Drug List for Emergency Services Only

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DRUG LIST FOR EMERGENCY SERVICES ONLY
1ST GENERATION CEPHALOSPORINS
cefadroxil
KEFLEX (cephalexin)*
cephalexin
2ND GENERATION CEPHALOSPORINS
CEFTIN (cefuroxime axetil)*
cefaclor
cefuroxime AXETIL
cefprozil
3RD GENERATION CEPHALOSPORINS–ORAL
cefdinir
cefixime
SUPRAX (cefixime)
cefpodoxime
OPHTHALMIC ANTIBIOTICS/ANTIFUNGALS/ANTIVIRALS
AZASITE (azithromycin) ophthalmic*
bacitracin ophthalmic ointment*
bacitracin–polymixin B ophth oint
BESIVANCE (besifloxacin) ophthalmic*
BLEPHAMIDE (sulfacetamide/prednisolone)
Bleph–10 (sulfacetamide sodium)*
CILOXAN OPHTH (ciprofloxacin)*
ciprofloxacin ophthalmic*
erythromycin ophthalmic
gatifloxacin ophthalmic*
GENTAK (gentamicin) ophthalmic
gentamicin (ophthalmic)
levofloxacin OPHTH*
MAXITROL (neomycin/polymixin B/dexameth) ophthalmic*
MOXEZA (moxifloxacin) ophthalmic*
moxifloxacin 0.5% (ophthalamic)*
NATACYN (natamycin)
neomycin–bacitracin–polymixin ophthalmic*
neomycin/bacitracin/polymixin/hydrocortisone ophthalmic*
neomycin, polymixin B,gramicidin ophthalmic
neomycin, polymixin B, dexamethasone ophthalmic
OCUFLOX (ofloxacin) ophthalmic*
ofloxacin ophthalmic*
POLYCIN (bacitracin/polymixin B sulfate) ophthalmic
POLYTRIM (polymixin B sulfate/trimethoprim) ophthalmic*
polymixin B sulfate/trimethoprim ophthalmic
PRED–G (gentamicin sulf/prednisolone) ophthalmic*
sulfacetamide ophthalmic ointment*
sulfacetamide ophthalmic solution
TOBRADEX (tobramycin/dexamethasone) ophthalmic
TOBRADEX ST (tobramycin/dexamethasone) ophthalmic*
tobramycin (ophthalamic)
tobramycin and dexamethasone ophthalmic*
TOBREX (tobramycin) ophthalmic*
VIGAMOX (moxifloxacin) ophthalmic*
VIROPTIC (trifluridine)*
ZIRGAN OPHTH (ganciclovir)
ZYMAXID (gatifloxacin) ophthalmic*
ZYLET (tobramycin–lotepred) ophthalmic*
AMEBICIDES
ALINIA (nitazoxanide)*
paromomycin*
TINDAMAX (tinidazole)*
tinidazole*
AMINOGLYCOSIDES
BETHKIS (tobramycin)*
KITABIS (tobramycin)*
neomycin (systemic)
TOBI (tobramycin)*
TOBI PODHALER (tobramycin)*
tobramycin (inhalation)*
ANTICHOLINERGICS–INHALED
ATROVENT HFA (ipratropium bromide)*
COMBIVENT RESPIMAT (ipratropium/albuterol)*
IPRATROPIUM BROMIDE*
ipratropium/albuterol sulfate*
ANTIFUNGALS
ANCOBON (flucytosine)
clotrimazole troche
CRESEMBA (isavuconazonium sulfate)
DIFLUCAN (fluconazole)*
fluconazole
flucytosine
griseofulvin micro*
griseofulvin ultra
GRIS–PEG (griseofulvin ultra)*
itraconazole*
ketoconazole oral
NOXAFIL (posaconazole)
nystatin (oral)
ONMEL (itraconazole)*
ORAVIG BUCCAL TABLETS (miconazole)
SPORANOX (itraconazole)*
terbinafine oral
VFEND (voriconazole)
voriconazole
ANTIHELMINTICS
ALBENZA (albendazole)
BILTRICIDE (praziquantel)
EMVERM (mebendazole)
STROMECTOL (ivermectin)
ivermectin
ANTIMALARIALS
(atovaquone/proguanil)
chloroquine
COARTEM (artemether/ lumefantrine)
DARAPRIM (pyrimethamine)*
hydroxychloroquine
MALARONE (atovaquone/proguanil)
mefloquine
PLAQUENIL (hydroxychloroquine)*
primaquine
QUALAQUIN (quinine sulfate)*
quinine sulfate*
ANTIMYCOBACTERIALS
cycloserine
ethambutol hcl
isoniazid
MYCOBUTIN (rifabutin)*
rifabutin
PASER GRANULES (aminosalicylic acid)
PRIFTIN (rifapentine)
pyrazinamide
RIFADIN (rifampin)*
rifampin
RIFAMATE (rifampin and isoniazid)
RIFATER TAB (rifampin, isonizaid, and pyrazinamide)
SIRTURO (bedaquiline)
TRECATOR (ethionamide)
ANTI–TRICHOMONAL/TRYPANOSOMALS
FLAGYL (metronidazole)*
metronidazole (oral)
ANTIVIRALS–OTHER THAN FOR HIV
acyclovir (oral)
famciclovir*
oseltamivir phosphate
RELENZA (zanamivir)
TAMIFLU (oseltamivir)
trifluridine ophthalmic
valacyclovir
VALCYTE (valganciclovir)
valganciclovir*
VALTREX (valacyclovir)*
ZOVIRAX (oral)*
CALCIMIMETIC, PARATHYROID CALCIUM ENHANCER (for patients with end stage renal disease (ESRD) on dialysis)
SENSIPAR (cinacalcet)
EXTENDED SPECTRUM PENICILLIN
amoxicillin
amoxicillin/potassium clavulanate
ampicillin
AUGMENTIN (amoxicillin and clavulanate)
FLUOROQUINOLONES
AVELOX (moxifloxacin)*
CIPRO XR (ciprofloxacin)*
ciprofloxacin*
LEVAQUIN (levofloxacin)*
levofloxacin solution*
levofloxacin tablet*
moxifloxacin tablet *
ofloxacin*
HYPERPARATHYROID AGENTS, VITAMIN D ANALOG (for patients with end stage renal disease (ESRD) on dialysis)
HECTOROL (doxercalciferol)
doxercalciferol
ZEMPLAR (paricalcitol)
paricalcitol
RAYALDEE (calcifediol)
MACROLIDES/LINCOSAMIDES ORAL
azithromycin
clarithromycin
CLEOCIN (clindamycin)*
clindamycin
DIFICID (fidaxomicin)*
E.E.S. (erythromycin ethyl succinate)
ERYPED (erythromycin ethyl succinate)
ERY–TAB EC (erythromycin base)
erythromycin
PCE (erythromycin base)
ZITHROMAX (azithromycin)*
ZMAX (azithromycin)
MISC. ANTIBACTERIALS
atovaquone
CAYSTON (aztreonam lysine)*
MEPRON (atovaquone)*
MONUROL SACHET (fosfomycin)
VANCOCIN CAPSULES (vancomycin)*
vancomycin CAPSULES
XIFAXAN (rifaximin)– 200MG ONLY*
NARCOTIC ANTAGONIST
NALOXONE 0.4 MG/ML
NARCAN (naloxone) nasal spray
NARCOTIC AGONIST ANALGESICS–SHORT ACTING
butorphanol nasal spray*
codeine sulfate oral*
hydromorphone oral*
levorphanol tablet*
meperidine tablet/oral liquid*
morphine tablet/oral liquid*
NUCYNTA (tapentadol)*
oxycodone oral*
oxymorphone*
ROXICODONE (oxycodone)*
tramadol*
ULTRAM (tramadol)*
NARCOTIC COMBOS– SHORT ACTING
acetaminophen with codeine*
codeine/butalbital/asa/caffeine*
codeine/butalbital/apap/caffeine*
belladonna and opium supp*
ENDOCET (oxycodone and apap)*
hydrocodone and apap*
hydrocodone and ibuprofen*
IBUDONE (hydrocodone/ibuprofen)*
LORCET hydrocodone and acetaminophen)*
LORCET HD (hydrocodone and acetaminophen)*
NORCO (hydrocodone and acetaminophen)*
oxycodone–acetaminophen*
oxycodone and aspirin*
oxycodone and ibuprofen*
pentazocine and naloxone*
PERCOCET (oxycodone and acetaminophen)*
PRIMLEV (oxycodone and acetaminophen)*
REPREXAIN (hydrocodone and ibuprofen)*
tramadol–acetaminophen*
TYLENOL WITH CODEINE (apap and codeine)*
ULTRACET (tramadol and acetaminophen)*
VERDROCET (hydrocodone and apap)*
VICODIN (hydrocodone/apap)*
VICODIN HP*
XODOL (hydrocodone and acetaminophen)*
XYLON (hydrocodone and ibuprofen)*
ZAMICET (hydrocodone and acetaminophen)*
ANTICOAGULANTS/ANTAGONISTS– INJECTABLE
ARIXTRA (fondaparinux)*
fondaparinux*
LOVENOX (enoxaparin)*
enoxaparin*
FRAGMIN (dalteparin)*
OXAZOLIDINONE ANTIBIOTICS
ZYVOX (linezolid) oral*
linezolid*
SIVEXTRO (tedizolid) oral*
PEN.V
penicillin v k oral
PENICILLINASE RESIST. PENICILLIN
dicloxacillin
PHOSPHATE BINDERS (for patients with end stage renal disease (ESRD) on dialysis)
ELIPHOS (calcium acetate)
PHOSLYRA (calcium acetate)*
calcium acetate
FOSRENOL (lanthanum)
lanthanum carbonate*
RENAGEL (sevelamer hydrochloride)
RENVELA (sevelamer carbonate)*
sevelamer*
SCABICIDES/PEDICULICIDES
ELIMITE (permethrin)
malathion 0.5% lotion
NATROBA 0.9% TOPICAL SUSP (spinosad)
OVIDE 0.5% LOTION (malathion)*
permethrin cream 5%
SKLICE 0.5% LOTION (ivermectin)
spinosad 0.9% topical susp
SHORT ACTING BETA AGONIST– INHALER
PROAIR HFA (albuterol)
PROAIR RESPICLICK (albuterol)
PROVENTIL HFA (albuterol)
VENTOLIN HFA (albuterol)*
albuterol sulfate other
XOPENEX HFA (levalbuterol)*
SHORT ACTING BETA AGONIST– NEBULIZER
albuterol sulfate
XOPENEX (levalbuterol)*
levalbuterol*
SULFONAMIDES ORAL
BACTRIM (sulfamethoxazole/trimethoprim)
SULFATRIM (sulfamethoxazole/trimethoprim)
sulfamethoxazole/ trimethoprim
sulfadiazine
SYMPATHOMIMETIC–ORAL
albuterol sulfate
metaproterenol
terbutaline sulfate
SYMPATHOMIMETIC–INJECTABLE
EPIPEN (epinephrine)*
epinephrine
TETRACYCLINES ORAL
doxycyline monohydrate
DORYX DR (doxycycline)*
MORGIDOX (doxycycline hyclate)
VIBRAMYCIN (doxycycline hyclate)*
doxycycline hyclate
minocycline
tetracycline
URINARY ANTI–INFECTIVES
HIPREX (methenamine hippurate)*
MACROBID (methenamine monohydrate)*
MONUROL SACHET (fosfomycin tromethamine)
nitrofurantoin
trimethoprim
URELLE (meth/meblue/sod phos/psal/hyos)
VITAMIN D PREPARATIONS (for patients with end stage renal disease (ESRD) on dialysis)
calcitriol oral
ROCALTROL (calcitriol)
ergocalciferol
VITAMIN D 50,000 UNITS
Please note that drugs listed with an asterisk (*) may require clinical criteria to be met prior to reimbursement. For information on Medicaid FFS Prior Authorization Programs please visit the following link: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PDL.pdf or call Magellan Medicaid Administration at 1–877–309–9493 Updated 12/1/17