelate/polysaccharide iron complex/calcium ascorbate and Limit: 1 bottle or 25 tabs/copay Stock 0.4mg tabletes O
Drug Name
Generic Name
FSC Description
Adult Strength/Dose/Form
P
Drug Name
Generic Name
FSC Description
Adult Strength/Dose/Form
Stock 25mg tabs, 12.5 & 25mg suppositories HMG CoA reductase inhibitor that does not interact with cytochrome P-450 metabolized drugs such as azole antifunals, macrolide antibiotics, cyclosporine, 0.3/1.5,0.45/1.5,0.625/2.5,0.625/5 Limit: 1 pack per copay Limit: 24 suppositories per copay. Stock 5 and 25mg Limit: 24 suppositories/copay. Note: stock 12.5mg Q
Drug Name
Generic Name
FSC Description
Adult Strength/Dose/Form
R
Drug Name
Generic Name
FSC Description
Adult Strength/Dose/Form
Limit: 2 boxes (60 single-unit containers) Limit: 15 or 20gm tube per copay. NOT covered for 0.025,0.05,0.1% crm; 0.01,0.025% cosmetic conditions. A diagnosis must be obtainable Limit: 15 or 20gm tube per copay. NOT covered for cosmetic conditions. A diagnosis must be obtainable 100,150,200,300 Must have current UNM Care / MIP Limit: 100 tabs per copay; Stock ONLY 5mg tabs and S
Drug Name
Generic Name
FSC Description
Adult Strength/Dose/Form
500,750 Must fail Tier 1 NSAIDS (ibuprofen, naproxen).
Limit: 120mls/copay. NOTE: only stock 2.5% 2nd line agent for asthma. NOT covered for Chronic T
Drug Name
Generic Name
FSC Description
Adult Strength/Dose/Form
2nd line agent. Must have failed carbamazepine bacitracin/neomycin/polymyxin B topical Y mineral oil/pramoxine/zinc oxide topical QL U
Drug Name
Generic Name
FSC Description
Adult Strength/Dose/Form
V
Drug Name
Generic Name
FSC Description
Adult Strength/Dose/Form
5,001,000 2nd line agent. Must have failed acyclovir.
W
Drug Name
Generic Name
FSC Description
Adult Strength/Dose/Form
2nd line agent for depression. Smoking Cessation 2nd line agent for depression. Smoking Cessation X
Drug Name
Generic Name
FSC Description
Adult Strength/Dose/Form
Z
Drug Name
Generic Name
FSC Description
Adult Strength/Dose/Form
Stock: 250mg tabs and suspension strengths.
Criteria: Must have failed/tried 2 other atypical

Source: http://hospitals.unm.edu/sci/documents/pdl_alpha.pdf