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This formulary is not inclusive nor does it guarantee coverage. It is an abbreviated list of Pharmacy and Therapeutics Committee approved drugs that may be prescribed for Navitus members. This document is subject to change. The most updated version of this document as well as a complete formulary listing is available at www.navitus.com or upon request. Drugs will be dispensed generically when acceptable generic equivalents are UA Net Plan –
available. This document is copyrighted by Navitus Health Solutions® and may be reprinted for personal use only. Colorado Springs
Reproduction of this document for any other reason is expressly prohibited, unless prior written consent is obtained from Navitus. Quick Reference Formulary
Anti-Convulsants
Reading the Drug List
Generic medications are listed in all lower case letters; brand name medications are listed in all upper case letters. Each drug Other Cardiovascular Agents
product is associated with a coverage tier, shown to the right of each drug product. Anti-Gout
Anti-Virals
Anti-Depressants
PRADAXA (PA/QL=2 caps/day) 2
Cases where drug products are followed by parentheses indicate that the entry relates to RELENZA (QL=20 units/fill)
TAMIFLU (QL=10 cap/fill)
Cholesterol Lowering Agents
(vaginal cream), or more than one form of the drug, e.g. ZOMIG (ZMT). Quantity limits provided are for prescriptions filled at retail pharmacies; please consult complete version of formulary for mail order quantity limits. CARDIOVASCULAR
All newly approved drugs on the market will Diuretics
initially NOT be covered, pending further CRESTOR (QL = 30 tabs/Rx)
review by the Navitus P and T Committee. CYMBALTA (QL=2 caps/day) 2
******************************************* A complete version of the Navitus Formulary, www.navitus.com
(QL=1 tab/day)
Beta Blockers
Anti-Psychotic Agents
ANTI-INFECTIVES
Penicillins
CNS & ANS AGENTS
Analgesics
Cephalosporins
Stimulants
OXYCONTIN (QL=4 tab/day)
ACE Inhibitors
Migraine Agents
Macrolides
(QL= 9 tabs/Rx; 2 fill/30 days)
(QL= 4 inj/Rx; 2 fill/30 days)
Anti-Parkinson Agents
(QL= 9 tabs/Rx; 2 fill/30 days)
Quinolones
Angiotensin Receptor Blockers
(QL= 6 spr/Rx; 2 fill/30 days)
(QL= 12 tabs/Rx; 3 fill/60 days)
Miscellaneous Anti-infectives
(QL= 6 spr/Rx; 2 fill/30 days)
Miscellaneous CNS Agents
nitrofurantoin monohydrate/macrocrystals 1
(QL=1 tab/day)
Calcium Channel Blockers
Anti-Anxiety Agents & Sedatives
ARICEPT 23mg (ST/QL=1 tab/day)
Anti-Fungals
PA=Prior authorization required; criteria needs to be met for product to be covered ST=Step Therapy QL=Quantity limits apply
NC=Not covered SP=Available through Navitus Specialty Pharmacy Program RS=Restricted to Specialists
Printed 04/14/11
This formulary is not inclusive nor does it guarantee coverage. It is an abbreviated list of Pharmacy and Therapeutics Committee approved drugs that may be prescribed for Navitus members. This document is subject to change. The most updated version of this document as well as a complete formulary listing is available at www.navitus.com or upon request. Drugs will be dispensed generically when acceptable generic equivalents are UA Net Plan –
available. This document is copyrighted by Navitus Health Solutions® and may be reprinted for personal use only. Colorado Springs
Reproduction of this document for any other reason is expressly prohibited, unless prior written consent is obtained from Navitus. Quick Reference Formulary
DIABETIC AGENTS
OB/GYN AGENTS
DERMATOLOGICALS
LUMIGAN (QL=2.5ml/fill)
Topical Anti-Infectives
TRAVATAN (Z) (QL=5ml/fill)
Diabetic Supplies
Contraceptives
XALATAN (QL=2.5ml/fill)
Miscellaneous Ophthalmic Agents
Topical Anti-Fungals
Estrogens/Combinations
PREMARIN/PREMPRO/PREMPHASE 2
Acne Agents
Hypoglycemic Agents
GASTROINTESTINAL
Antiulcer Agents
Osteoporosis Agents
Psoriasis /Eczema Agents
Miscellaneous Topical Agents
(QL=1 tab/day)
DEXILANT (ST/QL=1 cap/day) 2
RESPIRATORY AGENTS
Nasal Products
REGRANEX (QL=2-15gm tubes/copay) 2
Urinary Agents
EYES & EARS
THYROID AGENTS
Leukotriene Modifiers
Asthma/Pulmonary Agents
Ophthalmic Anti-Infectives/Steroids
MUSCULOSKELETAL
Miscellaneous Gastrointestinal Agents
(QL= 5 days tx)
ANTINEOPLASTICS/
IMMUNOSUPPRESSANTS
anastrozole (SP)
Glaucoma Agents
COX-2 Inhibitors
AFINITOR (SP/PA/QL)
CELEBREX (ST/QL=2 cap/day)
latanoprost (QL=2.5ml/fill)
Misc. Musculoskeletal
PA=Prior authorization required; criteria needs to be met for product to be covered ST=Step Therapy QL=Quantity limits apply
NC=Not covered SP=Available through Navitus Specialty Pharmacy Program RS=Restricted to Specialists
Printed 04/14/11

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