Formulary Documents

2012 Formulary - Alphabetical Listing
PDF | 56 KB

2012 Formulary -- Class Listing
PDF | 56 KB

Quantity Limits List
PDF | 128 KB

Medco Direct Claim Form
PDF | 87 KB

Pharmacy & Therapeutics Committee Meeting Minutes

Pharmacy and Therapeutics Committee Minutes - 02-21-12
PDF | 33 KB

Pharmacy and Therapeutics Committee Minutes - 11-15-11
PDF | 40 KB

Pharmacy and Therapeutics Committee Minutes - 05-17-11
PDF | 32 KB

Policies and Procedures

Step Therapy Criteria
PDF | 32 KB

Age Edit Restrictions (safety rules)
PDF | 41 KB

Quantity Limit Exceptions
PDF | 60 KB

Formulary Criteria
PDF | 48 KB

Nonformulary Requests
PDF | 58 KB

Off-label Policy
PDF | 58 KB

Drug Recall Policy
PDF | 50 KB

Pharmacy & Therapeutics Charter
PDF | 52 KB

Prior Authorization and Step Therapy Requests Policy
PDF | 59 KB

Prior Authorization Forms

ADD-ADHD Form (non-formulary)
PDF | 31 KB

Anti-depressants (non-formulary)
PDF | 31 KB

Atypical Antipsychotics (non-formulary)
PDF | 31 KB

Fibromyalgia Therapies (non-formulary)
PDF | 31 KB

General Prior Authorization/Non-Formulary Medication
PDF | 31 KB

Opioids (non-formulary)
PDF | 33 KB

Proton Pump Inhibitors (high dose and non-formulary)
PDF | 33 KB

Singulair
PDF | 30 KB

Suboxone
PDF | 39 KB

Prior Authorization Criteria

Actimmune
PDF | 162 KB

Adcirca
PDF | 33 KB

Adult ADHD Long-acting Stimulant
PDF | 36 KB

Androgel
PDF | 31 KB

Apokyn
PDF | 52 KB

Arixtra
PDF | 46 KB

Avonex
PDF | 47 KB

Copaxone
PDF | 49 KB

CSF Therapy
PDF | 35 KB

Enbrel
PDF | 60 KB

ESA Therapy
PDF | 65 KB

Forteo
PDF | 58 KB

Fragmin
PDF | 48 KB

Gleevec
PDF | 41 KB

Growth Hormone Therapy
PDF | 325 KB

Hepatitis B Therapy
PDF | 51 KB

Hepatitis C Treatment
PDF | 55 KB

Humira
PDF | 89 KB

Increlex
PDF | 59 KB

Insulin Pens
PDF | 25 KB

Intron A
PDF | 52 KB

Iplex
PDF | 58 KB

Leukine
PDF | 178 KB

Lidoderm
PDF | 27 KB

LMWH
PDF | 56 KB

Lovenox
PDF | 48 KB

Neulasta
PDF | 165 KB

Neupogen
PDF | 182 KB

Norditropin
PDF | 45 KB

Pegasys
PDF | 49 KB

Procrit
PDF | 177 KB

Ribavirin
PDF | 41 KB

Sandostatin
PDF | 48 KB

Singulair
PDF | 34 KB

Step Therapy Critera
PDF | 171 KB

Suboxone
PDF | 28 KB

Subutex
PDF | 29 KB

Tarceva
PDF | 36 KB

Temodar
PDF | 34 KB

Thalomid
PDF | 34 KB

Tracleer
PDF | 36 KB

Vivaglobin
PDF | 51 KB

Xeloda
PDF | 38 KB