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Medications Affected by Federal Pricing
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 ++]

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