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Blue Cross Blue Shield of Michigan and
Blue Care Network
Custom Formulary
2011
Custom Formulary
January 2011
January 2011 Custom Formulary - Chapter Names 1 ANTI-INFECTIVES 1A Penicillins
1B Cephalosporins
1C Tetracyclines
1D Macrolides
1E Quinolones
1F Sulfonamides and Combinations
1G Urinary Tract Agents
1H Antifungals
1I Antivirals
1J Antiretrovirals
1K Antimalarials
1L Antituberculars
1M Antiparasitics/Anthelmintics
1N Miscellaneous Anti-infectives
2 CARDIOVASCULAR, HYPERTENSION, CHOLESTEROL 2A Lipid-lowering Agents
2B Beta Blockers and Combinations
2C ACE Inhibitors and Combinations
2D Angiotensin II Receptor Blockers and Combinations
2E Calcium Channel Blockers and Combinations
2F Diuretics
2G Cardiovascular Treatment
2H Nitrates and Combinations
2I Anticoagulants and Hemostasis Agents
2J Alpha-adrenergic Agents
2K Miscellaneous Antihypertensives
3 CENTRAL NERVOUS SYSTEM 3A Antidepressants
3B Antipsychotics
3C Anxiolytics
3D Sedative/Hypnotics
3E CNS Stimulants
3F Nonsteroidal Anti-inflammatory Drugs
3G Salicylates
3H Narcotics
3I Narcotic/Analgesic Combinations
3J Narcotic Mixed Agonist/Antagonist
3K Narcotic Antagonists
3M Migraine Therapy
3N Antiemetics (see Chapter 4E)
3O Parkinsons Disease and Related Disorders
3P Anticonvulsants
3Q Skeletal Muscle Relaxants
3R Myasthenia Gravis
3S Miscellaneous CNS
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4 GASTROINTESTINAL AGENTS 4A H2-Receptor Antagonists
4B Proton Pump Inhibitors
4C Other Ulcer Therapy
4D Antidiarrheals and Antispasmodics
4E Antiemetics
4F Bile Acids
4G Digestive Enzymes
4H Miscellaneous Gastrointestinal Agents
5 OBSTETRICS AND GYNECOLOGY 5A Oral Contraceptives-Monophasic
5B Oral Contraceptives-Biphasic
5C Oral Contraceptives-Triphasic
5D Contraceptives-Misc.
5E Oral Contraceptives-Postcoital
5F Progestins
5G Estrogens
5H Estrogen/Progestin Combinations
5J Infertility Treatment
5K Vaginal Anti-infective/Antifungal
5L Miscellaneous OB-GYN
6 RHEUMATOLOGY AND MUSCULOSKELETAL 6A Salicylates (see Chapter 3G)
6B Gout Therapy
6C Corticosteroids
6D Miscellaneous Rheumatologic Agents
6E Osteoporosis/Hormonal Treatment
6F Osteoporosis/Bone Resorption
7 ENDOCRINOLOGY 7A Antithyroid Agents
7B Thyroid Hormones
7C Corticosteroids
7D Androgens
7E Miscellaneous Endocrine
7F Insulins
7G Noninsulin Hypoglycemic Agents
7H Growth Hormone and Related Products
8 ANTINEOPLASTICS AND IMMUNOSUPPRESSANTS 8A Alkylating Agents
8B Antimetabolites
8C Immunomodulators
8D Hormonal Agents
8E Miscellaneous Antineoplastic Agents
8F Adjuvant Therapy
8G Kinase Inhibitors and Molecular Target Inhibitors
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9 IMMUNOLOGY AND HEMATOLOGY 9B Hematopoietic Agents
9C Interferons and MS Therapy
10 DERMATOLOGY 10A Very High Potency Corticosteroids
10B High Potency Corticosteroids
10C Medium Potency Corticosteroids
10D Low Potency Corticosteroids
10E Topical Anesthetics
10F Acne Treatment
10G Topical Antibacterials
10H Topical Antifungals
10I Topical Antivirals
10J Wound and Burn Therapy
10K Antipsoriatic/Antiseborrheic
10L Scabicides/Pediculicides
10M Miscellaneous Dermatologicals
11 OPHTHALMOLOGY 11A Ophthalmic Beta Blockers
11B Other Glaucoma Agents
11C Cycloplegic Mydriatics
11D Ophthalmic Anti-inflammatory Agents
11E Ophthalmic Anti-infectives
11F Ophthalmic Steroids
11G Ophthalmic Anti-infective/Steroid Combinations
11H Miscellaneous Ophthalmic Agents
12 OTIC AND NASAL PREPARATIONS
12A Nasal Preparations
12B Otic Preparations
13 RESPIRATORY, COUGH AND COLD
13A Antihistamines
13B Antihistamine/Decongestant Combinations
13C Antitussive Combinations
13D Expectorant Combinations
13E Corticosteroids (see Chapter 7C)
13F Oral Beta-Agonists
13G Inhaled Beta-Agonists
13H Inhaled Steroids
13I Intranasal Steroids
13J Theophyllines
13K Epinephrine
13L Miscellaneous Pulmonary Agents
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14 UROLOGY
14A Urinary Antispasmodics
14B Miscellaneous Urologicals
14C BPH Treatment
15 VITAMINS AND SUPPLEMENTS 15A Vitamins and Minerals
15B Potassium Replacement
16 DIAGNOSTIC AND OTHER MISCELLANEOUS 16A Diagnostics & Other Miscellaneous
17 LIFESTYLE MODIFICATION
17A Impotence
17B Weight Loss Preparations
17C Smoking Cessation
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Introduction We are pleased to provide the Blue Cross Blue Shield of Michigan and Blue Care Network Custom Formulary 2011 as a useful reference and educational tool for prescribers, pharmacists and members. Our formulary is a regularly updated list of medications approved by the U.S. Food and Drug Administration and reviewed by the BCBSM and BCN Pharmacy and Therapeutics Committee. The list represents the clinical judgment of Michigan physicians, pharmacists and other experts in the diagnosis and treatment of disease and the promotion of health. Medications are selected based on clinical effectiveness, safety and opportunity for cost savings. The Custom Formulary will help in maintaining the quality of care for our members and containing costs for our clients. Physicians, pharmacists and members should regularly refer to the Custom Formulary for information regarding drug coverage and therapeutic options for BCBSM and BCN members. Physicians are encouraged to prescribe formulary medications whenever possible. The Custom Formulary is divided into major therapeutic categories by chapter for easy use. Products approved for more than one therapeutic indication may be included in more than one chapter. Within each chapter, drugs are identified according to whether they are formulary preferred (Tier 1), formulary options (Tier 2) or nonformulary (Tier 3). Formulary preferred (Tier 1): These drugs have a proven record of safety and effectiveness and offer the best value for members. Because they are Tier 1, they require the lowest copayment, making them your most cost-effective option for treatment. Most generic drugs are formulary preferred.
Formulary options (Tier 2): Our Tier 2 drugs also have a record of safety and effectiveness. However, because more cost-effective therapies or generic alternatives to these drugs are usually available, most Tier 2 drugs require a higher copayment.
Nonformulary (Tier 3): Nonformulary drugs are not on our list of approved drugs. These drugs may not have a proven record for safety or their clinical value may not be as high as the drugs in Tier 1 and Tier 2. Formulary alternatives are available. Depending on the drug coverage, the member may pay a higher copayment or even the entire cost of these drugs. BCBSM and BCN respect the judgment of the dispensing pharmacist. Pharmacists are expected to contact the prescriber when presented with a prescription for a drug or dose that may not be appropriate for a patient. We encourage pharmacists to also contact the prescriber, to suggest an alternative when a BCBSM or BCN member’s prescription is written for a nonformulary drug. Drug coverage Coverage and applicable copayment amounts for drugs on the Custom Formulary are based on a member’s drug plan. Not all drugs included in the Custom Formulary are necessarily covered by each patient’s plan. Most BCN members do not have coverage for nonformulary drugs unless a BCN-affiliated provider certifies that the prescription is medically necessary and BCN agrees. Similarly, BCBSM members with a closed (managed) formulary option do not have coverage for nonformulary drugs. Some BCBSM and BCN plans may require a different copayment amount or may not cover certain lifestyle drugs. These may include weight-loss products, drugs for smoking cessation and drugs to treat sexual dysfunction or infertility. BCN’s coverage for drugs used to treat infertility is based on the member’s BCN medical plan. Coverage for contraceptives is based on the member’s BCBSM or BCN drug plan. Some BCN drug plans do not include coverage for proton pump inhibitors. Members should consult their prescription drug benefit packet or contact a Customer Service representative to determine specific coverage. Approved medications In general, only FDA-approved prescription medications are eligible for coverage under a member’s policy. When a drug is available in the identical strength and dosage in either a prescription or a nonprescription
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medication, the prescription medication is usually not covered. In these cases, prescribers should refer the patient to the equivalent over-the-counter product. Certain OTC products, such as loratadine (Claritin®) are covered for BCN members and for some BCBSM members with a prescription. Other exceptions are identified in the Custom Formulary. Certain medications may be excluded from a BCBSM and BCN member’s pharmacy benefits, but may be covered under the medical benefits. Such medications include serums, vaccines and other medications that are generally administered in a physician’s office under the supervision of appropriate health care personnel and not normally dispensed to the patient for self-administration. Prior authorization and step therapy Prior authorization may be necessary for coverage of certain medications. In these cases, clinical criteria must be met based on current medical information and approved by the BCBSM and BCN Pharmacy and Therapeutics Committee, or other information must be provided before coverage is approved. Drugs subject to step therapy may require previous treatment with one or more drugs on the formulary before coverage is approved. The Blue Care Network Quality Interchange Program (pages seven to 19) and the BCBSM Prior Authorization and Step-Therapy Program (pages 20 to 31) provide a list of drugs that require prior authorization or must meet step-therapy requirements prior to coverage. A description of the BCN quality interchange program and the BCBSM prior authorization and step-therapy program are included in this Custom Formulary. To view the most recent version, please go to bcbsm.com/provider/pharmacy_services/index.shtml For BCBSM members: Members should consult their prescription drug benefit packet for information on how to obtain prior authorization or call the Customer Service number on the back of their Blues member ID card for additional information. Physicians can access the medication request forms on web-DENIS or contact the Blue Cross Blue Shield of Michigan and Blue Care Network Pharmacy Services Clinical Help Desk at 1-800-437-3803 and select option 1 for more information and to request coverage. For BCN members: The physician or office designee can access the medication request forms through web-DENIS. Alternatively, physicians can call the Blue Cross Blue Shield of Michigan and Blue Care Network Pharmacy Services Clinical Help Desk at 1-800-437-3803 and select option 2 to request prior authorization or a benefit exception, depending on the type of request and the member’s drug benefit. Urgent requests should be identified as such when calling. The form must be completed in its entirety and returned to the Pharmacy Services Clinical Help Desk for review. The physician is notified of approved requests, and the member’s claim will process accordingly. If the request is not approved, BCN provides written notification to both the member and practitioner. The notification includes the reason for the denial and an explanation of the appeal rights and the appeals process. As part of our 2011 focus on efficient service, drugs are listed alphabetically within each tier. The Custom Formulary is current at the time of publication (January and July) and is subject to change.
Blue Care NetworkQuality Interchange Program
January 2011
The Blue Care Network Quality Interchange Program helps ensure that safe, high-quality cost-effective drug therapy is prescribed prior to the use of more expensive agents that may not have proven value over current formulary medications. This program makes use of drug utilization management tools including prior authorization and step therapy. If a drug requires prior authorization, certain clinical criteria must be met, or other information must be provided, before coverage is approved. Drugs subject to step therapy require previous treatment with one or more formulary agents prior to coverage. The criteria for approval are based on current medical information and are approved by the BCBSM/BCN Pharmacy and Therapeutics Committee.
Most BCN members do not have coverage for nonformulary drugs. Requests for these nonformulary drugs will only be considered when the following criteria have been met:
• The member has tried and failed to respond to an adequate trial of the available formulary agents from the same drug class, or the available formulary agents would pose unnecessary risk to the member.The member meets any clinical criteria established for the prescribed drug or drug class.•
• The prescriber and BCN agree that it is medically necessary.
Authorization requests that do not include documentation of medical necessity and failure of formulary alternatives will be denied.
Brand-name drugs that physicians prescribe or members request to be dispensed as written (DAW), but are available as generics, are covered only when determined to be medically necessary by the physician and approved by BCN. The physician must submit a completed MedWatch form to the FDA with a copy to BCN to document serious adverse events or a quality issue with the covered generic. Information regarding the FDA MedWatch program and online forms are available at www.accessdata.fda.gov/scripts/medwatch. If a DAW prescription is not authorized, BCN members are required to pay the difference in cost between the brand-name and generic versions in addition to their usual brand-name copay amount.
Quantity limits may also apply to certain drugs. Please visit us online at MiBCN.com for more information.
This information applies to members with a BCN commercial drug benefit. Criteria for BCN AdvantageSM and BlueCaid®
members can be viewed on our Web site: MiBCN.com.
(g)=generic availableANTI-INFECTIVESAnti-FungalsNonformulary:Lamisil® Granules
Requires documentation that the member has experienced treatment failure of or intolerance to at least three months of treatment with griseofulvin (Grifulvin V(g)) suspension.
Miscellaneous Anti-infectivesNonformulary: Cayston®
Coverage is provided for the treatment of pneumonia in patients with cystic fibrosis.
QuinolonesFormulary: Cipro®XR(g) (ciprofloxacin)
Nonformulary:Proquin® XR
Formulary agents:Cipro XR(g): Approved only for uncomplicated urinary tract infection (cystitis). Alternatives include Cipro (g) 100-250mg BID x 3 days and Bactrim DS® (g) BID x 3-5 days.
Nonformulary agents: Proquin XR: Approved only for the treatment of uncomplicated urinary tract infection (cystitis) and requires documentation that member has experienced treatment failure of or intolerance to formulary Cipro XR(g).
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ANTI-INFECTIVES (Cont.)TetracyclinesNonformulary: Adoxa®(g), CK, TT; Oracea®, Solodyn®(g)
Nonformulary agents:Adoxa(g), CK, TT; Oracea: Requires documentation that the member has experienced treatment failure of or intolerance to generic doxycycline AND a copy of the completed MedWatch form (that has been submitted to the FDA) has been submitted to the plan to document treatment failure of or intolerance to generic doxycycline.Solodyn(g): Requires documentation that the member has experienced treatment failure of or intolerance to generic minocycline AND a copy of the completed MedWatch form (that has been submitted to the FDA) has been submitted to the plan to document treatment failure of or intolerance to generic minocycline.
ANTINEOPLASTICS & IMMUNOSUPPRESSANTSHormonal AgentsFormulary:Arimidex®(g) (anastrozole), Aromasin® (exemestane), Femara® (letrozole)
PA for males only: Approved only for ER-positive breast cancer treatment and other literature supported cancer therapies.
ImmunomodulatorsFormulary:Arcalyst™ (rilonacept)
Nonformulary:Revlimid®
Formulary agent:Arcalyst: Approved for the treatment of cryopyrin-associated periodic syndrome in members ≥12 years of age.
Nonformulary agent:Revlimid: Approved for treatment of transfusion-dependent anemia due to low or intermediate-1 risk myelodysplastic syndromes (MDS) with deletion 5q abnormality; multiple myeloma in members whom have experienced treatment failure of or intolerance to or have a contradindication to thalidomide; or members with documentation of enrollment in a Phase II-IV investigative study approved by an appropriate Investigational Review Board (IRB). MDS must be confirmed by FISH analysis or other genetic testing.
Kinase Inhibitors & Molecular Target InhibitorsFormulary:Afinitor® (everolimus), Hycamtin® (topotecan), Iressa® (gefitinib),Nexavar® (sorafenib), Sprycel® (dasatinib), Sutent® (sunitinib),
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Formulary agents:Afinitor: Approved for the treatment of advanced renal cell carcinoma in members who have experienced disease progression or recurrence following treatment with Sutent or Nexavar, OR requires documentation of enrollment in a Phase II-IV investigative study approved by an appropriate IRB.Hycamtin: Approved for treatment of relapsed small cell lung cancer, OR requires documentation of enrollment in a Phase II-IV investigative study approved by an appropriate IRB.Iressa: Approved only for members continuing existing therapy prior to the 09/2005 FDA label revisions.Nexavar: Approved for treatment of advanced or recurrent renal cell carcinoma or hepatocellular carcinoma, OR requires documentation of enrollment in a Phase II-IV investigative study approved by an appropriate IRB.Sprycel: Approved for treatment of chronic myelogenous leukemia in members who have experienced resistance or intolerance to Gleevec; treatment of Philadelphia chromosome-positive acute lymphoblastic leukemia in members who have experienced resistance or intolerance to Gleevec or cytotoxic chemotherapy; OR requires documentation of enrollment in a Phase II-IV investigative study approved by an appropriate IRB.Sutent: Approved for treatment of advanced renal cell carcinoma or gastrointestinal stromal tumor, OR requires documentation of enrollment in a Phase II-IV investigative study approved by an appropriate IRB. Evidence of disease progression or intolerance to Gleevec must be provided for members with gastrointestinal stromal tumor.
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ANTINEOPLASTICS & IMMUNOSUPPRESSANTS (Cont.)Kinase Inhibitors & Molecular Target Inhibitors (cont.)Formulary:Tarceva® (erlotinib), Tykerb® (lapatinib),VotrientTM (pazopanib)
Formulary agents:Tarceva: Approved for treatment of non-small cell lung cancer in members who have experienced treatment failure with at least one chemotherapy regimen or treatment of pancreatic cancer in members who will be receiving Tarceva in combination with gemcitabine, OR requires documentation of enrollment in a Phase II-IV investigative study approved by an appropriate IRB. Tykerb: Approved only for treatment of HER2 or HER2/neu positive advanced or metastatic breast cancer. Evidence of disease progression following treatment with an anthracycline, a taxane, and trastuzumab (Herceptin) must be provided. The member must be receiving Tykerb in combination with Xeloda, OR requires documentation of enrollment in phase II-IV investigative study approved by an appropriate IRB.Votrient: Approved for treatment of advanced renal cell carcinoma OR requires documentation of enrollment in phase II-IV investigative study approved by an appropriate IRB.
Miscellaneous Antineoplastic AgentsFormulary:Zolinza™ (vorinostat)
Approved for treatment of cutaneous manifestation of cutaneous T-cell lymphoma and requires documentation of persistent progressive or recurrent disease after trial with two systemic therapies, such as oral bexarotene (Targretin), α-interferon (Intron-A, Pegasys, PEG-Intron), denileukin diftitox (Ontak), photochemotherapy (Psoralen plus ultraviolet A (PUVA)), or systemic chemotherapy, OR requires documentation of enrollment in a Phase II-IV investigative study approved by an appropriate IRB.
CARDIOVASCULAR, HYPERTENSION, CHOLESTEROLAngiotensin Converting Enzyme Inhibitors (ACE-Inhibitor)Nonformulary:Altace® Tablets
Requires documentation that member has experienced failure of or intolerance to Altace(g) capsules.
Angiotensin II Receptor Blockers (ARBS)Formulary:Benicar® (olmesartan medoxomil), HCT
Nonformulary:Atacand®, HCT; Avapro®, Avalide®; Azor®, Diovan®, HCT; Exforge®, HCT; Micardis®, HCT; Teveten®, HCT; TribenzorTM, Twynsta®, Valturna®
Formulary agents:Benicar, HCT: Requires documentation that the member has experienced intolerance to an ACE inhibitor such as Prinivil/Zestril(g), Monopril(g), Lotensin(g), Vasotec(g), Accupril(g), etc.
Nonformulary agents:Atacand, HCT; Avapro, Avalide; Diovan, HCT; Micardis, HCT; Teveten, HCT: Requires documentation that the member has experienced intolerance to an ACE inhibitor and experienced treatment failure of or intolerance to a formulary ARB (Cozaar(g), Hyzaar(g); Benicar, HCT)Azor, Exforge, Tribenzor, Twynsta, Valturna: Requires successful treatment of at least three months of therapy with the individual agents contained in the requested medication at the prescribed dosage.Exforge HCT: Requires inadequate response with at least three months of therapy with Exforge.
Beta BlockersNonformulary:Bystolic®, Coreg CR™
Bystolic: Requires documentation that the member has experienced treatment failure of or intolerance to at least two unique formulary beta blockers, such as betaxolol, atenolol, acebutolol, metoprolol, or bisoprolol. Coreg CR: Requires documentation that the member experienced treatment failure of or intolerance to both carvedilol immediate-release (Coreg(g)) AND metoprolol succinate (Toprol XL(g)).
Cardiovascular TreatmentNonformulary:Ranexa®
Ranexa: Requires documentation that the member has experienced treatment failure of or intolerance to both a beta-blocker and a nitrate. The member must have no history of or high risk for cancer.
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CARDIOVASCULAR, HYPERTENSION, CHOLESTEROL (Cont.)Cholesterol-Lowering AgentsFormulary:Crestor® (rosuvastatin), Zetia® (ezetimibe)
Nonformulary:Advicor® , Altoprev®, Caduet®, Lescol®, XL; Lipitor®, Livalo®, Simcor®, TriLipix®, Vytorin®
Formulary agents: Crestor: Requires documentation that member has experienced failure of or intolerance to at least one high dose (>40mg) generic statin (Mevacor®(g), Zocor®(g), or Pravachol®(g)).Zetia: Requires documentation that member has experienced failure of or intolerance to at least two generic statins (Mevacor(g), Zocor(g), or Pravachol(g)) OR approved when added to a high dose (> 40mg) generic statin (Mevacor(g), Zocor(g), or Pravachol(g)).
Nonformulary agents:Altoprev, Caduet, Lescol, XL, Lipitor, Livalo, Vytorin: Requires documentation that member has experienced treatment failure of or intolerance to at least one high dose (>40mg) generic statin (Mevacor(g), Zocor(g), or Pravachol(g)) AND at least one formulary brand agent (Crestor or Zetia). Advicor, Simcor: Requires successful treatment of at least three months of therapy with the individual agents contained in the requested medication at the prescribed dosage.TriLipix: Requires documentation that the member has experienced treatment failure of or intolerance to ALL generic fibrates, such as Lofibra(g) and Lopid(g), AND supporting evidence for the use of this agent. Concomitant use of a statin does not satisfy criteria.
Miscellaneous AntihypertensivesNonformulary:TekamloTM; Tekturna®, HCT
Tekamlo: Requires successful treatment of at least three months of therapy with the individual agents contained in the requested medication at the prescribed dosage.Tekturna, HCT: Approved for the treatment of hypertension AND requires documentation that the member has experienced treatment failure of or intolerance to ALL of the following drug classes: diuretics, beta-blockers, ACE inhibitors, and angiotensin II receptor blockers (ARBS).
CENTRAL NERVOUS SYSTEMAnticonvulsantsNonformulary:Lyrica®
Requires documentation that the member has at least one of the following listed diagnoses: • Seizure disorder that is being treated concurrently with other anticonvulsants • Neuropathic pain associated with either diabetic peripheral neuropathy or post-herpetic
neuralgia AND the member has experienced treatment failure of or intolerance to:o Members ≥ 65 years of age: gabapentin 1200 mg per dayo Members ≤ 64 years: gabapentin 1200 mg per day AND a tricyclic antidepressant.• Fibromyalgia and documentation that the member has experienced intolerance to gabapentin
or inadequate relief from gabapentin 1200 mg per day AND treatment failure of or intolerance to at least three of the following: a tricyclic antidepressant, an SSRI, an SNRI, cyclobenzaprine, or tramadol.
Additional criteria:• Approvals are granted only at the specific strength requested.• Approved dosage is limited to < 300 mg per day for initial treatment and will not exceed 600 mg
per day if 300 mg/day is tolerated.• Any previous authorizations are discontinued when a new strength is approved.
AntidepressantsFormulary:Lexapro® (escitalopram)
Nonformulary:AplenzinTM
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Formulary agents: Requires documentation that member has experienced treatment failure of or intolerance to at least one generic antidepressant (Prozac(g), Celexa(g), Paxil(g), Effexor(g), Zoloft(g), or Wellbutrin SR, XL(g)).
Nonformulary agents: Aplenzin: Requires documentation that the member has experienced treatment failure of or intolerance to at least one generic antidepressant and one brand name formulary antidepressant AND documentation that continued use of Wellbutrin SR/XL(g) will adversely affect the member’s mental health.
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CENTRAL NERVOUS SYSTEM (Cont.)Antidepressants (cont.)Nonformulary:Cymbalta®, Luvox CR®, OleptroTM, Pexeva®, Pristiq®, Savella®
Nonformulary agents: Cymbalta: Depression and/or anxiety: Requires documentation that the member has experienced treatment failure of or intolerance to at least one generic antidepressant AND one brand name formulary antidepressant. Post-herpetic neuralgia or diabetic peripheral neuropathy: If older than 65 years, requires treatment failure of or intolerance to gabapentin 1200 mg per day. If under 65 years, requires treatment failure of or intolerance to gabapentin 1200 mg per day and a tricyclic antidepressant. Fibromyalgia: Documentation is required to show that the member has experienced intolerance to gabapentin OR inadequate relief from gabapentin 1200 mg per day AND treatment failure of or intolerance to at least three of the following: a tricyclic antidepressant, an SSRI, an SNRI, cyclobenzaprine, or tramadol.Luvox CR: Requires documentation that the member has experienced treatment failure of or intolerance to at least one generic antidepressant and one brand name formulary antidepressant AND documentation that continued use of Luvox(g) will adversely affect the member’s mental health.Oleptro: Approved for major depressive disorder in members who have experienced treatment failure of or intolerance to Desyrel®(g) AND documentation that continued use of Desyrel(g) will adversely affect the member’s mental health.Pexeva: Requires documentation that the member has experienced treatment failure of or intolerance to at least one generic antidepressant and one brand name formulary antidepressant AND documentation that continued use of Paxil(g) will adversely affect the member’s mental health.Pristiq: Requires documentation that the member has experienced treatment failure of or intolerance to at least one generic antidepressant and one brand name formulary antidepressant AND documentation that continued use of Effexor(g) or Effexor XR(g) will adversely affect the member’s mental health.Savella: Approved for treatment of fibromyalgia AND requires documentation that the member has experienced intolerance to gabapentin or inadequate relief from gabapentin 1200 mg per day and treatment failure of or intolerance to at least three of the following: a tricyclic antidepressant, an SSRI, an SNRI, cyclobenzaprine, or tramadol.
AntipsychoticsNonformulary:Invega®, Seroquel XR®
Requires documentation that the member has experienced treatment failure of or intolerance to all formulary atypical antipsychotic agents. Maximum dose of Invega is limited to 12 mg per day.
CNS StimulantsFormulary:Adderall XR® (amphet asp/amphet/d-amphet)(g), Provigil® (modafinil)
Nonformulary:Nuvigil®, Procentra™
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Formulary agents:Adderall XR(g): Requires documentation that member has experienced treatment failure of or intolerance to brand name Adderall XR.Provigil: Approved only for members with narcolepsy, obstructive sleep apnea, or an indication supported by peer-reviewed literature. Dosage limited to a maximum of 400mg per day. Shift-work sleep disorder is not covered since treatment is not medically necessary.
Nonformulary agents:Nuvigil: Approved for treatment of narcolepsy or obstructive sleep apnea and requires documentation that member has experienced treatment failure of or intolerance to Provigil.Procentra: Requires documentation that member has experienced treatment failure of or intolerance to both Metadate CD and Adderall XR; both of which may be sprinkled on food.
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CENTRAL NERVOUS SYSTEM (Cont.)CNS Stimulants (cont.)Nonformulary:Strattera™, Vyvanse™
Nonformulary agents:Strattera: Approvable when stimulants are contraindicated by medical history OR the following criteria by age:For BCN members age 5 to 20: Requires documentation that the member has experienced treatment failure of or intolerance to both a methylphenidate (such as Ritalin(g) or Concerta) AND an amphetamine (such as Adderall(g)).For BCN members age 21 and older: Requires documentation that the member has experienced treatment failure of or intolerance to either a methylphenidate OR an amphetamine.Note: The use of Strattera in members ≤ 4 years of age is not recommended or supported by literature.Vyvanse: Requires documentation that the member has experienced treatment failure of or intolerance to both a methylphenidate (such as Ritalin(g) or Concerta) AND an amphetamine (such as Adderall(g)).
Migraine TherapyFormulary:Amerge® (g) (naratriptan), Maxalt® , MLT® (rizatriptan)
Nonformulary:AlsumaTM, Axert® , Frova® , Relpax®, SumavelTM DoseProTM, Treximet®; Zomig® , ZMT® , nasal spray
Formulary agents:Amerge(g): Requires documentation that member has experienced failure of or intolerance to both sumatriptan (Imitrex(g)) and Maxalt.Maxalt, MLT: Requires documentation that member has experienced treatment failure of or intolerance to sumatriptan (Imitrex(g)).
Nonformulary agents:Alsuma, Axert, Frova, Relpax, Sumavel DosePro; Zomig, ZMT, nasal spray: Requires documentation that member has experienced failure of or intolerance to both sumatriptan (Imitrex(g)) and Maxalt.Treximet: Requires documentation that the member has experienced treatment failure of or intolerance to a combination of sumatriptan (Imitrex(g)) or Maxalt AND naproxen. Documentation as to why sumatriptan (Imitrex(g)) or Maxalt and naproxen as individual agents do not work for and/or may be harmful to the member must be provided.
Miscellaneous CNSNonformulary:Aricept® 23mg, IntunivTM
Aricept 23mg: Requires documentation for a progressive-type dementia AND requires successful treatment with Aricept 10mg for three months.Intuniv: Approved for treatment of ADHD and requires documentation that the member has experienced treatment failure of or intolerance to both a methylphenidate (such as Ritalin(g) or Concerta), an amphetamine (such as Adderall(g)), generic guanfacine immediate-release, and clonidine.
Narcotics Formulary:Actiq® (g) (fentanyl citrate), Opana® (g) (oxymorphone HCl)
Nonformulary:ButransTM, ExalgoTM
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Formulary agents:Actiq: Approved for the treatment of breakthrough cancer pain in members that are tolerant of high dose narcotics and is currently receiving a long-acting narcotic. The member must also have experienced treatment failure of or intolerance to the use of other oral immediate-release narcotics for the management of breakthrough pain. Opana(g): Requires documentation that the member has experienced treatment failure of or intolerance to morphine sulfate 20mg/mL (Roxanol(g)) or morphine sulfate immediate-release (MSIR(g)).
Nonformulary agents:Butrans: Coverage is provided for a diagnosis of moderate to severe chronic pain AND documentation that the member has experienced treatment failure of or intolerance to methadone, Duragesic(g) AND morphine sulfate (MS Contin(g) or Oramorph SR(g)).Exalgo: Coverage is provided for the management of moderate to severe pain in opioid tolerant patients requiring continuous analgesia for an extended period of time AND requires documentation that the member has experienced treatment failure of or intolerance to ALL of the following long-acting formulary agents: methadone, morphine sulfate extended-release (Oramorph(g), MS Contin(g)), and fentanyl transdermal patch (Duragesic(g)).
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CENTRAL NERVOUS SYSTEM (Cont.)Narcotics (cont.)Nonformulary:Fentora®, Onsolis®, Nucynta®; Opana® ER; Oxycontin®
Nonformulary agents:Fentora, Onsolis: Approved for the treatment of breakthrough cancer pain in members that are tolerant of high dose narcotics and is currently receiving a long-acting narcotic. The member must also have experienced treatment failure of or intolerance to the use of other oral immediate-release narcotics for the management of breakthrough pain. Also requires documentation that the member has experienced treatment failure of or intolerance to Actiq(g). Nucynta: Requires documentation that member has experienced treatment failure of or intolerance to a Ultram(g) or Ultracet(g) AND three formulary immediate-release narcotics. If use is to exceed 30 days, Nucynta must be used in combination with a long-acting narcotic, such as methadone, morphine sulfate extended-release (Oramorph(g), MS Contin(g)), and fentanyl transdermal patch (Duragesic(g)).Opana ER, Oxycontin: Requires documentation that the member has experienced treatment failure of or intolerance to ALL of the following long-acting formulary agents: methadone, morphine sulfate extended-release (Oramorph(g), MS Contin(g)), and fentanyl transdermal patch (Duragesic(g)).
Narcotic Mixed Agonist/AntagonistFormulary:Suboxone® SL tablets, Film (buprenorphine HCl/naloxone HCl),
Nonformulary:RybixTM ODT
Formulary agents:Suboxone SL tabs, Film: Approved only for the treatment of clinically diagnosed opioid dependence. Requires documentation of validated screening tools used to identify the opioid use problem.
Nonformulary agent:Rybix ODT: Requires documentation that member cannot swallow ANY oral tramadol tablets OR documentation that the member has had successful treatment with immediate release tramadol for a minimum of three months AND documentation as to why continued use of generic tramadol would harm the member.
Non-Steroidal Anti-Inflammatory DrugsNonformulary:Arthrotec®; Celebrex®, Flector® Patch, PennsaidTM, Prevacid NapraPACTM, VimovoTM, Voltaren® Gel
Arthrotec, Prevacid NapraPAC: Approved for members >60 years of age, receiving anticoagulant or antiplatelet therapy, receiving chronic treatment with oral corticosteroids (≥ 60 days duration), or a history of or current diagnosis of peptic ulcer disease, clinically significant gastrointestinal bleeding, and/or alcoholism. Celebrex: Approved for members >60 years of age whom are not at high risk for cardiovascular events, and do not have a previous history of stroke, MI, coronary heart disease, or blood clots. The member must not be receiving concomitant anticoagulant or an antiplatelet therapy. Approved for members ≤ 60 years of age whom are receiving chronic treatment with oral corticosteroids (≥ 60 days duration) or have a history of or current diagnosis of peptic ulcer disease, clinically significant gastrointestinal bleeding, and/or alcoholism. The member must not be receiving concomitant anticoagulant or antiplatelet therapy AND have no previous history or evidence of cardiovascular and thromboembolic disease. Note: Lodine®(g) is more selective than Celebrex for the COX-2 enzyme.Flector Patch: Approved only for the treatment of acute sprains AND requires treatment failure of or intolerance to Voltaren(g)/XR(g) tablets AND an OTC topical analgesic (Myoflex OR Aspercreme).Pennsaid, Voltaren Gel: Requires treatment failure of or intolerance to Voltaren(g)/XR(g) tablets AND an OTC topical analgesic (Myoflex OR Aspercreme).Vimovo: Requires documentation that member has had treatment failure of or intolerance to Prilosec(g), Protonix(g) and Prevacid(g) at a twice daily, high dose regimen AND meets any one of the following criteria:•Greater than 60 years of age•Receiving anticoagulant or antiplatelet therapy•Receiving chronic treatment with oral corticosteroids (>= 60 days duration)•A history or peptic ulcer disease, clinically significant gastrointestinal bleeding, and/or alcoholism.
Parkinson’s Disease and Related DisordersNonformulary: Mirapex ER®
Requires a diagnosis of Parkinson’s Disease. Must also try and fail Mirapex IR(g) AND documentation that the continued use of it will adversely afffect the member’s condition.
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CENTRAL NERVOUS SYSTEM (Cont.)Sedatives/HypnoticsFormulary:Ambien CR® (g)Nonformulary: EdluarTM, Lunesta®, Rozerem®, SilenorTM, ZolpiMistTM
Requires documentation that member has experienced treatment failure of or intolerance to an adequate trial of both zolpidem (Ambien®(g)) and zaleplon (Sonata®(g)).Silenor: Requires documentation that member has experienced treatment failure of or intolerance to Sinequan®(g), Ambien(g), Sonata(g) AND Desyrel®(g).
DERMATOLOGYAcne TreatmentNonformulary:Ziana™ gel
Requires documentation of medical necessity to identify why individual agents [Cleocin-T®(g) plus Retin-A®(g)] cannot be used.
Antipsoriatic/AntiseborrheicFormulary:Enbrel® (etanercept), Humira® (adalimumab)
Nonformulary:Taclonex, Scalp®
Formulary agents: Enbrel, Humira: Moderate to Severe Psoriasis: Requires 3 months of previous treatment with topical corticosteroids and 3 months treatment with PUVA.
Nonformulary agent:Taclonex: Requires documentation that the member has experienced treatment failure of or intolerance to at least 30 days of treatment with the combination of a very high potency corticosteroid [Diprolene ointment(g), Temovate(g), Psorcon(g)] PLUS Dovonex.
Miscellaneous DermatologicalsFormulary:Elidel® (pimecrolimus)
Nonformulary:Protopic®
Formulary agents: Elidel: Approved for members ≥2 years of age with a diagnosis of atopic dermatitis or eczema.
Nonformulary agent:Protopic: Approved for members ≥2 years of age with a diagnosis of atopic dermatitis or eczema and documentation that the member has experienced treatment failure of or intolerance to Elidel®. For members ages 2 to 15, only the 0.03% strength may be used.
Wound & Burn TherapyNonformulary:Regranex®
Requires documentation that the member has a diagnosis of diabetic skin ulcer or may be approved for wound therapy per policy criteria.
DIAGNOSTICS & OTHER MISCELLANEOUSDiagnostic & Other MiscellaneousFomulary:Carbaglu® (carglumic acid), Kuvan® (sapropterin dihydrochloride),Xenazine® (tetrabenazine)
Nonformulary:Campral®, Exjade®
Formulary agents:Carbaglu: Requires documentation that member has a diagnosis of hyperammonemia due to NAGS deficiency. Kuvan: Requires documentation that member has a diagnosis of phenylketonuria (PKU) and will be following a phenylalanine-restricted diet in conjunction with Kuvan.Xenazine: Requires documentation that member has a diagnosis of chorea associated with Huntingon’s disease.
Nonformulary agents:Campral: Approved for the treatment of alcohol dependence, to maintain abstinence from alcohol in members who have been abstinent at treatment initiation for at least 5 days post-detoxification. Members must be enrolled in a comprehensive alcohol management program that includes psychosocial support.Exjade: Approved for members ≥2 years of age with a diagnosis of chronic iron overload due to blood transfusions (transfusional hemosiderosis) and documentation that the member has experienced treatment failure of or intolerance to Desferal®(g) OR requires documentation that the member is enrolled in a Phase II-IV investigative study approved by an appropriate IRB.
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ENDOCRINOLOGYGrowth Hormone & Related ProductsFormulary:Genotropin® (somatropin),Nutropin®, AQ (somatropin)
Nonformulary:Humatrope®, Norditropin®, Omnitrope®, Saizen® , Serostim®, Tev-Tropin®, Valtropin®, Zorbtive™
Increlex™
Formulary agents:Children (<18 years of age): Requires a diagnosis of growth hormone deficiency, growth failure secondary to chronic renal failure/insufficiency in children who have not received a renal transplant, growth failure in children small for gestational age or with intrauterine growth retardation, Turner’s Syndrome, Noonan’s Syndrome, Prader-Willi Syndrome, SHOX deficiency, or for treatment of severe burns covering >40% of the total body surface area. The member’s current height and weight must be provided. The member must also have open epiphyses.Initial treatment: For growth hormone deficiency, two growth hormone stimulation tests OR one GH stimulation test along with a subnormal IGF-1 level and IGFBP-3 level must be provided. The member’s height must be below the 5th percentile.To continue: The member must achieve a growth velocity of > 4.5 cm/year while receivingtherapy over the past year. Treatment may continue until final height or epiphyseal closure hasbeen documented.Adults (≥18 years of age): Approved for treatment of growth hormone deficiency, AIDS wasting cachexia, Turner’s Syndrome, and Short Bowel Syndrome. The diagnosis must be made by an endocrinologist or a nephrologist. Initial diagnosis must be based on two growth hormonestimulation tests, 3 or more pituitary hormone deficiencies with an IGF-1 below 80ng/ml OR 1 growth hormone and at least 1 pituitary hormone deficiency Nonformulary agents: Also requires documentation that the member has experiencedtreatment failure of or intolerance to formulary agents.Increlex: Approved for treatment of severe IGF-1 deficiency, growth hormone gene deletion,and Laron’s syndrome in members <18 years of age, with open epiphyses, and height below the 3rd percentile. Member must have a normal or elevated growth hormone level with an IGF-1 level 3 or more standard deviations below normal. The prescriber must be a pediatric endocrinologist.Initial approval is granted for 1 year and renewal can be obtained if member has clinical response with therapy, as demonstrated by an annual growth velocity of ≥ 2.5cm
Non-Insulin Hypoglycemic Agents Formulary:Actos® (pioglitazone);Actoplus Met® (pioglitazone/metformin), Duetact® (pioglitazone/glimepiride)
Nonformulary: Actoplus Met® XR, Avandamet®, Avandaryl®, Avandia®, Byetta®, Januvia®, Janumet®, Onglyza™, Prandimet®, Symlin®, Victoza®
Formulary agents:Actos: Requires documentation that the member has experienced failure with metformin. If the member cannot tolerate metformin or if metformin is contraindicated, physicians are encouraged to prescribe a sulfonylurea, unless contraindicated, prior to treatment with a TZD.Actoplus Met, Duetact: Requires documentation that the member has experienced successful treatment with at least three months of therapy with the individual agents that are in the combination product.
Nonformulary agents:Actoplus Met XR, Avandamet, Avandaryl, Janumet, Prandimet: Requires documentation that the member has experienced successful treatment with at least three months of therapy with the individual agents that are in the combination product.Avandia: Requires documentation that the member has had treatment failure of or intolerance to both Glucophage(g) and Actos.Byetta, Victoza: Approved for treatment of type 2 diabetes in members with a contraindication to or have experienced treatment failure of or intolerance to metformin. The member must currently be taking either metformin, a sulfonylurea, a thiazolidinedione, a combination of metformin and a sulfonylurea, or a combination of metformin and a thiazolidinedione. The member must also have tried and failed to achieve desired glucose control with at least TWO types of oral agents and insulin. Insulin must be discontinued.Januvia, Onglyza: Requires documentation that member has experienced treatment failure of or intolerance to the use of three of the following: metformin, basal insulin, sulfonylurea, and a TZD. Symlin: Approved for members ≥18 years of age for the treatment of type 1 or 2 diabetes who are receiving insulin therapy and has not achieved desired glucose control (Hgb A1C >7%) despite good compliance with optimal insulin therapy.
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GASTROINTESTINAL AGENTSAntiemeticsNonformulary:Sancuso®, Zuplenz®
Sancuso: Requires documentation that the member has experienced treatment failure of or intolerance to both oral Kytril(g) AND Zofran(g), ODT(g).Zuplenz: Same as above AND documentation that the continued use of Zofran ODT(g) would adversely affect the member’s condition.
Miscellaneous Gastrointestinal AgentsFormulary:Relistor® (methylnaltrexone)
Nonformulary:Amitiza®, ChenodalTM, Cimzia®, Lotronex®, Xifaxan 550®
Formulary agent:Relistor: Approved for the treatment of opioid-induced constipation in members with advanced illness whom are receiving palliative care and requires documentation that the member has experienced inadequate response to at least 3 of the following laxatives: bulk laxatives (polycarbophil, psyllium, methylcellulose), saline laxatives (milk of magnesia/magnesium hydroxide), osmotic laxatives (Miralax(g)), or stimulant (Dulcolax(g), Senna(g)).
Nonformulary agents:Amitiza: Approved for the treatment of chronic idiopathic constipation (fewer than 3 bowel movements/week) or constipation predominant IBS (females only) in members 18 to 65 years of age whom have tried and failed ALL of the following: dietary advice, trials of bulk laxatives, stool softeners, and a short course of stimulant laxatives and are NOT taking medications causing constipation. A total of 12 weeks can be approved, with renewal, only if improvement in bowel frequency is seen with initial trial.Chenodal: Approved for dissolution of gallstones only in patients where surgery is not appropriate. In addition, member must have experience treatment failure of or have an intolerance to Actigall(g). Member cannot have history of hepatocellular disease.Cimzia: Approved for the treatment of Crohn’s disease in members ≥18 years of age whom have experienced treatment failure of or intolerance to Humira.Lotronex: Approved for the treatment of severe, diarrhea-predominant irritable bowel syndrome in women at least 18 years of age who have failed to respond to conventional diarrhea therapy including one OTC product (loperamide, bismuth subsalicylate) and one prescription agent (diphenoxylate/atropine (Lomotil(g)).Xifaxan 550: Requires diagnosis of hepatic encephalopathy AND documentation that the member has had treatment failure of or intolerance to lactulose.
Proton Pump InhibitorsFormulary:Prevacid®(g) capsule (lansoprazole), Prevacid SolutabTM (g), Prilosec®(g) (omeprazole) 40mg, Protonix®(g) (pantoprazole), Zegerid® (g) capsule (omeprazole/sodium bicarbonate)
Nonformulary:Aciphex®, DexilantTM, Nexium®, Prilosec suspension, Protonix suspension,Zegerid® Packet, VimovoTM
Formulary agents:Prevacid(g), Solutab(g): Requires documentation that the member has experienced failure of or intolerance to Prilosec OTC(g) or Prilosec(g).Prilosec 40mg(g): Requires documentation that member has experienced treatment failure with Prilosec OTC(g) or Prilosec(g) (2 x 20mg).Protonix(g): Requires documentation that member has experienced failure of or intolerance to Prilosec OTC(g) or Prilosec(g) unless the member is currently receiving Plavix.Zegerid(g): Requires documentation that member has experienced failure of or intolerance to Prilosec OTC(g) or Prilosec(g) AND Prevacid(g) or Prevacid Solutab.
Nonformulary agents:Aciphex, Zegerid Packet: Requires documentation that the member has experienced treatment failure of or intolerance to Prilosec OTC or Prilosec(g) AND Prevacid(g) or Prevacid Solutab. Dexilant, Nexium: Requires documentation that the member has experienced treatment failure of or intolerance to both BCN formulary alternatives [either Prilosec OTC or Prilosec(g) AND Prevacid(g)], one of which is at a twice daily, high dose regimen.Prilosec suspension, Protonix suspension: Requires documentation that member has experienced treatment failure of or intolerance to Prevacid Solutab.Vimovo: Requires documentation that member has had treatment failure of or intolerance to Prilosec(g), Protonix(g) and Prevacid(g) AND meets any one of the following criteria:•Greater than 60 years of age•Receiving anticoagulant or antiplatelet therapy•Receiving chronic treatment with oral corticosteroids (>= 60 days duration)•A history or peptic ulcer disease, clinically significant GI bleeding, and/or alcoholism.
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IMMUNOLOGY & HEMATOLOGYHematopoietic AgentsFormulary:Procrit® (epoetin alfa)
Promacta® (eltrombopag)
Nonformulary: Aranesp®, Epogen®
Formulary agents:Procrit: Requires documentation that the member has one of the following conditions: anemia secondary to chronic renal failure, chronic renal insufficiency, HIV infection, HIV therapy, chemotherapy, myelodysplasia, or chronic hepatitis C therapy, OR prophylaxis prior to surgery to reduce need for allogenic blood transfusions. A Hgb level of less than 10 g/dL is required for initial therapy. For continued coverage dose adjustments are required to maintain Hgb between 10 to 12 g/dL. Duration of approval is dependent on the indication.Promacta: Approved for treatment of thrombocytopenia with chronic immune thrombocytopenic purpura, has a platelet count of <400 x 109/L if continuing therapy, and inadequate response to, intolerance to, or is not a candidate for standard first-line treatments, such as corticosteroids, immunoglobulins, or splenectomy.
Nonformulary agents: Also requires documentation that member has experienced failure of or intolerance to formulary epoetin alfa (Procrit) and applicable criteria for Procrit.
Hepatitis B & C TherapyFormulary:Infergen (interferon alfacon-1), Intron-A (interferon alfa-2B), Pegasys (peginterferon alfa 2-A), Peg-Intron (peginterferon alfa-2B), ribavirin
Infergen: Approved for the treatment of Hepatitis B. Intron-A: Approved for the treatment of Hepatitis B, condyloma acuminate, essential thrombocythemia, hairy cell leukemia, Kaposi’s sarcoma, malignant melanoma, multiple myeloma, non-Hodgkin’s lymphoma, Philadelphia chromosome (Ph) positive chronic phase myelogenous leukemia (CML), and renal cell carcinoma. Peg-Intron, Pegasys: Approved for the treatment of Hepatitis B and Hepatitis C. For hepatitis C, approval is for members naïve to pegylated interferon therapy only. Genotype,HIV status, previous therapy and duration must also be provided. The member must receive peglylated interferon in combination with ribavirin unless contraindicated. For genotypes 2, 3: Approval is for a total of 24 weeks duration. For non-genotypes 2, 3: Approval is for a total of 48 weeks duration. Members must achieve a ≥2 log decrease in viral load after 12 weeks of treatment. Ribavirin: Approved for the treatment of Hepatitis C. Genotype, HIV status, previous therapy and duration must also be provided.
Interferons and MS TherapyNonformulary:AmpyraTM
Betaseron®
Ampyra: Initial treatment: Requires a diagnosis of multiple sclerosis and documentation of difficulty walking resulting in significant limitations of instrumental activities of daily living. Also requires two timed 25-foot walk (T25FW) measurements that must be within 10% variability and demonstrates that the patient is able to walk 25 feet in 8-45 seconds. To continue: Requires documentation of improvement in walking speed by at least 10% as assessed by the T25FW AND that limitations of instrumental activities of daily living has improved as a result of increased walking speed within the first 2 months of therapy.Betaseron: Requires documentation that member has experienced failure of or intolerance to formulary agents (Avonex, Copaxone or Rebif) AND Extavia®.
LIFESTYLE MODIFICATION PRODUCTSImpotenceFormulary:Caverject® (alprostadil), Cialis® (tadalafil), Muse® (alprostadil), Viagra® (sildenafil citrate)
Nonformulary:Edex®, Levitra®, StaxynTM
For men over the age of 34: requires a diagnosis of erectile dysfunction (ED). For men 34 years and younger: requires a diagnosis of ED secondary to a medical cause such as multiple sclerosis, spinal cord injury, Parkinson’s disease, radiation for prostate or bladder cancer, and other indications deemed appropriate. The member must not be using nitrates concomitantly and avoid use of alpha blockers with oral ED agents. Maximum of 6 doses per 28 days.
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LIFESTYLE MODIFICATION PRODUCTS (Cont.)Weight Loss ProductsFormulary:phentermine and related products
Nonformulary:Xenical®
Requires verification that member’s Body Mass Index (BMI) is ≥30 kg/m2 or >27 kg/m2 with co-morbidities. and concurrent lifestyle modification plan. Initial coverage for all anorexiants and related drugs is limited to 3 months. Additional coverage requires documentation of weight loss of at least 2 pounds per month. Maximum benefit is 12 months of treatment per lifetime; 24 months for Xenical.
OBSTETRICS AND GYNECOLOGYInfertility treatmentFormulary:Bravelle® (urofollitropin), Cetrotide® (cetrorelix acetate), FertinexTM (urofollitropin), Ganirelix acetate® (ganirelix acetate), Gonal-F®, RFF (follitropin alfa, recomb), Ovidrel® (HCG alfa, recomb), Novarel®/Pregnyl®/Profasi® (gonadotropin, chorionic, human), Repronex® (menotropins)
Nonformulary:Follistim® AQ, Luveris®, Menopur®
Coverage is provided for most BCN female members with an infertility benefit and also in accordance with generally accepted medical practice. BCN does not provide coverage for infertility drugs to be used as part of assisted reproductive technology treatment, such as in-vitro fertilization (IVF), zygote in vitro fertilization transfer (ZIFT), gamete in vitro fertilization transfer (GIFT). Authorization will be provided for one year. Additional coverage will be based on documentation that the member is being treated according to accepted medical practice. Requests are not considered for men.
OTIC & NASAL PREPARATIONSIntranasal SteroidsFormulary:Nasacort AQ® (triamcinolone acetonide)
Nonformulary:Beconase AQ®, Nasonex®, Omnaris™,Rhinocort Aqua®, Veramyst™
Formulary agent:Nasacort AQ: Requires documentation that member has experienced treatment failure of or intolerance to fluticasone (Flonase(g)) or flunisolide (Nasalide(g)/Nasarel(g)).
Nonformulary agents: Requires documentation that member has experienced treatment failure of or intolerance to fluticasone (Flonase(g)) or flunisolide (Nasalide(g)/Nasarel(g)) AND Nasacort AQ.
RESPIRATORY COUGH & COLDAntihistamines and CombinationsFormulary:Allegra-D®(g) (p-ephed/fexofenadine), Xyzal® (g) (levocetirizine)
Nonformulary:Allegra® suspension, Allegra® ODT, Clarinex®, Clarinex-D®, Clarinex Reditabs®, Clarinex Syrup®, Semprex-D®, Xyzal® Oral Solution
Formulary agent:Allegra-D(g): Requires documentation that the member has experienced treatment failure of or intolerance to OTC loratadine D or OTC cetirizine DXyzal (g): Requires documentation that the member has experienced treatment failure of or intolerance to OTC loratadine or OTC cetirizine, AND generic fexofenadine (Allegra(g) or Allegra-D(g)) in appropriate dosage form for requested drug.
Nonformulary agents:Requires documentation that the member has experienced treatment failure of or intolerance to OTC loratadine or OTC cetirizine, AND generic fexofenadine (Allegra(g) or Allegra-D(g)) in appropriate dosage form for requested drug.
Inhaled Beta-AgonistsNonformulary:Brovana®, Perforomist™
Requires documentation that the member has experienced treatment failure of or intolerance to BOTH Serevent® AND Foradil®.
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RESPIRATORY COUGH & COLD (Cont.)Pulmonary Arterial HypertensionFormulary:Letairis™ (ambrisentan), Revatio® (sildenafil), Tracleer® (bosentan), TyvasoTM (treprostinil), Ventavis® (iloprost)
Nonformulary:Adcirca™
Formulary agents: Letairis, Revatio, Tracleer, Tyvaso, Ventavis: Approved for the treatment of pulmonary arterial hypertension (PAH) WHO Class III or IV symptoms.
Nonformulary agent:Adcirca: Approved for the treatment of pulmonary arterial hypertension (PAH) WHO Class III or IV symptoms AND requires documentation that member has experienced treatment failure of or intolerance to Revatio.
RHEUMATOLOGY & MUSCULOSKELETALGout TherapyNonformulary:Uloric®
Approved for the treatment of gout and hyperuricemia in members that have experienced treatment failure of, at appropriate dose, or intolerance to generic allopurinol. Uloric 80mg requires documentation that the member has had an inadequate response to the 40mg dose.
Miscellaneous Rheumatologic AgentsFormulary:Enbrel®(etanercept), Humira®
(adalimumab)
Nonformulary:Cimzia®, Kineret®, SimponiTM
Formulary agents: Enbrel, Humira: Requires four month trial with two concurrent disease modifying antirheumatic drugs (one must be methotrexate unless contraindicated). Examples of DMARDs include: methotrexate, sulfasalazine, azathioprine, hydroxychloroquine/chloroquine, cyclosporine, gold and penicillamine.
Nonformulary agent:Cimzia, Kineret, Simponi: Approved for the treatment of moderate to severe rheumatoid arthritis and requires documentation that the member has experienced treatment failure of or intolerance to Enbrel and Humira.
Osteoporosis/Bone Resorption Inhibitors Formulary:Actonel® (risedronate); Actonel® plus Calcium
Nonformulary:Boniva®, ForteoTM, Fosamax D™
Formulary agents: Actonel, Actonel plus Calcium: Requires documentation that member has experienced treatment failure of or intolerance to alendronate (Fosamax(g)).
Nonformulary agents: Boniva, Fosamax D: Requires documentation that member has experienced treatment failure of or intolerance to both alendronate (Fosamax(g)) and Actonel.Forteo: Approved for the treatment of osteoporosis (T-score <= -2.5) AND requires documentation that the member has a contraindication to or experienced treatment failure of or intolerance to a bisphosphonate.
UROLOGYBPH TreatmentNonformulary:JalynTM
Requires successful treatment of at least three months of therapy with the individual agents contained in the requested medication at the prescribed dosage.
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Blue Cross Blue Shield of MI
Prior Authorization and Step Therapy Program January 2011
BCBSM monitors the use of certain medications to ensure our members receive the most appropriate and cost-effective drug therapy. Prior authorization for these drugs means that certain clinical criteria must be met before coverage is provided. In the case of drugs requiring step therapy, for example, previous treatment with one or more formulary drugs may be required. Drugs that must meet clinical criteria are identified in the formulary list with (PA) or (ST). Your physician can contact our pharmacy help desk to request prior authorization for these drugs. The criteria for authorization are based on current medical information and the recommendations of the Blues’ Pharmacy and Therapeutics Committee, a group of physicians, pharmacists and other experts. You may be required to pay the full cost of the drug if your physician does not obtain prior authorization. When your doctor prescribes a brand-name drug that’s nonformulary, requires prior authorization or is not covered under your drug rider, it may not be a covered benefit. BCBSM reviews all physician and member requests to determine if the drug is medically necessary and that there aren’t equally effective alternative drugs on the formulary. Please call the Customer Service number on the back of your BCBSM ID card if you have questions about your drug coverage, a drug claim or filing a benefit exception.
Prior Authorization and Step Therapy Drug Categories
(CUSTOM FORMULARY)
MEDICATION/ DRUG CLASS CRITERIA
AdcircaTM (tadalafil) Nonformulary
Approved for members with a diagnosis of Pulmonary Arterial Hypertension (PAH). Coverage for AdcircaTM in combination with bosentan (Tracleer®), epoprostenol (Flolan®), treprostinil (Remodulin®) or iloprost (Ventavis®) is provided after monotherapy with one of these agents has been found to be inadequate in the treatment of the patient’s symptoms. Coverage is NOT provided for AdcircaTM in situations where patients are receiving nitrate therapy.
Amitiza® (lubiprostone) Nonformulary
Patient must be 18 years or older and have a diagnosis of constipation predominant Irritable Bowel Syndrome (female only) OR chronic idiopathic constipation with documented failure with one fiber laxative and either a stimulant or osmotic laxative within the last 12 months. Drug induced constipation must also be ruled out.
AmpyraTM (dalfampridine extended release) Nonformulary
Coverage may be provided in patients ≥ 18 years of age when the criteria below are met: A. Diagnosis of multiple sclerosis B. Prescribing physician is a neurologist C. Patient has documented difficulty walking resulting in significant limitations of instrumental activities of daily living D. Ambulatory function assessed with the timed 25-foot walk (T25FW) meeting the following criteria:
I. Clinical notes documenting two measurements with variability within 10% demonstrating the patient is able to walk 25 feet in 8-45 seconds. The faster time of the two measurements will serve as the baseline value.
II. Measurements were not taken within 60 days of an MS exacerbation III. Clinical notes documenting whether a walking assistive device was used E. Does not have a history of seizure F. Does not have moderate to severe renal impairment (CrCl ≤ 50 ml/min) G. Initial approval length is for 3 months Coverage may be renewed for 12 months when the following criteria are met:
I. Clinical notes documenting improvement in walking speed by at least 10% as assessed by the T25FW
II. Clinical documentation indicating that the limitations of instrumental activities of daily living has resolved as a result of increased speed of ambulation III. Clinical notes documenting consistency in whether a walking assistive device was used for all measurements (baseline and re-testing for renewal of therapy)
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MEDICATION/ DRUG CLASS CRITERIA
AmpyraTM (dalfampridine extended release) continued Nonformulary
Coverage may not be provided for any other uses including, but not limited to: A. To improve walking ability in any other condition aside from MS B. Improvement in symptoms related to multiple sclerosis (MS) other than slow ambulation, including but not limited to: difficulty with balance, fatigue, foot drop, poor stamina and weakness including, but not limited to upper extremity weakness such as impaired handwriting C. Guillain-Barre syndrome D. Lambert-Eaton Myasthenic Syndrome E. Spinal cord injury
Anabolic Steroids Oxandrin® [g] (oxandrolone) Nonformulary: Anadrol-50® (oxymetholone) Deca-Durabolin® (nandrolone decanoate)
Oxandrin® [g]: Approved when used as an adjunct therapy to promote weight gain in patients who have had extensive surgery, chronic infection, or severe trauma OR for therapy to offset protein catabolism associated with prolonged use of corticosteroids OR for bone pain associated with osteoporosis OR if prophylactic therapy is needed in patients with hereditary angioedema. Anadrol-50® (oxymetholone) and Deca-Durabolin® (nandrolone decanoate): Approved for the treatment of clinically diagnosed anemia (documentation must support the trial of standard supportive measures for treating anemia including: transfusion, correction of iron, folic acid, vitamin B12, or pyridoxine deficiency, antibacterial therapy, and the appropriate use of corticosteroids) OR for the treatment of HIV-associated wasting OR if prophylactic therapy is needed in patients with hereditary angioedema.
Angiotensin II Receptor Blockers (ARBs): Cozaar® (losartan)/Hyzaar® (g) Benicar® (olmesartan)/HCT Nonformulary: Atacand®(candesartan)/HCT Avapro® (irbesartan)/Avalide® Diovan® (valsartan)/HCT Micardis® (telmisartan)/HCT Teveten®(eprosartan)/HCT
Approval of a branded formulary ARB requires documentation that the member has experienced failure of or intolerance to Cozaar® (losartan)/Hyzaar® (g). Approval of a nonformulary ARB requires documentation that the member has experienced failure of or intolerance to Cozaar® (losartan)/Hyzaar® (g) AND Benicar® (olmesartan)/HCT.
Betaseron® (Interferon beta-1b) Nonformulary
Requires trial and failure or intolerance of Extavia®
Bisphosphonates: Fosamax® [g] (alendronate) Fosamax® [g] weekly Actonel® (risedronate) Actonel® with Calcium Nonformulary: Boniva® (ibandronate) Fosamax Plus D
Approval of Actonel® (risedronate) requires documentation that the member has tried and failed/not tolerated treatment with Fosamax® [g]. Approval of Boniva® (ibandronate) requires documentation that the member has tried and failed/not tolerated treatment with both Fosamax® [g] and Actonel® (risendronate).
Butrans TM (buprenorphine) transdermal system Nonformulary
Coverage will be provided for the management of moderate to severe chronic pain in patients requiring around the clock opioid analgesia for an extended period of time. Criteria also requires trial and failure, or intolerance to both extended-release morphine and the fentanyl patch.
Byetta® (exenatide) Nonformulary
Approved as adjunctive therapy in combination with at least one of the following medications: metformin, sulfonylurea or a thiazolidinedione AND being used to improve glycemic control in patients who have a diagnosis of type II diabetes mellitus AND have tried at least 2 of the following: metformin, a sulfonylurea or a thiazolidinedione (unless contraindicated) AND the patient must have documentation of an A1c greater than 7%. Byetta® is NOT covered for the primary indication of weight loss in patients with or without diabetes.
Bystolic® (nebivolol) Nonformulary
Approval requires documentation that the patient has tried and failed/intolerant to at least 2 of the formulary cardioselective beta blockers: Kerlone® [g], Sectral ® [g], Tenormin ® [g], Zebeta ® [g], Lopressor® [g] OR Toprol XL® [g].
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MEDICATION/ DRUG CLASS CRITERIA
Carbaglu® (carglumic acid) Covered for the treatment of acute hyperammonemia due to the deficiency of the hepatic enzyme N-acetylglutamate synthase (NAGS).
Cayston® (aztreonam lysine) Nonformulary
Covered for the improvement of respiratory symptoms in cystic fibrosis patients with Pseudomonas aeruginosa.
ChenodalTM (chenodeoxycholic acid) Nonformulary
Coverage approved for patients with radiolucent stones in well-opacifying gallbladders, in whom selective surgery would be undertaken except for the presence of increased surgical risk because of systemic disease or age. Requires: 1. trial and failure or intolerance of ursodiol 2. patient is not a candidate for surgery 3. patient has no history of hepatocellular disease 4. if the patient is a woman, required that they are not pregnant and may not become pregnant. Coverage is limited to 24 months total of ursodiol plus ChenodalTM.
Cholesterol-lowering Agents Zocor® [g] (simvastatin) Mevacor® [g] (lovastatin) Pravachol® [g] (pravastatin) Crestor (rosuvastatin) Zetia (ezetimibe) Nonformulary: Altoprev (lovastatin ER) Lescol,Lescol XL (fluvastatin) Lipitor (atorvastatin) Livalo® (pitavastatin) Vytorin(simvastatin/ezetimibe) Advicor(lovastatin/niacin extended release) Simcor® (simvastatin/niacin extended release)
Crestor®: Requires documentation that member has experienced failure of or intolerance to at least one high dose (>40mg) generic statin (Mevacor® [g], Zocor® [g], and Pravachol® [g]). Zetia®: Patient has a documented trial and failure, intolerance, contraindication, or adverse reaction to Mevacor®[g], Pravachol®[g], or Zocor® [g].
OR Patient is currently on statin therapy and unable to reach therapeutic target after trial at maximum tolerated dose (minimum 40 mg). Nonformulary agents: Altoprev®, Lescol®, Lipitor®, Livalo®, Vytorin®: Requires documentation that member has experienced failure of or intolerance to at least one high dose (>40mg) generic statin (Mevacor® [g], Zocor® [g], and Pravachol® [g]) AND one formulary brand agent (Crestor® or Zetia®). Advicor®: Requires documentation that member has had at least 3 months of treatment with lovastatin and niacin extended release as individual agents when used concomitantly. Simcor®: Requires documentation that member has had at least 3 months of treatment with simvastatin and niacin extended release as individual agents when used concomitantly.
COX-2 Preferential NSAIDs: Celebrex (celecoxib) Nonformulary
Requires age > 60 OR concomitant use of anticoagulants OR oral steroids OR risk of GI bleed (history of PUD, previous GI bleed, alcoholism).
Cymbalta® (duloxetine) Nonformulary
Coverage for Cymbalta® will be provided for: Treatment of major depression Approval requires trial and failure with two formulary antidepressants including one generic SSRI/SNRI. OR Treatment of diabetic neuropathic pain If patient equal to or greater than 65 years of age: After a 30-day trial of gabapentin.
If patient less than 65 years of age: After a 30-day trial of gabapentin AND a tricyclic antidepressant, such as amitriptyline, desipramine, or imipramine. OR
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MEDICATION/ DRUG CLASS CRITERIA
Treatment of Fibromyalgia Fibromyalgia characterized by pain in all 4 body quadrants, for at least 3 months, with or without fatigue and sleep disturbance AND the patient has tried and experienced intolerance to gabapentin OR had inadequate pain relief at doses of 1200 mg or above AND has tried and experienced intolerance or inadequate pain relief to three of the following: tricyclic antidepressant, SSRI, SNRI, cyclobenzaprine, tramadol.
Erythropoiesis Stimulating Agents (ESAs) Procrit® (epoetin alfa) Nonformulary Aranesp® (darbepoetin alfa) Epogen® (epoetin alfa)
Information may need to be submitted describing the use and setting of the drug to make the determination. Approved for use in the following conditions with a hemoglobin less than 12mg/dl: anemia of chronic renal disease (not yet on dialysis), anemia secondary to active chemotherapy of solid tumors, anemia secondary to active zidovudine (AZT) therapy, anemia in myelodysplastic disorders and prophylactic use during some major surgeries. Coverage is NOT provided in the following conditions: A. Anemia due to folate, vitamin B-12, and iron deficiencies, hemolysis, bleeding, or bone marrow fibrosis, B. Anemia associated with treatment of acute and chronic myelogenous leukemias (CML, AML), or erythroid cancers, C. Anemia due to cancer treatment in patients with uncontrolled hypertension, D. Anemia not associated with cancer treatment or renal disease under inclusion criteria, E. Anemia associated only with radiotherapy, F. Prophylactic use to prevent chemotherapy induced anemia, G. Prophylactic use to reduce tumor hypoxia, H. Patients with Erythropoietin type resistance due to neutralizing antibodies. Coverage duration = 3 months
ExalgoTM (hydromorphone extended-release) Nonformulary
Coverage will be provided for management of moderate to severe pain in opioid tolerant patients requiring continuous, around the clock opioid analgesia for an extended period of time. Criteria also requires trial and failure, or intolerance to equivalent doses of both extended-release morphine and the fentanyl patch. Coverage will not be provided for use as an “as needed” analgesic or for acute pain or postoperative pain
Flector® (diclofenac patch) Nonformulary
For FDA approved indications only. Member must have tried and failed or demonstrated intolerance to oral diclofenac AND at least two other oral, traditional NSAIDs unless the patient is unable to take any oral medications. AND Coverage will NOT be provided in the presence of concurrent therapy with oral NSAIDs or a COX II inhibitor.
Forteo® (teriparatide) Nonformulary
Forteo® will be provided for the following guidelines: 1. For the treatment of postmenopausal women with osteoporosis who are at high risk of fracture or men with primary or hypogonadal osteoporosis who are at high risk for fracture and meet the following criteria (a, b and c): a. Have a bone mineral density (BMD) that is 2.5 standard deviations or more below the mean (T-score at or below -2.5). b. Patient has tried and failed a bisphosphonate (formulary agents include Fosamax® [g] and Actonel®) for a 24 month period except when:
1. contraindication to a bisphosphonate (such as a stricture or achalasia, inability to stand or sit upright for at least 30 minutes and increased risk of aspiration).
OR 2. documented intolerance to a bisphosphonate
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MEDICATION/ DRUG CLASS CRITERIA
c. Coverage will NOT be provided in the following situations: 1. Concurrent treatment with a bisphosphonate 2. Hypercalcemia 3. Paget’s disease 4. Bone metastases or a history of skeletal malignancies 5. Metabolic bone disease other than osteoporosis 6. Pediatric patients or young adults with open epiphyses 7. Prior radiation therapy involving the skeleton
2. Forteo will be approved for a maximum of two years.
Growth Hormone Genotropin (somatropin) Nutropin (somatropin) Nonformulary: Humatrope® Norditropin® Omnitrope® Saizen® Serostim® Tev-Tropin® Zorbtive™
Coverage will be provided for: Pediatric Growth Hormone Deficiency Children (M < 16 years old, F < 15 years old):
Initial Treatment: Req. > 6 months of initial height measurements, Ht < 5th percentile for age (based on initial evaluation), abnormal growth velocity based on > 6 mo. of measurement, < 50th percentile for age with growth hormone therapy, initial subnormal blood test for growth hormone. To continue treatment: must have a documented growth velocity of > 2.5 cm/year during the first 6 mo. of therapy & documented growth of > 4.5 cm/year for each succeeding 6 month review period. Treatment may continue until final height or epiphyseal closure has been documented or patient has reached age 16 years (M) or 15 years (F).
Adults: Diagnosis of growth hormone deficiency confirmed by laboratory testing (e.g. provocative stimulation), known indication for pituitary disease and multiple pituitary hormone deficiencies. Multiple stimulation tests may be required in certain clinical circumstances. May be approved for AIDS-wasting cachexia and Turner’s Syndrome. Growth hormone therapy is NOT covered for anti-aging, obesity or athletic enhancement.
HizentraTM (immune globulin subcutaneous) Nonformulary
Requires appropriate diagnosis for coverage and other criteria may apply depending on diagnosis.
H.P. Acthar Gel® (repository
corticotropin) Nonformulary
Coverage will be provided for the treatment of infantile spasms, OR for the diagnostic testing of adrenocortical function only if use of cosyntropin is contraindicated. Use of H.P. Acthar Gel® is NOT considered medically necessary as treatment of steroid-responsive conditions, unless there are medical contraindications or intolerance to corticosteroids that are not also expected to occur with use of H.P. Acthar Gel®.
Increlex® (mecasermin) Nonformulary
Approval will require the following: 1. Medication to be prescribed by a pediatric endocrinologist AND 2. Diagnosis of one of the following:
Severe primary IGF-1 deficiency or growth hormone gene deletion or genetic mutation of growth hormone receptor (Laron Syndrome) AND 3. Current height measurement at less than 3rd percentile for age and sex AND 4. IGF-1 level greater than or equal to 3 standard deviations below normal AND 5. Normal or elevated growth hormone levels based on at least one growth hormone stimulation test AND 6. Open growth plates Authorizations shall be reviewed at least annually to confirm that current medical necessity criteria are met and that the medication is effective. Continued authorization in children may be given for up to 12 months until any one of the following conditions occurs: 1. Growth velocity is less than 2.5 cm/year OR 2. Bone age in males exceeds 16 0/12 years of age OR 3. Bone age in females exceeds 14 0/12 years of age Increlex® is considered investigational for all other indications, including, but not limited to:
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MEDICATION/ DRUG CLASS CRITERIA
a. Amyotrophic lateral sclerosis (ALS) b. Children less than two years of age c. Combination treatment with growth hormone d. Diabetes e. Individuals with closed growth plates f. Secondary forms of IGF-1 deficiency, such as growth hormone deficiency, malnutrition, hypothyroidism or chronic treatment with steroids g. Idiopathic short stature h. Growth failure due to other identifiable causes (including, but not limited to Prader-Willi syndrome, Russell-Silver syndrome, Turner syndrome, Noonan syndrome) i. Less severe forms of IGF-1 deficiency
Intranasal Steroids Flonase® [g] (fluticasone) Nasarel® [g] (flunisolide) Nasacort AQ® (triamcinolone) Nonformulary: Beconase® AQ (beclomethasone) Nasonex® (mometasone) Omnaris® (ciclesonide) Rhinocort AQ® (budesonide) Veramyst® (fluticasone)
Approval of Nasacort AQ® requires trial and failure/intolerance to Flonase® [g] OR Nasarel® [g]. Approval of nonformulary agents requires trial and failure/intolerance to generic fluticasone (Flonase®) OR generic flunisolide (Nasarel®) AND trial and failure/intolerance to Nasacort AQ®.
IntunivTM (guanfacine extended-release) Nonformulary
Requires diagnosis of ADHD AND therapeutic failure, intolerance or contraindication to BOTH an amphetamine-type product AND a methylphenidate product.
Lotronex® (alosetron hydrochloride) Nonformulary
Approved for treatment of women > 18 years old with severe, diarrhea-predominant Irritable Bowel Syndrome (IBS) who have failed to respond to conventional IBS therapy.
Lyrica® (pregabalin) Nonformulary
Coverage of Lyrica® will be provided for: Adjunctive treatment for adult patients with partial onset of seizures OR Treatment of diabetic neuropathic pain or post-herpetic neuralgia If patient equal to or greater than 65 years of age: After a 30-day trial of gabapentin.
If patient less than 65 years of age: After a 30-day trial of gabapentin AND a tricyclic antidepressant, such as amitriptyline, desipramine, or imipramine. OR Treatment of Fibromyalgia Fibromyalgia characterized by pain in all 4 body quadrants, for at least 3 months, with or without fatigue and sleep disturbance AND the patient has tried and experienced intolerance to gabapentin OR had inadequate pain relief at doses of 1200 mg or above AND has tried and experienced intolerance or inadequate pain relief to three of the following: tricyclic antidepressant, SSRI, SNRI, cyclobenzaprine, tramadol.
Mirapex® ERTM (pramipexole extended release) Nonformulary
Coverage approved for the treatment of Parkinson's. Requires trial and failure of Mirapex® (g).
Narcotics Actiq® [g] (fentanyl citrate) Nonformulary: Fentora™ (fentanyl citrate) OnsolisTM (fentanyl citrate)
Requires appropriate diagnosis for coverage and tolerance to high doses of narcotics.
Non-Sedating Antihistamines: Claritin/-D™ OTC (loratadine/pseudoephedrine) Zyrtec/-D™ OTC (cetirizine/pseudoephedrine) Allegra [g] (fexofenadine) Allegra-D 12hr [g] (fexofenadine/pseudoephedrine) Allegra-D 24hr (fexofenadine/pseudoephedrine) Nonformulary:
Clarinex/Clarinex-D and Xyzal
Requires failure of or intolerance to OTC loratadine/loratadine-D AND OTC cetirizine/cetirizine-D, AND fexofenadine/fexofenadine-D. Allegra® Suspension and Allegra® ODT Requires failure or intolerance to loratadine AND cetirizine
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MEDICATION/ DRUG CLASS CRITERIA
Allegra Suspension (fexofenadine) Allegra ODT (fexofenadine) Clarinex/-D®
(desloratadine/pseudoephedrine) Xyzal (levocetirizine) OleptroTM (trazodone extended release) Nonformulary
Coverage approved for the treament of major depressive disorder. Requires trial and failure of Desyrel (g) and documentation why the long acting would be more efficacious.
Pennsaid® topical solution (diclofenac sodium) Nonformulary
For FDA approved indications only. Member must have tried and failed or demonstrated intolerance to oral diclofenac AND at least two other oral, traditional NSAIDs unless the patient is unable to take any oral medications. AND Coverage will NOT be provided in the presence of concurrent therapy with oral NSAIDs or a COX II inhibitor.
Promacta® (eltrombopag) Initial approval for coverage requires all of the following: 1, Age greater than 18 years old AND 2. Diagnosis of chronic immune thrombocytopenia (ITP) and persistent thrombocytopenia (platelet count < 150,000 mcL) for > 2 months AND 3. Prescribed by a hematologist or in consultation with a hematologist AND 4. Inadequate response or patient must not be a candidate for corticosteroids, immunoglobulins, or splenectomy AND 5. Current platelet count is < 50, 000 mcL AND 6. Dose is < 75mg/day Renewal approval for Promacta® requires recent platelet count of 30,000-150, 000 mcL AND dose is < 75mg/day.
Proton Pump Inhibitors (PPI’s): Prilosec OTC™ [g] (omeprazole) Prilosec®[g] (omeprazole) Protonix [g] (pantoprazole) Prevacid® [g] (lansoprazole) Prevacid® SoluTab™(g) (lansoprazole) Zegerid® (capsule (g) omeprazole/sodium bicarbinate Nonformulary: Aciphex (rabeprazole) DexilantTM (dexlansoprazole) Nexium (esomeprazole) Zegerid® powder for oral suspension(omeprazole/sodium bicarbonate
Approval of nonformulary medications requires failure of or intolerance to all formulary alternatives: Prilosec [g] OR Prilosec OTC™ [g] AND Protonix [g] AND Prevacid® [SoluTab™[g]
RelistorTM (methylnaltrexone bromide) injection
Coverage of RelistorTM will be provided for: 1. The treatment of opioid-induced constipation in patients with advanced illness who
are receiving palliative care, when response to laxative therapy has not been sufficient.
2. Patients shall be on stable doses of opioids for greater than 2 weeks. 3. Duration of methylnaltrexone therapy shall be limited to 3 months. 4. Previous history of treatment for constipation shall include fluids, stool softeners, bulk
laxatives, saline laxatives and osmotic laxatives. Laxatives trials shall be of at least 5 days duration.
5. Maximum initial regimen shall be 1 box (7 doses). Monthly doses shall not exceed 14.
6. Patients experiencing withdrawal symptoms while taking methylnaltrexone should consider using an alternate form of therapy.
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MEDICATION/ DRUG CLASS CRITERIA
Revatio® (sildenafil citrate) tablet Approved for members with a diagnosis of Pulmonary Arterial Hypertension (PAH). Coverage for sildenafil (Revatio®) in combination with bosentan (Tracleer®), epoprostenol (Flolan®), treprostinil (Remodulin®) or iloprost (Ventavis®) is provided after monotherapy with one of these agents has been found to be inadequate in the treatment of the patient’s symptoms. Coverage is NOT provided for sildenafil (Revatio®) in situations where patients are receiving nitrate therapy.
Sancuso® (granisetron) Nonformulary
Coverage of Sancuso® will be provided for: 1. Indication for prevention and/or treatment of nausea/vomiting associated with chemotherapy and/or radiation therapy AND 2. Documented treatment/failure with generic ondansetron (Zofran®) AND generic granisetron (Kytril®) AND 3. Not a candidate for IV granisetron therapy
Sandostatin® (octreotide) [g] Sandostatin LAR®
Sandostatin® [g] Approval requires one of the following (1, 2 or 3): 1. Clinically diagnosed acromegaly AND one of the following (a, b, or c) a. failure to respond to surgery or radiation OR b. not a candidate for surgery or radiation OR c. use to shrink tumor prior to surgery 2. Diagnosis of metastatic carcinoid tumor 3. Diagnosis of vasoactive intestinal peptide tumors (VIPomas) Sandostatin LAR® Approval requires member to have previously tried, responded and tolerated immediate-release octreotide injection AND one of the following (1,2 or 3): 1. Clinically diagnosed acromegaly AND one of the following (a,b or c) a. failure to respond to surgery or radiation OR b. not a candidate for surgery or radiation OR c. use to shrink tumor prior to surgery 2. Diagnosis of metastatic carcinoid tumor 3. Diagnosis of vasoactive intestinal peptide tumors (VIPomas)
SavellaTM (milnacipran) Nonformulary
Treatment of Fibromyalgia Fibromyalgia characterized by pain in all 4 body quadrants, for at least 3 months, with or without fatigue and sleep disturbance AND the patient has tried and experienced intolerance to gabapentin OR had inadequate pain relief at doses of 1200 mg or above AND has tried and experienced intolerance or inadequate pain relief to three of the following: tricyclic antidepressant, SSRI, SNRI, cyclobenzaprine, tramadol.
Sedative/Hypnotics Ambien® [g] (zolpidem) Ambien CR® [g] (zolpidem) Sonata® [g] (zaleplon)
Nonformulary: Edluar™ (zolpidem sublingual) Lunesta™ (eszopiclone) Rozerem™ (ramelteon) Zolpimist® (zolpidem tartrate oral spray)
Ambien CR® [g], LunestaTM and RozeremTM require documentation that member has experienced failure of or intolerance to Ambien® [g] OR Sonata® [g]. Edluar™ and Zolpimist® require trial and failure, or intolerance, to Ambien® (zolpidem) AND Sonata® (zaleplon) AND documentation of medical necessity.
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MEDICATION/ DRUG CLASS CRITERIA
Selective Reuptake Inhibitor – antidepressants: Celexa [g] (citalopram) Effexor/XR®[g] capsule (venlafaxine) Luvox [g] (fluvoxamine) Paxil [g] (paroxetine) Paxil CR® [g] (paroxetine) Prozac [g] (fluoxetine) Prozac Weekly [g] (fluoxetine) Remeron [g] (mirtazapine) Venlafaxine ER [g] tablet Wellbutrin SR [g] (bupropion) Wellbutrin XL® [g] (bupropion) Zoloft [g] (sertraline) Lexapro (escitalopram)
Nonformulary: Aplenzin® (bupropion hydrobromide) Luvox® CR (fluvoxamine) Pexeva (paroxetine) Pristiq (desvenlafaxine)
Lexapro requires step therapy with at least one of the following generic formulary alternatives; Celexa [g], Effexor/XR®[g], Luvox [g], Paxil/CR [g], Prozac [g], Remeron [g], Wellbutrin/SR [g], Wellbutrin XL® [g], or Zoloft [g]. Aplenzin®; requires trial/failure of at least 2 formulary agents plus documentation that continued use of Wellbutrin® [g] will adversely affect the member’s mental health. Luvox CR; requires trial/failure of at least 2 formulary agents plus documentation that continued use of Luvox® [g] will adversely affect the member’s mental health. Pexeva; requires trial/failure of at least two of the above formulary agents PLUS documentation that continued use of Paxil® [g] will adversely affect the member’s health. Pristiq; requires trial/failure of at least 2 formulary agents.
SilenorTM (doxepin) Nonformulary
Requires trial and failure of Ambien (g) AND Sonata (g)
Somavert® (pegvisomant) For the treatment of acromegaly in patients who have had an inadequate response to surgery and/or radiation therapy and/or other medical therapies, or for whom these therapies are not appropriate.
Strattera® (atomoxetine) Nonformulary
For members age 5-21: Requires documentation that member has experienced failure of or intolerance to BOTH a methylphenidate product (such as Ritalin® [g] or Concerta®) AND an amphetamine (such as Adderall® [g]). For members age >21: Requires documentation that the member has experienced failure of or intolerance to EITHER a methylphenidate product OR an amphetamine. Approvable when stimulants are contraindicated by medical history.
Tekturna® (aliskiren) Nonformulary
Requires documentation that the member has tried standard effective doses and not reached therapeutic goals or could not tolerate therapy with ALL of the following drug classes:
1. Diuretic 2. Beta-blocker 3. ACE-Inhibitor Angiotension II Receptor Blocker (ARB)
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MEDICATION/ DRUG CLASS CRITERIA
TNF-alpha agents and related products: Enbrel (etanercept) Humira (adalimumab) Nonformulary: Cimzia (certolizumab pegol injection) Kineret (anakinra) SimponiTM (golimumab)
Enbrel® and Humira®: Rheumatoid arthritis, juvenile RA, or psoriatic arthritis: Requires three-month trial with two concurrent DMARDs, (one must be methotrexate unless contraindicated). Examples of DMARDs include: methotrexate, sulfasalazine, azathioprine, hydroxychloroquine/chloroquine, cyclosporine, gold and penicillamine. Ankylosing spondylitis: requires therapy is being supervised by a Rheumatologist. Moderate to severe psoriasis: Requires 3 months of previous treatment with topical corticosteroids AND 3 months treatment with PUVA (unless PUVA is contraindicated) AND therapy must be supervised by a Dermatologist. Crohn’s Disease: Coverage for patients age 18 years and older, with a diagnosis of moderately to severely active Crohn’s disease with a history of inadequate response to conventional therapy. Applies to Humira® only. Cimzia®: The following criteria are used in reviewing medical exceptions for Cimzia®
A. OR B. A. Age 18 or older and for the treatment of acute exacerbation of moderate to severe Crohn’s disease when the following criteria are met (1 AND 2): 1) Treatment with an adequate course of systemic corticosteroids has been ineffective or is contraindicated or patient has been unable to taper or patient is experiencing breakthrough disease while stabilized on an immunomodulatory medication for at least 2 months. AND 2) Previous trial/failure/contraindication of Humira®. OR B. Age 18 or older and for the treatment of rheumatoid arthritis when the following criteria are met (1 AND 2) 1) Treatment failure with a three month trial with two concurrent DMARDs (one must be methotrexate unless contraindicated) AND
2) Treatment failure or documented intolerance to Adalimumab ( Humira® ) and Etanercept (Enbrel® )
Kineret®: Rheumatoid arthritis in adults: Requires three-month trial with two concurrent DMARDs, (one must be methotrexate unless contraindicated) AND treatment failure or intolerance to Enbrel
and Humira. Examples of DMARDs include: methotrexate, sulfasalazine, azathioprine, hydroxychloroquine/chloroquine, cyclosporine, gold and penicillamine. SimponiTM: 18 years of age or older and A OR B A. Rheumatoid arthritis and psoriatic arthritis: Requires a 3-month trial on two concurrent
Disease Modifying Anti-Rheumatic Drugs (DMARDs), one of which must be methotrexate unless contraindicated AND treatment failure or contraindication to both Enbrel® AND Humira®.
OR B. Ankylosing spondylitis: Requires a treatment failure or contraindication to both Enbrel® AND Humira®.
TreximetTM (sumatriptan/naproxen sodium) Nonformulary
Requires prior use of Imitrex® [g] and Naprosyn® [g] in combination AND documentation indicating why use of the individual agents is harmful to the member AND documentation of trial and failure of formulary option Maxalt®.
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MEDICATION/ DRUG CLASS CRITERIA
TriLipixTM (fenofibric acid) Nonformulary
Requires trial and failure of gemfibrozil [g] AND fenofibrate [g].
Triptans: Amerge® (g) (naratriptan) Imitrex® [g] (sumatriptan) Maxalt® (rizatriptan) Nonformulary AlsumaTM (sumatriptan) Axert® (almotriptan) Frova® (frovatriptan) Relpax® (eletriptan) SumavelTM DoseProTM
(sumatriptan needle-free injection) Zomig® (zolmitriptan)
The formulary option Maxalt® will require trial and failure of the generic formulary alternative Imitrex® [g]. Approval of the nonformulary triptans, Axert®, Frova®, Relpax®, Zomig®, will require trial and failure of both the formulary options Imitrex® [g] AND Maxalt®. Approval of the nonformulary triptans AlsumaTM and SumavelTM DoseProTM will require trial and failure of both formulary options Imitrex (g) injection AND Maxalt MLT®
Uloric® (febuxostat)
Requires treatment failure, intolerance or contraindication with formulary alternative generic allopurinol.
Victoza® (liraglutide) Nonformulary
Approved as adjunctive therapy in combination with at least one of the following medications: metformin, sulfonylurea or a thiazolidinedione AND being used to improve glycemic control in patients who have a diagnosis of type II diabetes mellitus AND have tried at least 2 of the following: metformin, a sulfonylurea or a thiazolidinedione (unless contraindicated) AND the patient must have documentation of an A1c greater than 7%. Victoza® is NOT covered for the primary indication of weight loss in patients with or without diabetes.
VimovoTM (naproxen/esomeprazole) Nonformulary
Approval requires trial and failure of Prilosec (g) AND Protonix (g) AND Prevacid (g) AND one of the following criteria: Member is >60 years of age or receiving anticoagulant or antiplatelet therapy or receiving chronic treatment with oral corticosteroids (>60 days duration) or has a history of or current diagnosis of peptic ulcer disease, clinically significant gastrointestinal bleeding and/or alcoholism.
Voltaren Gel® (diclofenac gel) Nonformulary
For FDA approved indications only. Member must have tried and failed or demonstrated intolerance to oral diclofenac AND at least two other oral, traditional NSAIDs unless the patient is unable to take any oral medications. AND Coverage will NOT be provided in the presence of concurrent therapy with oral NSAIDs or a COX II inhibitor.
Vyvanse™ (lisdexamfetamine) Nonformulary
Covered for the treatment of ADHD in children and adults 6 years of age and older who have experienced therapeutic failure or intolerance to BOTH an amphetamine-type product AND a methylphenidate product. Maximum dose approved per day will be 70 mg.
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MEDICATION/ DRUG CLASS CRITERIA
Xenazine® (tetrabenazine)
Approval will require diagnosis of chorea associated with Huntington’s disease AND for doses above 50mg per day, documentation of the CYP2D6 genotype of the patient will be required. Tetrabenazine is considered investigational when used for all other conditions, including, but not limited to:
A. Chorea not associated with Huntington’s disease B. Tardive dyskinesia C. Dystonia, tics and other dyskinesias D. Hyperkinetic or involuntary movement disorders E. Tourette’s syndrome F. Athetoid cerebral palsy
Xyrem® (sodium oxybate) Nonformulary
Requires a diagnosis of narcolepsy and A OR B: A. Cataplexy demonstrated by supporting chart documentation or sleep studies
OR B. Excessive daytime sleepiness demonstrated by supporting chart documentation or
sleep studies when (1 AND 2): 1. Modafinil in doses up to 400mg daily has been ineffective, not tolerated, or
contraindicated. AND 2. At least one other formulary/preferred treatment, such as methylphenidate or dextroamphetamine, has been ineffective, not tolerated, or
contraindicated. Xyrem® will NOT be approved if:
1. Patient is being treated with sedative hypnotic agents, other CNS depressants, or using alcohol
2. Patient has a history of drug abuse 3. Patient has succinic semialdehyde dehydrogenase deficiency
Xyrem® is NOT considered medically necessary for the following condition(s):
1. Alcohol dependence and withdrawal 2. Fibromyalgia
Xyrem® is considered investigational for all other conditions or applications, including, but not limited to, the treatment of:
1. Opioid dependence and withdrawal 2. Parkinsonism 3. Night eating syndrome 4. Myoclonus and essential tremor
ZuplenzTM (ondansetron) oral soluble film Nonformulary
Requires documentation that the member has experienced treatment failure or intolerance to Zofran ODT (g) AND oral Kyrtril (g). Documentation must be provided as to why continued use of Zofran ODT will harm the patient.
[g] = generic available
Page 31
Possible brand alternatives
Some medications are produced by more than one pharmaceutical manufacturer, under different brand names. In some cases, only one of the brand-name products is listed in the Blue Cross Blue Shield of Michigan and Blue Care Network Custom Formulary 2011. The other brands are considered nonformulary. We encourage prescribers to select the preferred product to help patients save out-of-pocket costs.
Possible brand alternatives Nonformulary Formulary alternative Epogen® Procrit® Follistim® Gonal-F® Humatrope®, Norditropin® , Omnitrope®, Saizen®, Serostim®, Tev-Tropin®, Zorbtive®
Genotropin®, Nutropin®
Ritalin LA® Metadate CD® Generic drug substitution Generic drug substitution is when a generic equivalent is dispensed rather than the brand-name product. Products designated in the formulary with “(g)” after the name are available as generics approved by the U.S. Food and Drug Administration. BCN members are required to use generic substitution. For BCN members, if a brand-name drug is requested when a generic version is available, members will pay their Tier 2 copayment plus the difference in cost between the brand and generic versions. Prescribers may request authorization for the brand-name version, based on medical necessity. A completed MedWatch form is required. BCBSM members are encouraged to receive the generic equivalent, if available, or they may be required to pay the difference in cost between the brand dispensed and the generic equivalent, in addition to the applicable copay. The maximum allowable cost list sets ceiling prices for reimbursement of certain generic prescription drugs. The drugs on the MAC list are commonly prescribed and dispensed, and have undergone the FDA’s review and approval process, which ensures:
o Generic drugs contain the same active ingredients and are the same strengths and dosage forms as their brand-name counterparts.
o The FDA has given the generics an “A” rating and have determined they are the equivalent of their
brand-name counterparts. Or the BCBSM and BCN Pharmacy and Therapeutics Committee has reviewed the products and found them to be acceptable generic substitutes.
When the above two criteria are met, generics can be substituted with the full expectation that they will produce the same clinical effects and have the same safety profiles as the prescribed brand-name products. Possible therapeutic alternatives The BCBSM-BCN Formulary Alternatives – January 2011 list represents possible options to nonformulary drugs. These alternative medications can generally be prescribed without approval from BCBSM or BCN, and can be dispensed with lesser copayments for members. Therapeutic alternatives may represent a different drug class, contain different ingredients or may be available in different strengths or dosage forms than the prescribed branded products. Pharmacists must obtain authorization from a patient’s physician to dispense an alternative product. Listed below are examples of the therapeutic alternatives a patient’s physician should consider when determining appropriate treatment for the patient. The physician should consider individual drug product characteristics and patient factors such as coexisting disease states, contraindications, therapeutic history, concurrent medications and other relevant circumstances. This list is also available at bcbsm.com/provider/pharmacy_services/index.shtml.
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BCBSM/BCN Formulary Alternatives - January 2011NonFormulary Formulary Alternative NonFormulary Formulary Alternative
ACIPHEX Prilosec OTC**; Prevacid(g)*, Solutab(g)*; Prilosec 20mg(g), Protonix(g)*, Zegerid(g)*
ACTIVELLA 0.5-0.1MG
Activella(g); Estratest(g), H.S.(g)
ACTOPLUS MET XR
Glucophage(g) plus Actos*; ActoPlus Met*
ACUVAIL Acular, LS(g); Voltaren(g)
ACZONE Topical OTC benzoyl peroxide, clindamycin, erythromycin
ADCIRCA Revatio*
ADOXA, CK, TT Monodox(g), Vibramycin(g)
ADVICOR Mevacor(g), Pravachol(g), Zocor(g), Crestor*; plus Niaspan
AEROBID, M Alvesco, Asmanex, Azmacort, Flovent, Pulmicort, QVAR
AGGRENOX Persantine(g) plus ASA OTC, Plavix
AKNE-MYCIN Erythromycin topical solution & gel(g)
ALAMAST Zaditor OTC(g), Alomide, Patanol
ALLEGRA ODT, SUSP
Claritin Syr OTC(g)**, Zyrtec Syr OTC(g)**
ALREX Decadron ophth(g), Pred Forte(g), Pred Mild
ALTABAX Triple Antibiotic OTC, Bactroban(g)
ALTACE TABLETS Altace capsules(g)
ALTOPREV Mevacor(g), Pravachol(g), Zocor(g), Crestor*, Zetia*
AMITIZA OTC laxatives and stool softeners, Glycolax(g), Lactulose(g)
AMRIX Flexeril(g)
ANADROL-50 Androxy(g), Depo-testosterone(g), Androderm, Delatestryl
ANDROGEL Androderm
ANGELIQ FemHRT, Prempro/Premphase, or Estradiol plus Progestin
ANTARA Lofibra(g), Lopid(g), Tricor
ANZEMET Kytril(g); Zofran(g), ODT(g)
APHTHASOL Kenalog in Orabase(g)
APLENZIN Generic SSRI/SNRI (Celexa(g), Prozac(g), Zoloft (g), Effexor(g), Effexor XR(g); Wellbutrin, SR, XL(g), etc.)
APRISO Azulfidine(g), Azulfidine En-Tab(g), Asacol, HD; Pentasa
ARANESP Procrit*
ARICEPT 23MG Aricept 5, 10mg(g)
ARIXTRA Lovenox(g)
ARMOUR THYROID
Synthroid(g)
ARTHROTEC Lodine(g), Mobic(g), Motrin(g), Naprosyn(g), Voltaren(g), etc. plus Cytotec(g)
ATACAND, HCT Cozaar(g), Hyzaar(g), Benicar*, HCT*
AVALIDE, AVAPRO Cozaar(g), Hyzaar(g), Benicar*, HCT*
AVANDAMET ActoPlus Met*
AVANDARYL Duetact*
AVANDIA Glucophage(g); Insulin or a sulfonylurea (Glucotrol, XL(g); Micronase(g), Amaryl(g)), Actos*
AVC Diflucan(g) oral, Terazol(g) vaginal
AVINZA Methadone(g), MSIR(g), MS Contin(g), Oramorph SR(g)
AXERT Amerge(g)*, Imitrex(g); Maxalt*, MLT*
AZASITE Ciloxan(g), Vigamox
AZELEX Retin-A(g)
AZILECT Eldepryl(g)
AZOR Generic ACE (lisinopril, benazepril, etc.), Benicar*, or Cozaar(g) PLUS Norvasc(g)
BECONASE AQ Flonase(g), Nasalide(g), Nasarel(g), Nasacort AQ*
BENZACLIN Individual agents (BPO and clindamycin)
BENZASHAVE OTC benzoyl peroxide
BEPREVE Zaditor OTC(g), Patanol
BESIVANCE Ciloxan(g), Ocuflox(g), Vigamox
BETASERON Avonex, Copaxone, Rebif
BETIMOL Betagan(g), Betoptic(g), Timoptic(g)
BEYAZ Yasmin(g), Yaz(g) PLUS Folic Acid 1MG
BONIVA Fosamax(g), Actonel*
BROVANA Foradil, Serevent Diskus
BUTISOL SODIUM Ambien(g), Prosom(g), Restoril(g), Sonata(g)
BUTRANS Duragesic(g), Methadone(g), MS Contin(g), Oramorph(g)
BYETTA Insulin, Glucophage(g), Sulfonylurea's, TZD's
BYSTOLIC Blocadren(g), Lopressor(g), Tenormin(g), Toprol XL(g), etc.
CADUET Mevacor(g), Pravachol(g), Zocor(g), Crestor*; plus Norvasc(g), Zetia*
CAMPRAL Revia(g), Antabuse
CANTIL Bentyl(g), Donnatal(g), Robinul(g)
CARAC Efudex(g)
CARBATROL Tegretol(g), XR(g)
CARDENE SR Cardene(g), Norvasc(g), Procardia XL(g)
* Prior Authorization or Step Therapy may be required.
Most BCN members and some BCBSM members do not have coverage for nonformulary agents. Please use this list as a guide when selecting alternatives.
** Covered with a prescription for BCN members and certain BCBSM members.
Page 33
NonFormulary Formulary Alternative NonFormulary Formulary Alternative
CARDURA XL Cardura(g), Flomax(g), Hytrin(g), Avodart, Uroxatral
CARMOL HC Hydrocortisone plus Aquaphor OTC, Hydrocortisone plus Eucerin OTC
CAYSTON Tobi
CEDAX Ceclor(g), Ceftin(g), Duricef(g), Keflex(g), Omnicef(g)
CELEBREX Lodine(g), Mobic(g), Motrin(g), Naprosyn(g), Voltaren(g), etc.
CENESTIN Estrace(g), Ogen(g), Premarin
CESAMET Kytril(g); Zofran(g), ODT(g)
CHENODAL Actigall(g), Urso(g)
CIMZIA SYRINGE Enbrel*, Humira*
CLARIFOAM EF Plexion(g), Sulfacet-R(g)
CLARINEX (ALL) Claritin OTC(g)**, Zyrtec OTC(g)**, Allegra(g), Allegra-D 12 hour(g)*, Allegra-D 24 hour*, Astelin(g)
CLEOCIN VAGINAL OVULES
Cleocin Vaginal Cream(g)
CLIMARA PRO Climara(g), Vivelle-DOT, or Estraderm plus a progestin
CLINAC BPO Individual agents (Cleocin(g) topical and OTC BPO)
CLINDESSE Cleocin vaginal cream(g)
CLOBEX, SPRAY Diprolene(g), Psorcon(g), Temovate(g), Ultravate(g)
COGNEX Razadyne, ER(g); Aricept, ODT(g); Namenda
COLESTID FLAVORED
Colestid(g), Questran(g), Questran Light(g)
COLY-MYCIN S Cortisporin(g), Floxin(g) Otic, Cipro HC
COMBIPATCH Climara(g), Vivelle-DOT, Estraderm plus Progestin
COREG CR Coreg(g), Toprol XL(g)
CORTISPORIN-TC Cortisporin(g), Floxin(g) Otic, Cipro Otic HC
CYMBALTA Generic SSRI/SNRI (Celexa(g), Effexor(g), Effexor XR(g), Prozac(g), Zoloft(g), etc.)
DAYTRANA Adderall, XR(g)*; Ritalin, SR(g); Concerta, Metadate CD
DENAVIR Zovirax 5% cream/ointment
DEPEN Cuprimine
DERMA-SMOOTHE/FS
Elocon(g), Locoid(g), Synalar solution(g), Capex
DESONATE Elocon(g), Locoid(g), Synalar solution(g), Capex
DEXILANT Prilosec OTC**; Prevacid(g)*, Solutab(g)*; Prilosec 20mg(g), Protonix(g)*, Zegerid(g)*
DIOVAN, HCT Cozaar(g), Hyzaar(g), Benicar*, HCT*
DIPENTUM Azulfidine(g), Azulfidine En-Tab(g), Asacol, HD; Pentasa
DONNATAL EXTENTABS
Bentyl(g), Donnatal(g), Robinul(g)
DORAL Ambien(g), Halcion(g), Prosom(g), Restoril(g), Sonata(g)
DORYX Vibramycin(g)
DUAC CS Individual agents (Cleocin(g) topical and OTC BPO)
DUREZOL Decadron ophth(g); Inflamase, Forte(g); Pred Forte(g), etc.
DYNACIRC CR Cardene(g), Dynacirc(g), Norvasc(g), Procardia XL(g)
EDEX Caverject*, Cialis*, Muse*, Viagra*
EDLUAR Ambien(g), Sonata(g)
EFUDEX OCCLUSION
Efudex(g)
ELESTAT Zaditor OTC(g), Alomide, Patanol
ELESTRIN Climara(g), Estrace(g), Ogen(g), Vivelle-DOT, Estraderm
ELIGARD Lupron, Depot;Trelstar, Depot
ELLA Plan B(g)
EMADINE Zaditor OTC(g), Alomide, Patanol
EMBEDA Methadone(g), MSIR(g), MS Contin(g), Oramorph SR(g)
EMSAM Celexa(g), Effexor(g), Effexor XR(g), Paxil(g), Prozac(g), Wellbutrin, SR, XL(g); Venlafaxine ER(g), Lexapro*
ENABLEX Ditropan(g), XL(g), Detrol, LA
ENJUVIA Premarin
ENTOCORT EC Prednisone(g), Prednisolone(g), Hydrocortisone(g), etc.
EPIDUO Individual agents: Differin plus OTC BPO
EPOGEN Procrit*
EQUETRO Tegretol, XR(g)
ERTACZO Lamisil AT(g) OTC; Lotrimin(g), Ultra OTC; Monistat-Derm(g), Nizoral cream(g), Spectazole(g)
ESTRACE VAGINAL CREAM
Premarin Vaginal Cream
ESTRASORB Climara(g), Estrace(g), Ogen(g), Estraderm, Vivelle-DOT
ESTROGEL Climara(g), Estrace(g), Ogen(g), Estraderm, Vivelle-DOT
EVAMIST Climara(g), Estrace(g), Ogen(g), Estraderm, Vivelle-DOT
EVOXAC Bethanechol(g), Salagen(g)
EXALGO Duragesic(g), Methadone(g), MS Contin(g), Oramorph(g)
* Prior Authorization or Step Therapy may be required.
Most BCN members and some BCBSM members do not have coverage for nonformulary agents. Please use this list as a guide when selecting alternatives.
** Covered with a prescription for BCN members and certain BCBSM members.
Page 34
NonFormulary Formulary Alternative NonFormulary Formulary Alternative
EXFORGE Lotrel(g), Generic ACE Inhibitor (lisinopril, benazepril, etc.), Benicar*, or Cozaar(g) PLUS Norvasc(g)
EXFORGE HCT Lotrel(g) plus HCTZ(g)
EXJADE Desferal(g)
EXTAVIA Avonex, Betaseron, Copaxone, Rebif
EXTINA Nizoral(g)
FACTIVE Erythromycin(g), Vibramycin(g), Zithromax(g), Avelox
FANAPT Clozaril(g), Risperdal(g), Abilify, Geodon, Seroquel, Zyprexa
FAZACLO Clozaril(g), Risperdal(g), Abilify, Geodon, Seroquel, Zyprexa
FEMCON FE Loestrin Fe(g) [NOT 24], Estrostep Fe(g)
FEMRING Estring
FEMTRACE Estrace(g), Ogen(g), Premarin
FENOGLIDE Lofibra(g), Lopid(g), Tricor
FENTORA Actiq(g)*, MSIR(g), MS Contin(g), Oramorph SR(g), Roxanol(g)
FEXMID Flexeril(g)
FINACEA, PLUS Metrogel topical(g), Metrolotion(g), Retin-A(g)
FLECTOR PATCH Topical OTC analgesic balms, i.e. trolamine salicylate; Voltaren oral(g)
FLOXIN OTIC SINGLES
Floxin(g)
FOCALIN XR Adderall, XR(g)*, Focalin(g); Ritalin, SR; Concerta, Metadate CD
FOLLISTIM AQ Gonal-F, Gonal RFF
FORTAMET Glucophage(g)
FORTEO Fosamax(g), Miacalcin Nasal Spray(g), Actonel*
FOSAMAX PLUS D Fosamax(g) plus OTC Vitamin D
FOSRENOL Tums OTC, Phoslo(g), Renagel, Renvela
FRAGMIN Lovenox(g)
FROVA Amerge(g)*, Imitrex(g); Maxalt*, MLT*
GALZIN OTC zinc supplements
GELNIQUE Ditropan, XL(g); Detrol, LA
GILENYA Avonex, Copaxone, Rebif
GLUMETZA Glucophage(g)
GLYSET Precose(g)
GYNAZOLE-1 Lotrimin OTC, Monistat OTC, Diflucan 150mg(g), Terazol(g)
HALFLYTELY Colyte(g) plus bisacodyl OTC
HECTOROL Rocaltrol(g)
HUMATROPE Genotropin*; Nutropin*, AQ*
INNOPRAN XL Inderal(g), Inderal LA(g), Inderide(g)
INTUNIV Catapres(g), Tenex(g)
INVEGA Clozaril(g), Risperdal(g), Abilify, Geodon, Seroquel, Zyprexa
IOPIDINE Alphagan(g), Alphagan P
IQUIX Ciloxan(g), Ocuflox(g), Vigamox
JALYN Cardura(g), Flomax(g), Hytrin(g), Avodart, Uroxatral
JANUMET Glucophage(g); Insulin or a Sulfonylurea (Glucotrol, XL(g); Micronase(g), Amaryl(g)), Actos*
JANUVIA Glucophage(g); Insulin or a Sulfonylurea (Glucotrol, XL(g); Micronase(g), Amaryl(g)), Actos*
KADIAN Methadone(g), MSIR(g), MS Contin(g), Oramorph SR(g)
KAOCHLOR-EFF Potassium Chloride(g) liquid, capsules or tablets
KEFLEX 750MG Keflex(g)
KEPPRA XR Keppra(g)
KETEK Erythromycin(g), Zithromax(g)
KINERET Enbrel*, Humira*
LAMICTAL ODT, XR
Lamictal(g), Disper tabs(g), Tegretol(g)
LAMISIL GRANULES
Lamisil(g)
LESCOL, XL Mevacor(g), Pravachol(g), Zocor(g), Crestor*, Zetia*
LEVAQUIN Vibramycin(g), Avelox
LEVATOL Inderal(g), Inderal LA(g), Lopressor(g), Sectral(g), Tenormin(g), Toprol XL(g)
LEVITRA Cialis*, Viagra*
LIALDA Azulfidine(g); Asacol, HD; Pentasa
LIDODERM PATCH Topical lidocaine, EMLA(g)
LIPITOR Mevacor(g), Pravachol(g), Zocor(g), Crestor*, Zetia*
LIPOFEN Lofibra(g), Lopid(g), Tricor
LIVALO Mevacor(g), Pravachol(g), Zocor(g), Crestor*, Zetia*
LOCOID LIPOCREAM
Aristocort(g), Elocon(g), Locoid(g), Synalar(g), Topicort(g)
LOESTRIN 24 FE Loestrin(g), Loestrin Fe(g)
LOPROX SHAMPOO
Nizoral Shampoo 2%(g)
LOSEASONIQUE Generic biphasic contraceptives
LOTEMAX Decadron ophth(g), Pred Forte(g), Pred Mild
LOTRONEX OTC Anti-diarrheals; Levbid(g); Levsin, SL(g); Levsinex(g); Lomotil(g)
LOVAZA OTC Omega products, Lofibra(g), Lopid(g), Tricor
LUNESTA Ambien(g), Halcion(g), Prosom(g), Restoril(g), Sonata(g)
* Prior Authorization or Step Therapy may be required.
Most BCN members and some BCBSM members do not have coverage for nonformulary agents. Please use this list as a guide when selecting alternatives.
** Covered with a prescription for BCN members and certain BCBSM members.
Page 35
NonFormulary Formulary Alternative NonFormulary Formulary Alternative
LUVERIS Repronex
LUVOX CR Luvox(g) immediate release
LUXIQ Aristocort(g), Elocon(g), Locoid(g), Synalar(g), Topicort(g)
LYRICA Effexor(g), Effexor XR(g), Flexeril(g), Neurontin(g), SSRI's(g), TCA's(g), Ultram(g)
MAGNACET Percocet(g), Tylox(g)
MARPLAN Parnate(g), Nardil
MAXIDEX Decadron ophth(g)
MEGACE ES Megace(g)
MENEST Estradiol (various), Ogen(g)
MENOPUR Repronex
MENOSTAR Climara(g), Estrace(g), Ogen(g), Vivelle-DOT, Estraderm
MENTAX Lamisil AT(g), OTC; Lotrimin(g), Ultra OTC; Monistat-Derm(g), Nizoral cream(g), Spectazole(g)
METHITEST Androxy(g), Depo-Testosterone(g), Oxandrin(g), Androderm, Delatestryl
METHYLIN CHEW Adderall XR(g)*, Metadate CD (Both of which may be "sprinkled" on food)
METOZOLV ODT Reglan(g)
MICARDIS, HCT Cozaar(g), Hyzaar(g), Benicar*, HCT*
MIRAPEX ER Mirapex(g)
MONUROL Bactrim(g), DS(g); Macrobid(g), Cipro(g)
MOVIPREP Colyte(g), Nulytely(g)
MOXATAG Amoxil capsules(g)
MYFORTIC Cellcept(g)
MYTELASE Mestinon(g), Prostigmin
NAFTIN Lotrimin(g), Monistat(g), Nystatin(g)
NAMENDA XR Razadyne, ER(g); Aricept, ODT(g); Namenda
NAPRELAN Mobic(g); Motrin(g); Naprosyn, EC(g); etc*
NASCOBAL SPRAY Cyanocobalamin tabs OTC, Cyanocobalamin injection
NASONEX Flonase(g), Nasalide(g), Nasarel(g), Nasacort AQ*
NATAZIA Yasmin(g), Yaz(g)
NEULASTA Neupogen
NEVANAC Ocufen(g), Voltaren ophth(g)
NEXIUM Prilosec OTC**; Prevacid(g)*, Solutab(g)*; Prilosec 20mg(g), Protonix(g)*
NICOTROL, NS Nicotine gum(g), lozenge(g), patch(g)
NORDITROPIN, NORDIFLEX
Genotropin*; Nutropin*, AQ*
NORITATE MetroCream(g)
NOROXIN Bactrim DS/Septra DS(g); Cipro(g), XR(g)*
NUCYNTA Ultram(g); MSIR(g), oxycodone IR(g)
NUVARING Oral contraceptives, Ortho Evra
NUVIGIL Provigil*
OLEPTRO Desyrel(g)
OLUX-E Diprolene(g), Psorcon(g), Temovate(g), Ultravate(g)
OMNARIS Flonase(g), Nasalide(g), Nasarel(g), Nasacort AQ*
OMNITROPE Genotropin*, Nutropin*, AQ*
ONGLYZA Glucophage(g); Insulin or a Sulfonylurea (Glucotrol, XL(g); Micronase(g), Amaryl(g)), Actos*
ONSOLIS Actiq(g)*, MSIR(g), MS Contin(g), Oramorph SR(g), Roxanol(g)
OPANA, ER Methadone(g), Morphine(g), MS Contin(g), Oramorph SR(g)
ORACEA Monodox(g), Vibramycin(g)
ORAPRED ODT Orapred(g)
ORAXYL Vibramycin(g)
ORTHO-PREFEST Use FemHRT, Prempro/Premphase, or Estradiol plus progestin
OSMOPREP Fleet's Phospho Soda OTC, Colyte(g)
OVCON-50, FE Modicon(g), Ortho-Cyclen(g), Ortho-Novum(g), Ovcon-35(g)
OXISTAT Lamisil AT(g), OTC; Lotrimin(g), Ultra OTC; Monistat-Derm(g), Nizoral cream(g), Spectazole(g)
OXYCONTIN Duragesic(g), Methadone(g), MS Contin(g), Oramorph(g)
OXYTROL Ditropan, XL(g); Detrol, LA
PANCRECARB MS - 16
Pancrease MT - 16(g), Viokase
PANCRECARB MS - 4
Pancrease MT - 4(g), Pancrealipase EC
PANDEL Aristocort(g), Elocon(g), Locoid(g), Synalar(g), Topicort(g), Cloderm, Cordran
PANIXINE Keflex(g)
PAREMYD Atropine(g), Cyclogyl(g), Mydriacyl(g)
PATADAY Zaditor OTC(g), Alocril, Alomide, Patanol
PATANASE Flonase(g), Nasalide(g), Nasarel(g), Astelin(g), Nasacort AQ*
PCE Biaxin(g), Erythromycin(g), Zithromax(g)
PENNSAID Topical OTC analgesic balms, i.e. trolamine salicylate; Voltaren oral(g)
PERANEX HC Anusol HC(g), Proctocream HC(g)
PERFOROMIST Serevent Diskus, Foradil MDI
* Prior Authorization or Step Therapy may be required.
Most BCN members and some BCBSM members do not have coverage for nonformulary agents. Please use this list as a guide when selecting alternatives.
** Covered with a prescription for BCN members and certain BCBSM members.
Page 36
NonFormulary Formulary Alternative NonFormulary Formulary Alternative
PEXEVA Generic SSRI/SNRI (Celexa(g), Prozac(g), Paxil(g), Zoloft (g), etc.)
PLAN B ONE-STEP Plan B(g)
PRANDIMET Individual agents: Prandin and Glucophage(g)
PRED-G Garamycin(g), Pred Forte(g)
PREVACID NAPRAPAC
Prilosec OTC**; Prevacid(g)*, Solutab(g)*; Prilosec 20mg(g), PLUS Naprosyn(g)
PRILOSEC SUSPENSION
Prilosec OTC**; Prevacid(g)*, Solutab(g)*; Prilosec 20 mg(g), Protonix(g)*
PRISTIQ Generic SSRI/SNRI (Celexa(g), Prozac(g), Zoloft (g), Effexor(g), Effexor XR(g), etc.)
PROCENTRA Adderall XR(g)*, Metadate CD (Both of which may be "sprinkled" on food)
PROQUIN XR Bactrim DS/Septra DS(g), Cipro(g), XR(g) *
PROTONIX SUSP Prilosec OTC**; Prevacid(g)*, Solutab(g)*; Prilosec 20mg(g); Protonix(g)*
PROTOPIC Topical corticosteroids, Elidel*
PROVENTIL HFA Proair HFA, Ventolin HFA
PYLERA Use Tetracycline(g) plus Flagyl(g) plus Bismuth; or Helidac or PREVPAC
QUALAQUIN Aralen(g), Lariam(g), Plaquenil(g)
QUIXIN Ciloxan(g), Vigamox
RANEXA Long-acting nitrate, plus a beta-blocker or calcium channel blocker
RANICLOR Ceclor(g), Ceftin(g), Duricef(g), Keflex(g), Omnicef(g)
RAPAFLO Cardura(g), Flomax(g), Hytrin(g), Avodart, Uroxatral
REGRANEX Ethezyme(g), Granulex(g)
RELPAX Amerge(g)*, Imitrex(g); Maxalt*, MLT*
REQUIP XL Requip(g)
REVLIMID Thalomid
RHINOCORT AQUA
Flonase(g), Nasalide(g), Nasarel(g), Nasacort AQ*
RIOMET Glucophage(g)
RITALIN LA Adderall, XR(g)*; Ritalin(g), Concerta, Metadate CD
ROZEREM Ambien(g), Halcion(g), Prosom(g), Restoril(g), Sonata(g)
RYBIX ODT Ultram(g)
RYTHMOL SR Rythmol(g)
RYZOLT Ultram(g)
SAIZEN Genotropin*; Nutropin*, AQ*
SANCTURA XR Ditropan, XL(g); Sanctura(g); Detrol, LA
SANCUSO PATCH Kytril(g); Zofran, ODT(g)
SAPHRIS Clozaril(g), Risperdal(g), Abilify, Geodon, Seroquel, Zyprexa
SARAFEM TABLET Sarafem capsule(g)
SAVELLA Effexor(g), Effexor XR(g), Flexeril(g), Neurontin(g), SSRI(g), TCA's(g), Ultram(g)
SEASONIQUE Generic biphasic contraceptives
SEMPREX D Claritin OTC(g)**, Zyrtec OTC(g)**, Allegra(g), Allegra-D 12 hour(g)*, Allegra-D 24 hour*, Astelin(g)
SEROQUEL XR Clozaril(g), Risperdal(g), Abilify, Geodon, Zyprexa, Seroquel(IR)
SEROSTIM Genotropin*, Nutropin*, AQ*
SERZONE(g) Generic SSRI/SNRI (Celexa(g), Prozac(g), Paxil(g), Zoloft(g), etc.)
SILENOR Ambien(g), Desyrel(g), Sinequan(g), Sonata(g)
SIMCOR Individual agents (Zocor(g) PLUS Niaspan)
SIMPONI Enbrel*, Humira*
SOLARAZE Efudex(g)
SOLODYN Monodox(g), Vibramycin(g)
SOLTAMOX Nolvadex(g)
SOMA 250 Soma(g)
STAXYN Cialis*, Viagra*
STRATTERA Adderall, XR(g)*; Focalin(g), Ritalin(g), Concerta, Metadate CD
STRIANT Androxy(g), Depo-testosterone(g), Oxandrin(g), Androderm, Delatestryl
SUMAVEL DOSEPRO
Amerge(g)*, Imitrex(g); Maxalt*, MLT*
SUPRAX Ceclor(g), Ceftin(g), Duricef(g), Keflex(g), Omnicef(g)
SYMBYAX Use Zyprexa plus Prozac(g)
SYMLIN Insulin
TACLONEX, SCALP
Use Dovonex plus Diprosone/Diprolene(g)
TASMAR Comtan
TEKAMLO Lotrel(g), Generic ACE Inhibitor (lisinopril, benazepril, etc.), Benicar*, or Cozaar(g) PLUS Norvasc(g)
TEKTURNA, HCT Generic ACE Inhibitors (benazapril, enalapril, lisinopril, etc.)
TESTIM Androderm
TESTRED, ANDROID
Androxy(g), Depo-testosterone(g), Oxandrin(g), Androderm, Delatestryl
TEVETEN, HCT Cozaar(g), Hyzaar(g), Benicar*, HCT*
TEV-TROPIN Genotropin*; Nutropin*, AQ*
* Prior Authorization or Step Therapy may be required.
Most BCN members and some BCBSM members do not have coverage for nonformulary agents. Please use this list as a guide when selecting alternatives.
** Covered with a prescription for BCN members and certain BCBSM members.
Page 37
NonFormulary Formulary Alternative NonFormulary Formulary Alternative
TIROSINT Synthroid(g)
TOVIAZ Ditropan, XL(g); Detrol, LA
TRANXENE SD Ativan(g), Buspar(g), Serax(g), Tranxene(g), Valium(g), Xanax(g)
TREXIMET Individual agents (Imitrex(g) PLUS naproxen); Amerge(g)*; Maxalt, MLT*
TRIBENZOR Cozaar(g), HCTZ(g), Hyzaar(g), PLUS Norvasc(g)
TRIGLIDE Lofibra(g), Lopid(g), Tricor
TRILIPIX Lofibra(g), Lopid(g), Tricor
TWYNSTA Lotrel(g), Generic ACE Inhibitor (lisinopril, benazepril, etc.), Benicar*, or Cozaar(g) PLUS Norvasc(g)
TYZEKA Baraclude, Epivir HBV, Hepsera
ULORIC Zyloprim(g)
ULTRAM ER 300MG
Ultram(g)
VAGIFEM Climara(g), Ogen(g), Vivelle-DOT, Estraderm, Estring, Premarin Vaginal
VALTURNA Generic ACE Inhibitors (benazapril, enalapril, lisinopril, etc.)
VANOS 0.1% CR Diprolene(g), Psorcon(g), Temovate(g), Ultravate(g)
VECTICAL Dovonex
VERAMYST Flonase(g), Nasalide(g), Nasarel(g), Nasacort AQ*
VERDESO Elocon(g), Locoid(g), Synalar solution(g), Capex
VEREGEN Condylox Solution(g), Gel
VESICARE Ditropan, XL(g); Detrol, LA
VICTOZA Insulin, Glucophage(g), Sulfonylurea's, TZD's
VISICOL Fleet's Phospho Soda OTC, Colyte(g)
VOLTAREN GEL Topical OTC analgesic balms, i.e. trolamine salicylate; Voltaren oral(g)
VUSION OTC diaper rash products
VYTORIN Mevacor(g), Pravachol(g), Zocor(g), Crestor*; plus Zetia*
VYVANSE Adderall, XR(g)*; Ritalin, SR(g); Concerta, Metadate CD
XENICAL Alli OTC, Bontril(g)*, Didrex(g)*, Phentermine(g)*, Tenuate(g)*
XERESE Zovirax cream PLUS HC cream
XIBROM Ocufen(g), Voltaren (ophthalmic)(g)
XIFAXAN 220MG Bactrim DS(g), Vibramycin(g)
XIFAXAN 550MG Lactulose
XODOL Vicodin(g)
XOLEGEL Nizoral(g)
XOPENEX, HFA Albuterol(g); Maxair; Proair HFA, Ventolin HFA
XYREM Ambien(g), Halcion(g), Prosom(g), Restoril(g)
XYZAL SOLUTION Claritin OTC(g)**, Zyrtec OTC(g)**, Allegra(g)
ZANAFLEX(g) Dantrium(g), Flexeril(g), Lioresal(g)
ZANTAC EFFERDOSE
Zantac, OTC(g); Pepcid(g)
ZAVESCA Ceredase, Cerezyme (medical benefit)
ZEGERID PACKET Prilosec OTC**; Prevacid(g)*, Solutab(g)*; Prilosec 20mg(g), Protonix(g)*, Zegerid(g)*
ZELAPAR Eldepryl(g)
ZEMPLAR Rocaltrol(g)
ZIANA GEL Individual agents: Cleocin topical(g) and Retin-A(g)*
ZIPSOR Mobic(g), Motrin(g), Naprosyn, EC(g); Voltaren(g), etc*
ZMAX Zithromax(g)
ZOLPIMIST Ambien(g), Sonata(g)
ZOMIG, ZMT, NASAL SPRAY
Amerge(g)*, Imitrex(g); Maxalt*, MLT*
ZORBTIVE Genotropin*; Nutropin*, AQ*
ZUPLENZ Kytril(g); Zofran, ODT(g)
ZYCLARA Aldara(g)
ZYDONE Lortab(g), Tylenol with Codeine(g), Vicodin(g)
ZYFLO CR Accolate(g), Inhaled Steroids, Singulair
ZYLET Maxitrol(g), Tobradex(g), Vasocidin(g)
ZYMAR Ciloxan(g), Vigamox
ZYMAXID Ciloxan(g), Ocuflox(g)
* Prior Authorization or Step Therapy may be required.
Most BCN members and some BCBSM members do not have coverage for nonformulary agents. Please use this list as a guide when selecting alternatives.
** Covered with a prescription for BCN members and certain BCBSM members.
Page 38
Dose Optimization and Quantity Limits The Blue Cross Blue Shield of Michigan and Blue Care Network dose optimization programs encourage appropriate prescribing of medications intended for once-daily administration. Quantities of these medications are limited to single daily doses of appropriate strengths. Michigan Blues pharmacists work closely with physicians and community pharmacists to achieve this goal, which promotes patient compliance and more cost-effective therapy. Examples of some drugs include certain cholesterol-lowering, diabetes, antidepressant and antihypertensive medications. Quantity limits also apply to both BCBSM and BCN for other medications, based on manufacturer recommendations, available package size and other criteria. These drugs are identified with a Quantity Limit (#) indicator. A complete list of medications subject to quantity limits is available at: bcbsm.com/provider/pharmacy_services/index.shtml. Copayments A member’s benefit plan design determines applicable copayments for covered prescriptions. Symbols used throughout the document
(g) Use generic equivalent (#) Quantity limits may apply [PA] Prior authorization required for some members [ST] Step therapy required prior to use for some members <s> Specialty drug BE Drugs offered a Tier 0 copayment for Blue EssentialsSM Rx benefit
Editor’s note: Please send us your comments and suggestions regarding this custom formulary. Your input is vital to its continued success. We review and consider all responses. Please send your comments to:
Drug Information Services — Mail Code B773 Blue Cross Blue Shield of Michigan 600 E. Lafayette Boulevard Detroit, MI 48226-2998
or Pharmacy Services — Mail Code C303 Blue Care Network of Michigan 20500 Civic Center Drive Southfield, MI 48076-5043
Page 39
1. ANTI-INFECTIVES
1A. Penicillins
Formulary PreferredGeneric NameTrade Name Utilization Management
AMOXICILLIN TRIHYDRATEAMOXIL (g)AMPICILLIN TRIHYDRATEAMPICILLIN (g)
AMOX TR/POTASSIUM CLAVULANATEAUGMENTIN, ES, XR (g)DICLOXACILLIN SODIUMDICLOXACILLIN (g)
PENICILLIN V POTASSIUMPENICILLIN VK (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
NONE
NonformularyGeneric NameTrade Name Utilization Management
AMOXICILLIN TRIHYDRATEMOXATAG
1B. Cephalosporins
Formulary PreferredGeneric NameTrade Name Utilization Management
CEFACLORCECLOR (g)CEFACLORCECLOR ER (g)
CEFUROXIME AXETILCEFTIN (g)CEFPROZILCEFZIL (g)
CEFADROXIL HYDRATEDURICEF (g)CEPHALEXIN MONOHYDRATEKEFLEX (g)
CEFDINIROMNICEF (g)CEFDITOREN PIVOXILSPECTRACEF (g) [QL]
CEFPODOXIME PROXETILVANTIN (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
NONE
NonformularyGeneric NameTrade Name Utilization Management
CEFTIBUTEN DIHYDRATECEDAXCEPHALEXIN MONOHYDRATEKEFLEX 750MG
CEFACLORRANICLORCEFIXIMESUPRAX
(g) Use generic equivalent
[PA] Prior authorization may be required
Page 40
[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
1C. Tetracyclines
Formulary PreferredGeneric NameTrade Name Utilization Management
DOXYCYCLINE MONOHYDRATEADOXA (g) [PA]MINOCYCLINE HCLMINOCIN, DYNACIN (g)
DOXYCYCLINE MONOHYDRATEMONODOX (g)DOXYCYCLINE HYCLATEPERIOSTAT (g)
MINOCYCLINE HCLSOLODYN 45, 90, 135MG(g) [PA]TETRACYCLINE HCLTETRACYCLINE (g)
DOXYCYCLINE HYCLATEVIBRAMYCIN, VIBRATABS (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
NONE
NonformularyGeneric NameTrade Name Utilization Management
DOXYCYCLINE MONOHYDRATEADOXA 150MG CAPSULE [PA]DOXYCYCLINE MONOHY/SKIN CLNSR9ADOXA CK, TT [PA]
DOXYCYCLINE HYCLATEDORYX [PA]DOXYCYCLINE MONOHYDRATEORACEA [PA]
DOXYCYCLINE HYCLATEORAXYLMINOCYCLINE HCLSOLODYN 55, 65, 80, 105, 115MG [PA]
1D. Macrolides
Formulary PreferredGeneric NameTrade Name Utilization Management
CLARITHROMYCINBIAXIN, XL (g)ERYTHROMYCIN ETHYLSUCCINATEERYTHROMYCIN (g)
ERYTHROMYCIN BASEERYTHROMYCIN STEARATE, BASE (g)ERY E-SUCC/SULFISOXAZOLEPEDIAZOLE (g)
AZITHROMYCINZITHROMAX (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
NONE
NonformularyGeneric NameTrade Name Utilization Management
TELITHROMYCINKETEKERYTHROMYCIN BASEPCE
AZITHROMYCINZMAX
(g) Use generic equivalent
[PA] Prior authorization may be required
Page 41
[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
1E. Quinolones
Formulary PreferredGeneric NameTrade Name Utilization Management
CIPROFLOXACIN HCLCIPRO (g)CIPROFLOXACIN HCL-BETAINE COMBCIPRO XR (g) [PA] [QL]
OFLOXACINFLOXIN (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
MOXIFLOXACIN HCLAVELOX, ABC
NonformularyGeneric NameTrade Name Utilization Management
GEMIFLOXACIN MESYLATEFACTIVELEVOFLOXACINLEVAQUINNORFLOXACINNOROXIN
CIPROFLOXACIN HCLPROQUIN XR [PA] [QL]
1F. Sulfonamides and Combinations
Formulary PreferredGeneric NameTrade Name Utilization Management
SULFAMETHOXAZOLE/TRIMETHOPRIMBACTRIM, DS, SEPTRA, DS (g)ERY E-SUCC/SULFISOXAZOLEPEDIAZOLE (g)
SULFADIAZINESULFADIAZINE (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
NONE
NonformularyGeneric NameTrade Name Utilization Management
NONE
1G. Urinary Tract Agents
Formulary PreferredGeneric NameTrade Name Utilization Management
METHENAMINE HIPPURATEHIPREX/UREX (g)NITROFURANTOIN/NITROFURAN MACMACROBID (g)NITROFURANTOIN MACROCRYSTALMACRODANTIN (g)
METHENAMINE MANDELATEMANDELAMINE (g)PHENAZOPYRIDINE HCLPYRIDIUM (g)
TRIMETHOPRIMTRIMETHOPRIM (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
NONE
NonformularyGeneric NameTrade Name Utilization Management
FOSFOMYCIN TROMETHAMINEMONUROL
(g) Use generic equivalent
[PA] Prior authorization may be required
Page 42
[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
1H. Antifungals
Formulary PreferredGeneric NameTrade Name Utilization Management FLUCONAZOLEDIFLUCAN (g)
GRISEOFULVIN,MICROSIZEGRIFULVIN V SUSP (g)TERBINAFINE HCLLAMISIL TABLETS (g)
CLOTRIMAZOLEMYCELEX TROCHE (g)KETOCONAZOLENIZORAL (g)
NYSTATINNYSTATIN (g)ITRACONAZOLESPORANOX CAPS (g)
Formulary OptionsGeneric NameTrade Name Utilization Management FLUCYTOSINEANCOBON
GRISEOFULVIN,MICROSIZEGRIFULVIN V 500MGGRISEOFULVIN ULTRAMICROSIZEGRIS PEG
POSACONAZOLENOXAFILITRACONAZOLESPORANOX SOLNVORICONAZOLEVFEND
NonformularyGeneric NameTrade Name Utilization Management
TERBINAFINE HCLLAMISIL GRANULES [PA]MICONAZOLEORAVIG [QL]
1I. Antivirals
Formulary PreferredGeneric NameTrade Name Utilization Management
RIBAVIRINCOPEGUS (g) [PA] <s>GANCICLOVIRCYTOVENE (g)FAMCICLOVIRFAMVIR (g) [QL]
RIMANTADINE HCLFLUMADINE (g)RIBAVIRINREBETOL (g) [PA] <s>
AMANTADINE HCLSYMMETREL (g)VALACYCLOVIR HCLVALTREX (g) [QL]
ACYCLOVIRZOVIRAX (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
ENTECAVIRBARACLUDE <s>LAMIVUDINEEPIVIR HBV
ADEFOVIR DIPIVOXILHEPSERA <s>RIBAVIRINREBETOL SOLUTION [PA] <s>ZANAMIVIRRELENZA [QL]
OSELTAMIVIR PHOSPHATETAMIFLU CAP, SUSP [QL]VALGANCICLOVIR HYDROCHLORIDEVALCYTE
NonformularyGeneric NameTrade Name Utilization Management TELBIVUDINETYZEKA <s>
(g) Use generic equivalent
[PA] Prior authorization may be required
Page 43
[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
1J. Antiretrovirals
Formulary PreferredGeneric NameTrade Name Utilization Management
ZIDOVUDINERETROVIR (g)DIDANOSINEVIDEX EC (g)STAVUDINEZERIT (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
TIPRANAVIRAPTIVUS(MUST BE USED WITH NORVIR)EFAVIRENZ/EMTRICITAB/TENOFOVIRATRIPLA
LAMIVUDINE/ZIDOVUDINECOMBIVIRINDINAVIR SULFATECRIXIVAN
EMTRICITABINEEMTRIVALAMIVUDINEEPIVIR
ABACAVIR SULFATE/LAMIVUDINEEPZICOMENFUVIRTIDEFUZEON <s>ETRAVIRINEINTELENCE
SAQUINAVIR MESYLATEINVIRASERALTEGRAVIR POTASSIUMISENTRESS
RITONAVIR/LOPINAVIRKALETRAFOSAMPRENAVIR CALCIUMLEXIVA
RITONAVIRNORVIRDARUNAVIR ETHANOLATEPREZISTA(MUST BE USED WITH NORVIR)DELAVIRDINE MESYLATERESCRIPTOR
ATAZANAVIR SULFATEREYATAZMARAVIROCSELZENTRYEFAVIRENZSUSTIVA
ABACAVIR/LAMIVUDINE/ZIDOVUDINETRIZIVIREMTRICITABINE/TENOFOVIRTRUVADA
DIDANOSINEVIDEXNELFINAVIR MESYLATEVIRACEPT
NEVIRAPINEVIRAMUNETENOFOVIR DISOPROXIL FUMARATEVIREAD
ABACAVIR SULFATEZIAGEN
NonformularyGeneric NameTrade Name Utilization Management
NONE
(g) Use generic equivalent
[PA] Prior authorization may be required
Page 44
[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
1K. Antimalarials
Formulary PreferredGeneric NameTrade Name Utilization Management
CHLOROQUINE PHOSPHATEARALEN (g)MEFLOQUINE HCLLARIAM (g)
HYDROXYCHLOROQUINE SULFATEPLAQUENIL (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
ARTEMETHER/LUMEFANTRINECOARTEM [QL]PYRIMETHAMINEDARAPRIM
ATOVAQUONE/PROGUANIL HCLMALARONEPRIMAQUINE PHOSPHATEPRIMAQUINE
NonformularyGeneric NameTrade Name Utilization Management
QUININE SULFATEQUALAQUIN
1L. Antituberculars
Formulary PreferredGeneric NameTrade Name Utilization Management
ETHAMBUTOL HCLETHAMBUTOL (g)ISONIAZIDISONIAZID (g)
PYRAZINAMIDEPYRAZINAMIDE (g)RIFAMPINRIFADIN (g)
RIFAMPIN/ISONIAZIDRIFAMATE (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
DAPSONEDAPSONERIFABUTINMYCOBUTIN
CYCLOSERINESEROMYCIN
NonformularyGeneric NameTrade Name Utilization Management RIFAPENTINEPRIFTIN
RIFAMPIN/INH/PYRAZINAMIDERIFATERETHIONAMIDETRECATOR
(g) Use generic equivalent
[PA] Prior authorization may be required
Page 45
[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
1M. Antiparasitics/Anthelmintics
Formulary PreferredGeneric NameTrade Name Utilization Management
METRONIDAZOLEFLAGYL (g)PAROMOMYCIN SULFATEHUMATIN (g)
MEBENDAZOLEVERMOX (g) [QL]
Formulary OptionsGeneric NameTrade Name Utilization Management NITAZOXANIDEALINIAPRAZIQUANTELBILTRICIDE
METRONIDAZOLEFLAGYL ERATOVAQUONEMEPRON
PENTAMIDINE ISETHIONATENEBUPENT AEROSOLIVERMECTINSTROMECTROL - SINGLE DOSE [QL]TINIDAZOLETINDAMAX [QL]
NonformularyGeneric NameTrade Name Utilization Management ALBENDAZOLEALBENZA
1N. Miscellaneous Anti-infectives
Formulary PreferredGeneric NameTrade Name Utilization Management
CLINDAMYCIN HCLCLEOCIN (g)NEOMYCIN SULFATENEOMYCIN (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
TOBRAMYCIN/0.25 NORMAL SALINETOBI [QL] <s>VANCOMYCIN HCLVANCOCIN HCL
LINEZOLIDZYVOX
NonformularyGeneric NameTrade Name Utilization Management
AZTREONAM LYSINECAYSTON [PA] [QL] <s>RIFAXIMINXIFAXAN 200MG [QL]RIFAXIMINXIFAXAN 550MG [PA] [QL]
(g) Use generic equivalent
[PA] Prior authorization may be required
Page 46
[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
2. CARDIOVASCULAR, HYPERTENSION, CHOLESTEROL
2A. Lipid-lowering Agents
Formulary PreferredGeneric NameTrade Name Utilization Management
COLESTIPOL HCLCOLESTID (g)FENOFIBRIC ACIDFIBRICOR (g)
FENOFIBRATE,MICRONIZEDLOFIBRA (g) BEGEMFIBROZILLOPID (g) BELOVASTATINMEVACOR (g) [QL] BE
PRAVASTATIN SODIUMPRAVACHOL (g) [QL] BECHOLESTYRAMINEQUESTRAN, QUESTRAN LIGHT (g)
SIMVASTATINZOCOR (g) [QL] BE
Formulary OptionsGeneric NameTrade Name Utilization Management
ROSUVASTATIN CALCIUMCRESTOR [ST] [QL]NIACINNIASPAN BE
FENOFIBRATE NANOCRYSTALLIZEDTRICOR [QL]COLESEVELAM HCLWELCHOL
EZETIMIBEZETIA [ST] [QL]
NonformularyGeneric NameTrade Name Utilization Management
NIACIN/LOVASTATINADVICOR [PA] [QL]LOVASTATINALTOPREV [PA] [QL]
FENOFIBRATE,MICRONIZEDANTARAAMLODIPINE/ATORVAST CALCADUET [PA] [QL]
COLESTIPOL HCLCOLESTID FLAVOREDFENOFIBRATEFENOGLIDE
FLUVASTATIN SODIUMLESCOL, XL [PA] [QL]ATORVASTATIN CALCIUMLIPITOR [PA] [QL]
FENOFIBRATELIPOFEN [QL]PITAVASTATIN CALCIUMLIVALO [ST] [QL]
OMEGA-3 ACID ETHYL ESTERSLOVAZANIACIN/SIMVASTATINSIMCOR [ST]
FENOFIBRATE NANOCRYSTALLIZEDTRIGLIDEFENOFIBRIC ACIDTRILIPIX [PA] [QL]
EZETIMIBE/SIMVASTATINVYTORIN [PA] [QL]
(g) Use generic equivalent
[PA] Prior authorization may be required
Page 47
[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
2B. Beta Blockers and Combinations
Formulary PreferredGeneric NameTrade Name Utilization Management SOTALOL HCLBETAPACE, AF (g) BE
TIMOLOL MALEATEBLOCADREN (g) BECARVEDILOLCOREG (g) BE
NADOLOLCORGARD (g) BENADOLOL/BENDROFLUMETHIAZIDECORZIDE (g) BE
PROPRANOLOL HCLINDERAL (g) BEPROPRANOLOL HCLINDERAL LA (g) [QL] BE
PROPRANOLOL/HYDROCHLOROTHIAZIDEINDERIDE (g) BEBETAXOLOL HCLKERLONE (g) BE
METOPROLOL TARTRATELOPRESSOR (g) BEMETOPROLOL/HYDROCHLOROTHIAZIDELOPRESSOR HCT (g) BE
LABETALOL HCLNORMODYNE (g) BEPINDOLOLPINDOLOL (g) BE
ACEBUTOLOL HCLSECTRAL (g) BEATENOLOL/CHLORTHALIDONETENORETIC (g) BE
ATENOLOLTENORMIN (g) BEMETOPROLOL SUCCINATETOPROL XL (g) BEBISOPROLOL FUMARATEZEBETA (g) BE
BISOPROL/HYDROCHLOROTHIAZIDEZIAC (g) BE
Formulary OptionsGeneric NameTrade Name Utilization Management
NONE
NonformularyGeneric NameTrade Name Utilization Management NEBIVOLOL HCLBYSTOLIC [PA] [QL]
CARVEDILOL PHOSPHATECOREG CR [PA] [QL]PROPRANOLOL HCLINNOPRAN XL
PENBUTOLOL SULFATELEVATOL
(g) Use generic equivalent
[PA] Prior authorization may be required
Page 48
[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
2C. ACE-Inhibitors and Combinations
Formulary PreferredGeneric NameTrade Name Utilization Management QUINAPRIL HCLACCUPRIL (g) BE
QUINAPRIL/HYDROCHLOROTHIAZIDEACCURETIC (g) BEPERINDOPRIL ERBUMINEACEON (g)
RAMIPRILALTACE CAPSULE (g) BECAPTOPRILCAPOTEN (g) BE
CAPTOPRIL/HYDROCHLOROTHIAZIDECAPOZIDE (g) BEBENAZEPRIL HCLLOTENSIN (g) BE
BENAZEPRIL/HYDROCHLOROTHIAZIDELOTENSIN HCT (g) BEAMLODIPINE BESYLATE/BENAZEPRILLOTREL (g) BE
TRANDOLAPRILMAVIK (g) BEFOSINOPRIL SODIUMMONOPRIL (g) BE
FOSINOPRIL/HYDROCHLOROTHIAZIDEMONOPRIL HCT (g) BELISINOPRILPRINIVIL, ZESTRIL (g) BE
LISINOPRIL/HYDROCHLOROTHIAZIDEPRINZIDE, ZESTORETIC (g) BETRANDOLAPRIL/VERAPAMIL HCLTARKA (g) [QL]
MOEXIPRIL/HYDROCHLOROTHIAZIDEUNIRETIC (g) BEMOEXIPRIL HCLUNIVASC (g) BE
ENALAPRIL/HYDROCHLOROTHIAZIDEVASERETIC (g) BEENALAPRIL MALEATEVASOTEC (g) BE
Formulary OptionsGeneric NameTrade Name Utilization Management
AMLODIPINE BESYLATE/BENAZEPRILLOTREL 5/40, 10/40 [QL]
NonformularyGeneric NameTrade Name Utilization Management
RAMIPRILALTACE TABLET [PA] [QL]
(g) Use generic equivalent
[PA] Prior authorization may be required
Page 49
[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
2D. Angiotensin II Receptor Blockers and Combinations
Formulary PreferredGeneric NameTrade Name Utilization Management
LOSARTAN POTASSIUMCOZAAR (g) [QL] BELOSARTAN/HYDROCHLOROTHIAZIDEHYZAAR (g) [QL] BE
Formulary OptionsGeneric NameTrade Name Utilization Management
OLMESARTAN MEDOXOMILBENICAR [ST] [QL]OLMESARTAN/HYDROCHLOROTHIAZIDEBENICAR HCT [ST] [QL]
NonformularyGeneric NameTrade Name Utilization Management
CANDESARTAN CILEXETILATACAND [PA] [QL]CANDESARTAN/HYDROCHLOROTHIAZIDATACAND HCT [PA]IRBESARTAN/HYDROCHLOROTHIAZIDEAVALIDE [PA] [QL]
IRBESARTANAVAPRO [PA] [QL]AMLODIPINE BES/OLMESARTAN MEDAZOR [PA] [QL]
VALSARTANDIOVAN [PA]VALSARTAN/HYDROCHLOROTHIAZIDEDIOVAN HCT [PA] [QL]
AMLODIPINE/VALSARTANEXFORGE [PA]AMLODIPINE/VALSARTAN/HCTZEXFORGE HCT [PA] [QL]
TELMISARTANMICARDIS [PA] [QL]TELMISARTAN/HYDROCHLOROTHIAZIDMICARDIS HCT [PA] [QL]
EPROSARTAN MESYLATETEVETEN [PA]EPROSARTAN/HYDROCHLOROTHIAZIDETEVETEN HCT [PA]OLMESARTAN MED/AMLODIPINE/HCTZTRIBENZOR [ST] [QL]
TELMISARTAN/AMLODIPINETWYNSTA [PA] [QL]ALISKIREN/VALSARTANVALTURNA [PA] [QL]
(g) Use generic equivalent
[PA] Prior authorization may be required
Page 50
[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
2E. Calcium Channel Blockers and Combinations
Formulary PreferredGeneric NameTrade Name Utilization Management
VERAPAMIL HCLCALAN SR/ISOPTIN SR (g)NICARDIPINE HCLCARDENE (g)
DILTIAZEM HCLCARDIZEM LA (g)DILTIAZEM HCLCARDIZEM, SR, CD (g)
ISRADIPINEDYNACIRC (g)AMLODIPINE BESYLATE/BENAZEPRILLOTREL (g) BE
AMLODIPINE BESYLATENORVASC (g) BEFELODIPINEPLENDIL (g)NIFEDIPINEPROCARDIA, XL;ADALAT CC (g) [QL]
NISOLDIPINESULAR (g)TRANDOLAPRIL/VERAPAMIL HCLTARKA (g) [QL]
DILTIAZEM HCLTIAZAC (g)VERAPAMIL HCLVERELAN (g)VERAPAMIL HCLVERELAN PM (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
VERAPAMIL HCLCOVERA-HSAMLODIPINE BESYLATE/BENAZEPRILLOTREL 5/40, 10/40 [QL]
NonformularyGeneric NameTrade Name Utilization Management
AMLODIPINE BES/OLMESARTAN MEDAZOR [PA] [QL]AMLODIPINE/ATORVAST CALCADUET [PA] [QL]
NICARDIPINE HCLCARDENE SRDILTIAZEM HCLCARDIZEM LA
ISRADIPINEDYNACIRC CRAMLODIPINE/VALSARTANEXFORGE [PA]
AMLODIPINE/VALSARTAN/HCTZEXFORGE HCT [PA] [QL]NISOLDIPINESULAR 8.5, 17, 25.5, 34MG
ALISKIREN/AMLODIPINETEKAMLO [ST] [QL]OLMESARTAN MED/AMLODIPINE/HCTZTRIBENZOR [ST] [QL]
TELMISARTAN/AMLODIPINETWYNSTA [PA] [QL]
(g) Use generic equivalent
[PA] Prior authorization may be required
Page 51
[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
2F. Diuretics
Formulary PreferredGeneric NameTrade Name Utilization Management
SPIRONOLACT/HYDROCHLOROTHIAZIDALDACTAZIDE (g) BESPIRONOLACTONEALDACTONE (g) BE
BUMETANIDEBUMEX (g) BETORSEMIDEDEMADEX (g) BE
ACETAZOLAMIDEDIAMOX (g)ACETAZOLAMIDEDIAMOX SEQUELS (g)CHLOROTHIAZIDEDIURIL (g) BE
HYDROCHLOROTHIAZIDEHYDRODIURIL, MICROZIDE (g) BECHLORTHALIDONEHYGROTON, THALITONE (g) BE
EPLERENONEINSPRA (g) BEFUROSEMIDELASIX (g) BEINDAPAMIDELOZOL (g) BE
TRIAMTERENE/HYDROCHLOROTHIAZIDMAXZIDE, DYAZIDE (g) BEAMILORIDE HCLMIDAMOR (g) BE
AMILORIDE/HYDROCHLOROTHIAZIDEMODURETIC (g) BEMETOLAZONEZAROXOLYN (g) BE
Formulary OptionsGeneric NameTrade Name Utilization Management TRIAMTERENEDYRENIUM
ETHACRYNIC ACIDEDECRIN
NonformularyGeneric NameTrade Name Utilization Management
NONE
2G. Cardiovascular Treatment
Formulary PreferredGeneric NameTrade Name Utilization Management SOTALOL HCLBETAPACE, AF (g) BE
AMIODARONE HCLCORDARONE (g)DIGOXINDIGOXIN ELIXIR (g)DIGOXINDIGOXIN TABS (g)
MEXILETINE HCLMEXITIL (g)DISOPYRAMIDE PHOSPHATENORPACE (g)
MIDODRINE HCLPROAMATINE (g)PROCAINAMIDE HCLPRONESTYL, SR (g)QUINIDINE SULFATEQUINIDEX (g)
QUINIDINE GLUCONATEQUINIDINE GLUCONATE SA (g)PROPAFENONE HCLRYTHMOL (g)
FLECAINIDE ACETATETAMBOCOR (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
DRONEDARONE HYDROCHLORIDEMULTAQ [QL]DISOPYRAMIDE PHOSPHATENORPACE CR
DOFETILIDETIKOSYN
NonformularyGeneric NameTrade Name Utilization Management RANOLAZINERANEXA [PA]
PROPAFENONE HCLRYTHMOL SR
(g) Use generic equivalent
[PA] Prior authorization may be required
Page 52
[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
2H. Nitrates and Combinations
Formulary PreferredGeneric NameTrade Name Utilization Management
ISOSORBIDE MONONITRATEIMDUR (g)ISOSORBIDE MONONITRATEISMO, MONOKET (g)
ISOSORBIDE DINITRATEISORDIL (g)NITROGLYCERINNITROGLYCERIN PATCH (g)NITROGLYCERINNITROGLYCERIN SA CAP (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
ISOSORBIDE DINITRATEDILATRATE-SRNITROGLYCERINNITRO-BID OINTMENTNITROGLYCERINNITROLINGUAL SPRAYNITROGLYCERINNITROMISTNITROGLYCERINNITROSTAT
NonformularyGeneric NameTrade Name Utilization Management
NONE
2I. Anticoagulants and Hemostasis Agents
Formulary PreferredGeneric NameTrade Name Utilization Management
ANAGRELIDE HCLAGRYLIN (g)AMINOCAPROIC ACIDAMICAR (g)WARFARIN SODIUMCOUMADIN (g) BE
HEPARIN SODIUM,PORCINEHEPARIN (g) <s>ENOXAPARIN SODIUMLOVENOX (g) <s>
DIPYRIDAMOLEPERSANTINE (g)CILOSTAZOLPLETAL (g)
TICLOPIDINE HCLTICLID (g)PENTOXIFYLLINETRENTAL (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
PRASUGREL HYDROCHLORIDEEFFIENT [QL]PHYTONADIONEMEPHYTON
CLOPIDOGREL BISULFATEPLAVIX
NonformularyGeneric NameTrade Name Utilization Management
ASPIRIN/DIPYRIDAMOLEAGGRENOXFONDAPARINUX SODIUMARIXTRA <s>
DALTEPARIN SODIUM,PORCINEFRAGMIN <s>TINZAPARIN SODIUM,PORCINEINNOHEP <s>
(g) Use generic equivalent
[PA] Prior authorization may be required
Page 53
[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
2J. Alpha-adrenergic Agents
Formulary PreferredGeneric NameTrade Name Utilization Management METHYLDOPAALDOMET (g)
METHYLDOPA/HYDROCHLOROTHIAZIDEALDORIL (g)DOXAZOSIN MESYLATECARDURA (g)
CLONIDINE HCLCATAPRES (g)CLONIDINE HCLCATAPRES-TTS (g)TERAZOSIN HCLHYTRIN (g)PRAZOSIN HCLMINIPRESS (g)
RESERPINERESERPINE (g)GUANFACINE HCLTENEX (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
NONE
NonformularyGeneric NameTrade Name Utilization Management
NONE
2K. Miscellaneous Antihypertensives
Formulary PreferredGeneric NameTrade Name Utilization Management
HYDRALAZINE HCLAPRESOLINE (g)MINOXIDILLONITEN (g)
PAPAVERINE HCLPAPAVERINE CAPS (g)ISOXSUPRINE HCLVASODILAN (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
NONE
NonformularyGeneric NameTrade Name Utilization Management
ALISKIREN/AMLODIPINETEKAMLO [ST] [QL]ALISKIREN HEMIFUMARATETEKTURNA [PA]
ALISKIREN/HYDROCHLOROTHIAZIDETEKTURNA HCT [PA]ALISKIREN/VALSARTANVALTURNA [PA] [QL]
(g) Use generic equivalent
[PA] Prior authorization may be required
Page 54
[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
3. CENTRAL NERVOUS SYSTEM
3A. Antidepressants
Formulary PreferredGeneric NameTrade Name Utilization Management
AMOXAPINEAMOXAPINE (g)CLOMIPRAMINE HCLANAFRANIL (g) BE
CITALOPRAM HYDROBROMIDECELEXA (g) BETRAZODONE HCLDESYREL (g) BE
VENLAFAXINE HCLEFFEXOR (g) BEVENLAFAXINE HCLEFFEXOR XR (g) [QL] BE
AMITRIPTYLINE HCLELAVIL (g) BEAMITRIPTYLINE HCL/PERPHENAZINEETRAFON (g)
FLUVOXAMINE MALEATEFLUVOXAMINE MALEATE (g) BEAMITRIP HCL/CHLORDIAZEPOXIDELIMBITROL, DS (g)
MAPROTILINE HCLMAPROTILINE HCL (g) BEDESIPRAMINE HCLNORPRAMIN (g) BE
NORTRIPTYLINE HCLPAMELOR, AVENTYL (g) BETRANYLCYPROMINE SULFATEPARNATE (g)
PAROXETINE HCLPAXIL (g) BEPAROXETINE HCLPAXIL CR (g)FLUOXETINE HCLPROZAC WEEKLY (g) [QL]FLUOXETINE HCLPROZAC, SARAFEM (g) BE
MIRTAZAPINEREMERON (g) BEMIRTAZAPINEREMERON SOLTAB (g) BEDOXEPIN HCLSINEQUAN, ADAPIN (g) BE
TRIMIPRAMINE MALEATESURMONTIL (g)IMIPRAMINE HCLTOFRANIL (g) BE
IMIPRAMINE PAMOATETOFRANIL-PM (g)VENLAFAXINE HCLVENLAFAXINE HCL ER (g) [QL] BE
PROTRIPTYLINE HCLVIVACTIL (g)BUPROPION HCLWELLBUTRIN XL (g) [QL]BUPROPION HCLWELLBUTRIN, SR (g) BESERTRALINE HCLZOLOFT (g) BE
Formulary OptionsGeneric NameTrade Name Utilization Management
ESCITALOPRAM OXALATELEXAPRO [ST] [QL]PHENELZINE SULFATENARDIL
TRIMIPRAMINE MALEATESURMONTIL 100MG
NonformularyGeneric NameTrade Name Utilization Management
BUPROPRION HBRAPLENZIN [PA]DULOXETINE HCLCYMBALTA [PA] [QL]
SELEGILINEEMSAM [QL]FLUVOXAMINE MALEATELUVOX CR [ST] [QL]
ISOCARBOXAZIDMARPLANTRAZODONE HCLOLEPTRO ER [PA] [QL]
PAROXETINE MESYLATEPEXEVA [PA] [QL]DESVENLAFAXINE SUCCINATEPRISTIQ [ST] [QL]
FLUOXETINE HCLSARAFEM TABLETNEFAZODONE HCLSERZONE (g)
(g) Use generic equivalent
[PA] Prior authorization may be required
Page 55
[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
3B. Antipsychotics
Formulary PreferredGeneric NameTrade Name Utilization Management
CLOZAPINECLOZARIL (g) BEHALOPERIDOLHALDOL (g) BE
LOXAPINE SUCCINATELOXITANE (g)THIORIDAZINE HCLMELLARIL (g) BE
THIOTHIXENENAVANE (g)PERPHENAZINEPERPHENAZINE (g)
FLUPHENAZINE HCLPROLIXIN (g) BERISPERIDONERISPERDAL (g) (TIER 0-BCN ONLY) BERISPERIDONERISPERDAL M-TAB (g) BE
TRIFLUOPERAZINE HCLSTELAZINE (g) BECHLORPROMAZINE HCLTHORAZINE (g) BE
Formulary OptionsGeneric NameTrade Name Utilization Management ARIPIPRAZOLEABILIFY, DISCMELT, SOLUTION
ZIPRASIDONE HCLGEODONPIMOZIDEORAP
QUETIAPINE FUMARATESEROQUELOLANZAPINEZYPREXA, ZYDIS
NonformularyGeneric NameTrade Name Utilization Management ILOPERIDONEFANAPT
CLOZAPINEFAZACLOPALIPERIDONEINVEGA [PA] [QL]
ASENAPINESAPHRIS [QL]QUETIAPINE FUMARATESEROQUEL XR [PA] [QL]
OLANZAPINE/FLUOXETINE HCLSYMBYAX
3C. Anxiolytics
Formulary PreferredGeneric NameTrade Name Utilization Management
LORAZEPAMATIVAN (g)BUSPIRONE HCLBUSPAR (g)
CHLORDIAZEPOXIDE HCLLIBRIUM (g)MEPROBAMATEMILTOWN, EQUANIL (g)ALPRAZOLAMNIRAVAM (g)
OXAZEPAMSERAX (g)CLORAZEPATE DIPOTASSIUMTRANXENE (g)
DIAZEPAMVALIUM (g)ALPRAZOLAMXANAX, XR (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
NONE
NonformularyGeneric NameTrade Name Utilization Management
CLORAZEPATE DIPOTASSIUMTRANXENE SD
(g) Use generic equivalent
[PA] Prior authorization may be required
Page 56
[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
3D. Sedative/Hypnotics
Formulary PreferredGeneric NameTrade Name Utilization Management
ZOLPIDEM TARTRATEAMBIEN (g) [QL]ZOLPIDEM TARTRATEAMBIEN CR (g) [PA] [QL]CHLORAL HYDRATECHLORAL HYDRATE (g)FLURAZEPAM HCLDALMANE (g) [QL]
TRIAZOLAMHALCION (g) [QL]ESTAZOLAMPROSOM (g) [QL]TEMAZEPAMRESTORIL (g) [QL]ZALEPLONSONATA (g) [QL]
Formulary OptionsGeneric NameTrade Name Utilization Management
NONE
NonformularyGeneric NameTrade Name Utilization Management
BUTABARBITAL SODIUMBUTISOL SODIUMQUAZEPAMDORAL [QL]
ZOLPIDEM TARTRATEEDLUAR [PA] [QL]ESZOPICLONELUNESTA [PA] [QL]RAMELTEONROZEREM [PA] [QL]
DOXEPIN HCLSILENOR [PA] [QL]ZOLPIDEM TARTRATEZOLPIMIST [PA] [QL]
3E. CNS Stimulants
Formulary PreferredGeneric NameTrade Name Utilization Management
AMPHET ASP/AMPHET/D-AMPHETADDERALL (g) [QL]AMPHET ASP/AMPHET/D-AMPHETADDERALL XR (BRAND-BCN ONLY) [QL]AMPHET ASP/AMPHET/D-AMPHETADDERALL XR (g) (BCBSM ONLY) [QL]
METHAMPHETAMINE HCLDESOXYN (g) [QL]D-AMPHETAMINE SULFATEDEXEDRINE (g) [QL]
DEXMETHYLPHENIDATE HCLFOCALIN (g) [QL]METHYLPHENIDATE HCLMETHYLIN SOLN (g) [QL]METHYLPHENIDATE HCLRITALIN, SR; METHYLIN, ER (g) [QL]
Formulary OptionsGeneric NameTrade Name Utilization Management
METHYLPHENIDATE HCLCONCERTA [QL]METHYLPHENIDATE HCLMETADATE CD [QL]
MODAFINILPROVIGIL [PA] [QL]
NonformularyGeneric NameTrade Name Utilization Management
METHYLPHENIDATEDAYTRANA [QL]DEXMETHYLPHENIDATE HCLFOCALIN XR [QL]
METHYLPHENIDATE HCLMETHYLIN CHEW [QL]ARMODAFINILNUVIGIL [PA] [QL]
D-AMPHETAMINE SULFATEPROCENTRA [PA]METHYLPHENIDATE HCLRITALIN LA [QL]
ATOMOXETINE HCLSTRATTERA [PA] [QL]LISDEXAMFETAMINE DIMESYLATEVYVANSE [PA] [QL]
(g) Use generic equivalent
[PA] Prior authorization may be required
Page 57
[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
3F. Nonsteroidal Anti-inflammatory Drugs
Formulary PreferredGeneric NameTrade Name Utilization Management
NAPROXEN SODIUMANAPROX, DS (g)FLURBIPROFENANSAID (g)
DICLOFENAC POTASSIUMCATAFLAM (g)SULINDACCLINORIL (g)
OXAPROZINDAYPRO (g)NAPROXENEC-NAPROSYN (g)PIROXICAMFELDENE (g)
INDOMETHACININDOCIN, SR (g)KETOPROFENKETOPROFEN (g)
ETODOLACLODINE (g)ETODOLACLODINE XL (g)
MECLOFENAMATE SODIUMMECLOMEN (g)MELOXICAMMOBIC (g)IBUPROFENMOTRIN (g)NAPROXENNAPROSYN (g)
NABUMETONERELAFEN (g)TOLMETIN SODIUMTOLECTIN, DS (g)
KETOROLAC TROMETHAMINETORADOL (g) [QL]DICLOFENAC SODIUMVOLTAREN (g)DICLOFENAC SODIUMVOLTAREN-XR (g)
Formulary OptionsGeneric NameTrade Name Utilization Management INDOMETHACININDOCIN SUPPOSITORY
MEFENAMIC ACIDPONSTEL
NonformularyGeneric NameTrade Name Utilization Management
DICLOFENAC SODIUM/MISOPROSTOLARTHROTEC [PA]DICLOFENAC POTASSIUMCAMBIA [PA] [QL]
CELECOXIBCELEBREX [PA] [QL]DICLOFENAC EPOLAMINEFLECTOR PATCH [PA] [QL]
NAPROXEN SODIUMNAPRELANNAPROXEN SODIUMNAPRELAN CR DOSEPAK
DICLOFENAC SODIUMPENNSAID [PA] [QL]LANSOPRAZOLE/NAPROXENPREVACID NAPRAPAC [PA]
NAPROXEN/ESOMEPRAZOLE MAGVIMOVO [PA] [QL]DICLOFENAC SODIUMVOLTAREN GEL [PA] [QL]
DICLOFENAC POTASSIUMZIPSOR
(g) Use generic equivalent
[PA] Prior authorization may be required
Page 58
[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
3G. Salicylates
Formulary PreferredGeneric NameTrade Name Utilization Management
SALSALATEDISALCID, SALFLEX (g)DIFLUNISALDOLOBID (g)
CHOLINE MAGNESIUM TRISALICYLATETRILISATE (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
ASPIRINZORPRIN
NonformularyGeneric NameTrade Name Utilization Management
NONE
3H. Narcotics
Formulary PreferredGeneric NameTrade Name Utilization Management
FENTANYL CITRATEACTIQ (g) [PA] [QL]CODEINE SULFATE(g)CODEINE SULFATE (g)
MEPERIDINE HCLDEMEROL (g)HYDROMORPHONE HCLDILAUDID (g)
FENTANYLDURAGESIC (g) [QL]METHADONE HCLMETHADONE (g)
MORPHINE SULFATEMS CONTIN/ORAMORPH SR (g)MORPHINE SULFATEMSIR (g)OXYMORPHONE HCLOPANA (g) [PA] [QL]
OXYCODONE HCLOXYCODONE IMMEDIATE RELEASE (g)MORPHINE SULFATERMS SUPPOSITORY (g)MORPHINE SULFATEROXANOL (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
NONE
NonformularyGeneric NameTrade Name Utilization Management
MORPHINE SULFATEAVINZA [QL]MORPHINE SULFATE/NALTREXONEEMBEDA [QL]
HYDROMORPHONE HCLEXALGO [PA] [QL]FENTANYL CITRATEFENTORA [PA] [QL]MORPHINE SULFATEKADIAN
TAPENTADOL HYDROCHLORIDENUCYNTA [PA] [QL]FENTANYL CITRATEONSOLIS [PA] [QL]OXYMORPHONE HCLOPANA ER [PA] [QL]
OXYCODONE HCLOXYCONTIN [PA] [QL]
(g) Use generic equivalent
[PA] Prior authorization may be required
Page 59
[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
3I. Narcotic/Analgesic Combinations
Formulary PreferredGeneric NameTrade Name Utilization Management
CODEINE PHOS/ASPIRINASPIRIN W/CODEINE (g)CODEINE/BUTALBUT/ACETAMIN/CAFFFIORICET W/CODEINE (g)BUTALB/ACETAMINOPHEN/CAFFEINEFIORICET;ESGIC, PLUS (g)
BUTALBITAL/ASPIRIN/CAFFEINEFIORINAL (g)CODEINE/BUTALBITAL/ASA/CAFFEINFIORINAL W/CODEINE (g)OXYCODONE HCL/ACETAMINOPHENPERCOCET (g)
OXYCODONE HCL/ASPIRINPERCODAN (g)BUTALBITAL/ACETAMINOPHENPHRENILIN (g)
CODEINE PHOS/ACETAMINOPHENTYLENOL W/CODEINE (g)OXYCODONE HCL/ACETAMINOPHENTYLOX (g)
HYDROCODONE BIT/ACETAMINOPHENVICODIN, LORTAB (g)HYDROCODONE/IBUPROFENVICOPROFEN (g)
BUTALB/ACETAMINOPHEN/CAFFEINEZEBUTAL (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
BUTALBITAL/ACETAMINOPHENPHRENILIN FORTEDIHYDROCODEINE/ASPIRIN/CAFFEINSYNALGOS-DC
NonformularyGeneric NameTrade Name Utilization Management
OXYCODONE HCL/ACETAMINOPHENMAGNACETHYDROCODONE BIT/ACETAMINOPHENXODOLHYDROCODONE BIT/ACETAMINOPHENZYDONE
3J. Narcotic Mixed Agonist/Antagonist
Formulary PreferredGeneric NameTrade Name Utilization Management
BUTORPHANOL TARTRATESTADOL NS (g)PENTAZOCINE HCL/ACETAMINOPHENTALACEN (g)PENTAZOCINE HCL/NALOXONE HCLTALWIN NX (g)TRAMADOL HCL/ACETAMINOPHENULTRACET (g)
TRAMADOL HCLULTRAM (g)TRAMADOL HCLULTRAM ER 100MG, 200MG (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
BUPRENORPHINE HCL/NALOXONE HCLSUBOXONE FILM, TABS [PA]
NonformularyGeneric NameTrade Name Utilization Management
BUPRENORPHINEBUTRANS [PA] [QL]TRAMADOL HCLRYBIX ODT [PA] [QL]TRAMADOL HCLRYZOLT [QL]TRAMADOL HCLULTRAM ER 300MG
(g) Use generic equivalent
[PA] Prior authorization may be required
Page 60
[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
3K. Narcotic Antagonists
Formulary PreferredGeneric NameTrade Name Utilization Management
NALTREXONE HCLREVIA (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
METHYLNALTREXONERELISTOR [PA] [QL]
NonformularyGeneric NameTrade Name Utilization Management
NONE
3M. Migraine Therapy
Formulary PreferredGeneric NameTrade Name Utilization Management
NARATRIPTAN HCLAMERGE (g) [ST] [QL]BUTALBITAL/ACETAMINOPHENBUPAP (g)
ERGOTAMINE TARTRATE/CAFFEINECAFERGOT (g) [QL]DIHYDROERGOTAMINE MESYLATED.H.E.45 (g) [QL]
BUTALB/ACETAMINOPHEN/CAFFEINEFIORICET;ESGIC, PLUS (g)BUTALBITAL/ASPIRIN/CAFFEINEFIORINAL (g)
CODEINE/BUTALBITAL/ASA/CAFFEINFIORINAL W/CODEINE (g)SUMATRIPTAN SUCCINATEIMITREX INJECTION (g) [QL]
SUMATRIPTANIMITREX NASAL SPRAY (g) [QL]SUMATRIPTAN SUCCINATEIMITREX TABLETS (g) [QL]
ISOMETHEPTENE/APAP/DICHLPHENMIDRIN (g)BUTALBITAL/ACETAMINOPHENPHRENILIN (g)
BUTORPHANOL TARTRATESTADOL NS (g)BUTALB/ACETAMINOPHEN/CAFFEINEZEBUTAL (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
ERGOTAMINE TARTRATEERGOMAR [QL]RIZATRIPTAN BENZOATEMAXALT, MLT [ST] [QL]
DIHYDROERGOTAMINE MESYLATEMIGRANAL [QL]BUTALBITAL/ACETAMINOPHENPHRENILIN FORTE
NonformularyGeneric NameTrade Name Utilization Management
SUMATRIPTAN SUCCINATEALSUMA [ST] [QL]ALMOTRIPTAN MALATEAXERT [ST] [QL]
DICLOFENAC POTASSIUMCAMBIA [PA] [QL]FROVATRIPTAN SUCCINATEFROVA [ST] [QL]
ELETRIPTAN HYDROBROMIDERELPAX [ST] [QL]SUMATRIPTAN SUCCINATESUMAVEL DOSEPRO [ST] [QL]
SUMATRIPTAN SUCC/NAPROXEN SODTREXIMET [PA] [QL]ZOLMITRIPTANZOMIG NASAL SPRAY [ST] [QL]ZOLMITRIPTANZOMIG, ZMT [ST] [QL]
(g) Use generic equivalent
[PA] Prior authorization may be required
Page 61
[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
3O. Parkinsons Disease and Related Disorders
Formulary PreferredGeneric NameTrade Name Utilization Management
TRIHEXYPHENIDYL HCLARTANE (g)BENZTROPINE MESYLATECOGENTIN (g)
CABERGOLINEDOSTINEX (g)SELEGILINE HCLELDEPRYL(g)
PRAMIPEXOLE DI-HCLMIRAPEX (g)CARBIDOPA/LEVODOPAPARCOPA (g)
BROMOCRIPTINE MESYLATEPARLODEL (g)ROPINIROLE HCLREQUIP (g)
CARBIDOPA/LEVODOPASINEMET (g)CARBIDOPA/LEVODOPASINEMET CR (g)
AMANTADINE HCLSYMMETREL (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
APOMORPHINE HCLAPOKYN <s>ENTACAPONECOMTAN
CARBIDOPA/LEVODOPA/ENTACAPONESTALEVO
NonformularyGeneric NameTrade Name Utilization Management
RASAGILINE MESYLATEAZILECTPRAMIPEXOLE DI-HCLMIRAPEX ER [PA] [QL]
ROPINIROLE HCLREQUIP XL [QL]TOLCAPONETASMAR
SELEGILINE HCLZELAPAR [QL]
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
3P. Anticonvulsants
Formulary PreferredGeneric NameTrade Name Utilization Management
VALPROATE SODIUMDEPAKENE (g)DIVALPROEX SODIUMDEPAKOTE (g)DIVALPROEX SODIUMDEPAKOTE ER (g)DIVALPROEX SODIUMDEPAKOTE SPRINKLES (g)
ACETAZOLAMIDEDIAMOX (g)DIAZEPAMDIASTAT 2.5MG (g)
PHENYTOIN SODIUM EXTENDEDDILANTIN (g)LEVETIRACETAMKEPPRA (g)
CLONAZEPAMKLONOPIN, WAFER (g)LAMOTRIGINELAMICTAL DISPERTABS (g)LAMOTRIGINELAMICTAL TABS (g)
MEPHOBARBITALMEBARAL (g)PRIMIDONEMYSOLINE (g)
GABAPENTINNEURONTIN (g)PHENOBARBITALPHENOBARBITAL (g)CARBAMAZEPINETEGRETOL (g)CARBAMAZEPINETEGRETOL XR (g)
TOPIRAMATETOPAMAX (g)TOPIRAMATETOPAMAX SPRINKLE (g)
OXCARBAZEPINETRILEPTAL (g)OXCARBAZEPINETRILEPTAL SUSP (g)ETHOSUXIMIDEZARONTIN (g)
ZONISAMIDEZONEGRAN (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
RUFINAMIDEBANZELMETHSUXIMIDECELONTIN
DIAZEPAMDIASTATPHENYTOINDILANTIN CHEW TABSFELBAMATEFELBATOL
TIAGABINE HCLGABITRILGABAPENTINNEURONTIN SOLUTION
ETHOTOINPEGANONEVIGABATRINSABRIL <s>
CARBAMAZEPINETEGRETOL XR 100MGLACOSAMIDEVIMPAT
NonformularyGeneric NameTrade Name Utilization Management
CARBAMAZEPINECARBATROLCARBAMAZEPINEEQUETROLEVETIRACETAMKEPPRA XR
LAMOTRIGINELAMICTAL ODT [QL]LAMOTRIGINELAMICTAL XR [QL]PREGABALINLYRICA [PA] [QL]
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
3Q. Skeletal Muscle Relaxants
Formulary PreferredGeneric NameTrade Name Utilization Management
DANTROLENE SODIUMDANTRIUM (g)CYCLOBENZAPRINE HCLFLEXERIL (g)
BACLOFENLIORESAL (g)ORPHENADRINE CITRATENORFLEX (g)
ORPHENADRINE/ASPIRIN/CAFFEINENORGESIC, FORTE (g)CHLORZOXAZONEPARAFLEX, PARAFON FORTE DSC (g)METHOCARBAMOLROBAXIN (g)
METAXALONESKELAXIN (g)CARISOPRODOLSOMA (g)
CARISOPRODOL/ASPIRINSOMA COMPOUND (g)CODEINE PHOS/CARISOPRODOL/ASASOMA COMPOUND W/CODEINE (g)
DIAZEPAMVALIUM (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
NONE
NonformularyGeneric NameTrade Name Utilization Management
CYCLOBENZAPRINE HCLAMRIX [QL]CYCLOBENZAPRINE HCLFEXMID
TIZANIDINE HCLZANAFLEX CAPSTIZANIDINE HCLZANAFLEX TABS (g)
3R. Myesthenia Gravis
Formulary PreferredGeneric NameTrade Name Utilization Management
PYRIDOSTIGMINE BROMIDEMESTINON (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
PYRIDOSTIGMINE BROMIDEMESTINON TIMESPAN, SYRUPNEOSTIGMINE BROMIDEPROSTIGMIN
NonformularyGeneric NameTrade Name Utilization Management
AMBENONIUM CHLORIDEMYTELASE
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
3S. Miscellaneous CNS
Formulary PreferredGeneric NameTrade Name Utilization Management DONEPEZIL HCLARICEPT, ODT (g)
LITHIUM CARBONATEESKALITH (g)LITHIUM CARBONATEESKALITH CR (g)
RIVASTIGMINE TARTRATEEXELON (g) [QL]LITHIUM CITRATELITHIUM CITRATE (g)
LITHIUM CARBONATELITHOBID (g)NIMODIPINENIMOTOP (g)
GALANTAMINE HYDROBROMIDERAZADYNE SOLUTION (g)GALANTAMINE HYDROBROMIDERAZADYNE, ER (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
RIVASTIGMINE TARTRATEEXELON [QL]MEMANTINE HCLNAMENDA, SOLN
RILUZOLERILUTEK
NonformularyGeneric NameTrade Name Utilization Management DONEPEZIL HCLARICEPT 23MG [ST]
TACRINE HCLCOGNEXGUANFACINE HCLINTUNIV [PA] [QL]MILNACIPRAN HCLSAVELLA [PA] [QL]SODIUM OXYBATEXYREM [PA] [QL]
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
4. GASTROINTESTINAL AGENTS
4A. H2-Receptor Antagonists
Formulary PreferredGeneric NameTrade Name Utilization Management
NIZATIDINEAXID (RX ONLY) (g)FAMOTIDINEPEPCID (RX ONLY) (g)CIMETIDINETAGAMET (RX ONLY) (g)
RANITIDINE HCLZANTAC (RX ONLY) (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
NONE
NonformularyGeneric NameTrade Name Utilization Management RANITIDINE HCLZANTAC EFFERDOSE
4B. Proton Pump Inhibitors
Formulary PreferredGeneric NameTrade Name Utilization Management OMEPRAZOLEOMEPRAZOLE OTC (g)
LANSOPRAZOLEPREVACID (g) [ST]LANSOPRAZOLEPREVACID SOLUTAB (g) [PA]
OMEPRAZOLEPRILOSEC (g)OMEPRAZOLEPRILOSEC 40MG [PA]
OMEPRAZOLE MAGNESIUMPRILOSEC OTCPANTOPRAZOLE SODIUMPROTONIX (g) [PA]
OMEPRAZOLE/SODIUM BICARBONATEZEGERID CAP (Rx Only) (g) [PA] [QL]
Formulary OptionsGeneric NameTrade Name Utilization Management
NONE
NonformularyGeneric NameTrade Name Utilization Management
RABEPRAZOLE SODIUMACIPHEX [PA]DEXLANSOPRAZOLEDEXILANT [PA][ST] [QL]
ESOMEPRAZOLE MAG TRIHYDRATENEXIUM [PA][ST]OMEPRAZOLE MAGNESIUMPRILOSEC SUSPENSION [PA]PANTOPRAZOLE SODIUMPROTONIX SUSPENSION [ST]
NAPROXEN/ESOMEPRAZOLE MAGVIMOVO [PA] [QL]OMEPRAZOLE/SODIUM BICARBONATEZEGERID PACKET [PA] [QL]
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
4C. Other Ulcer Therapy
Formulary PreferredGeneric NameTrade Name Utilization Management SUCRALFATECARAFATE SUSP (g)SUCRALFATECARAFATE TABS (g)
MISOPROSTOLCYTOTEC (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
TETRACYC HCL/BIS SS/METRONIDHELIDACLANSOPRAZOLE/AMOX TR/CLARITHPREVPAC
NonformularyGeneric NameTrade Name Utilization Management
BISMUTH/METRONID/TETRACYCLINEPYLERA
4D. Antidiarrheals and Antispasmodics
Formulary PreferredGeneric NameTrade Name Utilization Management
ERGOTAMINE TART/BELLAD ALK/PBBELLAMINE/BELLASPAS (g)DICYCLOMINE HCLBENTYL (g)
BELLADONNA ALKALOIDS/PHENOBARBDONNATAL (g)HYOSCYAMINE SULFATELEVBID (g)HYOSCYAMINE SULFATELEVSIN, SL (g)HYOSCYAMINE SULFATELEVSINEX (g)
CLIDINIUM BR/CHLORDIAZEPOXIDELIBRAX (g)DIPHENOXYLATE HCL/ATROP SULFLOMOTIL (g)
PAREGORICPAREGORIC (g)PROPANTHELINE BROMIDEPRO-BANTHINE 15MG (g)
GLYCOPYRROLATEROBINUL, FORTE (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
NONE
NonformularyGeneric NameTrade Name Utilization Management
MEPENZOLATE BROMIDECANTILBELLADONNA ALKALOIDS/PHENOBARBDONNATAL EXTENTABS
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
4E. Antiemetics
Formulary PreferredGeneric NameTrade Name Utilization Management MECLIZINE HCLANTIVERT (g)
PROCHLORPERAZINE MALEATECOMPAZINE (g)GRANISETRON HCLKYTRIL (g) [QL]
DRONABINOLMARINOL (g) [QL]PROMETHAZINE HCLPHENERGAN (g)
TRIMETHOBENZAMIDE HCLTIGAN (g)ONDANSETRON HCLZOFRAN (g)
ONDANSETRONZOFRAN ODT (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
APREPITANTEMEND 80,125MG CAPSULES [QL]SCOPOLAMINE HYDROBROMIDETRANSDERM-SCOP
NonformularyGeneric NameTrade Name Utilization Management
DOLASETRON MESYLATEANZEMET [QL]NABILONECESAMET
GRANISETRONSANCUSO [ST] [QL]ONDANSETRONZUPLENZ [ST] [QL]
4F. Bile Acids
Formulary PreferredGeneric NameTrade Name Utilization Management
URSODIOLACTIGALL (g)URSODIOLURSO (g)URSODIOLURSO FORTE (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
NONE
NonformularyGeneric NameTrade Name Utilization Management
CHENODIOLCHENODAL [PA]
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
4G. Digestive Enzymes
Formulary PreferredGeneric NameTrade Name Utilization Management
AMYLASE/LIPASE/PROTEASEDYGASE (g)AMYLASE/LIPASE/PROTEASELAPASE (g)AMYLASE/LIPASE/PROTEASEPANCREASE MT 10, 16, 20 (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
AMYLASE/LIPASE/PROTEASECREONAMYLASE/LIPASE/PROTEASELIPRAM-UL20AMYLASE/LIPASE/PROTEASEPANCREASE MT 4AMYLASE/LIPASE/PROTEASEPANCRELIPASE ECAMYLASE/LIPASE/PROTEASEPANGESTYME UL 12AMYLASE/LIPASE/PROTEASEULTRASE MTAMYLASE/LIPASE/PROTEASEVIOKASE
NonformularyGeneric NameTrade Name Utilization Management
LIPASE/PROTEASE/AMYLASEPANCREAZEAMYLASE/LIPASE/PROTEASEPANCRECARB MSAMYLASE/LIPASE/PROTEASEZENPEP
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
4H. Miscellaneous Gastrointestinal Agents
Formulary PreferredGeneric NameTrade Name Utilization Management
HC ACETATE/PRAMOXINE HCLANALPRAM HC (g)LIDOCAINE HCL/HCANAMANTLE HC (g)HYDROCORTISONEANNUSOL HC, PROCTOCREAM HC (g)
SULFASALAZINEAZULFIDINE EN-TAB (g)SULFASALAZINEAZULFIDINE TAB (g)
BALSALAZIDE DISODIUMCOLAZAL (g)HYDROCORTISONE ACETATECORTENEMA (g)POLYETHYLENE GLYCOL 3350GLYCOLAX (g)
LACTULOSELACTULOSE (g)HC ACETATE/PRAMOXINE HCLPRAMOSONE (g)HYDROCORTISONE ACETATEPROCTOCORT SUPPOSITORY (g)
METOCLOPRAMIDE HCLREGLAN TAB, SOLUTION (g)MESALAMINEROWASA ENEMA (g)
Formulary OptionsGeneric NameTrade Name Utilization Management MESALAMINEASACOLMESALAMINEASACOL HDMESALAMINECANASA
HYDROCORTISONE ACETATECORTIFOAMMESALAMINEPENTASA
METHYLNALTREXONERELISTOR [PA] [QL]
NonformularyGeneric NameTrade Name Utilization Management LUBIPROSTONEAMITIZA [PA] [QL]
MESALAMINEAPRISOCERTOLIZUMABCIMZIA SYRINGE [PA] [QL] <s>
OLSALAZINE SODIUMDIPENTUMMESALAMINELIALDA [QL]
ALOSETRON HCLLOTRONEX [PA] [QL]METOCLOPRAMIDE HCLMETOZOLV ODT
HC ACETATE/LIDOCAINE HCLPERANEX HCHC ACETATE/PRAMOXINE HCLPRAMOSONE LOTION
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
5. OBSTETRICS AND GYNECOLOGY
5A. Contraceptives-Monophasic
Formulary PreferredGeneric NameTrade Name Utilization Management
LEVONORGESTREL-ETH ESTRAALESSE (g), LEVLITE (g)ETHYNODIOL D-ETHINYL ESTRADIOLDEMULEN (g)DESOGESTREL-ETHINYL ESTRADIOLDESOGEN (g), ORTHO-CEPT (g)NORGESTREL-ETHINYL ESTRADIOLLO/OVRAL (g)NORETH A-ET ESTRA/FE FUMARATELOESTRIN, FE (g)NORETHINDRONE-ETHINYL ESTRADMODICON (g)
LEVONORGESTREL-ETH ESTRANORDETTE, LEVLEN (g)NORETHINDRONE-MESTRANOLNORINYL 1/35 (g), ORTHO-NOVUM 1/35 (g)
NORETHINDRONE-ETHINYL ESTRADNORINYL 1/50 (g), ORTHO-NOVUM 1/50 (g)NORGESTIMATE-ETHINYL ESTRADIOLORTHO-CYCLEN (g)NORETHINDRONE-ETHINYL ESTRADOVCON 35 (g)NORGESTREL-ETHINYL ESTRADIOLOVRAL (g)
LEVONORGESTREL-ETH ESTRASEASONALE (g) [QL]ETHINYL ESTRADIOL/DROSPIRENONEYASMIN 28 (g)ETHINYL ESTRADIOL/DROSPIRENONEYAZ (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
LEVONORGESTREL-ETH ESTRALYBREL
NonformularyGeneric NameTrade Name Utilization Management
NORETH-ETHINYL ESTRADIOL/IRONFEMCON FENORETH A-ET ESTRA/FE FUMARATELOESTRIN 24 FENORETHINDRONE-ETHINYL ESTRADOVCON-50, FE
5B. Contraceptives-Biphasic
Formulary PreferredGeneric NameTrade Name Utilization Management
DESOG-ET ESTRA/ETHIN ESTRAMIRCETTE (g)NORETHINDRONE-ETHINYL ESTRADNECON 10/11 (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
NONE
NonformularyGeneric NameTrade Name Utilization Management
L-NORGEST-ETH ESTR/ETHIN ESTRALOSEASONIQUE [QL]L-NORGEST-ETH ESTR/ETHIN ESTRASEASONIQUE [QL]
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
5C. Contraceptives-Triphasic
Formulary PreferredGeneric NameTrade Name Utilization Management
DESOGESTREL-ETHINYL ESTRADIOLCYCLESSA (g)NORETH A-ET ESTRA/FE FUMARATEESTROSTEP FE (g)
NORGESTIMATE-ETHINYL ESTRADIOLORTHO TRI-CYCLEN (g)NORETHINDRONE-ETHINYL ESTRADORTHO-NOVUM 7/7/7 (g)NORETHINDRONE-ETHINYL ESTRADTRI-NORINYL (g)
LEVONORGESTREL-ETH ESTRATRIPHASIL, TRILEVLEN (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
NORGESTIMATE-ETHINYL ESTRADIOLORTHO TRI-CYCLEN LO
NonformularyGeneric NameTrade Name Utilization Management
NONE
5D. Contraceptives-Misc.
Formulary PreferredGeneric NameTrade Name Utilization Management
NORETHINDRONEORTHO MICRONOR (g), NOR-QD (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
ETHINYL ESTRADIOL/NORELGESTORTHO EVRA [QL]
NonformularyGeneric NameTrade Name Utilization Management
DROSPIR/ETH ESTRA/LEVOMEFOL CABEYAZESTRADIOL VALERATE/DIENOGESTNATAZIA
ETONOGESTREL/ETHINYL ESTRADIOLNUVARING [QL]
5E. Contraceptives-Postcoital
Formulary PreferredGeneric NameTrade Name Utilization Management
LEVONORGESTRELPLAN B (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
NONE
NonformularyGeneric NameTrade Name Utilization Management
ULIPRISTAL ACETATEELLA [QL]LEVONORGESTRELPLAN B ONE-STEP
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
5F. Progestins
Formulary PreferredGeneric NameTrade Name Utilization Management
NORETHINDRONE ACETATEAYGESTIN (g)MEDROXYPROGESTERONE ACETDEPO-PROVERA 150MG (g)
PROGESTERONEPROGESTERONE IN OIL (INJ) (g)MEDROXYPROGESTERONE ACETPROVERA (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
PROGESTERONE,MICRONIZEDCRINONEMEDROXYPROGESTERONE ACETDEPO-SUBQ PROVERA 104PROGESTERONE, MICRONIZEDENDOMETRINPROGESTERONE,MICRONIZEDPROCHIEVEPROGESTERONE,MICRONIZEDPROMETRIUM
NonformularyGeneric NameTrade Name Utilization Management
NONE
5G. Estrogens
Formulary PreferredGeneric NameTrade Name Utilization Management
ESTRADIOLCLIMARA (g) [QL]ESTRADIOLESTRACE (g)
ESTROPIPATEOGEN, ORTHO-EST (g)ESTRADIOLVIVELLE (g) [QL]
Formulary OptionsGeneric NameTrade Name Utilization Management
ESTRADIOLALORA [QL]ESTRADIOLESTRADERM [QL]ESTRADIOLESTRING [QL]
ESTROGENS,CONJUGATEDPREMARIN CREAMESTROGENS,CONJUGATEDPREMARIN, PREMARIN LOW DOSE
ESTRADIOLVIVELLE-DOT [QL]
NonformularyGeneric NameTrade Name Utilization Management
ESTROGENS,CONJ.,SYNTHETIC ACENESTINESTRADIOLDIVIGELESTRADIOLELESTRIN [QL]
ESTROGENS,CONJ.,SYNTHETIC BENJUVIA [QL]ESTRADIOLESTRACE VAGINAL CREAMESTRADIOLESTRASORB [QL]ESTRADIOLESTROGEL [QL]
ESTRADIOL TRANSDERMAL SPRAYEVAMIST [QL]ESTRADIOL ACETATEFEMRING [QL]ESTRADIOL ACETATEFEMTRACE
ESTROGENS,ESTERIFIEDMENESTESTRADIOLMENOSTAR [QL]ESTRADIOLVAGIFEM
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
5H. Estrogen/Progestin Combinations
Formulary PreferredGeneric NameTrade Name Utilization Management
ESTRADIOL/NORETH ACACTIVELLA (g)ESTROGEN,ESTER/ME-TESTOSTERONEESTRATEST, H.S. (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
ETHINYL ESTRADIOL/NORETH ACFEMHRTESTROGEN,CON/M-PROGEST ACETPREMPRO, LOW DOSE/PREMPHASE
NonformularyGeneric NameTrade Name Utilization Management
ESTRADIOL/NORETH ACACTIVELLA 0.5-0.1MGESTRADIOL/DROSPIRENONEANGELIQ
ESTRADIOL/LEVONORGESTRELCLIMARA PRO [QL]ESTRADIOL/NORETH ACCOMBIPATCH [QL]
ESTRADIOL/NORGESTIMATEORTHO-PREFEST
5J. Infertility Treatment
Formulary PreferredGeneric NameTrade Name Utilization Management
CLOMIPHENE CITRATECLOMID (g)LEUPROLIDE ACETATELUPRON (g) [PA] <s>
Formulary OptionsGeneric NameTrade Name Utilization Management
UROFOLLITROPIN (FSH)BRAVELLE [PA] <s>CETRORELIX ACETATECETROTIDE [PA] <s>UROFOLLITROPIN (FSH)FERTINEX [PA] <s>
GANIRELIX ACETATEGANIRELIX ACETATE [PA] <s>FOLLITROPIN ALPHA,RECOMBGONAL-F, RFF [PA] <s>
GONADOTROPIN,CHORIONIC,HUMANNOVAREL, PREGNYL, PROFASI [PA] <s>HCG ALPHA,RECOMBINANTOVIDREL [PA] <s>
GONADOTROPIN,CHORIONIC,HUMANPROFASI 5000UNITS [PA] <s>MENOTROPINSREPRONEX [PA] <s>
NonformularyGeneric NameTrade Name Utilization Management
FOLLITROPIN BETA,RECOMBFOLLISTIM AQ [PA] <s>LUTROPIN ALPHALUVERIS [PA] <s>
MENOTROPINSMENOPUR [PA] <s>
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
5K. Vaginal Anti-infective/Antifungal
Formulary PreferredGeneric NameTrade Name Utilization Management
CLINDAMYCIN PHOSPHATECLEOCIN VAG CREAM (g)FLUCONAZOLEDIFLUCAN (g)
METRONIDAZOLEMETROGEL-VAGINAL (g)NYSTATINNYSTATIN (g)
TERCONAZOLETERAZOL- 3, 7 (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
NONE
NonformularyGeneric NameTrade Name Utilization Management SULFANILAMIDEAVC
CLINDAMYCIN PHOSPHATECLEOCIN VAGINAL OVULESCLINDAMYCIN PHOSPHATECLINDESSEBUTOCONAZOLE NITRATEGYNAZOLE-1
5L. Miscellaneous OB-GYN
Formulary PreferredGeneric NameTrade Name Utilization Management
NONE
Formulary OptionsGeneric NameTrade Name Utilization Management
LEUPROLIDE ACETATELUPRON DEPOT <s>METHYLERGONOVINE MALEATEMETHERGINE
NAFARELIN ACETATESYNAREL
NonformularyGeneric NameTrade Name Utilization Management
TRANEXAMIC ACIDLYSTEDA [QL]
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
6. RHEUMATOLOGY AND MUSCULOSKELETAL
6A. Salicylates
Formulary PreferredGeneric NameTrade Name Utilization Management
SEE CHAPTERS 3F & 3GSALICYLATES AND NSAIDS
Formulary OptionsGeneric NameTrade Name Utilization Management
NONE
NonformularyGeneric NameTrade Name Utilization Management
NONE
6B. Gout Therapy
Formulary PreferredGeneric NameTrade Name Utilization Management
COLCHICINE/PROBENECIDCOLBENEMID (g)PROBENECIDPROBENECID (g)ALLOPURINOLZYLOPRIM (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
COLCHICINECOLCRYSFEBUXOSTATULORIC [PA] [QL]
NonformularyGeneric NameTrade Name Utilization Management
NONE
6C. Corticosteroids
Formulary PreferredGeneric NameTrade Name Utilization Management
SEE CHAPTER 7CCORTICOSTEROIDS
Formulary OptionsGeneric NameTrade Name Utilization Management
NONE
NonformularyGeneric NameTrade Name Utilization Management
NONE
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
6D. Miscellaneous Rheumatologic Agents
Formulary PreferredGeneric NameTrade Name Utilization Management LEFLUNOMIDEARAVA (g) [QL]
SULFASALAZINEAZULFIDINE EN-TAB (g)SULFASALAZINEAZULFIDINE TAB (g)AZATHIOPRINEIMURAN (g)
METHOTREXATE SODIUM/PFMETHOTREXATE (g)HYDROXYCHLOROQUINE SULFATEPLAQUENIL (g)
Formulary OptionsGeneric NameTrade Name Utilization Management PENICILLAMINECUPRIMINEETANERCEPTENBREL [PA] [QL] <s>ADALIMUMABHUMIRA [PA] [QL] <s>
METHOTREXATE SODIUMRHEUMATREX, TREXALLAURANOFINRIDAURA
NonformularyGeneric NameTrade Name Utilization Management CERTOLIZUMABCIMZIA SYRINGE [PA] [QL] <s>PENICILLAMINEDEPEN
ANAKINRAKINERET [PA] [QL] <s>GOLIMUMABSIMPONI [PA] [QL] <s>
6E. Osteoporosis/Hormonal Treatment
Formulary PreferredGeneric NameTrade Name Utilization Management
ESTRADIOLCLIMARA (g) [QL]ESTRADIOLESTRACE (g)
ESTROGEN,ESTER/ME-TESTOSTERONEESTRATEST, H.S. (g)ESTROPIPATEOGEN, ORTHO-EST (g)
ESTRADIOLVIVELLE (g) [QL]
Formulary OptionsGeneric NameTrade Name Utilization Management
ESTRADIOLALORA [QL]ESTRADIOLESTRADERM [QL]
ETHINYL ESTRADIOL/NORETH ACFEMHRTESTROGENS,CONJUGATEDPREMARIN CREAMESTROGENS,CONJUGATEDPREMARIN, PREMARIN LOW DOSE
ESTROGEN,CON/M-PROGEST ACETPREMPRO, LOW DOSE/PREMPHASEESTRADIOLVIVELLE-DOT [QL]
NonformularyGeneric NameTrade Name Utilization Management
ESTROGENS,CONJ.,SYNTHETIC ACENESTINESTROGENS,CONJ.,SYNTHETIC BENJUVIA [QL]
TERIPARATIDEFORTEO [PA] [QL] <s>ESTROGENS,ESTERIFIEDMENEST
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
6F. Osteoporosis/Bone Resorption
Formulary PreferredGeneric NameTrade Name Utilization Management
ETIDRONATE DISODIUMDIDRONEL (g) [QL]FIRST-LINE THERAPY WHEN APPROPRIATEESTROGENS
ALENDRONATE SODIUMFOSAMAX (g) BEALENDRONATE SODIUMFOSAMAX WEEKLY (g) [QL] BE
CALCITONIN,SALMON,SYNTHETICMIACALCIN NASAL SPRAY (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
RISEDRON SOD/CALCIUM CARBONATEACTONEL WITH CALCIUM [ST] [QL]RISEDRONATE SODIUMACTONEL, WEEKLY, 150MG [ST] [QL]
RALOXIFENE HCLEVISTACALCITONIN,SALMON,SYNTHETICMIACALCIN INJECTION
NonformularyGeneric NameTrade Name Utilization Management
IBANDRONATE SODIUMBONIVA [ST] [QL]ALENDRONATE SODIUM/VITAMIN D3FOSAMAX PLUS D [ST] [QL]
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
7. ENDOCRINOLOGY
7A. Antithyroid Agents
Formulary PreferredGeneric NameTrade Name Utilization Management
PROPYLTHIOURACILPROPYLTHIOURACIL (g)POTASSIUM IODIDESSKI (g)
METHIMAZOLETAPAZOLE (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
NONE
NonformularyGeneric NameTrade Name Utilization Management
NONE
7B. Thyroid Hormones
Formulary PreferredGeneric NameTrade Name Utilization Management
LIOTHYRONINE SODIUMCYTOMEL (g)LEVOTHYROXINE SODIUMLEVOTHYROXINE (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
LIOTRIXTHYROLAR
NonformularyGeneric NameTrade Name Utilization Management
THYROIDARMOUR THYROIDLEVOTHYROXINE SODIUMTIROSINT
7C. Corticosteroids
Formulary PreferredGeneric NameTrade Name Utilization Management
HYDROCORTISONECORTEF, HYDROCORTISONE (g)CORTISONE ACETATECORTISONE ACETATE (g)
DEXAMETHASONEDECADRON (g)FLUDROCORTISONE ACETATEFLORINEF (g)
METHYLPREDNISOLONEMEDROL, DOSEPAK (g)PREDNISOLONE SOD PHOSPHATEORAPRED (g)
PREDNISOLONEPREDNISOLONE, TABS, SYRUP (g)PREDNISONEPREDNISONE (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
NONE
NonformularyGeneric NameTrade Name Utilization Management BUDESONIDEENTOCORT EC
PREDNISOLONE SOD PHOSPHATEORAPRED ODT
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
7D. Androgens
Formulary PreferredGeneric NameTrade Name Utilization Management
FLUOXYMESTERONEANDROXY 10MG (g)DANAZOLDANOCRINE (g)
TESTOSTERONE CYPIONATEDEPO-TESTOSTERONE (g)OXANDROLONEOXANDRIN (g) [PA]
Formulary OptionsGeneric NameTrade Name Utilization Management
TESTOSTERONEANDRODERM [QL]TESTOSTERONE ENANTHATEDELATESTRYL
NonformularyGeneric NameTrade Name Utilization Management
OXYMETHOLONEANADROL-50 [PA]TESTOSTERONEANDROGEL [QL]
METHYLTESTOSTERONEMETHITEST [PA]TESTOSTERONESTRIANT [QL]TESTOSTERONETESTIM [QL]
METHYLTESTOSTERONETESTRED, ANDROID
7E. Miscellaneous Endocrine
Formulary PreferredGeneric NameTrade Name Utilization Management
ERGOCALCIFEROLCALCIFEROL (g)DESMOPRESSIN ACETATEDDAVP SPRAY (g)DESMOPRESSIN ACETATEDDAVP TABS (g)
CABERGOLINEDOSTINEX (g)CALCITONIN,SALMON,SYNTHETICMIACALCIN NASAL SPRAY (g)
FINASTERIDEPROSCAR (g)CALCITRIOLROCALTROL (g)
OCTREOTIDE ACETATESANDOSTATIN (g) [PA] <s>
Formulary OptionsGeneric NameTrade Name Utilization Management
DESMOPRESSIN ACETATEDDAVP SOLNGLUCAGON,HUMAN RECOMBINANTGLUCAGON EMERGENCY KIT
LEUPROLIDE ACETATELUPRON DEPOT-PED <s>CALCITONIN,SALMON,SYNTHETICMIACALCIN INJECTION
OCTREOTIDE ACETATESANDOSTATIN LAR [PA] <s>CINACALCET HCLSENSIPAR <s>
LANREOTIDE ACETATESOMATULINE DEPOT <s>PEGVISOMANTSOMAVERT [PA] <s>
DESMOPRESSIN ACETATESTIMATENAFARELIN ACETATESYNAREL
NonformularyGeneric NameTrade Name Utilization Management
DOXERCALCIFEROLHECTOROLPARICALCITOLZEMPLAR
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
7F. Insulins
Formulary PreferredGeneric NameTrade Name Utilization Management
NONE
Formulary OptionsGeneric NameTrade Name Utilization Management
INSULIN GLULISINEAPIDRA (PEN/CARTRIDGE)INSULIN GLULISINEAPIDRA (VIAL)
INSULIN LISPRO,HUMAN REC.ANLOGHUMALOG, MIX (PEN/CARTRIDGE)INSULIN NPL/INSULIN LISPROHUMALOG, MIX (VIAL) BE
HUMULINHUMULIN 70/30 (PEN/CARTRIDGE)HUMULINHUMULIN 70/30 (VIAL) BE
NPH, HUMAN INSULIN ISOPHANEHUMULIN N (PEN/CARTRIDGE)NPH, HUMAN INSULIN ISOPHANEHUMULIN N (VIAL) BEINSULIN REGULAR HUMAN RECHUMULIN R (VIAL) BE
INSULIN GLARGINE,HUM.REC.ANLOGLANTUS (PEN/CARTRIDGE)INSULIN GLARGINE,HUM.REC.ANLOGLANTUS (VIAL)
INSULIN DETEMIRLEVEMIR (PEN)INSULIN DETEMIRLEVEMIR (VIAL)
INSULIN REGULAR HUMAN RECNOVOLIN (PEN/CARTRIDGE)INSULIN REGULAR HUMAN RECNOVOLIN (VIAL) BE
INSULIN ASPARTNOVOLOG (PEN/CARTRIDGE)INSULIN ASPARTNOVOLOG (VIAL) BE
INSULN ASP PRT/INSULIN ASPARTNOVOLOG MIX (PEN/CARTRIDGE)
NonformularyGeneric NameTrade Name Utilization Management
NONE
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
7G. Non-insulin Hypoglycemic Agents
Formulary PreferredGeneric NameTrade Name Utilization Management GLIMEPIRIDEAMARYL (g) BEGLYBURIDEDIABETA, MICRONASE (g) BE
CHLORPROPAMIDEDIABINESE (g) BEMETFORMIN HCLGLUCOPHAGE (g) BEMETFORMIN HCLGLUCOPHAGE XR (g) BE
GLIPIZIDEGLUCOTROL (g) BEGLIPIZIDEGLUCOTROL XL (g) BE
GLYBURIDE/METFORMIN HCLGLUCOVANCE (g) BEGLYBURIDE,MICRONIZEDGLYNASE (g) BE
GLIPIZIDE/METFORMIN HCLMETAGLIP (g) BETOLBUTAMIDEORINASE (g)
ACARBOSEPRECOSE (g)NATEGLINIDESTARLIX (g)TOLAZAMIDETOLINASE (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
PIOGLITAZONE HCL/METFORMIN HCLACTOPLUS MET [ST] [QL]PIOGLITAZONE HCLACTOS [ST] [QL]
PIOGLITAZONE/GLIMEPIRIDEDUETACT [ST] [QL]REPAGLINIDEPRANDIN
NonformularyGeneric NameTrade Name Utilization Management
PIOGLITAZONE HCL/METFORMIN HCLACTOPLUS MET XR [ST] [QL]ROSIGLITAZONE/METFORMIN HCLAVANDAMET [ST] [QL]
ROSIGLITAZONE MALEATE/GLIMEPIRAVANDARYL [ST]ROSIGLITAZONE MALEATEAVANDIA [ST] [QL]
EXENATIDEBYETTA [PA] [QL]METFORMIN HCLFORTAMETMETFORMIN HCLGLUMETZA
MIGLITOLGLYSETSITAGLIPTIN PHOS/METFORMIN HCLJANUMET [PA]
SITAGLIPTIN PHOSPHATEJANUVIA [PA] [QL]SAXAGLIPTIN HYDROCHLORIDEONGLYZA [PA] [QL]REPAGLINIDE/METFORMIN HCLPRANDIMET [PA]
METFORMIN HCLRIOMETPRAMLINTIDE ACETATESYMLIN [ST] [QL]
LIRAGLUTIDEVICTOZA [PA] [QL]
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
7H. Growth Hormone and Related Products
Formulary PreferredGeneric NameTrade Name Utilization Management
NONE
Formulary OptionsGeneric NameTrade Name Utilization Management SOMATROPINGENOTROPIN [PA] <s>SOMATROPINNUTROPIN [PA] <s>SOMATROPINNUTROPIN AQ [PA] <s>SOMATROPINNUTROPIN AQ NUSPIN [PA] <s>
NonformularyGeneric NameTrade Name Utilization Management SOMATROPINHUMATROPE [PA] <s>MECASERMININCRELEX [PA] <s>SOMATROPINNORDITROPIN NORDIFLEX [PA] <s>SOMATROPINOMNITROPE [PA] <s>SOMATROPINSAIZEN [PA] <s>SOMATROPINSEROSTIM [PA] <s>SOMATROPINTEV-TROPIN [PA] <s>SOMATROPINZORBTIVE [PA] <s>
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
8. ANTINEOPLASTICS AND IMMUNOSUPPRESANTS
8A. Alkylating Agents
Formulary PreferredGeneric NameTrade Name Utilization Management
CYCLOPHOSPHAMIDECYTOXAN (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
MELPHALANALKERANLOMUSTINECEENU
CHLORAMBUCILLEUKERANBUSULFANMYLERAN
TEMOZOLOMIDETEMODAR <s>
NonformularyGeneric NameTrade Name Utilization Management
NONE
8B. Antimetabolites
Formulary PreferredGeneric NameTrade Name Utilization Management
METHOTREXATE SODIUM/PFMETHOTREXATE (g)MERCAPTOPURINEPURINETHOL (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
FLUDARABINE PHOSPHATEOFORTA [QL] <s>THIOGUANINETHIOGUANINECAPECITABINEXELODA <s>
NonformularyGeneric NameTrade Name Utilization Management
NONE
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
8C. Immunomodulators
Formulary PreferredGeneric NameTrade Name Utilization Management
MYCOPHENOLATE MOFETILCELLCEPT (g) <s>AZATHIOPRINEIMURAN (g)
CYCLOSPORINE, MODIFIEDNEORAL (g) <s>PREDNISONEPREDNISONE (g)
TACROLIMUS ANHYDROUSPROGRAF (g) <s>
Formulary OptionsGeneric NameTrade Name Utilization Management RILONACEPTARCALYST [PA] <s>
MYCOPHENOLATE MOFETILCELLCEPT SUSPENSION <s>SIROLIMUSRAPAMUNE TABS, SOLUTION <s>
CYCLOSPORINESANDIMMUNE <s>THALIDOMIDETHALOMID <s>
NonformularyGeneric NameTrade Name Utilization Management
MYCOPHENOLATE SODIUMMYFORTIC <s>LENALIDOMIDEREVLIMID [PA] [QL] <s>
8D. Hormonal Agents
Formulary PreferredGeneric NameTrade Name Utilization Management ANASTROZOLEARIMIDEX (g) [PA] <s>BICALUTAMIDECASODEX (g) <s>
FLUTAMIDEEULEXIN (g)LEUPROLIDE ACETATELUPRON (g) <s>MEGESTROL ACETATEMEGACE (g)TAMOXIFEN CITRATETAMOXIFEN CITRATE (g)
Formulary OptionsGeneric NameTrade Name Utilization Management EXEMESTANEAROMASIN [PA] <s>
MEDROXYPROGESTERONE ACETDEPO-PROVERA 400MGTOREMIFENE CITRATEFARESTON
FULVESTRANTFASLODEXLETROZOLEFEMARA [PA] <s>
LEUPROLIDE ACETATELUPRON DEPOT <s>NILUTAMIDENILANDRON
TRIPTORELIN PAMOATETRELSTAR DEPOT, LA <s>GOSERELIN ACETATEZOLADEX [QL] <s>
NonformularyGeneric NameTrade Name Utilization Management
LEUPROLIDE ACETATEELIGARD <s>MEGESTROL ACETATEMEGACE ES
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
8E. Miscellaneous Antineoplastic Agents
Formulary PreferredGeneric NameTrade Name Utilization Management HYDROXYUREAHYDREA (g)
OCTREOTIDE ACETATESANDOSTATIN (g) [PA] <s>ETOPOSIDEVEPESID (g)
Formulary OptionsGeneric NameTrade Name Utilization Management HYDROXYUREADROXIA
ESTRAMUSTINE PHOSPHATE SODIUMEMCYTALTRETAMINEHEXALEN
TOPOTECAN HCLHYCAMTIN [PA] <s>MITOTANELYSODREN
PROCARBAZINE HCLMATULANEOCTREOTIDE ACETATESANDOSTATIN LAR [PA] <s>
TRETINOINVESANOIDVORINOSTATZOLINZA [PA] <s>
NonformularyGeneric NameTrade Name Utilization Management BEXAROTENETARGRETIN ORAL <s>
8F. Adjuvant Therapy
Formulary PreferredGeneric NameTrade Name Utilization Management
LEUCOVORIN CALCIUMLEUCOVORIN (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
SARGRAMOSTIMLEUKINE <s>MESNAMESNEX
FILGRASTIMNEUPOGEN <s>EPOETIN ALFAPROCRIT [PA] <s>
NonformularyGeneric NameTrade Name Utilization Management
DARBEPOETIN ALFA IN ALBUMN SOLARANESP [PA] <s>EPOETIN ALFAEPOGEN [PA] <s>
PEGFILGRASTIMNEULASTA [QL] <s>
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
8G. Kinase Inhibitors and Molecular Target Inhibitors
Formulary PreferredGeneric NameTrade Name Utilization Management
NONE
Formulary OptionsGeneric NameTrade Name Utilization Management EVEROLIMUSAFINITOR [PA] [QL] <s>
IMATINIB MESYLATEGLEEVEC <s>GEFITINIBIRESSA [PA] <s>
SORAFENIB TOSYLATENEXAVAR [PA] [QL] <s>DASATINIBSPRYCEL [PA] <s>
SUNITINIB MALATESUTENT [PA] [QL] <s>ERLOTINIB HCLTARCEVA [PA] <s>
NILOTINIB HYDROCHLORIDETASIGNA <s>LAPATINIB DITOSYLATETYKERB [PA] <s>
PAZOPANIB HYDROCHLORIDEVOTRIENT [PA] <s>EVEROLIMUSZORTRESS [QL] <s>
NonformularyGeneric NameTrade Name Utilization Management
NONE
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
9. IMMUNOLOGY AND HEMATOLOGY
9B. Hematopoietic Agents
Formulary PreferredGeneric NameTrade Name Utilization Management
NONE
Formulary OptionsGeneric NameTrade Name Utilization Management
SARGRAMOSTIMLEUKINE <s>OPRELVEKINNEUMEGA <s>FILGRASTIMNEUPOGEN <s>
EPOETIN ALFAPROCRIT [PA] <s>ELTROMBOPAG OLAMINEPROMACTA [PA] [QL] <s>
NonformularyGeneric NameTrade Name Utilization Management
DARBEPOETIN ALFA IN ALBUMN SOLARANESP [PA] <s>EPOETIN ALFAEPOGEN [PA] <s>
PEGFILGRASTIMNEULASTA [QL] <s>
9C. Interferons and MS Therapy
Formulary PreferredGeneric NameTrade Name Utilization Management
NONE
Formulary OptionsGeneric NameTrade Name Utilization Management
INTERFERON GAMMA-1B,RECOMB.ACTIMMUNE <s>INTERFERON ALFA-N3ALFERON NINTERFERON BETA-1AAVONEX <s>GLATIRAMER ACETATECOPAXONE <s>
INTERFERON ALFACON-1INFERGEN [PA] <s>INTERFERON ALFA-2B,RECOMB.INTRON A [PA] <s>
PEGINTERFERON ALFA-2APEGASYS [PA] [QL] <s>PEGINTERFERON ALFA-2BPEG-INTRON, REDIPEN [PA] [QL] <s>
INTERFERON BETA-1A/ALBUMINREBIF <s>
NonformularyGeneric NameTrade Name Utilization Management
FAMPRIDINE (4-AMINOPYRIDINE)AMPYRA [PA] [QL] <s>INTERFERON BETA-1BBETASERON [PA] <s>INTERFERON BETA-1BEXTAVIA <s>
FINGOLIMOD HYDROCHLORIDEGILENYA [PA] [QL] <s>
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
10. DERMATOLOGY
10A. Very High Potency Corticosteriods
Formulary PreferredGeneric NameTrade Name Utilization Management
BETAMET DIPROP/PROP GLYDIPROLENE OINTMENT (g)CLOBETASOL PROPIONATEOLUX (g)DIFLORASONE DIACETATEPSORCON, FLORONE (g)CLOBETASOL PROPIONATETEMOVATE (g), CLOBEVATE (g)
HALOBETASOL PROPIONATEULTRAVATE (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
NONE
NonformularyGeneric NameTrade Name Utilization Management
CLOBETASOL PROPIONATECLOBEX, SPRAYCLOBETASOL PROPIONATE/EMOLLOLUX-E
HALOBETASOL PROP/AMMONIUM LACULTRAVATE PACFLUOCINONIDEVANOS 0.1% CR
10B. High Potency Corticosteroids
Formulary PreferredGeneric NameTrade Name Utilization Management
TRIAMCINOLONE ACETONIDEARISTOCORT, KENALOG 0.5% CR (g)AMCINONIDECYCLOCORT (g)
BETAMET DIPROP/PROP GLYDIPROLENE AF, GEL, CR, LOT (g)BETAMETHASONE DIPROPIONATEDIPROSONE (g), MAXIVATE (g)
FLUOCINONIDELIDEX, E (g)DIFLORASONE DIACETATEPSORCON, FLORONE (g)
DESOXIMETASONETOPICORT CR, GEL, OINT (g)BETAMETHASONE VALERATEVALISONE CR, LOTION, OINT (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
NONE
NonformularyGeneric NameTrade Name Utilization Management
DIFLORASONE DIACETATE/EMOLLAPEXICON EHALCINONIDEHALOG
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
10C. Medium Potency Corticosteroids
Formulary PreferredGeneric NameTrade Name Utilization Management
TRIAMCINOLONE ACETONIDEARISTOCORT, KENALOG (g)FLUTICASONE PROPIONATECUTIVATE (g)
PREDNICARBATEDERMATOP (g)MOMETASONE FUROATEELOCON (g)
HYDROCORTISONE BUTYRATELOCOID CM, OINT, SOLN (g)HYDROCORTISONE BUTYRATE/EMOLLLOCOID LIPOCREAM (g)
FLUOCINOLONE ACETONIDESYNALAR 0.025% CREAM, OINT (g)DESOXIMETASONETOPICORT LP (g)
BETAMETHASONE VALERATEVALISONE CR, LOTION, OINT (g)HYDROCORTISONE VALERATEWESTCORT (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
CLOCORTOLONE PIVALATECLODERMFLURANDRENOLIDECORDRAN, TAPE, SP
NonformularyGeneric NameTrade Name Utilization Management
FLUTICASONE PROPIONATECUTIVATE LOTIONHYDROCORTISONE BUTYRATELOCOID LOTIONBETAMETHASONE VALERATELUXIQ
HYDROCORTISONE PROBUTATEPANDEL
10D. Low Potency Corticosteroids
Formulary PreferredGeneric NameTrade Name Utilization Management
ALCLOMETASONE DIPROPIONATEACLOVATE (g)HYDROCORTISONEDERMACORT, HYTONE (Rx Only) (g)
DESONIDEDESOWEN, TRIDESILON (g)FLUOCINOLONE ACETONIDESYNALAR CREAM, SOLN (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
FLUOCINOLONE ACETONIDECAPEX SHAMPOO
NonformularyGeneric NameTrade Name Utilization Management
FLUOCINOLONE ACETONIDEDERMA-SMOOTHE/FSDESONIDEDESONATE [ST]DESONIDEVERDESO [ST]
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
10E. Topical Anesthetics
Formulary PreferredGeneric NameTrade Name Utilization Management
LIDOCAINE/PRILOCAINEEMLA (g)LIDOCAINE HCLXYLOCAINE (Rx Only) (g)LIDOCAINE HCLXYLOCAINE VISCOUS (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
NONE
NonformularyGeneric NameTrade Name Utilization Management
LIDOCAINELIDODERM PATCH
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
10F. Acne Treatment
Formulary PreferredGeneric NameTrade Name Utilization Management ISOTRETINOINACCUTANE (REQ DERM CONSULT) (g)
ERYTHROMYCIN BASE/BENZ PERBENZAMYCIN (g)BENZOYL PEROXIDEBENZOYL PEROXIDE-RX (g)BENZOYL PEROXIDEBREVOXYL GEL (g)
CLINDAMYCIN PHOSPHATECLEOCIN T (g)ADAPALENEDIFFERIN 0.1% CREAM, GEL (g)ADAPALENEDIFFERIN LOTION
ERYTHROMYCIN BASE/ETHANOLERYTHROMYCIN TOPICAL SOLN, GEL (g)CLINDAMYCIN PHOSPHATEEVOCLIN FOAM(g)
METRONIDAZOLEMETROCREAM, GEL, LOTION (g)BENZOYL PEROXIDE MICROSPHERESNEOBENZ MICRO
SULFACETAMIDE SODIUM/SULFURPLEXION, TS (g)TRETINOINRETIN-A, AVITA (g)
SULFACETAMIDE SOD/SULFUR/UREAROSULA CLEANSER (g)SULFACETAMIDE SODIUM/SULFURSULFACET-R (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
ADAPALENEDIFFERIN 0.3% GELMETRONIDAZOLEMETROGEL TOPICAL 1%
TRETINOIN MICROSPHERESRETIN-A MICROTAZAROTENETAZORAC
NonformularyGeneric NameTrade Name Utilization Management
DAPSONEACZONE [QL]ERYTHROMYCIN BASEAKNE-MYCIN
RETAPAMULINALTABAXAZELAIC ACIDAZELEX
CLINDAMYCIN PHOSPHATE/BENZ PERBENZACLINBENZOYL PEROXIDEBENZASHAVEBENZOYL PEROXIDECLINAC BPO
CLINDAMYCIN PHOSPHATE/BENZ PERDUAC, CSADAPALENE/BENZOYL PEROXIDEEPIDUO
AZELAIC ACIDFINACEAMETRONIDAZOLENORITATE
SULFACETAMIDE SODIUM/SULFURROSULA FOAMCLINDAMYCIN/TRETINOINZIANA GEL [PA]
10G. Topical Antibacterials
Formulary PreferredGeneric NameTrade Name Utilization Management
MUPIROCINBACTROBAN OINTMENT (g)GENTAMICIN SULFATEGENTAMICIN CR, OINT (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
MUPIROCIN CALCIUMBACTROBAN CREAM, NASAL
NonformularyGeneric NameTrade Name Utilization Management RETAPAMULINALTABAX
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
10H. Topical Antifungals
Formulary PreferredGeneric NameTrade Name Utilization Management
CICLOPIROX OLAMINELOPROX CR, LOTION, GEL (g)CICLOPIROXLOPROX SHAMPOO (g)
CLOTRIMAZOLELOTRIMIN (g)CLOTRIMAZOLE/BETAMET DIPROPLOTRISONE CR, LOTION (g)
MICONAZOLE NITRATEMONISTAT-DERM (g)NYSTATINMYCOSTATIN (g)
KETOCONAZOLENIZORAL CREAM (g)KETOCONAZOLENIZORAL SHAMPOO 2% (g)
NYSTATIN/TRIAMCINNYSTATIN W/TRIAMCINOLONE (g)CICLOPIROXPENLAC (g)
ECONAZOLE NITRATESPECTAZOLE (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
CICLOPIROX/NAIL LACQUER REMOVRCNL 8
NonformularyGeneric NameTrade Name Utilization Management
SERTACONAZOLE NITRATEERTACZOSULCONAZOLE NITRATEEXELDERM SOLN, CR
KETOCONAZOLEEXTINABUTENAFINE HCLMENTAX
NAFTIFINE HCLNAFTINOXICONAZOLE NITRATEOXISTAT
MICONAZOLE NITRATE/ZINC OXIDEVUSIONKETOCONAZOLEXOLEGEL
KETOCONAZOLE/HYDROCORTISONEXOLEGEL COREPAK
10I. Topical Antivirals
Formulary PreferredGeneric NameTrade Name Utilization Management
NONE
Formulary OptionsGeneric NameTrade Name Utilization Management
ACYCLOVIRZOVIRAX CREAM, OINT
NonformularyGeneric NameTrade Name Utilization Management PENCICLOVIRDENAVIR
ACYCLOVIR/HYDROCORTISONEXERESE
(g) Use generic equivalent
[PA] Prior authorization may be required
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[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
10J. Wound and Burn Therapy
Formulary PreferredGeneric NameTrade Name Utilization Management PAPAIN/UREAACCUZYME, ETHEZYME, GLADASE (g)
TRYPSIN/BALSAM PERU/CASTOR OILGRANULEX (g)SILVER SULFADIAZINESILVADENE (g)
Formulary OptionsGeneric NameTrade Name Utilization Management COLLAGENASESANTYL
NonformularyGeneric NameTrade Name Utilization Management BECAPLERMINREGRANEX [PA]
10K. Antipsoriatic/Antiseborrheic
Formulary PreferredGeneric NameTrade Name Utilization Management
CALCIPOTRIENEDOVONEX OINT(g)CALCIPOTRIENEDOVONEX SOLUTION (g)
ANTHRALINDRITHOCREME HP (g)SELENIUM SULFIDESELSUN RX (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
CALCIPOTRIENEDOVONEX CREAMANTHRALINDRITHO-SCALP
ETANERCEPTENBREL [PA] [QL] <s>ADALIMUMABHUMIRA [PA] [QL] <s>
METHOXSALEN, RAPIDOXSORALEN, ULTRAACITRETINSORIATANE [QL]
NonformularyGeneric NameTrade Name Utilization Management
BETAMET DIPROP/CALCIPOTRIENETACLONEX, SCALP [PA]CALCITRIOLVECTICAL
10L. Scabicides/Pediculicides
Formulary PreferredGeneric NameTrade Name Utilization Management PERMETHRINELIMITE (g)MALATHIONOVIDE (g)
Formulary OptionsGeneric NameTrade Name Utilization Management CROTAMITONEURAX
LINDANELINDANE
NonformularyGeneric NameTrade Name Utilization Management
NONE
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
10M. Miscellaneous Dermatologicals
Formulary PreferredGeneric NameTrade Name Utilization Management
IMIQUIMODALDARA (g) [QL]PODOFILOXCONDYLOX SOLN (g)
ALUMINUM CHLORIDEDRYSOL (g)FLUOROURACILEFUDEX (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
PODOFILOXCONDYLOX GELPIMECROLIMUSELIDEL [PA]ALITRETINOINPANRETINDOXEPIN HCLZONALON, PRUDOXIN
NonformularyGeneric NameTrade Name Utilization Management FLUOROURACILCARAC
HYDROCORTISONE ACETATE/UREACARMOL HCFLUOROURACIL/ADHESIVE BANDAGEEFUDEX OCCLUSION
TACROLIMUSPROTOPIC [ST]DICLOFENAC SODIUMSOLARAZE
BEXAROTENETARGRETIN GEL <s>SINECATECHINSVEREGEN
IMIQUIMODZYCLARA [QL]
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
11. OPHTHALMOLOGY
11A. Ophthalmic Beta Blockers
Formulary PreferredGeneric NameTrade Name Utilization Management
LEVOBUNOLOL HCLBETAGAN (g)BETAXOLOL HCLBETOPTIC SOLN (g)CARTEOLOL HCLOCUPRESS (g)METIPRANOLOLOPTIPRANOLOL (g)
TIMOLOL MALEATETIMOPTIC - XE (g)TIMOLOL MALEATETIMOPTIC (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
BETAXOLOL HCLBETOPTIC STIMOLOL MALEATEISTALOL
NonformularyGeneric NameTrade Name Utilization Management
TIMOLOLBETIMOL
11B. Other Glaucoma Agents
Formulary PreferredGeneric NameTrade Name Utilization Management
BRIMONIDINE TARTRATEALPHAGAN (g)BRIMONIDINE TARTRATEALPHAGAN P 0.15% (g)
TIMOLOL MALEATE/DORZOLAM HCLCOSOPT (g)APRACLONIDINE HCLIOPIDINE DROPS (g)
PILOCARPINE HCLPILOCAR, ISOPTO-CARPINE (g)DORZOLAMIDE HCLTRUSOPT (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
BRIMONIDINE TARTRATEALPHAGAN P 0.1%BRINZOLAMIDEAZOPT
CARBACHOLISOPTO CARBACHOLBIMATOPROSTLUMIGAN
ECHOTHIOPHATE IODIDEPHOSPHOLINE IODIDEPILOCARPINE HCLPILOPINE HSDIPIVEFRIN HCLPROPINETRAVOPROSTTRAVATAN, Z
LATANOPROSTXALATAN
NonformularyGeneric NameTrade Name Utilization Management
BRIMONIDINE TARTRATE/TIMOLOLCOMBIGANAPRACLONIDINE HCLIOPIDINE DROPERETTE
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
11C. Cycloplegic Mydriatics
Formulary PreferredGeneric NameTrade Name Utilization Management
CYCLOPENTOLATE HCLCYCLOGYL (g)ATROPINE SULFATEISOPTO ATROPINE (g)HOMATROPINE HBRISOPTO HOMATROPINE (g)
TROPICAMIDEMYDRIACYL (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
SCOPOLAMINE HYDROBROMIDEISOPTO HYOSCINE
NonformularyGeneric NameTrade Name Utilization Management
HYDROXYAMPHETAMINE/TROPICAMIDEPAREMYD
11D. Ophthalmic Anti-inflammatory Agents
Formulary PreferredGeneric NameTrade Name Utilization Management
KETOROLAC TROMETHAMINEACULAR, LS (g)FLURBIPROFEN SODIUMOCUFEN (g)
DICLOFENAC SODIUMVOLTAREN (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
NONE
NonformularyGeneric NameTrade Name Utilization Management
KETOROLAC TROMETHAMINEACUVAILNEPAFENACNEVANAC
BROMFENAC SODIUMXIBROM
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
11E. Ophthalmic Anti-infectives
Formulary PreferredGeneric NameTrade Name Utilization Management
BACITRACINBACITRACIN (g)SULFACETAMIDE SODIUMBLEPH-10, SODIUM SULAMYDE (g)
CIPROFLOXACIN HCLCILOXAN DROPS (g)GENTAMICIN SULFATEGARAMYCIN (g)ERYTHROMYCIN BASEILOTYCIN (g)
NEOMYCIN/GRAMICIDIN/POLYMYXN BNEOSPORIN OPHTH SOLN (g)NEOMY SULF/BACITRA/POLYMYXIN BNEOSPORIN OPTH OINT (g)
OFLOXACINOCUFLOX (g)BACITRACIN/POLYMYXIN B SULFATEPOLYSPORIN (g)
POLYMYXIN B SULFATE/TMPPOLYTRIM (g)TOBRAMYCIN SULFATETOBREX (g)
TRIFLURIDINEVIROPTIC (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
CIPROFLOXACIN HCLCILOXAN OINTNATAMYCINNATACYN
MOXIFLOXACIN HCLVIGAMOXGANCICLOVIRZIRGAN
NonformularyGeneric NameTrade Name Utilization Management AZITHROMYCINAZASITE
BESIFLOXACIN HYDROCHLORIDEBESIVANCEIQUIXIQUIX
LEVOFLOXACINQUIXINGATIFLOXACINZYMARGATIFLOXACINZYMAXID
11F. Ophthalmic Steroids
Formulary PreferredGeneric NameTrade Name Utilization Management
DEXAMETHASONE SOD PHOSPHATEDECADRON OPTH (g)FLUOROMETHOLONEFML (g)
PREDNISOLONE SOD PHOSPHATEINFLAMASE, FORTE (g)PREDNISOLONE ACETATEPRED FORTE (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
FLUOROMETHOLONEFML FORTE, S.O.P.PREDNISOLONE ACETATEPRED MILD
RIMEXOLONEVEXOL
NonformularyGeneric NameTrade Name Utilization Management
LOTEPREDNOL ETABONATEALREXDIFLUPREDNATEDUREZOL
LOTEPREDNOL ETABONATELOTEMAXDEXAMETHASONEMAXIDEX
(g) Use generic equivalent
[PA] Prior authorization may be required
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[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
11G. Ophthalmic Anti-infective/Steroid Combinations
Formulary PreferredGeneric NameTrade Name Utilization Management
NEOMY SULF/POLYMYX B SULF/HCCORTISPORIN (g)NEO/POLYMYX B SULF/DEXAMETHMAXITROL (g)TOBRAMYCIN SULFATE/DEXAMETHTOBRADEX (g)
NA SULFACETM/PREDNIS SPVASOCIDIN (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
NA SULFACETM/PREDNISOL ACBLEPHAMIDE DROPS, OINTNEOMY SULF/POLYMYX B SULF/PREDPOLY-PRED
TOBRAMYCIN SULFATE/DEXAMETHTOBRADEX OINT
NonformularyGeneric NameTrade Name Utilization Management
GENTAMICIN/PREDNISOL ACPRED-GTOBRAMYCIN/LOTEPRED ETABZYLET
11H. Miscellaneous Ophthalmic Agents
Formulary PreferredGeneric NameTrade Name Utilization Management
NAPHAZOLINE HCLALBALON (g)PHENYLEPHRINE HCLNEO-SYNEPHRINE (g)CROMOLYN SODIUMOPTICROM (g)
AZELASTINE HCLOPTIVAR (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
NEDOCROMIL SODIUMALOCRILLODOXAMIDE TROMETHAMINEALOMIDEHYDROXYPROPYL CELLULOSELACRISERT
OLOPATADINE HCLPATANOLCYCLOSPORINERESTASIS
NonformularyGeneric NameTrade Name Utilization Management
PEMIROLAST POTASSIUMALAMASTBEPOTASTINE BESILATEBEPREVE
EPINASTINE HCLELESTATEMEDASTINE DIFUMARATEEMADINE
OLOPATADINE HCLPATADAY
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
12. OTIC & NASAL PREPARATIONS
12A. Nasal Preparations
Formulary PreferredGeneric NameTrade Name Utilization Management
AZELASTINE HCLASTELIN NASAL SPRAY(g)IPRATROPIUM BROMIDEATROVENT NASAL SPRAY (g)
FLUTICASONE PROPIONATEFLONASE (g)FLUNISOLIDE 0.025% SPRAYNASALIDE (g)
FLUNISOLIDENASAREL (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
AZELASTINE HCLASTEPRO NASAL SPRAYTRIAMCINOLONE ACETONIDENASACORT AQ [ST]
NonformularyGeneric NameTrade Name Utilization Management
BECLOMETHASONE DIPROPIONATEBECONASE AQ [ST]MOMETASONE FUROATENASONEX [ST]
CICLESONIDEOMNARIS [ST]OLOPATADINE HCLPATANASE
BUDESONIDERHINOCORT AQUA [ST]FLUTICASONE FUROATEVERAMYST [ST]
12B. Otic Preparations
Formulary PreferredGeneric NameTrade Name Utilization Management
ACETIC ACID/HYDROCORTISONEACETASOL, HC/VOSOL, HC (g)AA/ANTPY/BCAINE/POLICO/AL ACETAURALGAN (g)NEOMY SULF/POLYMYX B SULF/HCCORTISPORIN (g)ACETIC ACID/ALUMINUM ACETATEDOMEBORO OTIC (g)
OFLOXACINFLOXIN OTIC (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
CIPROFLOXACIN HCL/HCCIPRO HCCIPROFLOXACIN HCL/DEXAMETHCIPRODEX
NonformularyGeneric NameTrade Name Utilization Management
NEOMYCIN SULFATE/COLIST SUL/HCCOLY-MYCIN SNEOMY SULF/COLIST SUL/HC/THONZCORTISPORIN-TC
OFLOXACINFLOXIN OTIC SINGLES
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
13. RESPIRATORY, COUGH & COLD
13A. Antihistamines
Formulary PreferredGeneric NameTrade Name Utilization Management
FEXOFENADINE HCLALLEGRA (g)AZELASTINE HCLASTELIN NASAL SPRAY(g)
HYDROXYZINEATARAX, VISTARIL (g)DIPHENHYDRAMINE HCLBENADRYL (g)
LORATADINECLARITIN, ALAVERT(OTC) (g)CYPROHEPTADINE HCLPERIACTIN (g)
PROMETHAZINE HCLPHENERGAN (g)DEXCHLORPHENIRAMINE MALEATEPOLARAMINE (g)
CLEMASTINE FUMARATETAVIST RX (2.68MG, SYRUP) (g)LEVOCETIRIZINE DIHYDROCHLORIDEXYZAL TABS (g) [ST] [QL]
CETIRIZINE HCLZYRTEC (OTC) (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
AZELASTINE HCLASTEPRO NASAL SPRAY
NonformularyGeneric NameTrade Name Utilization Management
FEXOFENADINE HCLALLEGRA ODT [ST]FEXOFENADINE HCLALLEGRA SUSP [ST]
DESLORATADINECLARINEX (ALL) [PA] [QL]OLOPATADINE HCLPATANASE
LEVOCETIRIZINE DIHYDROCHLORIDEXYZAL SOLUTION [PA] [QL]
13B. Antihistamine/Decongestant Combinations
Formulary PreferredGeneric NameTrade Name Utilization Management
P-EPHED HCL/FEXOFENADINE HCLALLEGRA-D 12 HOUR (g) [ST] [QL]P-EPHED HCL/BROMPHENIRAMINBROMFED, PD (g)
P-EPHED SUL/LORATADINECLARITIN-D 12HR, 24HR(OTC) (g)PSEUDOEPHEDRINE HCL/CHLOR-MALDECONAMINE SYRUP, SR (g)
PHENYLEPHRINE HCL/CHLOR-MALRONDEC (g)PHENYLEPHRINE/CHLOR-TANRYNATAN (g)PHENYLEPHRINE/CHLOR-TANRYNATAN PED SUSP (g)P-EPHED HCL/CETIRIZINE HCLZYRTEC-D(OTC) (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
P-EPHED HCL/FEXOFENADINE HCLALLEGRA-D 24 HOUR [ST] [QL]PSEUDOEPHEDRINE HCL/CHLOR-MALDECONAMINE SR
NonformularyGeneric NameTrade Name Utilization Management
P-EPHED SUL/DESLORATADINECLARINEX-D [PA] [QL]PSEUDOEPHEDRINE HCL/ACRIVASSEMPREX-D [ST]
(g) Use generic equivalent
[PA] Prior authorization may be required
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[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
13C. Antitussive combinations
Formulary PreferredGeneric NameTrade Name Utilization Management
D-METHORPHAN HB/P-EPD HCL/BPMBROMFED-DM (g)GUAIFENESIN/P-EPHED HCL/HCODDECONAMINE CX, SR (g)GUAIFENESIN/D-METHORPHAN HBHUMABID DM (g)D-METHORPHAN HB/PROMETH HCLPHENERGAN DM (g)
CODEINE/PROMETHAZINE HCLPHENERGAN W/CODEINE (g)D-METHORPHAN HB/PE/CHLORPHENIRRONDEC-DM (g)
BENZONATATETESSALON, PERLES (g)HYDROCODONE/CHLORPHEN POLISTUSSIONEX (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
HYDROCODONE/CHLORPHEN POLISTUSSICAPS
NonformularyGeneric NameTrade Name Utilization Management
NONE
13D. Expectorant combinations
Formulary PreferredGeneric NameTrade Name Utilization Management
GUAIFENESIN/P-EPHED HCLGUAIFED, ENTEX PSE (g)GUAIFENESIN/PHENYLEPHRINE HCLGUAIFED-PD (g)PHENYLEPHRINE HCL/PROMETH HCLPHENERGAN VC (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
NONE
NonformularyGeneric NameTrade Name Utilization Management
NONE
13F. Oral Beta-Agonists
Formulary PreferredGeneric NameTrade Name Utilization Management
METAPROTERENOL SULFATEALUPENT (g)TERBUTALINE SULFATEBRETHINE (g)ALBUTEROL SULFATEPROVENTIL SOLUTION (g)ALBUTEROL SULFATEVOSPIRE ER (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
NONE
NonformularyGeneric NameTrade Name Utilization Management
NONE
(g) Use generic equivalent
[PA] Prior authorization may be required
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[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
13G. Inhaled Beta-Agonists
Formulary PreferredGeneric NameTrade Name Utilization Management
ALBUTEROL SULFATEACCUNEB (g)ALBUTEROL SULFATEALBUTEROL NEBULIZER SOLN (g)
METAPROTERENOL SULFATEMETAPROTERENOL SOLN (g)LEVALBUTEROL HCLXOPENEX 1.25MG/0.5ML (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
FORMOTEROL FUMARATEFORADILPIRBUTEROL ACETATEMAXAIR AUTOHALER
ALBUTEROLPROAIR HFA, VENTOLIN HFASALMETEROL XINAFOATESEREVENT DISKUS
NonformularyGeneric NameTrade Name Utilization Management
ARFORMOTEROL TARTRATEBROVANA [PA] [QL]FORMOTEROL FUMARATEPERFOROMIST [PA] [QL]
ALBUTEROLPROVENTIL HFALEVALBUTEROL TARTRATEXOPENEX HFA
LEVALBUTEROL HCLXOPENEX SOLUTION
13H. Inhaled Steroids
Formulary PreferredGeneric NameTrade Name Utilization Management BUDESONIDEPULMICORT 0.25MG, 0.5MG/2ML (g) BE
Formulary OptionsGeneric NameTrade Name Utilization Management CICLESONIDEALVESCO (TIER 1-BCN ONLY) BE
MOMETASONE FUROATEASMANEX (TIER 1-BCN ONLY) BETRIAMCINOLONE ACETONIDEAZMACORT (TIER 1-BCN ONLY) BEFLUTICASONE PROPIONATEFLOVENT HFA, DISKUS (TIER 1-BCN ONLY) BE
BUDESONIDEPULMICORT 1MG/2ML (TIER 1-BCN ONLY)BUDESONIDEPULMICORT INH (TIER 1-BCN ONLY) BE
BECLOMETHASONE DIPROPIONATEQVAR (TIER 1-BCN ONLY) BE
NonformularyGeneric NameTrade Name Utilization Management
FLUNISOLIDE/MENTHOLAEROBID, M
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
13I. Intranasal Steroids
Formulary PreferredGeneric NameTrade Name Utilization Management
FLUTICASONE PROPIONATEFLONASE (g)FLUNISOLIDE 0.025% SPRAYNASALIDE (g)
FLUNISOLIDENASAREL (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
TRIAMCINOLONE ACETONIDENASACORT AQ [ST]
NonformularyGeneric NameTrade Name Utilization Management
BECLOMETHASONE DIPROPIONATEBECONASE AQ [ST]MOMETASONE FUROATENASONEX [ST]
CICLESONIDEOMNARIS [ST]BUDESONIDERHINOCORT AQUA [ST]
FLUTICASONE FUROATEVERAMYST [ST]
13J. Theophyllines
Formulary PreferredGeneric NameTrade Name Utilization Management
THEOPHYLLINE ANHYDROUSTHEOPHYLLINE ANHYDROUS (g)THEOPHYLLINE ANHYDROUSUNIPHYL (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
THEOPHYLLINE ANHYDROUSTHEO-24
NonformularyGeneric NameTrade Name Utilization Management
NONE
13K. Epinephrine
Formulary PreferredGeneric NameTrade Name Utilization Management
NONE
Formulary OptionsGeneric NameTrade Name Utilization Management EPINEPHRINEEPIPEN, JR
NonformularyGeneric NameTrade Name Utilization Management
NONE
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
13L. Miscellaneous Pulmonary Agents
Formulary PreferredGeneric NameTrade Name Utilization Management ZAFIRLUKASTACCOLATE(g) [QL]
IPRATROPIUM BROMIDEATROVENT NASAL SPRAY (g)IPRATROPIUM BROMIDEATROVENT SOLN (g)
IPRATROPIUM/ALBUTEROL SULFATEDUONEB (g)CROMOLYN SODIUMINTAL SOLUTION (g)
ACETYLCYSTEINEMUCOMYST (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
FLUTICASONE/SALMETEROLADVAIRIPRATROPIUM BROMIDEATROVENT INHALER
ALBUTEROL SULFATE/IPRATROPIUMCOMBIVENTMOMETASONE/FORMOTEROLDULERA [QL]
AMBRISENTANLETAIRIS [PA] [QL] <s>DORNASE ALFAPULMOZYME <s>
SILDENAFIL CITRATEREVATIO [PA] [QL] <s>MONTELUKAST SODIUMSINGULAIR [QL]TIOTROPIUM BROMIDESPIRIVA
BUDESONIDE/FORMOTEROL FUMARATESYMBICORTBOSENTANTRACLEER [PA] <s>
TREPROSTINILTYVASO [PA] [QL] <s>ILOPROSTVENTAVIS [PA] [QL] <s>
NonformularyGeneric NameTrade Name Utilization Management
TADALAFILADCIRCA [PA] [QL] <s>ZILEUTONZYFLO, CR [QL]
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
14. UROLOGY
14A. Urinary Antispasmodics
Formulary PreferredGeneric NameTrade Name Utilization Management
DICYCLOMINE HCLBENTYL (g)OXYBUTYNIN CHLORIDEDITROPAN (g)OXYBUTYNIN CHLORIDEDITROPAN XL (g)HYOSCYAMINE SULFATELEVBID (g)HYOSCYAMINE SULFATELEVSIN, SL (g)HYOSCYAMINE SULFATELEVSINEX (g)
PROPANTHELINE BROMIDEPRO-BANTHINE 15MG (g)TROSPIUM CHLORIDESANCTURA (g)
FLAVOXATE HCLURISPAS (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
TOLTERODINE TARTRATEDETROLTOLTERODINE TARTRATEDETROL LA
NonformularyGeneric NameTrade Name Utilization Management
DARIFENACIN HYDROBROMIDEENABLEXOXYBUTYNIN CHLORIDEGELNIQUE [QL]
OXYBUTYNINOXYTROL [QL]TROSPIUM CHLORIDESANCTURA XR [QL]
FESOTERODINE FUMARATETOVIAZ [QL]SOLIFENACIN SUCCINATEVESICARE
14B. Miscellaneous Urologicals
Formulary PreferredGeneric NameTrade Name Utilization Management
CITRIC ACID/POTASSIUM CITRATECYTRA-2, 3, K (g)PHOSPHORUS #1K-PHOS NEUTRAL (g)
SOD/POTASS/K CIT/SOD CIT/CAPOLYCITRA (g)PHENAZOPYRIDINE HCLPYRIDIUM (g)
BETHANECHOL CHLORIDEURECHOLINE (g)POTASSIUM CITRATEUROCIT-K (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
PENTOSAN POLYSULFATE SODIUMELMIRONMAG CARB/CITRIC ACID/G-LACTONERENACIDINMTH/ME BLUE/BA/SALICY/ATP/HYOSURETRON D-S
NonformularyGeneric NameTrade Name Utilization Management
NONE
(g) Use generic equivalent
[PA] Prior authorization may be required
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[QL] Quantity limits may apply
[ST] Step therapy may be required
<s> Specialty Drug
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
14C. BPH Treatment
Formulary PreferredGeneric NameTrade Name Utilization Management
DOXAZOSIN MESYLATECARDURA (g)TAMSULOSIN HCLFLOMAX (g)TERAZOSIN HCLHYTRIN (g)
FINASTERIDEPROSCAR (g)
Formulary OptionsGeneric NameTrade Name Utilization Management DUTASTERIDEAVODART
ALFUZOSIN HCLUROXATRAL
NonformularyGeneric NameTrade Name Utilization Management
DOXAZOSIN MESYLATECARDURA XLDUTASTERIDE/TAMSULOSIN HCLJALYN [ST] [QL]
SILODOSINRAPAFLO [QL]
(g) Use generic equivalent
[PA] Prior authorization may be required
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15. VITAMINS AND SUPPLEMENTS
15A. Vitamins and Minerals
Formulary PreferredGeneric NameTrade Name Utilization Management
ERGOCALCIFEROLCALCIFEROL (g)CYANOCOBALAMINCYANOCOBALAMIN INJ (g)
FOLIC ACIDFOLVITE (g)SODIUM FLUORIDELURIDE (g)
FLUORIDE ION/MULTIVITAMINSPOLY-VI-FLOR (g)PRENATAL VIT/IRON,CARB/DOSS/FAPRENATAL VITS (g)
SODIUM FLUORIDEPREVIDENT (g)CALCITRIOLROCALTROL (g)
FLUORIDE ION/VIT A,C&DTRI-VI-FLOR (g)
Formulary OptionsGeneric NameTrade Name Utilization Management PHYTONADIONEMEPHYTON
NonformularyGeneric NameTrade Name Utilization Management ZINC ACETATEGALZIN
DOXERCALCIFEROLHECTOROLCYANOCOBALAMINNASCOBAL SPRAY
IRON ASPGLY&PS/C/B12/FA/CA/SUCNIFEREX GOLDLYSINE HCL/VIT B COMP/FA/ZINCSUPERVITE
PARICALCITOLZEMPLAR
15B. Potassium Replacement
Formulary PreferredGeneric NameTrade Name Utilization Management
POTASSIUM CHLORIDEKAYCIEL, KAON-CL, KAON LIQUID (g)POTASSIUM CHLORIDEK-LOR, KLOR-CON (g)
POTASSIUM BICARBONATE/CIT ACK-LYTE, KLOR-CON/EF (g)POTASSIUM CHLORIDEK-TAB, K-DUR, SLOW-K, KAON CL (g)POTASSIUM CHLORIDEMICRO-K(g)
Formulary OptionsGeneric NameTrade Name Utilization Management
NONE
NonformularyGeneric NameTrade Name Utilization Management
POTASSIUM CHLORIDE/POT BICARBKAOCHLOR-EFF
(g) Use generic equivalent
[PA] Prior authorization may be required
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16. DIAGNOSTIC AND OTHER MISCELLANEOUS
16A. Diagnostics and Other Miscellaneous
Formulary PreferredGeneric NameTrade Name Utilization Management
LEVOCARNITINECARNITOR (g)SOD SULF/SOD/NAHCO3/KCL/PEG'SCOLYTE (g)
DEFEROXAMINE MESYLATEDESFERAL (g)PEG 3350/NA SULF,BICARB,CL/KCLGOLYTELY (g)
SODIUM POLYSTYRENE SULFONATEKAYEXALATE (g)SOD SULF/SOD/NAHCO3/KCL/PEG'SNULYTELY (g)
CHLORHEXIDINE GLUCONATEPERIDEX (g)CALCIUM ACETATEPHOSLO (g)NALTREXONE HCLREVIA (g)PILOCARPINE HCLSALAGEN (g)
Formulary OptionsGeneric NameTrade Name Utilization Management
DISULFIRAMANTABUSECARGLUMIC ACIDCARBAGLU [PA] <s>PENICILLAMINECUPRIMINE
PEG 3350/NA SULF,BICARB,CL/KCLGOLYTELY PACKETSAPROPTERIN DIHYDROCHLORIDEKUVAN [PA] <s>
NITISINONEORFADIN <s>PRUSSIAN BLUERADIOGARDASE [QL]SEVELAMER HCLRENAGEL
SEVELAMER CARBONATERENVELA PACKET 2.4GSEVELAMER CARBONATERENVELA TABLET
TOLVAPTANSAMSCA <s>TRIENTINE HCLSYPRINE <s>
TETRABENAZINEXENAZINE [PA] [QL] <s>
NonformularyGeneric NameTrade Name Utilization Management
AMLEXANOXAPHTHASOLACAMPROSATE CALCIUMCAMPRAL [PA]
CEVIMELINE HCLEVOXACDEFERASIROXEXJADE [PA] <s>
LANTHANUM CARBONATEFOSRENOLBISAC/NACL/NAHCO3/KCL/PEG 3350HALFLYTELY [QL]PEG3350/SOD SUL/NACL/ASB/C/KCLMOVIPREP
NAPHOS M-B M-H/NA PHOS,DI-BAOSMOPREP, VISICOLSEVELAMER CARBONATERENVELA PACKET 0.8G
MIGLUSTATZAVESCA
(g) Use generic equivalent
[PA] Prior authorization may be required
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17. LIFESTYLE MODIFICATION
17A. Impotence
Formulary PreferredGeneric NameTrade Name Utilization Management YOHIMBINE HCLYOHIMBINE HCL (g)
Formulary OptionsGeneric NameTrade Name Utilization Management ALPROSTADILCAVERJECT [PA] [QL]
TADALAFILCIALIS [PA] [QL]ALPROSTADILMUSE [PA] [QL]
SILDENAFIL CITRATEVIAGRA [PA] [QL]
NonformularyGeneric NameTrade Name Utilization Management ALPROSTADILEDEX [PA] [QL]
VARDENAFIL HCLLEVITRA [PA] [QL]VARDENAFIL HCLSTAXYN [PA] [QL]
17B. Weight Loss Preparations
Formulary PreferredGeneric NameTrade Name Utilization Management
PHENTERMINE HCLADIPEX-P (g) [PA] [QL]PHENDIMETRAZINE TARTRATEBONTRIL (g) [PA] [QL]
BENZPHETAMINE HCLDIDREX (g) [PA] [QL]DIETHYLPROPION HCLTENUATE (g) [PA] [QL]
Formulary OptionsGeneric NameTrade Name Utilization Management
PHENTERMINE RESINIONAMIN [PA] [QL]
NonformularyGeneric NameTrade Name Utilization Management
ORLISTATXENICAL [PA] [QL]
17C. Smoking Cessation
Formulary PreferredGeneric NameTrade Name Utilization Management
NICOTINE POLACRILEXCOMMIT LOZENGE OTC (g) (BCN ONLY) [QL] BENICOTINE POLACRILEXNICOTINE GUM, NICORETTE (g) (BCN ONLY) [QL] BE
NICOTINENICOTINE PATCH (g) [QL] BEBUPROPION HCLZYBAN (g) BE
Formulary OptionsGeneric NameTrade Name Utilization Management
VARENICLINE TARTRATECHANTIX [QL]
NonformularyGeneric NameTrade Name Utilization Management
NICOTINENICOTROL, NS [QL]
(g) Use generic equivalent
[PA] Prior authorization may be required
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Index
Trade Name Page Trade Name PageABILIFY, DISCMELT, SOLUTION 56
ACCOLATE(g) 105
ACCUNEB (g) 103
ACCUPRIL (g) 49
ACCURETIC (g) 49
ACCUTANE (REQ DERM CONSULT) (g) 92
ACCUZYME, ETHEZYME, GLADASE (g) 94
ACEON (g) 49
ACETASOL, HC/VOSOL, HC (g) 100
ACIPHEX 66
ACLOVATE (g) 90
ACTIGALL (g) 68
ACTIMMUNE 88
ACTIQ (g) 59
ACTIVELLA (g) 74
ACTIVELLA 0.5-0.1MG 74
ACTONEL WITH CALCIUM 78
ACTONEL, WEEKLY, 150MG 78
ACTOPLUS MET 82
ACTOPLUS MET XR 82
ACTOS 82
ACULAR, LS (g) 97
ACUVAIL 97
ACZONE 92
ADCIRCA 105
ADDERALL (g) 57
ADDERALL XR (BRAND-BCN ONLY) 57
ADDERALL XR (g) (BCBSM ONLY) 57
ADIPEX-P (g) 110
ADOXA (g) 41
ADOXA 150MG CAPSULE 41
ADOXA CK, TT 41
ADVAIR 105
ADVICOR 47
AEROBID, M 103
AFINITOR 87
AGGRENOX 53
AGRYLIN (g) 53
AKNE-MYCIN 92
ALAMAST 99
ALBALON (g) 99
ALBENZA 46
ALBUTEROL NEBULIZER SOLN (g) 103
ALDACTAZIDE (g) 52
ALDACTONE (g) 52
ALDARA (g) 95
ALDOMET (g) 54
ALDORIL (g) 54
ALESSE (g), LEVLITE (g) 71
ALFERON N 88
ALINIA 46
ALKERAN 84
ALLEGRA (g) 101
ALLEGRA ODT 101
ALLEGRA SUSP 101
ALLEGRA-D 12 HOUR (g) 101
ALLEGRA-D 24 HOUR 101
ALOCRIL 99
ALOMIDE 99
ALORA 73
ALORA 77
ALPHAGAN (g) 96
ALPHAGAN P 0.1% 96
ALPHAGAN P 0.15% (g) 96
ALREX 98
ALSUMA 61
ALTABAX 92
ALTABAX 92
ALTACE CAPSULE (g) 49
ALTACE TABLET 49
ALTOPREV 47
ALUPENT (g) 102
ALVESCO (TIER 1-BCN ONLY) 103
AMARYL (g) 82
AMBIEN (g) 57
AMBIEN CR (g) 57
AMERGE (g) 61
AMICAR (g) 53
AMITIZA 70
AMOXAPINE (g) 55
AMOXIL (g) 40
AMPICILLIN (g) 40
AMPYRA 88
AMRIX 64
ANADROL-50 80
ANAFRANIL (g) 55
ANALPRAM HC (g) 70
ANAMANTLE HC (g) 70
ANAPROX, DS (g) 58
ANCOBON 43
ANDRODERM 80
ANDROGEL 80
ANDROXY 10MG (g) 80
ANGELIQ 74
ANNUSOL HC, PROCTOCREAM HC (g) 70
ANSAID (g) 58
ANTABUSE 109
ANTARA 47
ANTIVERT (g) 68
ANZEMET 68
APEXICON E 89
APHTHASOL 109
APIDRA (PEN/CARTRIDGE) 81
APIDRA (VIAL) 81
APLENZIN 55
APOKYN 62
Trade Name Page Trade Name PageAPRESOLINE (g) 54
APRISO 70
APTIVUS(MUST BE USED WITH NORVIR) 44
ARALEN (g) 45
ARANESP 88
ARANESP 86
ARAVA (g) 77
ARCALYST 85
ARICEPT 23MG 65
ARICEPT, ODT (g) 65
ARIMIDEX (g) 85
ARISTOCORT, KENALOG (g) 90
ARISTOCORT, KENALOG 0.5% CR (g) 89
ARIXTRA 53
ARMOUR THYROID 79
AROMASIN 85
ARTANE (g) 62
ARTHROTEC 58
ASACOL 70
ASACOL HD 70
ASMANEX (TIER 1-BCN ONLY) 103
ASPIRIN W/CODEINE (g) 60
ASTELIN NASAL SPRAY(g) 100
ASTELIN NASAL SPRAY(g) 101
ASTEPRO NASAL SPRAY 100
ASTEPRO NASAL SPRAY 101
ATACAND 50
ATACAND HCT 50
ATARAX, VISTARIL (g) 101
ATIVAN (g) 56
ATRIPLA 44
ATROVENT NASAL SPRAY (g) 105
ATROVENT NASAL SPRAY (g) 100
ATROVENT INHALER 105
ATROVENT SOLN (g) 105
AUGMENTIN, ES, XR (g) 40
AURALGAN (g) 100
AVALIDE 50
AVANDAMET 82
AVANDARYL 82
AVANDIA 82
AVAPRO 50
AVC 75
AVELOX, ABC 42
AVINZA 59
AVODART 107
AVONEX 88
AXERT 61
AXID (RX ONLY) (g) 66
AYGESTIN (g) 73
AZASITE 98
AZELEX 92
AZILECT 62
AZMACORT (TIER 1-BCN ONLY) 103
AZOPT 96
AZOR 51
AZOR 50
AZULFIDINE EN-TAB (g) 70
AZULFIDINE EN-TAB (g) 77
AZULFIDINE TAB (g) 77
AZULFIDINE TAB (g) 70
BACITRACIN (g) 98
BACTRIM, DS, SEPTRA, DS (g) 42
BACTROBAN CREAM, NASAL 92
BACTROBAN OINTMENT (g) 92
BANZEL 63
BARACLUDE 43
BECONASE AQ 100
BECONASE AQ 104
BELLAMINE/BELLASPAS (g) 67
BENADRYL (g) 101
BENICAR 50
BENICAR HCT 50
BENTYL (g) 106
BENTYL (g) 67
BENZACLIN 92
BENZAMYCIN (g) 92
BENZASHAVE 92
BENZOYL PEROXIDE-RX (g) 92
BEPREVE 99
BESIVANCE 98
BETAGAN (g) 96
BETAPACE, AF (g) 52
BETAPACE, AF (g) 48
BETASERON 88
BETIMOL 96
BETOPTIC S 96
BETOPTIC SOLN (g) 96
BEYAZ 72
BIAXIN, XL (g) 41
BILTRICIDE 46
BLEPH-10, SODIUM SULAMYDE (g) 98
BLEPHAMIDE DROPS, OINT 99
BLOCADREN (g) 48
BONIVA 78
BONTRIL (g) 110
BRAVELLE 74
BRETHINE (g) 102
BREVOXYL GEL (g) 92
BROMFED, PD (g) 101
BROMFED-DM (g) 102
BROVANA 103
BUMEX (g) 52
BUPAP (g) 61
BUSPAR (g) 56
BUTISOL SODIUM 57
BUTRANS 60
BYETTA 82
Trade Name Page Trade Name PageBYSTOLIC 48
CADUET 51
CADUET 47
CAFERGOT (g) 61
CALAN SR/ISOPTIN SR (g) 51
CALCIFEROL (g) 80
CALCIFEROL (g) 108
CAMBIA 58
CAMBIA 61
CAMPRAL 109
CANASA 70
CANTIL 67
CAPEX SHAMPOO 90
CAPOTEN (g) 49
CAPOZIDE (g) 49
CARAC 95
CARAFATE SUSP (g) 67
CARAFATE TABS (g) 67
CARBAGLU 109
CARBATROL 63
CARDENE (g) 51
CARDENE SR 51
CARDIZEM LA 51
CARDIZEM LA (g) 51
CARDIZEM, SR, CD (g) 51
CARDURA (g) 107
CARDURA (g) 54
CARDURA XL 107
CARMOL HC 95
CARNITOR (g) 109
CASODEX (g) 85
CATAFLAM (g) 58
CATAPRES (g) 54
CATAPRES-TTS (g) 54
CAVERJECT 110
CAYSTON 46
CECLOR (g) 40
CECLOR ER (g) 40
CEDAX 40
CEENU 84
CEFTIN (g) 40
CEFZIL (g) 40
CELEBREX 58
CELEXA (g) 55
CELLCEPT (g) 85
CELLCEPT SUSPENSION 85
CELONTIN 63
CENESTIN 73
CENESTIN 77
CESAMET 68
CETROTIDE 74
CHANTIX 110
CHENODAL 68
CHLORAL HYDRATE (g) 57
CIALIS 110
CILOXAN DROPS (g) 98
CILOXAN OINT 98
CIMZIA SYRINGE 77
CIMZIA SYRINGE 70
CIPRO (g) 42
CIPRO HC 100
CIPRO XR (g) 42
CIPRODEX 100
CLARINEX (ALL) 101
CLARINEX-D 101
CLARITIN, ALAVERT(OTC) (g) 101
CLARITIN-D 12HR, 24HR(OTC) (g) 101
CLEOCIN (g) 46
CLEOCIN T (g) 92
CLEOCIN VAG CREAM (g) 75
CLEOCIN VAGINAL OVULES 75
CLIMARA (g) 77
CLIMARA (g) 73
CLIMARA PRO 74
CLINAC BPO 92
CLINDESSE 75
CLINORIL (g) 58
CLOBEX, SPRAY 89
CLODERM 90
CLOMID (g) 74
CLOZARIL (g) 56
CNL 8 93
COARTEM 45
CODEINE SULFATE (g) 59
COGENTIN (g) 62
COGNEX 65
COLAZAL (g) 70
COLBENEMID (g) 76
COLCRYS 76
COLESTID (g) 47
COLESTID FLAVORED 47
COLY-MYCIN S 100
COLYTE (g) 109
COMBIGAN 96
COMBIPATCH 74
COMBIVENT 105
COMBIVIR 44
COMMIT LOZENGE OTC (g) (BCN ONLY) 110
COMPAZINE (g) 68
COMTAN 62
CONCERTA 57
CONDYLOX GEL 95
CONDYLOX SOLN (g) 95
COPAXONE 88
COPEGUS (g) 43
CORDARONE (g) 52
CORDRAN, TAPE, SP 90
COREG (g) 48
Trade Name Page Trade Name PageCOREG CR 48
CORGARD (g) 48
CORTEF, HYDROCORTISONE (g) 79
CORTENEMA (g) 70
CORTICOSTEROIDS 76
CORTIFOAM 70
CORTISONE ACETATE (g) 79
CORTISPORIN (g) 99
CORTISPORIN (g) 100
CORTISPORIN-TC 100
CORZIDE (g) 48
COSOPT (g) 96
COUMADIN (g) 53
COVERA-HS 51
COZAAR (g) 50
CREON 69
CRESTOR 47
CRINONE 73
CRIXIVAN 44
CUPRIMINE 77
CUPRIMINE 109
CUTIVATE (g) 90
CUTIVATE LOTION 90
CYANOCOBALAMIN INJ (g) 108
CYCLESSA (g) 72
CYCLOCORT (g) 89
CYCLOGYL (g) 97
CYMBALTA 55
CYTOMEL (g) 79
CYTOTEC (g) 67
CYTOVENE (g) 43
CYTOXAN (g) 84
CYTRA-2, 3, K (g) 106
D.H.E.45 (g) 61
DALMANE (g) 57
DANOCRINE (g) 80
DANTRIUM (g) 64
DAPSONE 45
DARAPRIM 45
DAYPRO (g) 58
DAYTRANA 57
DDAVP SOLN 80
DDAVP SPRAY (g) 80
DDAVP TABS (g) 80
DECADRON (g) 79
DECADRON OPTH (g) 98
DECONAMINE CX, SR (g) 102
DECONAMINE SR 101
DECONAMINE SYRUP, SR (g) 101
DELATESTRYL 80
DEMADEX (g) 52
DEMEROL (g) 59
DEMULEN (g) 71
DENAVIR 93
DEPAKENE (g) 63
DEPAKOTE (g) 63
DEPAKOTE ER (g) 63
DEPAKOTE SPRINKLES (g) 63
DEPEN 77
DEPO-PROVERA 150MG (g) 73
DEPO-PROVERA 400MG 85
DEPO-SUBQ PROVERA 104 73
DEPO-TESTOSTERONE (g) 80
DERMACORT, HYTONE (Rx Only) (g) 90
DERMA-SMOOTHE/FS 90
DERMATOP (g) 90
DESFERAL (g) 109
DESOGEN (g), ORTHO-CEPT (g) 71
DESONATE 90
DESOWEN, TRIDESILON (g) 90
DESOXYN (g) 57
DESYREL (g) 55
DETROL 106
DETROL LA 106
DEXEDRINE (g) 57
DEXILANT 66
DIABETA, MICRONASE (g) 82
DIABINESE (g) 82
DIAMOX (g) 63
DIAMOX (g) 52
DIAMOX SEQUELS (g) 52
DIASTAT 63
DIASTAT 2.5MG (g) 63
DICLOXACILLIN (g) 40
DIDREX (g) 110
DIDRONEL (g) 78
DIFFERIN 0.1% CREAM, GEL (g) 92
DIFFERIN 0.3% GEL 92
DIFFERIN LOTION 92
DIFLUCAN (g) 75
DIFLUCAN (g) 43
DIGOXIN ELIXIR (g) 52
DIGOXIN TABS (g) 52
DILANTIN (g) 63
DILANTIN CHEW TABS 63
DILATRATE-SR 53
DILAUDID (g) 59
DIOVAN 50
DIOVAN HCT 50
DIPENTUM 70
DIPROLENE AF, GEL, CR, LOT (g) 89
DIPROLENE OINTMENT (g) 89
DIPROSONE (g), MAXIVATE (g) 89
DISALCID, SALFLEX (g) 59
DITROPAN (g) 106
DITROPAN XL (g) 106
DIURIL (g) 52
DIVIGEL 73
Trade Name Page Trade Name PageDOLOBID (g) 59
DOMEBORO OTIC (g) 100
DONNATAL (g) 67
DONNATAL EXTENTABS 67
DORAL 57
DORYX 41
DOSTINEX (g) 62
DOSTINEX (g) 80
DOVONEX CREAM 94
DOVONEX OINT(g) 94
DOVONEX SOLUTION (g) 94
DRITHOCREME HP (g) 94
DRITHO-SCALP 94
DROXIA 86
DRYSOL (g) 95
DUAC, CS 92
DUETACT 82
DULERA 105
DUONEB (g) 105
DURAGESIC (g) 59
DUREZOL 98
DURICEF (g) 40
DYGASE (g) 69
DYNACIRC (g) 51
DYNACIRC CR 51
DYRENIUM 52
EC-NAPROSYN (g) 58
EDECRIN 52
EDEX 110
EDLUAR 57
EFFEXOR (g) 55
EFFEXOR XR (g) 55
EFFIENT 53
EFUDEX (g) 95
EFUDEX OCCLUSION 95
ELAVIL (g) 55
ELDEPRYL(g) 62
ELESTAT 99
ELESTRIN 73
ELIDEL 95
ELIGARD 85
ELIMITE (g) 94
ELLA 72
ELMIRON 106
ELOCON (g) 90
EMADINE 99
EMBEDA 59
EMCYT 86
EMEND 80,125MG CAPSULES 68
EMLA (g) 91
EMSAM 55
EMTRIVA 44
ENABLEX 106
ENBREL 94
ENBREL 77
ENDOMETRIN 73
ENJUVIA 77
ENJUVIA 73
ENTOCORT EC 79
EPIDUO 92
EPIPEN, JR 104
EPIVIR 44
EPIVIR HBV 43
EPOGEN 88
EPOGEN 86
EPZICOM 44
EQUETRO 63
ERGOMAR 61
ERTACZO 93
ERYTHROMYCIN (g) 41
ERYTHROMYCIN STEARATE, BASE (g) 41
ERYTHROMYCIN TOPICAL SOLN, GEL (g) 92
ESKALITH (g) 65
ESKALITH CR (g) 65
ESTRACE (g) 77
ESTRACE (g) 73
ESTRACE VAGINAL CREAM 73
ESTRADERM 73
ESTRADERM 77
ESTRASORB 73
ESTRATEST, H.S. (g) 77
ESTRATEST, H.S. (g) 74
ESTRING 73
ESTROGEL 73
ESTROGENS 78
ESTROSTEP FE (g) 72
ETHAMBUTOL (g) 45
ETRAFON (g) 55
EULEXIN (g) 85
EURAX 94
EVAMIST 73
EVISTA 78
EVOCLIN FOAM(g) 92
EVOXAC 109
EXALGO 59
EXELDERM SOLN, CR 93
EXELON 65
EXELON (g) 65
EXFORGE 51
EXFORGE 50
EXFORGE HCT 51
EXFORGE HCT 50
EXJADE 109
EXTAVIA 88
EXTINA 93
FACTIVE 42
FAMVIR (g) 43
FANAPT 56
Trade Name Page Trade Name PageFARESTON 85
FASLODEX 85
FAZACLO 56
FELBATOL 63
FELDENE (g) 58
FEMARA 85
FEMCON FE 71
FEMHRT 74
FEMHRT 77
FEMRING 73
FEMTRACE 73
FENOGLIDE 47
FENTORA 59
FERTINEX 74
FEXMID 64
FIBRICOR (g) 47
FINACEA 92
FIORICET W/CODEINE (g) 60
FIORICET;ESGIC, PLUS (g) 60
FIORICET;ESGIC, PLUS (g) 61
FIORINAL (g) 60
FIORINAL (g) 61
FIORINAL W/CODEINE (g) 61
FIORINAL W/CODEINE (g) 60
FLAGYL (g) 46
FLAGYL ER 46
FLECTOR PATCH 58
FLEXERIL (g) 64
FLOMAX (g) 107
FLONASE (g) 100
FLONASE (g) 104
FLORINEF (g) 79
FLOVENT HFA, DISKUS (TIER 1-BCN ONLY) 103
FLOXIN (g) 42
FLOXIN OTIC (g) 100
FLOXIN OTIC SINGLES 100
FLUMADINE (g) 43
FLUVOXAMINE MALEATE (g) 55
FML (g) 98
FML FORTE, S.O.P. 98
FOCALIN (g) 57
FOCALIN XR 57
FOLLISTIM AQ 74
FOLVITE (g) 108
FORADIL 103
FORTAMET 82
FORTEO 77
FOSAMAX (g) 78
FOSAMAX PLUS D 78
FOSAMAX WEEKLY (g) 78
FOSRENOL 109
FRAGMIN 53
FROVA 61
FUZEON 44
GABITRIL 63
GALZIN 108
GANIRELIX ACETATE 74
GARAMYCIN (g) 98
GELNIQUE 106
GENOTROPIN 83
GENTAMICIN CR, OINT (g) 92
GEODON 56
GILENYA 88
GLEEVEC 87
GLUCAGON EMERGENCY KIT 80
GLUCOPHAGE (g) 82
GLUCOPHAGE XR (g) 82
GLUCOTROL (g) 82
GLUCOTROL XL (g) 82
GLUCOVANCE (g) 82
GLUMETZA 82
GLYCOLAX (g) 70
GLYNASE (g) 82
GLYSET 82
GOLYTELY (g) 109
GOLYTELY PACKET 109
GONAL-F, RFF 74
GRANULEX (g) 94
GRIFULVIN V 500MG 43
GRIFULVIN V SUSP (g) 43
GRIS PEG 43
GUAIFED, ENTEX PSE (g) 102
GUAIFED-PD (g) 102
GYNAZOLE-1 75
HALCION (g) 57
HALDOL (g) 56
HALFLYTELY 109
HALOG 89
HECTOROL 80
HECTOROL 108
HELIDAC 67
HEPARIN (g) 53
HEPSERA 43
HEXALEN 86
HIPREX/UREX (g) 42
HUMABID DM (g) 102
HUMALOG, MIX (PEN/CARTRIDGE) 81
HUMALOG, MIX (VIAL) 81
HUMATIN (g) 46
HUMATROPE 83
HUMIRA 94
HUMIRA 77
HUMULIN 70/30 (PEN/CARTRIDGE) 81
HUMULIN 70/30 (VIAL) 81
HUMULIN N (PEN/CARTRIDGE) 81
HUMULIN N (VIAL) 81
HUMULIN R (VIAL) 81
HYCAMTIN 86
Trade Name Page Trade Name PageHYDREA (g) 86
HYDRODIURIL, MICROZIDE (g) 52
HYGROTON, THALITONE (g) 52
HYTRIN (g) 107
HYTRIN (g) 54
HYZAAR (g) 50
ILOTYCIN (g) 98
IMDUR (g) 53
IMITREX INJECTION (g) 61
IMITREX NASAL SPRAY (g) 61
IMITREX TABLETS (g) 61
IMURAN (g) 77
IMURAN (g) 85
INCRELEX 83
INDERAL (g) 48
INDERAL LA (g) 48
INDERIDE (g) 48
INDOCIN SUPPOSITORY 58
INDOCIN, SR (g) 58
INFERGEN 88
INFLAMASE, FORTE (g) 98
INNOHEP 53
INNOPRAN XL 48
INSPRA (g) 52
INTAL SOLUTION (g) 105
INTELENCE 44
INTRON A 88
INTUNIV 65
INVEGA 56
INVIRASE 44
IONAMIN 110
IOPIDINE DROPERETTE 96
IOPIDINE DROPS (g) 96
IQUIX 98
IRESSA 87
ISENTRESS 44
ISMO, MONOKET (g) 53
ISONIAZID (g) 45
ISOPTO ATROPINE (g) 97
ISOPTO CARBACHOL 96
ISOPTO HOMATROPINE (g) 97
ISOPTO HYOSCINE 97
ISORDIL (g) 53
ISTALOL 96
JALYN 107
JANUMET 82
JANUVIA 82
KADIAN 59
KALETRA 44
KAOCHLOR-EFF 108
KAYCIEL, KAON-CL, KAON LIQUID (g) 108
KAYEXALATE (g) 109
KEFLEX (g) 40
KEFLEX 750MG 40
KEPPRA (g) 63
KEPPRA XR 63
KERLONE (g) 48
KETEK 41
KETOPROFEN (g) 58
KINERET 77
KLONOPIN, WAFER (g) 63
K-LOR, KLOR-CON (g) 108
K-LYTE, KLOR-CON/EF (g) 108
K-PHOS NEUTRAL (g) 106
K-TAB, K-DUR, SLOW-K, KAON CL (g) 108
KUVAN 109
KYTRIL (g) 68
LACRISERT 99
LACTULOSE (g) 70
LAMICTAL DISPERTABS (g) 63
LAMICTAL ODT 63
LAMICTAL TABS (g) 63
LAMICTAL XR 63
LAMISIL GRANULES 43
LAMISIL TABLETS (g) 43
LANTUS (PEN/CARTRIDGE) 81
LANTUS (VIAL) 81
LAPASE (g) 69
LARIAM (g) 45
LASIX (g) 52
LESCOL, XL 47
LETAIRIS 105
LEUCOVORIN (g) 86
LEUKERAN 84
LEUKINE 88
LEUKINE 86
LEVAQUIN 42
LEVATOL 48
LEVBID (g) 67
LEVBID (g) 106
LEVEMIR (PEN) 81
LEVEMIR (VIAL) 81
LEVITRA 110
LEVOTHYROXINE (g) 79
LEVSIN, SL (g) 106
LEVSIN, SL (g) 67
LEVSINEX (g) 106
LEVSINEX (g) 67
LEXAPRO 55
LEXIVA 44
LIALDA 70
LIBRAX (g) 67
LIBRIUM (g) 56
LIDEX, E (g) 89
LIDODERM PATCH 91
LIMBITROL, DS (g) 55
LINDANE 94
LIORESAL (g) 64
Trade Name Page Trade Name PageLIPITOR 47
LIPOFEN 47
LIPRAM-UL20 69
LITHIUM CITRATE (g) 65
LITHOBID (g) 65
LIVALO 47
LO/OVRAL (g) 71
LOCOID CM, OINT, SOLN (g) 90
LOCOID LIPOCREAM (g) 90
LOCOID LOTION 90
LODINE (g) 58
LODINE XL (g) 58
LOESTRIN 24 FE 71
LOESTRIN, FE (g) 71
LOFIBRA (g) 47
LOMOTIL (g) 67
LONITEN (g) 54
LOPID (g) 47
LOPRESSOR (g) 48
LOPRESSOR HCT (g) 48
LOPROX CR, LOTION, GEL (g) 93
LOPROX SHAMPOO (g) 93
LOSEASONIQUE 71
LOTEMAX 98
LOTENSIN (g) 49
LOTENSIN HCT (g) 49
LOTREL (g) 49
LOTREL (g) 51
LOTREL 5/40, 10/40 49
LOTREL 5/40, 10/40 51
LOTRIMIN (g) 93
LOTRISONE CR, LOTION (g) 93
LOTRONEX 70
LOVAZA 47
LOVENOX (g) 53
LOXITANE (g) 56
LOZOL (g) 52
LUMIGAN 96
LUNESTA 57
LUPRON (g) 74
LUPRON (g) 85
LUPRON DEPOT 75
LUPRON DEPOT 85
LUPRON DEPOT-PED 80
LURIDE (g) 108
LUVERIS 74
LUVOX CR 55
LUXIQ 90
LYBREL 71
LYRICA 63
LYSODREN 86
LYSTEDA 75
MACROBID (g) 42
MACRODANTIN (g) 42
MAGNACET 60
MALARONE 45
MANDELAMINE (g) 42
MAPROTILINE HCL (g) 55
MARINOL (g) 68
MARPLAN 55
MATULANE 86
MAVIK (g) 49
MAXAIR AUTOHALER 103
MAXALT, MLT 61
MAXIDEX 98
MAXITROL (g) 99
MAXZIDE, DYAZIDE (g) 52
MEBARAL (g) 63
MECLOMEN (g) 58
MEDROL, DOSEPAK (g) 79
MEGACE (g) 85
MEGACE ES 85
MELLARIL (g) 56
MENEST 77
MENEST 73
MENOPUR 74
MENOSTAR 73
MENTAX 93
MEPHYTON 53
MEPHYTON 108
MEPRON 46
MESNEX 86
MESTINON (g) 64
MESTINON TIMESPAN, SYRUP 64
METADATE CD 57
METAGLIP (g) 82
METAPROTERENOL SOLN (g) 103
METHADONE (g) 59
METHERGINE 75
METHITEST 80
METHOTREXATE (g) 77
METHOTREXATE (g) 84
METHYLIN CHEW 57
METHYLIN SOLN (g) 57
METOZOLV ODT 70
METROCREAM, GEL, LOTION (g) 92
METROGEL TOPICAL 1% 92
METROGEL-VAGINAL (g) 75
MEVACOR (g) 47
MEXITIL (g) 52
MIACALCIN INJECTION 80
MIACALCIN INJECTION 78
MIACALCIN NASAL SPRAY (g) 80
MIACALCIN NASAL SPRAY (g) 78
MICARDIS 50
MICARDIS HCT 50
MICRO-K(g) 108
MIDAMOR (g) 52
Trade Name Page Trade Name PageMIDRIN (g) 61
MIGRANAL 61
MILTOWN, EQUANIL (g) 56
MINIPRESS (g) 54
MINOCIN, DYNACIN (g) 41
MIRAPEX (g) 62
MIRAPEX ER 62
MIRCETTE (g) 71
MOBIC (g) 58
MODICON (g) 71
MODURETIC (g) 52
MONISTAT-DERM (g) 93
MONODOX (g) 41
MONOPRIL (g) 49
MONOPRIL HCT (g) 49
MONUROL 42
MOTRIN (g) 58
MOVIPREP 109
MOXATAG 40
MS CONTIN/ORAMORPH SR (g) 59
MSIR (g) 59
MUCOMYST (g) 105
MULTAQ 52
MUSE 110
MYCELEX TROCHE (g) 43
MYCOBUTIN 45
MYCOSTATIN (g) 93
MYDRIACYL (g) 97
MYFORTIC 85
MYLERAN 84
MYSOLINE (g) 63
MYTELASE 64
NAFTIN 93
NAMENDA, SOLN 65
NAPRELAN 58
NAPRELAN CR DOSEPAK 58
NAPROSYN (g) 58
NARDIL 55
NASACORT AQ 100
NASACORT AQ 104
NASALIDE (g) 100
NASALIDE (g) 104
NASAREL (g) 104
NASAREL (g) 100
NASCOBAL SPRAY 108
NASONEX 100
NASONEX 104
NATACYN 98
NATAZIA 72
NAVANE (g) 56
NEBUPENT AEROSOL 46
NECON 10/11 (g) 71
NEOBENZ MICRO 92
NEOMYCIN (g) 46
NEORAL (g) 85
NEOSPORIN OPHTH SOLN (g) 98
NEOSPORIN OPTH OINT (g) 98
NEO-SYNEPHRINE (g) 99
NEULASTA 88
NEULASTA 86
NEUMEGA 88
NEUPOGEN 86
NEUPOGEN 88
NEURONTIN (g) 63
NEURONTIN SOLUTION 63
NEVANAC 97
NEXAVAR 87
NEXIUM 66
NIASPAN 47
NICOTINE GUM, NICORETTE (g) (BCN ONLY 110
NICOTINE PATCH (g) 110
NICOTROL, NS 110
NIFEREX GOLD 108
NILANDRON 85
NIMOTOP (g) 65
NIRAVAM (g) 56
NITRO-BID OINTMENT 53
NITROGLYCERIN PATCH (g) 53
NITROGLYCERIN SA CAP (g) 53
NITROLINGUAL SPRAY 53
NITROMIST 53
NITROSTAT 53
NIZORAL (g) 43
NIZORAL CREAM (g) 93
NIZORAL SHAMPOO 2% (g) 93
NORDETTE, LEVLEN (g) 71
NORDITROPIN NORDIFLEX 83
NORFLEX (g) 64
NORGESIC, FORTE (g) 64
NORINYL 1/35 (g), ORTHO-NOVUM 1/35 (g) 71
NORINYL 1/50 (g), ORTHO-NOVUM 1/50 (g) 71
NORITATE 92
NORMODYNE (g) 48
NOROXIN 42
NORPACE (g) 52
NORPACE CR 52
NORPRAMIN (g) 55
NORVASC (g) 51
NORVIR 44
NOVAREL, PREGNYL, PROFASI 74
NOVOLIN (PEN/CARTRIDGE) 81
NOVOLIN (VIAL) 81
NOVOLOG (PEN/CARTRIDGE) 81
NOVOLOG (VIAL) 81
NOVOLOG MIX (PEN/CARTRIDGE) 81
NOXAFIL 43
NUCYNTA 59
NULYTELY (g) 109
Trade Name Page Trade Name PageNUTROPIN 83
NUTROPIN AQ 83
NUTROPIN AQ NUSPIN 83
NUVARING 72
NUVIGIL 57
NYSTATIN (g) 43
NYSTATIN (g) 75
NYSTATIN W/TRIAMCINOLONE (g) 93
OCUFEN (g) 97
OCUFLOX (g) 98
OCUPRESS (g) 96
OFORTA 84
OGEN, ORTHO-EST (g) 77
OGEN, ORTHO-EST (g) 73
OLEPTRO ER 55
OLUX (g) 89
OLUX-E 89
OMEPRAZOLE OTC (g) 66
OMNARIS 104
OMNARIS 100
OMNICEF (g) 40
OMNITROPE 83
ONGLYZA 82
ONSOLIS 59
OPANA (g) 59
OPANA ER 59
OPTICROM (g) 99
OPTIPRANOLOL (g) 96
OPTIVAR (g) 99
ORACEA 41
ORAP 56
ORAPRED (g) 79
ORAPRED ODT 79
ORAVIG 43
ORAXYL 41
ORFADIN 109
ORINASE (g) 82
ORTHO EVRA 72
ORTHO MICRONOR (g), NOR-QD (g) 72
ORTHO TRI-CYCLEN (g) 72
ORTHO TRI-CYCLEN LO 72
ORTHO-CYCLEN (g) 71
ORTHO-NOVUM 7/7/7 (g) 72
ORTHO-PREFEST 74
OSMOPREP, VISICOL 109
OVCON 35 (g) 71
OVCON-50, FE 71
OVIDE (g) 94
OVIDREL 74
OVRAL (g) 71
OXANDRIN (g) 80
OXISTAT 93
OXSORALEN, ULTRA 94
OXYCODONE IMMEDIATE RELEASE (g) 59
OXYCONTIN 59
OXYTROL 106
PAMELOR, AVENTYL (g) 55
PANCREASE MT 10, 16, 20 (g) 69
PANCREASE MT 4 69
PANCREAZE 69
PANCRECARB MS 69
PANCRELIPASE EC 69
PANDEL 90
PANGESTYME UL 12 69
PANRETIN 95
PAPAVERINE CAPS (g) 54
PARAFLEX, PARAFON FORTE DSC (g) 64
PARCOPA (g) 62
PAREGORIC (g) 67
PAREMYD 97
PARLODEL (g) 62
PARNATE (g) 55
PATADAY 99
PATANASE 101
PATANASE 100
PATANOL 99
PAXIL (g) 55
PAXIL CR (g) 55
PCE 41
PEDIAZOLE (g) 41
PEDIAZOLE (g) 42
PEGANONE 63
PEGASYS 88
PEG-INTRON, REDIPEN 88
PENICILLIN VK (g) 40
PENLAC (g) 93
PENNSAID 58
PENTASA 70
PEPCID (RX ONLY) (g) 66
PERANEX HC 70
PERCOCET (g) 60
PERCODAN (g) 60
PERFOROMIST 103
PERIACTIN (g) 101
PERIDEX (g) 109
PERIOSTAT (g) 41
PERPHENAZINE (g) 56
PERSANTINE (g) 53
PEXEVA 55
PHENERGAN (g) 68
PHENERGAN (g) 101
PHENERGAN DM (g) 102
PHENERGAN VC (g) 102
PHENERGAN W/CODEINE (g) 102
PHENOBARBITAL (g) 63
PHOSLO (g) 109
PHOSPHOLINE IODIDE 96
PHRENILIN (g) 61
Trade Name Page Trade Name PagePHRENILIN (g) 60
PHRENILIN FORTE 60
PHRENILIN FORTE 61
PILOCAR, ISOPTO-CARPINE (g) 96
PILOPINE HS 96
PINDOLOL (g) 48
PLAN B (g) 72
PLAN B ONE-STEP 72
PLAQUENIL (g) 45
PLAQUENIL (g) 77
PLAVIX 53
PLENDIL (g) 51
PLETAL (g) 53
PLEXION, TS (g) 92
POLARAMINE (g) 101
POLYCITRA (g) 106
POLY-PRED 99
POLYSPORIN (g) 98
POLYTRIM (g) 98
POLY-VI-FLOR (g) 108
PONSTEL 58
PRAMOSONE (g) 70
PRAMOSONE LOTION 70
PRANDIMET 82
PRANDIN 82
PRAVACHOL (g) 47
PRECOSE (g) 82
PRED FORTE (g) 98
PRED MILD 98
PRED-G 99
PREDNISOLONE, TABS, SYRUP (g) 79
PREDNISONE (g) 85
PREDNISONE (g) 79
PREMARIN CREAM 73
PREMARIN CREAM 77
PREMARIN, PREMARIN LOW DOSE 73
PREMARIN, PREMARIN LOW DOSE 77
PREMPRO, LOW DOSE/PREMPHASE 77
PREMPRO, LOW DOSE/PREMPHASE 74
PRENATAL VITS (g) 108
PREVACID (g) 66
PREVACID NAPRAPAC 58
PREVACID SOLUTAB (g) 66
PREVIDENT (g) 108
PREVPAC 67
PREZISTA(MUST BE USED WITH NORVIR) 44
PRIFTIN 45
PRILOSEC (g) 66
PRILOSEC 40MG 66
PRILOSEC OTC 66
PRILOSEC SUSPENSION 66
PRIMAQUINE 45
PRINIVIL, ZESTRIL (g) 49
PRINZIDE, ZESTORETIC (g) 49
PRISTIQ 55
PROAIR HFA, VENTOLIN HFA 103
PROAMATINE (g) 52
PRO-BANTHINE 15MG (g) 106
PRO-BANTHINE 15MG (g) 67
PROBENECID (g) 76
PROCARDIA, XL;ADALAT CC (g) 51
PROCENTRA 57
PROCHIEVE 73
PROCRIT 88
PROCRIT 86
PROCTOCORT SUPPOSITORY (g) 70
PROFASI 5000UNITS 74
PROGESTERONE IN OIL (INJ) (g) 73
PROGRAF (g) 85
PROLIXIN (g) 56
PROMACTA 88
PROMETRIUM 73
PRONESTYL, SR (g) 52
PROPINE 96
PROPYLTHIOURACIL (g) 79
PROQUIN XR 42
PROSCAR (g) 107
PROSCAR (g) 80
PROSOM (g) 57
PROSTIGMIN 64
PROTONIX (g) 66
PROTONIX SUSPENSION 66
PROTOPIC 95
PROVENTIL HFA 103
PROVENTIL SOLUTION (g) 102
PROVERA (g) 73
PROVIGIL 57
PROZAC WEEKLY (g) 55
PROZAC, SARAFEM (g) 55
PSORCON, FLORONE (g) 89
PSORCON, FLORONE (g) 89
PULMICORT 0.25MG, 0.5MG/2ML (g) 103
PULMICORT 1MG/2ML (TIER 1-BCN ONLY) 103
PULMICORT INH (TIER 1-BCN ONLY) 103
PULMOZYME 105
PURINETHOL (g) 84
PYLERA 67
PYRAZINAMIDE (g) 45
PYRIDIUM (g) 42
PYRIDIUM (g) 106
QUALAQUIN 45
QUESTRAN, QUESTRAN LIGHT (g) 47
QUINIDEX (g) 52
QUINIDINE GLUCONATE SA (g) 52
QUIXIN 98
QVAR (TIER 1-BCN ONLY) 103
RADIOGARDASE 109
RANEXA 52
Trade Name Page Trade Name PageRANICLOR 40
RAPAFLO 107
RAPAMUNE TABS, SOLUTION 85
RAZADYNE SOLUTION (g) 65
RAZADYNE, ER (g) 65
REBETOL (g) 43
REBETOL SOLUTION 43
REBIF 88
REGLAN TAB, SOLUTION (g) 70
REGRANEX 94
RELAFEN (g) 58
RELENZA 43
RELISTOR 61
RELISTOR 70
RELPAX 61
REMERON (g) 55
REMERON SOLTAB (g) 55
RENACIDIN 106
RENAGEL 109
RENVELA PACKET 0.8G 109
RENVELA PACKET 2.4G 109
RENVELA TABLET 109
REPRONEX 74
REQUIP (g) 62
REQUIP XL 62
RESCRIPTOR 44
RESERPINE (g) 54
RESTASIS 99
RESTORIL (g) 57
RETIN-A MICRO 92
RETIN-A, AVITA (g) 92
RETROVIR (g) 44
REVATIO 105
REVIA (g) 109
REVIA (g) 61
REVLIMID 85
REYATAZ 44
RHEUMATREX, TREXALL 77
RHINOCORT AQUA 100
RHINOCORT AQUA 104
RIDAURA 77
RIFADIN (g) 45
RIFAMATE (g) 45
RIFATER 45
RILUTEK 65
RIOMET 82
RISPERDAL (g) (TIER 0-BCN ONLY) 56
RISPERDAL M-TAB (g) 56
RITALIN LA 57
RITALIN, SR; METHYLIN, ER (g) 57
RMS SUPPOSITORY (g) 59
ROBAXIN (g) 64
ROBINUL, FORTE (g) 67
ROCALTROL (g) 80
ROCALTROL (g) 108
RONDEC (g) 101
RONDEC-DM (g) 102
ROSULA CLEANSER (g) 92
ROSULA FOAM 92
ROWASA ENEMA (g) 70
ROXANOL (g) 59
ROZEREM 57
RYBIX ODT 60
RYNATAN (g) 101
RYNATAN PED SUSP (g) 101
RYTHMOL (g) 52
RYTHMOL SR 52
RYZOLT 60
SABRIL 63
SAIZEN 83
SALAGEN (g) 109
SALICYLATES AND NSAIDS 76
SAMSCA 109
SANCTURA (g) 106
SANCTURA XR 106
SANCUSO 68
SANDIMMUNE 85
SANDOSTATIN (g) 86
SANDOSTATIN (g) 80
SANDOSTATIN LAR 86
SANDOSTATIN LAR 80
SANTYL 94
SAPHRIS 56
SARAFEM TABLET 55
SAVELLA 65
SEASONALE (g) 71
SEASONIQUE 71
SECTRAL (g) 48
SELSUN RX (g) 94
SELZENTRY 44
SEMPREX-D 101
SENSIPAR 80
SERAX (g) 56
SEREVENT DISKUS 103
SEROMYCIN 45
SEROQUEL 56
SEROQUEL XR 56
SEROSTIM 83
SERZONE (g) 55
SILENOR 57
SILVADENE (g) 94
SIMCOR 47
SIMPONI 77
SINEMET (g) 62
SINEMET CR (g) 62
SINEQUAN, ADAPIN (g) 55
SINGULAIR 105
SKELAXIN (g) 64
Trade Name Page Trade Name PageSOLARAZE 95
SOLODYN 45, 90, 135MG(g) 41
SOLODYN 55, 65, 80, 105, 115MG 41
SOMA (g) 64
SOMA COMPOUND (g) 64
SOMA COMPOUND W/CODEINE (g) 64
SOMATULINE DEPOT 80
SOMAVERT 80
SONATA (g) 57
SORIATANE 94
SPECTAZOLE (g) 93
SPECTRACEF (g) 40
SPIRIVA 105
SPORANOX CAPS (g) 43
SPORANOX SOLN 43
SPRYCEL 87
SSKI (g) 79
STADOL NS (g) 61
STADOL NS (g) 60
STALEVO 62
STARLIX (g) 82
STAXYN 110
STELAZINE (g) 56
STIMATE 80
STRATTERA 57
STRIANT 80
STROMECTROL - SINGLE DOSE 46
SUBOXONE FILM, TABS 60
SULAR (g) 51
SULAR 8.5, 17, 25.5, 34MG 51
SULFACET-R (g) 92
SULFADIAZINE (g) 42
SUMAVEL DOSEPRO 61
SUPERVITE 108
SUPRAX 40
SUPRINE 109
SURMONTIL (g) 55
SURMONTIL 100MG 55
SUSTIVA 44
SUTENT 87
SYMBICORT 105
SYMBYAX 56
SYMLIN 82
SYMMETREL (g) 43
SYMMETREL (g) 62
SYNALAR 0.025% CREAM, OINT (g) 90
SYNALAR CREAM, SOLN (g) 90
SYNALGOS-DC 60
SYNAREL 80
SYNAREL 75
TACLONEX, SCALP 94
TAGAMET (RX ONLY) (g) 66
TALACEN (g) 60
TALWIN NX (g) 60
TAMBOCOR (g) 52
TAMIFLU CAP, SUSP 43
TAMOXIFEN CITRATE (g) 85
TAPAZOLE (g) 79
TARCEVA 87
TARGRETIN GEL 95
TARGRETIN ORAL 86
TARKA (g) 49
TARKA (g) 51
TASIGNA 87
TASMAR 62
TAVIST RX (2.68MG, SYRUP) (g) 101
TAZORAC 92
TEGRETOL (g) 63
TEGRETOL XR (g) 63
TEGRETOL XR 100MG 63
TEKAMLO 51
TEKAMLO 54
TEKTURNA 54
TEKTURNA HCT 54
TEMODAR 84
TEMOVATE (g), CLOBEVATE (g) 89
TENEX (g) 54
TENORETIC (g) 48
TENORMIN (g) 48
TENUATE (g) 110
TERAZOL- 3, 7 (g) 75
TESSALON, PERLES (g) 102
TESTIM 80
TESTRED, ANDROID 80
TETRACYCLINE (g) 41
TEVETEN 50
TEVETEN HCT 50
TEV-TROPIN 83
THALOMID 85
THEO-24 104
THEOPHYLLINE ANHYDROUS (g) 104
THIOGUANINE 84
THORAZINE (g) 56
THYROLAR 79
TIAZAC (g) 51
TICLID (g) 53
TIGAN (g) 68
TIKOSYN 52
TIMOPTIC - XE (g) 96
TIMOPTIC (g) 96
TINDAMAX 46
TIROSINT 79
TOBI 46
TOBRADEX (g) 99
TOBRADEX OINT 99
TOBREX (g) 98
TOFRANIL (g) 55
TOFRANIL-PM (g) 55
Trade Name Page Trade Name PageTOLECTIN, DS (g) 58
TOLINASE (g) 82
TOPAMAX (g) 63
TOPAMAX SPRINKLE (g) 63
TOPICORT CR, GEL, OINT (g) 89
TOPICORT LP (g) 90
TOPROL XL (g) 48
TORADOL (g) 58
TOVIAZ 106
TRACLEER 105
TRANSDERM-SCOP 68
TRANXENE (g) 56
TRANXENE SD 56
TRAVATAN, Z 96
TRECATOR 45
TRELSTAR DEPOT, LA 85
TRENTAL (g) 53
TREXIMET 61
TRIBENZOR 50
TRIBENZOR 51
TRICOR 47
TRIGLIDE 47
TRILEPTAL (g) 63
TRILEPTAL SUSP (g) 63
TRILIPIX 47
TRILISATE (g) 59
TRIMETHOPRIM (g) 42
TRI-NORINYL (g) 72
TRIPHASIL, TRILEVLEN (g) 72
TRI-VI-FLOR (g) 108
TRIZIVIR 44
TRUSOPT (g) 96
TRUVADA 44
TUSSICAPS 102
TUSSIONEX (g) 102
TWYNSTA 50
TWYNSTA 51
TYKERB 87
TYLENOL W/CODEINE (g) 60
TYLOX (g) 60
TYVASO 105
TYZEKA 43
ULORIC 76
ULTRACET (g) 60
ULTRAM (g) 60
ULTRAM ER 100MG, 200MG (g) 60
ULTRAM ER 300MG 60
ULTRASE MT 69
ULTRAVATE (g) 89
ULTRAVATE PAC 89
UNIPHYL (g) 104
UNIRETIC (g) 49
UNIVASC (g) 49
URECHOLINE (g) 106
URETRON D-S 106
URISPAS (g) 106
UROCIT-K (g) 106
UROXATRAL 107
URSO (g) 68
URSO FORTE (g) 68
VAGIFEM 73
VALCYTE 43
VALISONE CR, LOTION, OINT (g) 89
VALISONE CR, LOTION, OINT (g) 90
VALIUM (g) 56
VALIUM (g) 64
VALTREX (g) 43
VALTURNA 50
VALTURNA 54
VANCOCIN HCL 46
VANOS 0.1% CR 89
VANTIN (g) 40
VASERETIC (g) 49
VASOCIDIN (g) 99
VASODILAN (g) 54
VASOTEC (g) 49
VECTICAL 94
VENLAFAXINE HCL ER (g) 55
VENTAVIS 105
VEPESID (g) 86
VERAMYST 104
VERAMYST 100
VERDESO 90
VEREGEN 95
VERELAN (g) 51
VERELAN PM (g) 51
VERMOX (g) 46
VESANOID 86
VESICARE 106
VEXOL 98
VFEND 43
VIAGRA 110
VIBRAMYCIN, VIBRATABS (g) 41
VICODIN, LORTAB (g) 60
VICOPROFEN (g) 60
VICTOZA 82
VIDEX 44
VIDEX EC (g) 44
VIGAMOX 98
VIMOVO 66
VIMOVO 58
VIMPAT 63
VIOKASE 69
VIRACEPT 44
VIRAMUNE 44
VIREAD 44
VIROPTIC (g) 98
VIVACTIL (g) 55
Trade Name Page Trade Name PageVIVELLE (g) 77
VIVELLE (g) 73
VIVELLE-DOT 73
VIVELLE-DOT 77
VOLTAREN (g) 97
VOLTAREN (g) 58
VOLTAREN GEL 58
VOLTAREN-XR (g) 58
VOSPIRE ER (g) 102
VOTRIENT 87
VUSION 93
VYTORIN 47
VYVANSE 57
WELCHOL 47
WELLBUTRIN XL (g) 55
WELLBUTRIN, SR (g) 55
WESTCORT (g) 90
XALATAN 96
XANAX, XR (g) 56
XELODA 84
XENAZINE 109
XENICAL 110
XERESE 93
XIBROM 97
XIFAXAN 200MG 46
XIFAXAN 550MG 46
XODOL 60
XOLEGEL 93
XOLEGEL COREPAK 93
XOPENEX 1.25MG/0.5ML (g) 103
XOPENEX HFA 103
XOPENEX SOLUTION 103
XYLOCAINE (Rx Only) (g) 91
XYLOCAINE VISCOUS (g) 91
XYREM 65
XYZAL SOLUTION 101
XYZAL TABS (g) 101
YASMIN 28 (g) 71
YAZ (g) 71
YOHIMBINE HCL (g) 110
ZANAFLEX CAPS 64
ZANAFLEX TABS (g) 64
ZANTAC (RX ONLY) (g) 66
ZANTAC EFFERDOSE 66
ZARONTIN (g) 63
ZAROXOLYN (g) 52
ZAVESCA 109
ZEBETA (g) 48
ZEBUTAL (g) 61
ZEBUTAL (g) 60
ZEGERID CAP (Rx Only) (g) 66
ZEGERID PACKET 66
ZELAPAR 62
ZEMPLAR 108
ZEMPLAR 80
ZENPEP 69
ZERIT (g) 44
ZETIA 47
ZIAC (g) 48
ZIAGEN 44
ZIANA GEL 92
ZIPSOR 58
ZIRGAN 98
ZITHROMAX (g) 41
ZMAX 41
ZOCOR (g) 47
ZOFRAN (g) 68
ZOFRAN ODT (g) 68
ZOLADEX 85
ZOLINZA 86
ZOLOFT (g) 55
ZOLPIMIST 57
ZOMIG NASAL SPRAY 61
ZOMIG, ZMT 61
ZONALON, PRUDOXIN 95
ZONEGRAN (g) 63
ZORBTIVE 83
ZORPRIN 59
ZORTRESS 87
ZOVIRAX (g) 43
ZOVIRAX CREAM, OINT 93
ZUPLENZ 68
ZYBAN (g) 110
ZYCLARA 95
ZYDONE 60
ZYFLO, CR 105
ZYLET 99
ZYLOPRIM (g) 76
ZYMAR 98
ZYMAXID 98
ZYPREXA, ZYDIS 56
ZYRTEC (OTC) (g) 101
ZYRTEC-D(OTC) (g) 101
ZYVOX 46
104277BCNMCB 2870 NOV 10