These drugs will remain available in TRICARE mail order without needing a provider pre-authorization; the implementation date for these drugs will not take affect until after 1 JAN 10 and no later than 180 days after the TRICARE Management Activity (TMA) Director’s approval; and if a Price Agreement is received prior to 14 OCT the drug may stay in Tier 2 and not be moved to Tier 3. The P&T Committee recommended a transition period at Military Treatment Facilities allowing them the opportunity to keep the drug on Tier 2 rather than Tier 3 until 1 JAN 11. All of this information will be available on DoD’s TRICARE pharmacy website.
Table 5
(Tier 2)
Recommended to retain formulary on Uniform Formulary
Prod Name Subclass Manufacturer Sum of Patients
ACTIMMUNE Immunomodulators INTERMUNE 25
APOKYN Parkinsons medications TERCICA INC 47
DERMA-SMOOTHE-FS Topical corticosteroids HILL DERM 1421
DERMOTIC Otic medications anti-inflammatory HILL DERM 1886
INTAL Mast cell stabilizers, inhalation KING PHARM 439
PANRETIN Topical antineoplastic & premalignant lesion medic EISAI INC. 1
RADIOGARDASE Radiation exposure (cesium, thallium) HEYLTEX CORPORA
STROMECTOL Antihelmintic MERCK & CO. 514
THIOLA Kidney stone agents MISSION PHARM. 12
VANCOCIN HCL Misc antibiotics VIROPHARMA INCO 1491
Grand Total 5836
Table 6
(Tier 3)
Recommended to retain or be designated non-formulary on Uniform Formulary
Prod Name Subclass Manufacturer Sum of Patients
ACIPHEX PPIs EISAI INC. 2 5,129
ACLOVATE Topical corticosteroids Pharmaderm 1
AGRYLIN Platelet reducing agents SHIRE US INC. 8
ALA-HIST 1st gen AH POLY PHARM. 216
ALA-HIST D 1st gen AH-decongestant POLY PHARM. 590
ALTACE ACE inhibitors MONARCH PHRM 69
ANAPROX NSAIDs ROCHE LABS.
ANAPROX DS NSAIDs ROCHE LABS. 3
ANDROID Androgens/anabolic steroids VALEANT 57
APTIVUS HIV antivirals, protease inhibitors BOEHRINGER ING. 6
ATROVENT Nasal anticholinergics BOEHRINGER ING. 11
ATROVENT HFA Inhaled anticholinergics BOEHRINGER ING. 3,565
AZOR ARB / CCB combo DAIICHI SANKYO, 4,471
BREVOXYL-4 Keratolytics STIEFEL LABS. 296
BREVOXYL-8 Keratolytics STIEFEL LABS. 325
BROVEX 1st gen antihistamines MCR/AMERICAN PH 1
BROVEX CT 1st gen antihistamines MCR/AMERICAN PH
BROVEX SR 1st gen AH-decongestant MCR/AMERICAN PH
BROVEX-D 1st gen AH-decongestant MCR/AMERICAN PH
BUPHENYL Ammonia inhibitors MEDICIS DERM 7
CADUET Statin/CCB combo PFIZER US PHARM 129
CARBATROL Anticonvulsants SHIRE US INC. 1,311
CARNITOR Metabolic deficiency agents SIGMA-TAU 15
CARNITOR SF Metabolic deficiency agents SIGMA-TAU 2
CATAPRES Sympatholytics BOEHRINGER ING. 19
CETROTIDE LHRH (GNRH) antagonist, pituitary suppressant agen EMD SERONO, INC 34
CHROMAGEN Iron replacement THER-RX 511
CHROMAGEN FORTE Iron replacement THER-RX 225
CORDRAN Topical corticosteroids AQUA PHARMACEUT 145
CORGARD Beta blockers KING PHARM 42
CORTISPORIN Otic medications, anti-infective MONARCH PHRM 3
Topical antibiotics & combos MONARCH PHRM 298
CUTIVATE Topical corticosteroids Pharmaderm 1,355
CYTOMEL Thyroid replacement KING PHARM 2,955
CYTOXAN Alkylating agents BMS ONCO/IMMUN
DAYTRANA ADHD medications SHIRE US INC. 2,700
DECLOMYCIN Tetracyclines STONEBRIDGE PHA 2
DEGARELIX Antineoplastic LHRH agonists FERRING PH INC
DEPAKENE Anticonvulsants ABBOTT LABS. 12
DERMA-SMOOTHE-FS Topical corticosteroids HILL DERM 2,239
24 Sept 2009 Beneficiary Advisory Panel Meeting
Page 7 of 19
Table 6: (cont) Recommended to retain or be designated non-formulary on Uniform Formulary
ProdName Subclass Manufacturer Sum of Patients
DIBENZYLINE Alpha blockers, cardiovascular WELLSPRING PHAR 46
DIPENTUM Medications for inflammatory bowel disease ALAVEN PHARMACE 3
DYNEX 12 antitussive-decongestant ATHLON PHARM
DYNEX LA decongestant-expectorant ATHLON PHARM 4
DYNEX VR antitussive-expectorant ATHLON PHARM
DYRENIUM Potassium sparing diuretics WELLSPRING PHAR 277
ELDEPRYL Parkinsons medications SOMERSET PHARM 1
ELESTRIN Estrogens AZUR PHARMA, IN 26
ELIGARD Antineoplastic LHRH agonists SANOFI PHARM 20
EMSAM MAOIs BMS PRIMARYCARE 137
ENDOMETRIN Pregnancy facilitating/maintaining agent FERRING PH INC 350
ESTRACE Vaginal estrogen preparations WC PROF PRODS 8,663
EURAX Topical antiparasitics RANBAXY BRAND D 54
EVOXAC Parasympathetic agents DAIICHI SANKYO, 1,399
EXELDERM Topical antifungals RANBAXY BRAND D 231
FIORICET Analgesic combos WATSON PHARMA 300
FLEXERIL Skeletal muscle relaxants MC NEIL CONS. 1
FLOMAX selective alpha blockers for BPH BOEHRINGER ING. 2 9,039
FLOXIN Otic medications, anti-infective DAIICHI SANKYO, 77
FOSRENOL Phosphate binders SHIRE US INC. 635
GESTICARE Prenatal vitamins AZUR PHARMA, IN 57
GYNAZOLE-1 Vaginal antifungals THER-RX 908
HALOG Topical corticosteroids RANBAXY BRAND D 261
HEMATRON Iron replacement SEYER INC. 22
HEMATRON-AF Iron replacement SEYER INC. 131
HYCODAN antitussive-anticholinergic ENDO PHARM INC.
INTELENCE HIV antivirals, NNRTIs ORTHO BIOTECH 20
KADIAN Higher potency single analgesic agents ALPHARMA BPD 1,512
KAON-CL 10 Potassium replacement SAVAGE LAB. 35
KAPIDEX PPIs TAKEDA PHARM 1,435
KENALOG Topical corticosteroids RANBAXY BRAND D 638
KINERET Targeted immunomodulatory biologics BIOVITRUM 27
KLONOPIN Anticonvulsants ROCHE LABS. 199
K-PHOS NO.2 Urinary pH modifiers BEACH PRODUCTS 7
K-PHOS ORIGINAL Urinary pH modifiers BEACH PRODUCTS 85
KYTRIL 5HT3 antiemetics ROCHE LABS. 3
LAC-HYDRIN Emollients RANBAXY BRAND D 25
LACTINOL Emollients PEDINOL PHARM. 13
LACTINOL-E Emollients PEDINOL PHARM. 22
LEVULAN Acne meds DUSA PHARM
LIALDA Medications for inflammatory bowel disease SHIRE US INC. 1,677
LIMBITROL TCAs & combos VALEANT
LITHOSTAT Ammonia inhibitors MISSION PHARM. 1
LOCOID Topical corticosteroids TRIAX PHARMACEU
LUVERIS Luteinizing hormones EMD SERONO, INC 17
METANX Vitamin B preparations PAN AMERICAN 7,475
MICRO-K Potassium replacement THER-RX 55
MINOCIN Tetracyclines TRIAX PHARMACEU
MIRAPEX Parkinsons medications BOEHRINGER ING. 8,405
MOBIC NSAIDs BOEHRINGER ING. 18
MONODOX Tetracyclines AQUA PHARMACEUT 2
MS CONTIN Higher potency single analgesic agents PURDUE PHARMA L 18
MUSE Prostaglandins for ED VIVUS 686
24 Sept 2009 Beneficiary Advisory Panel Meeting
Page 8 of 19
Table 6: (cont) Recommended to retain or be designated non-formulary on Uniform Formulary
MYAMBUTOL Antitubercular medications X-GEN PHARMACEU 1
NEOBENZ MICRO Keratolytics SKINMEDICA 223
NIFEREX GOLD Iron replacement THER-RX 44
NIFEREX-150 FORTE Iron replacement THER-RX 378
NIRAVAM Anxiolytics AZUR PHARMA, IN 181
NOVASTART Prenatal vitamins AZUR PHARMA, IN 2
NUZON Topical corticosteroids WRASER PHARMA 25
OBSTETRIX EC Prenatal vitamins SEYER INC. 81
OMNICEF 3rd gen cephalosporins ABBOTT LABS. 7
OXANDRIN Androgens/anabolic steroids SAVIENT PHARMAC 2
OXISTAT Topical antifungals Pharmaderm 2,460
OXSORALEN Hyperpigmentation agents VALEANT 9
PAMINE Anticholinergics/antispasmodics KENWOOD LAB. 4
PAMINE FORTE Anticholinergics/antispasmodics KENWOOD LAB. 1
PAMINE FQ Anticholinergics/antispasmodics KENWOOD LAB. 2
PCE Macrolide ABBOTT LABS. 16
PEDIAPRED Oral corticosteroids UCB PHARMA 4
PENTASA Medications for inflammatory bowel disease SHIRE US INC. 1,553
PERCODAN Higher potency narcotic analgesic combos ENDO PHARM INC. 34
PERPHENAZINE Typical antipsychotics SANDOZ 356
PERSANTINE Platelet aggregation inhibitors BOEHRINGER ING. 4
PHOSLO Phosphate binders FRESENIUS MED 24
PLETAL Platelet aggregation inhibitors OTSUKA AMERICA 9
POLY HIST DM antitussive-1st gen AH-decongestant POLY PHARM. 98
POLY HIST FORTE 1st gen AH-decongestant POLY PHARM. 514
POLY HIST PD 1st gen AH-decongestant POLY PHARM. 19
POLY TAN D 1st gen AH-decongestant POLY PHARM. 63
POLY TAN DM antitussive-1st gen AH-decongestant POLY PHARM. 154
POLY-TUSSIN DHC antitussive-1st gen AH-decongestant POLY PHARM. 939
POLY-TUSSIN DM antitussive-1st gen AH-decongestant POLY PHARM. 132
POTASSIUM CHLORIDE Potassium replacement SCHERING CORP G 8,159
PRECARE Prenatal vitamins THER-RX 245
PRECARE CONCEIVE Prenatal vitamins THER-RX 51
PRECARE PREMIER Prenatal vitamins THER-RX 473
PREFERA-OB Prenatal vitamins ALAVEN PHARMACE 279
PREMESIS RX Prenatal vitamins THER-RX 68
PROAMATINE Adrenergic vasopressors SHIRE US INC. 4
PROCRIT RBC Stimulants ORTHO BIOTECH 2,201
P-TEX 1st gen antihistamines POLY PHARM.
QUIXIN Ophthalmic antibiotics, quinolones VISTAKON PHARMA 350
RESPA A.R. 1st gen AH-decongestant-anticholinergic RESPA PHARM. 503
RESPA-BR 1st gen antihistamines RESPA PHARM. 85
RHEUMATREX Antirheumatics DAVA PHARMACEUT 10
RIOMET Biguanides RANBAXY BRAND D 105
SAIZEN Growth hormone EMD SERONO, INC 31
SALAGEN Parasympathetic agents EISAI INC. 10
SEDAPAP Analgesic combos MERZ
SEPTRA Sulfonamides/folate antagonists MONARCH PHRM
24 Sept 2009 Beneficiary Advisory Panel Meeting
Page 9 of 19
Table 6: (cont) Recommended to retain or be designated non-formulary on Uniform Formulary
ProdName Subclass Manufacturer Sum of Patients
SEPTRA DS Sulfonamides/folate antagonists MONARCH PHRM 3
SEROSTIM Growth hormone EMD SERONO, INC 3
SILVADENE Topical sulfonamides MONARCH PHRM 7
SONATA Newer sedative hypnotics KING PHARM 282
SORIATANE CK Psoriasis medications, oral STIEFEL LABS. 577
SULFAMYLON Topical sulfonamides UDL 13
TAPAZOLE Antithyroid medications KING PHARM 6
TEMOVATE Topical corticosteroids Pharmaderm 4
TEMOVATE EMOLLIENT Topical corticosteroids Pharmaderm 2
TENEX Sympatholytics PROMIUS PHARMA 19
TESTRED Androgens/anabolic steroids VALEANT 72
THALITONE Thiazides MONARCH PHRM 29
TIGAN Other antiemetics MONARCH PHRM 2
TINDAMAX Antiprotozoal MISSION PHARM. 691
TRANSDERM-SCOP Other antiemetics BAXTER HEALTHCA 974
NOVARTIS CONSUM 6,163
TRETIN-X Acne meds TRIAX PHARMACEU 94
ULTRAVATE Topical corticosteroids RANBAXY BRAND D 8
ULTRAVATE PAC Topical corticosteroids RANBAXY BRAND D 144
VALIUM Anxiolytics ROCHE LABS. 249
VESANOID Misc antineoplastics ROCHE LABS. 7
VIRAMUNE HIV antivirals, NNRTIs BOEHRINGER ING. 52
VIROPTIC Ophthalmic antivirals MONARCH PHRM 5
VYVANSE ADHD medications SHIRE US INC. 1 4,885
WELCHOL Bile acid sequestrants DAIICHI SANKYO, 7,541
WESTCORT Topical corticosteroids RANBAXY BRAND D
ZAROXOLYN Thiazides UCB PHARMA 9
ZONEGRAN Anticonvulsants EISAI INC. 85
ZORBTIVE Growth hormone EMD SERONO, INC
[Source: www.tricare.mil/pharmacy/bap/ 24 Sep 09 Handout Table 5 & 6 ++]
