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Ff40764g cummins file sheet_v2

Cummins Custom
Formulary File Sheet
Key Therapeutic Drug Categories
The following is a list of the most commonly prescribed drugs. It represents an abbreviated version of the formulary that is the core of your benefit plan.
The list is not all-inclusive and does not guarantee coverage. In addition to using this list, you are encouraged to ask your doctor to prescribe generic drugswhenever appropriate. This list is effective through December 31, 2011 and is subject to change.
MAOI Antidepressants
Lamisil Oral Granules (Terbinafine HCl) GENERICS
Sporanox Oral Solution (Itraconazole) = Weigh risk of birth defects or other adverse outcomes.
Oral Miscellaneous Agents
GENERICS
SSRI Antidepressants
Anti-Infectives (Antibiotics/Antifungals)
Neomycin Sulfate (Neomycin Sulfate) GENERICS
Oral Penicillins
GENERICS
Tobi Ampul for Nebulization (Tobramycin/0.25 Normal Saline) Amoxicillin Trihydrate/Potassium Clavulanate (Augmentin) Amoxicillin Trihydrate/Potassium Clavulanate (Augmentin XR) Vaginal Antifungals
GENERICS
Penicillin V Potassium (Pen-Vee K) Cardiovascular (Blood Pressure/Heart/Cholesterol)
Miconazole Nitrate Vaginal Suppository (Monistat 3) Beta Blockers
(Amoxicillin Trihydrate/Potassium Clavulanate) GENERICS
(Amoxicillin Trihydrate/Potassium Clavulanate) Oral Tetracyclines
Psychotherapeutics (Anxiety/Depression)
GENERICS
Hypnotic Agents
Doxycycline Hyclate Capsule (Vibramycin Capsule) GENERICS
Doxycycline Hyclate Tablet (Vibra-Tabs Tablet) Labetalol HCl (Normodyne, Trandate) Doxycycline Monohydrate (Monodox, Vibramycin Suspension) Minocycline HCl (Dynacin, Minocin) Propranolol HCl Capsule, Sustained Action 24 hr (Inderal LA) Tricyclic Antidepressants
Oral Cephalosporins
GENERICS
GENERICS
Cefpodoxime Proxetil Tablet (Vantin Tablet) Calcium Blockers
GENERICS
Diltiazem HCl Capsule, Sustained Action (Tiazac) Trimipramine Maleate (Surmontil 25mg, 50mg) Oral Erythromycins
Diltiazem HCl Capsule, Sustained Release 12 hr (Cardizem SR) Surmontil 100mg (Trimipramine Maleate) Diltiazem HCl Capsule, Sustained Release 24 hr (Cardizem CD) GENERICS
Diltiazem HCl Tablet, Sustained Release 24 hr (Cardizem LA) Miscellaneous Antidepressants
GENERICS
Bupropion HCl Tablet (Wellbutrin Tablet) Verapamil HCl Capsule, 24 hr Sustained Release Pellets Bupropion HCl Tablet, Sustained Action Erythromycin Ethylsuccinate (Eryped) Erythromycin Ethylsuccinate/Sulfisoxazole Acetyl (Pediazole) Bupropion HCl Tablet, Sustained Release Verapamil HCl Tablet, Sustained Action Erythromycin Stearate (Erythrocin Stearate) Oral Quinolones
Verapamil HCl Tablet, Sustained Release Osmotic Push (Covera-HS.) Mirtazapine Tablet (Remeron Tablet) Mirtazapine Tablet, Rapid Dissolve (Remeron SolTab) GENERICS
Dihydropyridines
GENERICS
Pristiq (Desvenlafaxine Succinate) Antipsychotics
Oral Sulfas
GENERICS
Nifedipine Tablet, Sustained Action (Adalat CC) Nifedipine Tablet, Sustained Release Osmotic Push (Procardia XL) GENERICS
Erythromycin Ethylsuccinate/Sulfisoxazole Acetyl (Pediazole) Sulfamethoxazole/Trimethoprim (Bactrim DS, Septra DS) Nitroglycerin Patches
Haloperidol Lactate Concentrate, Oral (Haldol) GENERICS
Oral Urinary Tract Agents
Nitroglycerin Patch (Nitroglycerin Patch) GENERICS
Methenamine Mandelate (Mandelamine) Nitrofurantoin Macrocrystal (Macrodantin) Adrenergic Antagonists & Related Drugs
Nitrofurantoin/Nitrofurantoin Macrocrystal (Macrobid) GENERICS
Clonidine HCl (Catapres-TTS Patch) Oral Antifungal Agents
Zyprexa, Zyprexa Zydis (Olanzapine) GENERICS
Anxiolytics
GENERICS
Griseofulvin Ultramicrosize (Gris-Peg) Angiotensin II Blockers & Renin Inhibitors
Clorazepate Dipotassium (Tranxene T-Tab) GENERICS
Losartan/Hydrochlorothiazide (Hyzaar) Antilipidemics
Contraceptive Agents
Respiratory (Allergy/Asthma)
GENERICS
GENERICS
Beta Agonists Oral
Cholestyramine/Aspartame (Questran Light) Desogestrel-Ethinyl Estradiol (Cyclessa) GENERICS
Desogestrel-Ethinyl Estradiol (Desogen) Desogestrel-Ethinyl Estradiol (Ortho-Cept) Desogestrel-Ethinyl Estradiol/Ethinyl Estradiol (Mircette) Ethinyl Estradiol/Drospirenone (Yasmin) Ethinyl Estradiol/Drospirenone (Yaz) Beta Agonist Inhalers
Fenofibrate, Nanocrystallized (Tricor) Ethynodiol D-Ethinyl Estradiol (Demulen) GENERICS
Levonorgestrel-Ethinyl Estradiol (Alesse) Albuterol Aerosol (Proventil Aerosol) Levonorgestrel-Ethinyl Estradiol (Nordette) Levonorgestrel-Ethinyl Estradiol (Seasonale) Albuterol Sulfate Solution (Proventil Solution) Levonorgestrel-Ethinyl Estradiol (Tri-Levlen) Isoetharine HCl Solution (Bronkosol Solution) Levonorgestrel-Ethinyl Estradiol (Triphasil) Levalbuterol HCl 1.25mg/0.5ml (Xopenex Solution) Niacin Tablet, Sustained Action Sequential (Niaspan) Metaproterenol Sulfate Solution (Alupent Solution) Omega-3 Acid Ethyl Esters (Lovaza) Norethindrone A-E Estradiol (Loestrin) Norethindrone A-E Estradiol/Ferrous Fumarate (Estrostep Fe) Norethindrone A-E Estradiol/Ferrous Fumarate (Loestrin Fe) Maxair Autohaler (Pirbuterol Acetate) Norethindrone-Ethinyl Estradiol (Brevicon) Norethindrone-Ethinyl Estradiol (Modicon) Norethindrone-Ethinyl Estradiol (Norinyl) Serevent Diskus (Salmeterol Xinafoate) Norethindrone-Ethinyl Estradiol (Ortho-Novum) Xopenex HFA (Levalbuterol Tartrate) ACE Inhibitors
Xopenex Solution (Levalbuterol HCl) Norethindrone-Mestranol (Ortho-Novum) GENERICS
Norgestimate-Ethinyl Estradiol (Ortho Tri-Cyclen) Inhaled Steroids
Norgestimate-Ethinyl Estradiol (Ortho Tri-Cyclen Lo) GENERICS
Norgestimate-Ethinyl Estradiol (Ortho-Cyclen) Norgestrel-Ethinyl Estradiol (Lo/Ovral) Norgestrel-Ethinyl Estradiol (Ovral) Lybrel (Levonorgestrel-Ethinyl Estradiol) Flovent HFA (Fluticasone Propionate) NuvaRing (Etonogestrel/Ethinyl Estradiol) Flovent Diskus (Fluticasone Propionate) Seasonique (Levonorgestrel-Ethinyl Estradiol/Ethinyl Estradiol) QVAR (Beclomethasone Dipropionate) Estrogens/Estrogen Combinations
Nasal Corticosteroids
GENERICS
GENERICS
Combination Antihypertensives
Estradiol/Norethindrone (Activella 1-0.5mg) Miscellaneous Pulmonary Agents
GENERICS
Methyltestosterone/Estrogens, Esterified (Estratest, Estratest H.S.) GENERICS
Amlodipine Besylate/Benazepril HCl (Lotrel) Methyltestosterone/Estrogens, Esterified (Syntest D.S., Syntest H.S.) Atenolol/Chlorthalidone (Tenoretic) Cromolyn Sodium Ampul for Nebulization (Intal) Benazepril HCl/Hydrochlorothiazide (Lotensin HCT) Combipatch (Estradiol/Norethindrone Acetate) Ipratropium Bromide Solution (Atrovent) Bisoprolol Fumarate/Hydrochlorothiazide (Ziac) Depo-Estradiol (Estradiol Cypionate) Ipratropium/Albuterol Sulfate (Duoneb) Captopril/Hydrochlorothiazide (Capozide) Enjuvia (Estrogens, Conjugated Synthetic) Enalapril Maleate/Hydrochlorothiazide (Vaseretic) Advair Diskus (Fluticasone Propionate/Salmeterol Xinafoate) Advair HFA (Fluticasone/Salmeterol) Hydralazine HCl/Hydrochlorothiazide (Apresazide) Atrovent HFA (Ipratropium Bromide) Lisinopril/Hydrochlorothiazide (Prinzide, Zestoretic) Methyldopa/Hydrochlorothiazide (Aldoril) Combivent Inhaler (Albuterol Sulfate/Ipratropium Bromide) Propranolol HCl/Hydrochlorothiazide (Inderide) Ortho-Prefest (Estradiol, Norgestimate) Quinapril HCl/Hydrochlorothiazide (Accuretic) Premarin Tablets (Estrogens, Conjugated) Endocrine
Premarin Vaginal Cream (Estrogens, Conjugated) Premphase (Estrogens, Conjugated/Medroxyprogesterone Acet) Insulin Therapy
Prempro (Estrogens, Conjugated/Medroxyprogesterone Acet) Symbicort (Budesonide/Formoterol Fumarate) Apidra, Apidra Solostar (Insulin Glulisine) Humalog, Humalog Mix (Insulin Lispro, Human Rec. Anlog) Humulin (Insulin Human Recombinant) G. I. (Ulcer)
Lantus, Lantus Solostar (Insulin Glargine, Human Recombinant Analog) F Ulcer Drugs
Antihistamine/Decongestant Combinations
GENERICS
Novolin (Insulin Human Recombinant) GENERICS
Cimetidine HCl Liquid (Tagamet Liquid) Novolog, Novolog Mix (Insulin Aspart) Carbetapentane Tannate/Chlorpheniramine Tannate (Tussi-12) Cimetidine Tablet (Tagamet Tablet) Carbetapentane Tannate/Ephedrine Tannate/Phenylephrine/ Non-Insulin Hypoglycemic Agents
Chlorpheniramine Suspension (Rynatuss) Carbetapentane Tannate/Phenylephrine Tannate/Chlorpheniramine GENERICS
Phenylephrine HCl/Phenyltoloxamine Citrate/Chlorpheniramine (Nalex-A) G Phenylephrine HCl/Promethazine HCl (Phenergan VC) Phenylephrine Tannate/Chlorpheniramine Tannate (Rynatan) Phenylephrine Tannate/Diphenhydramine Tannate Suspension Glipizide/Metformin HCl (Metaglip) Other G.I. Drugs
Phenylephrine Tannate/Pyrilamine Tannate (Ryna-12 S) Phenylephrine Tannate/Pyrilamine Tannate/Chlorpheniramine (Rynatan) G GENERICS
Pseudoephedrine HCl/Brompheniramine Maleate (Bromfed) Sucralfate Tablet (Carafate Tablet) Glyburide/Metformin HCl (Glucovance) Pseudoephedrine HCl/Brompheniramine Maleate (Histex SR) Pseudoephedrine HCl/Chlorpheniramine Maleate Pylera (Bismuth/Metronid/Tetracycline) Pseudoephedrine HCl/Chlorpheniramine Maleate (Biohist-LA) Pseudoephedrine HCl/Chlorpheniramine Maleate (Histex) NSAIDs (Pain Relievers)
Pseudoephedrine Tannate/Chlorpheniramine Tannate (Tanafed) Pseudoephedrine Tannate/Dexchlorpheniramine Tannate (Tanafed DP) GENERICS
Antihistamines
GENERICS
Etodolac Tablet, Sustained Release 24 hr (Lodine XL) Dexchlorpheniramine Maleate Syrup Indomethacin Capsule, Sustained Action (Indocin SR) Diphenhydramine HCl 50mg (Benadryl) Blood Glucose Test Strips
Ketoprofen Capsule, 24 hr Sustained Release Pellets (Oruvail) Meclofenamate Sodium (Meclofenamate Sodium) GENERICS
Alcohol Antiseptic Pads (Alcohol Prep) Accu-Chek Active Test Strips (Blood Sugar Diagnostic) Naproxen Sodium (Anaprox, Anaprox DS) Miscellaneous
Accu-Chek Aviva Test Strips (Blood Sugar Diagnostic) Naproxen Sodium Tablet, Sustained Action (Naprelan) Accu-Chek Comfort Curve Test Strips (Blood Sugar Diagnostic) GENERICS
Accu-Chek Compact Test Strips (Blood Sugar Diagnostic) Calcitonin, Salmon, Synthetic (Miacalcin) Fast Take Test Strips (Blood Sugar Diagnostic) One Touch Test Strips (Blood Sugar Diagnostic) One Touch Ultra Test Strips (Blood Sugar Diagnostic) NSAID COX-2 Inhibitors
Surestep Pro Test Strips (Blood Sugar Diagnostic) Surestep Test Strips (Blood Sugar Diagnostic) Fosamax Oral Solution (Alendronate Sodium)

Source: https://healthspan.cummins.com/Guides/2011%20Formulary.pdf

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