Gastrointestinal Drugs
Miscellaneous Gastrointestinal Drugs

Brand/Generic Name Dosage/Strength Status Restrictions Notes Relative Cost
Apriso
mesalamine		 capsule,extended release 24hr   approved.gif (510 bytes)  

$$$$
Asacol
mesalamine		 tablet,delayed release (DR/EC)   approved.gif (510 bytes)  

$$$$
Asacol HD
mesalamine		 800 mg tablet,delayed release (DR/EC)   approved.gif (510 bytes)

ql.gif

$$$$
Azulfidine generic.gif (400 bytes)
sulfasalazine		 500 mg tablet   approved.gif (510 bytes)  

$
Azulfidine EN-tabs generic.gif (400 bytes)
sulfasalazine		 500 mg tablet,delayed release (DR/EC)   approved.gif (510 bytes)  

$
Canasa
mesalamine		 Suppository   approved.gif (510 bytes)  

$$$$$
Colazal generic.gif (400 bytes)
balsalazide		 750 mg capsule   approved.gif (510 bytes)  

$$$
Delzicol
mesalamine		 400 mg capsule   nonform.gif (625 bytes)

ql.gif st.gif

Not Applicable
Dipentum
olsalazine		 250 mg capsule   nonform.gif (625 bytes)  

$$$$$
Gattex
teduglutide		 5 mg vial   nonform.gif (625 bytes)

priorauth.gif (377 bytes) ql.gif mo.gif sp.gif (377 bytes)

Not Applicable
Giazo
balsalazide		 1.1 g tablet   nonform.gif (625 bytes)

st.gif

Not Applicable
Lialda
mesalamine		 1.2 g tablet,delayed release (DR/EC)   nonform.gif (625 bytes)

st.gif

Not Applicable
Pentasa
mesalamine		 capsule, extended release   nonform.gif (625 bytes)  

Not Applicable
Remicade
infliximab		 100 mg Recon Soln   notreimb.gif (545 bytes)

priorauth.gif (377 bytes)

NOTES_restrict.gif (377 bytes)

Not Applicable
Rowasa generic.gif (400 bytes)
mesalamine		 Enema   approved.gif (510 bytes)  

$$$$$
Uceris
budesonide		 9 mg capsule,extended release   nonform.gif (625 bytes)

ql.gif st.gif

Not Applicable

Key for Product(s) Listed Above
Formulary Prior Authorization (PA may not be required for some benefit plans) Non-Formulary
(Third tier coverage applies for selected plans)		 Not Reimbursed
Quantity Limit Not available through mail order as 90-day supply* Step Therapy Generic Available. Brand name medication may be covered at a higher member cost or may not be covered for certain plans.
Notes $Relative cost compared to others in category Specialty distribution for selected plans (Fourth or fifth tier coverage applied for selected plans)

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