HEALTHSOURCE– Summary of Formulary Drug Changes:

The following formulary changes will become effective 10/1/01. In addition to formulary changes, Clinical Guidelines will be implemented to ensure appropriate use and utilization patterns. The Clinical Guidelines will include quantity limits and prerequisite (step) therapy.

Drug Classification/Drug Name & Strength	Add Date	Delete Date	Quantity Limitations per 30 days	Clinical Guideline requirements	Add’l Covered Formulary Alternatives (if applicable)
Proton Pump Inhibitor (PPI) Protonix 40mg Aciphex		9/30/01	Max. 30 units per Rx per month	All members requesting a PPI therapy will be required to have received 30 consecutive days of a H-2 antagonist (per paid claim history), and then they may proceed to a PPI without authorization or exception request 1^stPPI – Protonix – min. 30 consecutive days, prior to proceeding to 2^nd PPI	H-2 Antagonists: Zantac (geq) Tagamet (geq) PPI: 1^st Protonix
Transdermal Estrogens Alora	9/1/01		Max 8 patches per month per strength	Females Only	Estrogens: Premarin Prempro Premphase Ogen (geq)
Anti-Migraine (5HT) Imitrex 25, 50, 100mg Tabs Amerge 2.5, 5mg Tabs Imitrex Injection Imitrex Inhaler	9/1/01 9/1/01 9/1/01 9/1/01 9/1/01		Tabs: limited to 9 tabs per month Injections: limited to 2 inj per month Inhalers: limited to 1 inhaler per month
Inhaled Corticosteroids Oral and Nasal Oral: Vanceril Vanceril DS Nasal: Nasarel Nasonex Vancenase Vancenase AQ Flonase	9/1/01	9/30/01 9/30/01 9/30/01 9/30/01 9/30/01 9/30/01	Limited to 2 inhalers per month per drug per strength		Oral : Azmacort Flovent Nasal: Flonase Nasacort Nasacort AQ
Lipid Lowering Agents (HMG) Lipitor	9/1/01		Limited to 30 units per Rx per drug per strength		Lipitor
Alpha Adrenergic Blocking Agents Hytrin (geq)	9/1/01				Minipres (geq)
Calcium Channel Blockers Procardia XL (geq) Norvasc	9/1/01 9/1/01		* Limit to 30 units per Rx per month		Cardizem (geq) Cardizem SR (geq) Isoptin (geq) Isoptin SR (geq) *Norvasc Adalat CC (geq)