January 2014 Standard Drug Formulary - Blue Cross … 2014 Standard Drug Formulary . ... example,...

2656-A IL © Prime Therapeutics LLC 01/14

Contents

Introduction .................................................................... I How formulary drugs are selected ................................... I How member payment is determined .............................. I How to use this list ........................................................... I Generic drugs ................................................................. II Coverage considerations ............................................... III Specialty drugs .............................................................. IV Abbreviation key ............................................................. V

Therapeutic Class Drug List ........................................ 1 Anti-Infective Drugs ........................................................ 1 Cancer Drugs .................................................................. 3 Hormones, Diabetes and Related Drugs ........................ 3 Heart and Circulatory Drugs ........................................... 5 Respiratory Agents ......................................................... 7 Gastrointestinal Drugs .................................................... 8 Genitourinary Drugs ........................................................ 9 Central Nervous System Drugs .................................... 10 Pain Relief Drugs .......................................................... 11 Neuromuscular Drugs ................................................... 12 Supplements ................................................................. 13 Blood Modifying Drugs .................................................. 14 Topical Drugs ................................................................ 14 Miscellaneous Categories (includes Supplies and Devices) ............................................................... 17

Index ............................................................................. 19

Please consider talking to your doctor about prescribing formulary medications, which may help reduce your out-of-pocket costs. This list may help guide you and your doctor in selecting an appropriate medication for you.

The drug formulary is regularly updated. Please visit bcbsil.com for the most up-to-date information.

To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click on Search.

January 2014

Standard Drug Formulary

Blue Cross and Blue Shield of Illinois January 2014 Drug Formulary I

Introduction

Blue Cross and Blue Shield of Illinois is pleased to present the 2014 Drug Formulary. This is a list of formulary drugs which includes Formulary Brand drugs and a partial listing of generic drugs. Members are encouraged to show this list to their physicians and pharmacists. Physicians are encouraged to prescribe drugs on this list, when right for the member. However decisions regarding therapy and treatment are always between members and their physician.

Drug formulary updates – This list is regularly updated as generic drugs become available and changes take place in the pharmaceuticals market. For the most up-to-date information, visit bcbsil.com and log in to Blue Access for MembersSM or call the number on the back of your ID card. Physicians can access the list from the provider portal at bcbsil.com.

How formulary drugs are selected

Drugs on this list are selected based on the recommendations of a committee made up of physicians and pharmacists from throughout the country. The committee, which includes at least one representative from your health plan, reviews drugs regulated by the U.S. Food and Drug Administration (FDA).

Both drugs that are newly approved by the FDA as well as those that have been on the market for some time are considered. Drugs are selected based on safety, efficacy, cost and how they compare to other drugs currently on the list.

How member payment is determined

This list shows prescription drug products in tiers. Generally, each drug is placed into one of three or four member payment tiers: generic, Formulary Brand or Non-Formulary Brand (not listed in this document). Specialty drugs can either be within the previous three tiers or can be a separate fourth tier depending on your benefit design. To verify your payment amount for a drug, visit bcbsil.com and log in to Blue Access for Members or call the number on the back of your ID card.

Your pharmacy benefit includes coverage for many prescription drugs, although some exclusions may apply. For example, drugs indicated for cosmetic purposes, e.g., Propecia, for hair growth, may not be covered. Prescription products that have over-the-counter (OTC) equivalents may not be covered. Drugs that are not FDA-approved for self-administration may be available through your medical benefit.

How to use this list

Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand drug in (parentheses). The reference brand drug is a non-formulary (NF) brand and is only included as a reference to the brand. Some generic products have no reference brand.

Example: atorvastatin (Lipitor – brand is NF)

Formulary brand drugs are listed in all CAPITAL letters.

Drugs used to treat multiple conditions

Some drugs in the same dosage form may be used to treat more than one medical condition. In these instances, each medication is classified according to its first FDA-approved use. Please check the index if you do not find your particular medication in the class/condition section that corresponds to your use.

Blue Cross and Blue Shield of Illinois January 2014 Drug Formulary II

Generic drugs

Using generic drugs, when right for you, can help you save on your out-of-pocket medication costs. Generic drugs must be approved by the FDA just as brand drugs are, and must meet the same strict standards.

There are two types of generic drugs:

• A generic equivalent is made with the same active ingredient(s) at the same dosage as the reference drug.

• A generic alternative is a drug typically used to treat the same condition, but the active ingredient(s) differs from the brand drug.

According to the FDA, compared to its brand counterpart, an FDA-approved generic drug:

• Is chemically the same

• Works just as well in the body

• Is as safe and effective

• Meets the same standards set by the FDA

The main difference between the reference brand drug and the generic equivalent is that the generic often costs much less.

Formulary brand drugs typically move to a non-formulary brand tier after a generic equivalent becomes available. You may be responsible for the non-formulary brand member payment amount plus the difference in cost between the brand and generic equivalent if you or your doctor requests the reference brand rather than the generic. Generic drugs have the lowest member payment amount.

Consider talking to your doctor about generic drugs

If your doctor writes a prescription for a brand drug that does not have a generic equivalent, consider asking if an appropriate generic alternative is available.

You can also let your pharmacist know that you would like a generic equivalent for a brand drug, whenever one is available. Your pharmacist can usually substitute a generic equivalent for its brand counterpart without a new prescription from your doctor.

Only your doctor can determine whether a generic alternative is right for you and must prescribe the medication.

Blue Cross and Blue Shield of Illinois January 2014 Drug Formulary III

Coverage considerations

Most prescription drug benefit plans provide coverage for up to a 30-day supply of medication, with some exceptions. Your plan may also provide coverage for up to a 90-day supply of maintenance medications. Maintenance medications are those drugs you may take on an ongoing basis for conditions such as high blood pressure, diabetes or high cholesterol. Some plans may exclude coverage for certain agents or drug categories, like those used for erectile dysfunction or weight loss.

Over-the-counter exclusions: Your benefit plan may not provide coverage for prescription medications that have an over-the-counter version. You should refer to your benefit plan material for details about your particular benefits.

Compounded medications: Your benefit plan may not provide coverage for compounded medications. Please see your plan materials or call the number on the back of your ID card to determine whether compounded medications are covered and/or verify your payment amount.

Repackaged medications: Repackaged versions of medications already available on the market are not covered.

Prior Authorization (PA): Your benefit plan may require prior authorization for certain drugs that are high-cost or have the potential for misuse. This means that your doctor will need to submit a prior authorization request for coverage of these medications, and the request will need to be approved, before the medication will be covered under your plan. For the formulary medications listed in this document, if a prior authorization is commonly required, it will generally be noted next to the medication with a dot under the prior authorization column. Some plans may have prior authorization on additional medications beyond those noted in this document.

Step Therapy (ST): Your benefit plan may include a step therapy program. This means you may need to try another proven, cost-effective medication before coverage may be available for the drug included in the program. Many brand drugs have less-expensive generic or brand alternatives that might be an option for you. For the formulary medications listed in this document, if a step therapy is commonly required, it will generally be noted next to the medication with a dot under the step therapy column. Some plans may have step therapy programs on additional medications beyond those noted in this document.

Dispensing Limits (DL): Drug Dispensing limits help encourage medication use as intended by the FDA. Coverage limits are placed on medications in certain drug categories. For the formulary medications listed in this document, if a dispensing limit applies, it will generally be noted next to the medication with a dot under the dispensing limits column. Limits may include: quantity of covered medication per prescription, quantity of covered medication in a given time period, coverage only for members within a certain age range, and coverage only for members of a specific gender. If your doctor prescribes a greater quantity of medication than what the dispensing limit allows, you can still get the medication. However, you will be responsible for the full cost of the prescription beyond what your coverage allows. For a list of medications and their dispensing limits, visit bcbsil.com.

Remember, medication decisions are between you and your doctor. Only your doctor can determine which medication is right for you. Discuss any questions or concerns you have about medications you are taking or are prescribed with your doctor.

Blue Cross and Blue Shield of Illinois January 2014 Drug Formulary IV

Specialty drugs

Specialty drugs are used in the treatment of medical conditions such as hepatitis, hemophilia, multiple sclerosis and rheumatoid arthritis. Specialty drugs may be oral, topical or injectable medications that can either be self-administered or administered by a health care professional. For a current list of specialty medications, visit myprime.com or bcbsil.com and log in to Blue Access for Members.

Note that some drug classes may be excluded by some plans and therefore may not be covered under your pharmacy benefit. Your plan may have a different coverage level for specialty drugs. If you have questions about your coverage for specialty medications or your prescription drug benefit, call the number on the back of your ID card.

Prime Therapeutics Specialty Pharmacy Program

Through Prime Therapeutics Specialty Pharmacy, members can have covered specialty medications delivered directly to them or their doctor’s office. When you receive specialty medications through Prime, you also receive at no additional charge the following services:

• Coordination of coverage between you, your doctor and your health plan

• Educational materials about your particular condition and information about managing potential medication side effects

• Syringes, sharps containers and other supplies with every shipment for self-injectables

• 24/7/365 phone access to a pharmacist for urgent medication issues

To order through Prime Therapeutics Specialty Pharmacy:

• Have your doctor call or fax your prescription to Prime Therapeutics Specialty Pharmacy. Your doctor can call 877-627-6337 or fax to 877-828-3939.

• If you have an existing prescription for a covered specialty medication, you can call 877-627-6337 to transfer your prescription.

• A Prime Therapeutics coordinator will contact you to arrange delivery of your medication.

• The prescription can be shipped directly to you or your prescribing doctor’s office. Each package is individually marked for each member. Refrigerated drugs are shipped in temperature-controlled packaging.

If you have questions, please contact Prime Therapeutics Specialty Pharmacy at 877-627-6337, visit www.PrimeTherapeutics.com/specialty, or call the number on the back of your ID card.

* Blue Cross and Blue Shield of Illinois is a Division of Health Care Service Corporation, a Mutual Legal Reserve Company (“HCSC”). HCSC is an independent licensee of the Blue Cross Blue Shield Association. HCSC contracts with Prime Therapeutics to provide pharmacy benefit management and mail order pharmacy services and to administer this specialty pharmacy program. HCSC, as well as several other independent Blue Cross and Blue Shield licensees, has an ownership interest in Prime Therapeutics LLC.

Blue Cross and Blue Shield of Illinois January 2014 Drug Formulary V

Abbreviation key

caps .................................................................... capsules chew tabs ............................................. chewable tablets conc .............................................................. concentrate crm ......................................................................... cream DL ........................................................... dispensing limits ext-release ........................................... extended-release inhal................................................................... inhalation inj ......................................................................... injection lotn ........................................................................... lotion NF ............................................................... non-formulary ODT ....................................... orally disintegrating tablets

oint ..................................................................... ointment ophth ............................................................... ophthalmic OSM ......................................................... osmotic-release PA ........................................................ prior authorization SL ..................................................................... sublingual soln ....................................................................... solution supp ............................................................ suppositories susp ................................................................ suspension ST ................................................................. step therapy tabs ......................................................................... tablets

2014

Blue Cross and Blue Shield of Illinois January 2014 Drug Formulary 1

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

ANTI-INFECTIVE DRUGS

PENICILLINS

amoxicillin/potassiumclavulanate (Augmentin – brand isNF)

amoxicillin/potassium clavulanateext-release (Augmentin XR – brand isNF)

amoxicillin, NF = chew tabs

ampicillin caps

dicloxacillin

penicillin v potassium

CEPHALOSPORINS

cefaclor caps

cefadroxil

cefdinir

cefpodoxime

cefprozil

ceftriaxone (Rocephin – brand is NF)

cefuroxime (Ceftin – brand is NF)

cephalexin, NF = tabs (Keflex – brandis NF)

SUPRAX tabs

MACROLIDES

azithromycin susp (Zithromax – brandis NF)

azithromycin tabs (Zithromax – brandis NF)

•

clarithromycin (Biaxin – brand is NF)

clarithromycin ext-release (Biaxin XL– brand is NF)

•

erythromycin delayed-release caps

ZITHROMAX packets

TETRACYCLINES

demeclocycline

doxycycline hyclate (Vibramycin –brand is NF)

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

doxycycline monohydrate (Adoxa,Monodox - brands are NF)

minocycline (Dynacin, Minocin –brands are NF)

FLUOROQUINOLONES

ciprofloxacin (Cipro – brand is NF)

ciprofloxacin ext-release (Cipro XR –brand is NF)

•

levofloxacin (Levaquin – brand is NF)

ofloxacin tabs

AMINOGLYCOSIDES

neomycin sulfate

paromomycin

TOBI, NF = Podhaler • •TUBERCULOSIS

ethambutol (Myambutol – brand is NF)

isoniazid tabs

isoniazid/rifampin (Rifamate – brand isNF)

MYCOBUTIN

PRIFTIN

pyrazinamide

rifampin (Rifadin – brand is NF)

FUNGAL INFECTIONS

fluconazole (Diflucan – brand is NF)

flucytosine (Ancobon – brand is NF)

griseofulvin microsize (Grifulvin V –brand is NF)

itraconazole (Sporanox – brand is NF)

NOXAFIL •nystatin oral

terbinafine (Lamisil – brand is NF)

voriconazole (Vfend – brand is NF) •VIRAL INFECTIONS

Cytomegalovirus

VALCYTE

2014

2 Blue Cross and Blue Shield of Illinois January 2014 Drug Formulary

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

Hepatitis

adefovir (Hepsera – brand is NF)

BARACLUDE

INCIVEK • •PEGASYS • •ribavirin (Copegus, Rebetol – brands

are NF)•

VICTRELIS • •Herpes

acyclovir (Zovirax – brand is NF)

famciclovir (Famvir – brand is NF)

valacyclovir (Valtrex – brand is NF)

HIV/AIDS

abacavir tabs (Ziagen – brand is NF) •APTIVUS •ATRIPLA •CRIXIVAN •didanosine delayed-release (Videx EC

– brand is NF)•

EMTRIVA •EPIVIR soln •EPZICOM •FUZEON • •INTELENCE •INVIRASE •ISENTRESS •KALETRA •lamivudine (Epivir tabs – brand is NF) •lamivudine/zidovudine (Combivir –

brand is NF)•

LEXIVA •nevirapine tabs (Viramune – brand is

NF)•

NORVIR •PREZISTA •RESCRIPTOR •

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

REYATAZ •SELZENTRY •stavudine (Zerit – brand is NF) •STRIBILD •SUSTIVA •TIVICAY •TRIZIVIR •TRUVADA •VIDEX •VIRACEPT •VIRAMUNE susp •VIRAMUNE XR •VIREAD •ZIAGEN soln •zidovudine (Retrovir – brand is NF) •MALARIA

atovaquone/proguanil250-100 mg (Malarone – brand is NF)

chloroquine phosphate (Aralen –brand is NF)

DARAPRIM

hydroxychloroquine (Plaquenil –brand is NF)

MALARONE 62.5-25 mg

mefloquine

PRIMAQUINE

WORM INFECTIONS

ALBENZA

BILTRICIDE

STROMECTOL

OTHER ANTI-INFECTIVES

clindamycin (Cleocin, CleocinPediatric – brands are NF)

DAPSONE

erythromycin/sulfisoxazole

2014


Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

metronidazole tabs (Flagyl – brand isNF)

sulfamethoxazole/trimethoprim (Bactrim – brand is NF)

trimethoprim

vancomycin (Vancocin – brand is NF)

XIFAXAN 550 mg •ZYVOX •CANCER DRUGS

AFINITOR, NF = DISPERZ • •ALKERAN tabs

anastrozole (Arimidex – brand is NF)

bicalutamide (Casodex – brand is NF)

CYCLOPHOSPHAMIDE tabs

EMCYT

exemestane (Aromasin – brand is NF)

FARESTON

flutamide

GLEEVEC • •hydroxyurea (Hydrea – brand is NF)

letrozole (Femara – brand is NF)

LEUCOVORIN CALCIUM tabs, 10 mg,15 mg

leucovorin calcium tabs, 5 mg,25 mg

LEUKERAN

megestrol (Megace – brand is NF)

MEKINIST • •mercaptopurine (Purinethol – brand is

NF)

MESNEX tabs

methotrexate

MYLERAN

NEXAVAR • •NILANDRON

SPRYCEL • •

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

SUTENT • •SYLATRON • •TABLOID

TAFINLAR • •tamoxifen

TARCEVA • •TASIGNA • •temozolomide (Temodar – brand is NF) • •tretinoin caps • •TREXALL

VOTRIENT • •XALKORI • •XELODA • •ZELBORAF • •ZYTIGA • •HORMONES, DIABETES AND RELATED DRUGS

CORTICOSTEROIDS

budesonide ext-release (Entocort EC –brand is NF)

CORTISONE

dexamethasone elixir; tabs, 0.5 mg,0.75 mg, 1.5 mg, 4 mg, 6 mg

DEXAMETHASONE soln, 0.5 mg/5 mL

fludrocortisone

hydrocortisone (Cortef – brand is NF)

methylprednisolone (Medrol – brand isNF)

prednisolone (Prelone – brand is NF)

prednisolone sodium soln (Orapred –brand is NF)

PREDNISONE soln, 5 mg/5 mL; tabs,50 mg

prednisone tabs, 1 mg, 2.5 mg, 5 mg,10 mg, 20 mg

PREDNISONE INTENSOL

MALE HORMONES

2014


Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

ANDRODERM • •ANDROGEL • •ANDROXY •danazol •testosterone cypionate (Depo-

Testosterone – brand is NF)• •

testosterone enanthate (Delatestryl –brand is NF)

• •

ESTROGENS

COMBIPATCH

DIVIGEL

ENJUVIA

estradiol patches (Climara – brand isNF)

•

estradiol tabs (Estrace – brand is NF)

estradiol/norethindroneacetate (Activella – brand is NF)

estropipate, NF = 3 mg

VIVELLE-DOT •PROGESTINS

medroxyprogesteroneacetate (Provera – brand is NF)

norethindrone acetate (Aygestin –brand is NF)

progesterone micronized (Prometrium– brand is NF)

BIRTH CONTROL

ELLA •levonorgestrel (Plan B, Plan B One-

Step – brands are NF)•

medroxyprogesterone acetate inj,150 mg/mL (Depo-Provera – brand isNF)

NUVARING •oral contraceptives – all generics •ORTHO EVRA •INFERTILITY

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

chorionic gonadotropin • •clomiphene (Clomid – brand is NF) •FOLLISTIM AQ • •GANIRELIX ACETATE • •REPRONEX • •DIABETES

acarbose (Precose – brand is NF)

glimepiride (Amaryl – brand is NF)

glipizide (Glucotrol – brand is NF)

glipizide ext-release (Glucotrol XL –brand is NF)

glipizide/metformin (Metaglip – brandis NF)

GLUCAGON EMERGENCY KIT

glyburide

glyburide micronized (Glynase –brand is NF)

glyburide/metformin (Glucovance –brand is NF)

JANUMET •JANUMET XR •JANUVIA •JUVISYNC •KOMBIGLYZE XR •metformin (Glucophage – brand is NF)

metformin ext-release (GlucophageXR – brand is NF)

metformin ext-release OSM (Fortamet– brand is NF)

nateglinide (Starlix – brand is NF)

ONGLYZA •pioglitazone (Actos – brand is NF)

pioglitazone/metformin (Actoplus Met– brand is NF)

repaglinide (Prandin – brand is NF)

VICTOZA • •DIABETES - INSULINS

2014


Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

Rapid-Acting Insulins

HUMALOG •NOVOLOG •Short-Acting Insulins

HUMULIN R •NOVOLIN R •Intermediate-Acting Insulins

HUMALOG MIX 50/50, 75/25 •HUMULIN N •HUMULIN 70/30 •NOVOLIN N •NOVOLIN 70/30 •NOVOLOG MIX 70/30 •Basal Insulins

LANTUS •LEVEMIR •THYROID REGULATION

levothyroxine (Synthroid – brand is NF)

liothyronine (Cytomel – brand is NF)

methimazole (Tapazole – brand is NF)

propylthiouracil

GROWTH HORMONE

INCRELEX •OMNITROPE • •OTHER HORMONES AND RELATED DRUGS

ACTONEL •alendronate tabs, 5 mg, 10 mg,

35 mg, 70 mg (Fosamax – brand isNF)

•

cabergoline

calcitonin-salmon (Miacalcin – brand isNF)

calcitriol (Rocaltrol – brand is NF)

desmopressin (DDAVP – brand is NF)

EVISTA

FORTEO • • •

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

ibandronate (Boniva – brand is NF) •levocarnitine (Carnitor – brand is NF)

methylergonovine

octreotide (Sandostatin – brand is NF) •ORFADIN •paricalcitol (Zemplar – brand is NF)

SENSIPAR

STIMATE

HEART AND CIRCULATORY DRUGS

ANGIOTENSIN CONVERTING ENZYME (ACE)INHIBITORS AND COMBINATIONS

benazepril (Lotensin – brand is NF)

benazepril/hydrochlorothiazide (Lotensin HCT– brand is NF)

captopril

enalapril (Vasotec – brand is NF)

enalapril/hydrochlorothiazide (Vaseretic –brand is NF)

fosinopril

fosinopril/hydrochlorothiazide

lisinopril (Prinivil, Zestril – brands areNF)

lisinopril/hydrochlorothiazide (Zestoretic –brand is NF)

moexipril (Univasc – brand is NF)

moexipril/hydrochlorothiazide (Uniretic –brand is NF)

perindopril (Aceon – brand is NF)

quinapril (Accupril – brand is NF)

quinapril/hydrochlorothiazide (Accuretic –brand is NF)

ramipril (Altace – brand is NF)

trandolapril (Mavik – brand is NF)

2014


Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS)AND COMBINATIONS

BENICAR

BENICAR HCT

irbesartan (Avapro – brand is NF)

irbesartan/hydrochlorothiazide (Avalide –brand is NF)

losartan (Cozaar – brand is NF)

losartan/hydrochlorothiazide (Hyzaar– brand is NF)

valsartan/hydrochlorothiazide (DiovanHCT – brand is NF)

BETA BLOCKERS AND COMBINATIONS

acebutolol (Sectral – brand is NF)

atenolol (Tenormin – brand is NF)

atenolol/chlorthalidone (Tenoretic –brand is NF)

bisoprolol (Zebeta – brand is NF)

bisoprolol/hydrochlorothiazide (Ziac– brand is NF)

carvedilol (Coreg – brand is NF)

INNOPRAN XL

labetalol (Trandate – brand is NF)

metoprolol succinate ext-release (Toprol XL – brand is NF)

metoprolol tartrate (Lopressor – brandis NF)

nadolol (Corgard – brand is NF)

PROPRANOLOL soln

propranolol tabs

propranolol ext-release (Inderal LA –brand is NF)

TIMOLOL tabs

CALCIUM CHANNEL BLOCKERS ANDCOMBINATIONS

amlodipine (Norvasc – brand is NF)

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

amlodipine/benazepril (Lotrel – brandis NF)

diltiazem (Cardizem – brand is NF)

diltiazem ext-release (Cardizem CD,Cardizem LA, Dilacor XR, Tiazac –brands are NF)

felodipine ext-release

nifedipine ext-release (Adalat CC,Procardia XL – brands are NF)

verapamil ext-release (Calan SR,Isoptin SR, Verelan, Verelan PM –brands are NF)

verapamil, NF = 40 mg (Calan – brandis NF)

CHEST PAIN

isosorbide dinitrate, NF = SLtabs (Isordil – brand is NF)

isosorbide mononitrate (Monoket –brand is NF)

isosorbide mononitrate ext-release (Imdur – brand is NF)

nitroglycerin (Nitro-Dur – brand is NF)

NITROSTAT

CHOLESTEROL LOWERING

atorvastatin (Lipitor – brand is NF)

cholestyramine (Questran, QuestranLight – brands are NF)

colestipol (Colestid – brand is NF)

CRESTOR

fenofibrate (Lofibra, Tricor – brandsare NF)

fenofibrate micronized (Lofibra –brand is NF)

fenofibric acid delayed-release (Trilipix – brand is NF)

gemfibrozil (Lopid – brand is NF)

lovastatin (Mevacor – brand is NF)

niacin ext-release (Niaspan – brand isNF)

2014


Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

pravastatin (Pravachol – brand is NF)

simvastatin (Zocor – brand is NF)

WELCHOL

FLUID RETENTION

acetazolamide 250 mg

acetazolamide ext-release (DiamoxSequels – brand is NF)

amiloride

amiloride/hydrochlorothiazide

bumetanide

chlorothiazide

furosemide, NF = soln, 8 mg/mL (Lasix – brand is NF)

hydrochlorothiazide caps (Microzide –brand is NF)

hydrochlorothiazide tabs

indapamide

methazolamide (Neptazane – brand isNF)

metolazone (Zaroxolyn – brand is NF)

spironolactone (Aldactone – brand isNF)

spironolactone/hydrochlorothiazide (Aldactazide –brand is NF)

torsemide (Demadex – brand is NF)

triamterene/hydrochlorothiazide(Dyazide, Maxzide, Maxzide-25 –brands are NF)

HEART RHYTHM

amiodarone (Cordarone – brand is NF)

disopyramide (Norpace – brand is NF)

flecainide

mexiletine

MULTAQ

propafenone (Rythmol – brand is NF)

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

propafenone ext-release (Rythmol SR– brand is NF)

quinidine gluconate ext-release

quinidine sulfate, NF = ext-release

sotalol (Betapace, Betapace AF –brands are NF)

OTHER HEART RELATED DRUGS

ADCIRCA • • •clonidine (Catapres, Catapres-TTS –

brands are NF)

DIBENZYLINE

digoxin tabs (Lanoxin – brand is NF)

doxazosin (Cardura – brand is NF)

eplerenone (Inspra – brand is NF)

guanfacine (Tenex – brand is NF)

hydralazine

LETAIRIS • • •methyldopa

midodrine

minoxidil

prazosin (Minipress – brand is NF)

sildenafil (Revatio – brand is NF) • • •terazosin

TRACLEER • • •ERECTILE DYSFUNCTION

CIALIS • •BEE STING KITS

EPIPEN

EPIPEN-JR

RESPIRATORY AGENTS

ANTIHISTAMINES

cetirizine syrup

cyproheptadine

promethazine, NF = supp, 50 mg

NASAL PRODUCTS

ASTEPRO •

2014


Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

azelastine (Astelin – brand is NF) •flunisolide (Flunisolide – brand is NF) •fluticasone propionate (Flonase –

brand is NF)•

ipratropium (Atrovent – brand is NF) •NASONEX •triamcinolone (Nasacort AQ – brand is

NF)•

COUGH/COLD/ALLERGY

acetylcysteine

ASTHMA/COPD

ADVAIR DISKUS •ADVAIR HFA •albuterol inhal soln, 0.083%, 0.5% •albuterol syrup, tabs

albuterol 0.63 mg/3 mL,1.25 mg/3 mL (Accuneb – brand isNF)

•

ASMANEX •ATROVENT HFA •BREO ELLIPTA •budesonide (Pulmicort Respules –

brand is NF)•

COMBIVENT •COMBIVENT RESPIMAT •cromolyn inhal soln •DULERA •FLOVENT DISKUS •FLOVENT HFA •FORADIL AEROLIZER •ipratropium inhal soln •ipratropium/albuterol (Duoneb – brand

is NF)•

montelukast (Singulair – brand is NF)

PROAIR HFA •QVAR •

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

SPIRIVA HANDIHALER •SYMBICORT •terbutaline

theophylline ext-release

VENTOLIN HFA •zafirlukast (Accolate – brand is NF)

OTHER RESPIRATORY DRUGS

FIRAZYR • •KALYDECO • •PULMOZYME •GASTROINTESTINAL DRUGS

LAXATIVES

lactulose

PEG – electrolytes for soln (Colyte,Golytely, Nulytely – brands are NF)

ULCER/GERD

cimetidine

dicyclomine caps, tabs (Bentyl –brand is NF)

famotidine (Pepcid – brand is NF)

glycopyrrolate (Robinul – brand is NF)

hyoscyamine (Anaspaz, Levsin,Levsin/SL – brands are NF)

hyoscyamine ext-release (Levbid,Symax DuoTab – brands are NF)

lansoprazole delayed-release (Prevacid – brand is NF)

•

methscopolamine (Pamine, PamineForte – brands are NF)

misoprostol (Cytotec – brand is NF)

NEXIUM • •omeprazole delayed-release (Prilosec

– brand is NF)•

pantoprazole delayed-release (Protonix – brand is NF)

•

ranitidine (Zantac – brand is NF)

sucralfate (Carafate – brand is NF)

2014


Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

NAUSEA AND VOMITING

EMEND caps •granisetron •meclizine (Antivert – brand is NF)

ondansetron (Zofran, Zofran ODT –brands are NF)

•

ondansetron 24 mg •trimethobenzamide (Tigan – brand is

NF)

DIGESTIVE ENZYMES

CREON

ZENPEP

OTHER GASTROINTESTINAL DRUGS

ASACOL HD

balsalazide (Colazal – brand is NF)

calcium acetate (Eliphos, Phoslo –brands are NF)

CANASA

CHENODAL •DELZICOL

diphenoxylate/atropine tabs (Lomotil –brand is NF)

lactulose

LIALDA

loperamide

mesalamine

metoclopramide (Reglan – brand isNF)

PENTASA

RENVELA

sulfasalazine (Azulfidine – brand is NF)

sulfasalazine delayed-release (Azulfidine EN-Tabs – brandis NF)

ursodiol (Actigall, Urso 250, Urso Forte– brands are NF)

GENITOURINARY DRUGS

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

URINARY TRACT INFECTIONS

nitrofurantoin (Furadantin – brand isNF)

nitrofurantoinmacrocrystalline (Macrodantin –brand is NF)

nitrofurantoin monohydrate/macrocrystalline (Macrobid – brandis NF)

URINARY TRACT SPASMS

DETROL LA

oxybutynin

oxybutynin ext-release (Ditropan XL –brand is NF)

tolterodine (Detrol – brand is NF)

VESICARE

VAGINAL PRODUCTS

CLEOCIN supp

clindamycin (Cleocin – brand is NF)

CRINONE •ESTRACE crm

metronidazole (MetroGel-Vaginal –brand is NF)

terconazole (Terazol – brand is NF)

VAGIFEM

OTHER GENITOURINARY DRUGS

alfuzosin ext-release (Uroxatral –brand is NF)

AVODART

CYSTAGON •finasteride (Proscar – brand is NF)

POTASSIUM CITRATE

potassium citrate/citric acidpowder (Polycitra-K – brand is NF)

sodium citrate/citric acid (Shohl's –brand is NF)

tamsulosin (Flomax – brand is NF)

2014


Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

CENTRAL NERVOUS SYSTEM DRUGS

ANXIETY

alprazolam (Xanax – brand is NF)

alprazolam ext-release (Xanax XR –brand is NF)

•

buspirone

DIAZEPAM oral soln, 1 mg/mL

diazepam tabs (Valium – brand is NF)

hydroxyzine hcl

hydroxyzine pamoate 25 mg,50 mg (Vistaril – brand is NF)

lorazepam (Ativan – brand is NF)

lorazepam conc (Lorazepam Intensol –brand is NF)

DEPRESSION

amitriptyline

bupropion (Wellbutrin – brand is NF)

bupropion ext-release (Wellbutrin SR,Wellbutrin XL – brands are NF)

citalopram (Celexa – brand is NF)

clomipramine (Anafranil – brand is NF)

desipramine (Norpramin – brand is NF)

doxepin, NF = caps, 75 mg

escitalopram (Lexapro – brand is NF)

fluoxetine, NF = 60 mg (Prozac –brand is NF)

fluvoxamine

imipramine hcl (Tofranil – brand is NF)

mirtazapine, NF = 7.5 mg (Remeron,Remeron SolTab – brands are NF)

nortriptyline caps (Pamelor – brand isNF)

paroxetine hcl (Paxil – brand is NF)

paroxetine hcl ext-release (Paxil CR –brand is NF)

phenelzine (Nardil – brand is NF)

sertraline (Zoloft – brand is NF)

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

tranylcypromine (Parnate – brand isNF)

trazodone

venlafaxine

venlafaxine ext-release caps (EffexorXR – brand is NF)

venlafaxine ext-release tabs, NF =225 mg

•

PSYCHOTIC AND BIPOLAR DISORDERS

chlorpromazine

clozapine (Clozaril – brand is NF) •FLUPHENAZINE HCL conc, elixir

fluphenazine hcl tabs

haloperidol decanoate (Haldol – brandis NF)

haloperidol lactate oral conc

haloperidol tabs

lithium carbonate

lithium carbonate ext-release300 mg (Lithobid – brand is NF)

lithium carbonate ext-release 450 mg

loxapine (Loxitane – brand is NF)

olanzapine (Zyprexa, Zyprexa Zydis –brands are NF)

•

perphenazine

prochlorperazine

quetiapine (Seroquel – brand is NF) •risperidone (Risperdal, Risperdal M-

Tab – brands are NF)•

SEROQUEL XR •thiothixene

trifluoperazine

ziprasidone (Geodon – brand is NF) •SLEEP AIDS

estazolam

phenobarbital soln; tabs, 16.2 mg,32.4 mg

2014


Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

temazepam (Restoril – brand is NF)

zaleplon (Sonata – brand is NF) •zolpidem (Ambien – brand is NF) •zolpidem ext-release (Ambien CR –

brand is NF)•

HYPERACTIVITY/NARCOLEPSY

amphetamine/dextroamphetamine (Adderall –brand is NF)

•

amphetamine/dextroamphetamineext-release (Adderall XR – brand isNF)

•

caffeine citrate (Cafcit – brand is NF)

dextroamphetamine •dextroamphetamine ext-

release (Dexedrine Spansule – brandis NF)

•

INTUNIV •methylphenidate tabs (Ritalin – brand

is NF)•

methylphenidate ext-release caps;tabs, 20 mg (Metadate CD, RitalinLA, Ritalin SR – brands are NF)

•

modafinil (Provigil – brand is NF) •VYVANSE •MULTIPLE SCLEROSIS

BETASERON • •COPAXONE • •REBIF • •TECFIDERA • •OTHER CENTRAL NERVOUS SYSTEM DRUGS

bupropion ext-release (Zyban – brandis NF)

CHANTIX

disulfiram (Antabuse – brand is NF)

donepezil (Aricept, Aricept ODT –brands are NF)

EXELON patches, soln

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

galantamine (Razadyne – brand is NF)

galantamine ext-release (RazadyneER – brand is NF)

naltrexone (ReVia – brand is NF) •NICOTROL INHALER

NICOTROL NS

NUEDEXTA

ORAP

rivastigmine caps (Exelon – brand isNF)

PAIN RELIEF DRUGS

NON-NARCOTIC DRUGS

butalbital/acetaminophen

butalbital/acetaminophen/caffeine(Esgic, Esgic-Plus, Fioricet – brandsare NF)

butalbital/aspirin/caffeinecaps (Fiorinal – brand is NF)

salsalate

NARCOTIC DRUGS

acetaminophen/codeine (Tylenol w/Codeine – brand is NF)

buprenorphine • •buprenorphine/naloxone SL tabs • •butalbital/aspirin/caffeine/

codeine (Fiorinal w/Codeine – brandis NF)

CODEINE SULFATE 15 mg

fentanyl lollipop (Actiq – brand is NF) • •fentanyl patches (Duragesic – brand is

NF)•

hydrocodone/acetaminophen, NF =tabs, 2.5-325 mg (Lortab – brand isNF)

hydrocodone/ibuprofen (Ibudone,Reprexain, Vicoprofen – brands areNF)

2014


Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

hydromorphone soln, tabs (Dilaudid –brand is NF)

KADIAN •methadone conc (Methadose – brand

is NF)

methadone soln

methadone tabs (Dolophine – brand isNF)

morphine sulfate conc, soln •morphine sulfate ext-release (Kadian) •morphine sulfate ext-release (MS

Contin – brand is NF)•

MORPHINE SULFATE supp, tabs

NUCYNTA ER •oxycodone (Roxicodone – brand is NF)

oxycodone caps, conc, soln

oxycodone/acetaminophen (Percocet– brand is NF)

oxycodone/aspirin (Percodan – brandis NF)

OXYCONTIN •SUBOXONE film • •tramadol (Ultram – brand is NF) •tramadol/acetaminophen (Ultracet –

brand is NF)

RHEUMATOID AND OSTEOARTHRITIS

CELEBREX • •diclofenac potassium (Cataflam –

brand is NF)

diclofenac sodium delayed-release

diclofenac sodium ext-release (Voltaren-XR – brand is NF)

ENBREL • •etodolac

flurbiprofen

HUMIRA • •ibuprofen

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

indomethacin

ketoprofen

leflunomide (Arava – brand is NF)

meloxicam tabs (Mobic – brand is NF)

nabumetone

naproxen (Naprosyn – brand is NF)

naproxen delayed-release (EC-Naprosyn – brand is NF)

naproxen sodium (Anaprox – brand isNF)

oxaprozin (Daypro – brand is NF)

piroxicam (Feldene – brand is NF)

sulindac (Clinoril – brand is NF)

MIGRAINE HEADACHES

acetaminophen/isometheptene/dichloralphenazone

IMITREX nasal spray •MIGRANAL •naratriptan (Amerge – brand is NF) •rizatriptan (Maxalt, Maxalt-MLT –

brands are NF)•

sumatriptan inj, tabs (Imitrex – brandis NF)

•

GOUT

allopurinol (Zyloprim – brand is NF)

COLCRYS

probenecid

probenecid/colchicine

NEUROMUSCULAR DRUGS

SEIZURES

carbamazepine (Tegretol – brand isNF)

carbamazepine ext-release(Carbatrol, Tegretol-XR – brands areNF)

CELONTIN

clonazepam (Klonopin – brand is NF)

2014


Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

DIASTAT •DILANTIN 30 mg

divalproex delayed-release(Depakote, Depakote Sprinkles –brands are NF)

divalproex ext-release (Depakote ER –brand is NF)

ethosuximide (Zarontin – brand is NF)

gabapentin (Neurontin – brand is NF)

GABITRIL 12 mg, 16 mg

lamotrigine (Lamictal – brand is NF)

levetiracetam (Keppra – brand is NF)

LYRICA caps

oxcarbazepine (Trileptal – brand is NF)

phenytoin chew tabs (Dilantin Infatabs– brand is NF)

phenytoin sodium ext-release(Dilantin, Phenytek – brands are NF)

phenytoin susp (Dilantin – brand is NF)

primidone (Mysoline – brand is NF)

SABRIL

TEGRETOL-XR 100 mg

topiramate (Topamax, TopamaxSprinkle – brands are NF)

valproic acid (Depakene – brand is NF)

zonisamide (Zonegran – brand is NF)

PARKINSON'S DISEASE

amantadine, NF = tabs

APOKYN •AZILECT

benztropine

bromocriptine (Parlodel – brand is NF)

carbidopa/levodopa (Parcopa,Sinemet – brands are NF)

carbidopa/levodopa ext-release (Sinemet CR – brand is NF)

entacapone (Comtan – brand is NF)

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

pramipexole (Mirapex – brand is NF)

ropinirole (Requip – brand is NF)

selegiline caps (Eldepryl – brand is NF)

selegiline tabs

trihexyphenidyl

MUSCLE RELAXANTS

baclofen

chlorzoxazone (Parafon Forte DSC –brand is NF)

cyclobenzaprine

dantrolene (Dantrium – brand is NF)

metaxalone (Skelaxin – brand is NF)

methocarbamol (Robaxin – brand isNF)

orphenadrine citrate ext-release

orphenadrine/aspirin/caffeine25-385-30 mg

tizanidine (Zanaflex – brand is NF) •OTHER NEUROMUSCULAR DRUGS

MESTINON syrup

MESTINON TIMESPAN

pyridostigmine (Mestinon – brand isNF)

riluzole (Rilutek – brand is NF)

SUPPLEMENTS

VITAMINS

ergocalciferol (Drisdol – brand is NF)

MEPHYTON

MULTIVITAMINS

pediatric multivitamins

pediatric vitamins ADC

PRENAPLUS

PRENATABS FA

PRENATAL VITAMINS PLUS

PRENATAL 19, PRENATAL LOWIRON, PRENATAL PLUS

2014


Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

SE-NATAL 19

MINERALS AND ELECTROLYTES

K-PHOS

potassium bicarbonate/chlorideeffervescent tabs, 25 mEq

potassium chloride packets; soln,10%

potassium chloride ext-release (K-Tabs – brand is NF)

potassium chloride ext-releasecaps (Micro-K – brand is NF)

potassium phosphate/sodiumphosphates (K-Phos Neutral – brandis NF)

sodium fluoride chew tabs,soln (Luride – brand is NF)

BLOOD MODIFYING DRUGS

ADVATE •ALPHANATE •ALPHANINE SD •anagrelide (Agrylin – brand is NF)

ARANESP • •BEBULIN •BEBULIN VH •BENEFIX •cilostazol (Pletal – brand is NF)

clopidogrel (Plavix – brand is NF)

CORIFACT •cyanocobalamin inj

dipyridamole (Persantine – brand isNF)

DROXIA

enoxaparin (Lovenox – brand is NF) •EPOGEN • •FEIBA NF •FEIBA VH IMMUNO •folic acid 1 mg

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

HELIXATE FS •HEMOFIL M •HUMATE-P •KOATE-DVI •KOGENATE FS •KOGENATE FS BIO-SET •MONOCLATE-P •MONONINE •NEULASTA •NEUPOGEN •NOVOSEVEN RT •pentoxifylline ext-release (Trental –

brand is NF)

PROCRIT • •PROFILNINE SD •RECOMBINATE •RIXUBIS •warfarin (Coumadin – brand is NF)

WILATE •XARELTO •XYNTHA •XYNTHA SOLOFUSE •TOPICAL DRUGS

EYE

Anti-infectives

BACITRACIN oint

bacitracin/polymyxin B oint

ciprofloxacin soln (Ciloxan – brand isNF)

erythromycin oint

gentamicin oint, soln (Garamycin –brand is NF)

NATACYN

neomycin/polymyxin B/bacitracinoint

2014


Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

neomycin/polymyxin B/gramicidinsoln (Neosporin – brand is NF)

ofloxacin soln (Ocuflox – brand is NF)

polymyxin B/trimethoprimsoln (Polytrim – brand is NF)

sulfacetamide sodium soln (Bleph-10– brand is NF)

tobramycin soln (Tobrex – brand isNF)

trifluridine soln (Viroptic – brand is NF)

VIGAMOX

Steroids and Combination Products

dexamethasone sodium phosphatesoln

fluorometholone susp (FML Liquifilm –brand is NF)

LOTEMAX

neomycin/polymyxin B/bacitracin/hydrocortisone oint

neomycin/polymyxin B/dexamethasone oint, susp (Maxitrol– brand is NF)

prednisolone acetate susp (Pred Forte– brand is NF)

PREDNISOLONE SODIUMPHOSPHATE soln, 1%

sulfacetamide sodium/prednisolonesoln

TOBRADEX oint

tobramycin/dexamethasonesusp (Tobradex – brand is NF)

ZYLET

Glaucoma

ALPHAGAN P 0.1%

AZOPT

brimonidine soln, 0.15% (Alphagan P– brand is NF)

brimonidine soln, 0.2%

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

carteolol soln

dorzolamide soln (Trusopt – brand isNF)

dorzolamide/timolol maleatesoln (Cosopt – brand is NF)

latanoprost soln (Xalatan – brand isNF)

•

levobunolol soln, 0.5% (Betagan –brand is NF)

LUMIGAN •metipranolol soln (Optipranolol –

brand is NF)

pilocarpine soln (Isopto Carpine –brand is NF)

SIMBRINZA

timolol maleate soln (Timoptic,Timoptic-XE – brands are NF)

TRAVATAN Z •Other Eye Products

atropine sulfate soln (Isopto Atropine –brand is NF)

azelastine soln (Optivar – brand is NF)

cromolyn soln

cyclopentolate soln (Cyclogyl – brandis NF)

diclofenac soln (Voltaren – brand isNF)

flurbiprofen soln (Ocufen – brand isNF)

homatropine soln (Isopto Homatropine– brand is NF)

ketorolac soln (Acular, Acular LS –brands are NF)

PATADAY

tropicamide soln (Mydriacyl – brand isNF)

EAR

acetic acid soln

2014


Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

benzocaine/antipyrine soln

CIPRODEX

hydrocortisone/acetic acidsoln (Vosol HC – brand is NF)

neomycin/polymyxin B/hydrocortisone soln,susp (Cortisporin – brand is NF)

ofloxacin soln

MOUTH AND THROAT (local)

cevimeline (Evoxac – brand is NF)

chlorhexidine oral rinse (Peridex –brand is NF)

clotrimazole troche

lidocaine viscous

nystatin susp

pilocarpine (Salagen – brand is NF)

sodium fluoride (Prevident – brand isNF)

triamcinolone dental paste

ANORECTAL AGENTS

CORTIFOAM

hydrocortisone acetate crm, supp(Anusol-HC, Proctocort – brands areNF)

hydrocortisone enema (Cortenema –brand is NF)

SKIN CONDITIONS/PRODUCTS

Acne

adapalene (Differin – brand is NF) •clindamycin (Cleocin-T – brand is NF)

clindamycin/benzoyl peroxide(Benzaclin, Duac – brands are NF)

DIFFERIN gel, 0.3% •erythromycin pads, soln

erythromycin/benzoylperoxide (Benzamycin – brand is NF)

FINACEA

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

isotretinoin, NF = 30 mg

metronidazole (Metrocream, Metrogel,Metrolotion – brands are NF)

sulfacetamide sodium (Klaron – brandis NF)

sulfacetamide sodium/sulfur, NF =susp, 10-5%

TAZORAC

tretinoin (Retin-A – brand is NF) •tretinoin microsphere (Retin-A Micro –

brand is NF)•

Anti-infectives

ciclopirox crm, gel, shampoo,susp (Loprox – brand is NF)

ciclopirox soln (Penlac – brand is NF)

econazole

ketoconazole crm

ketoconazole shampoo, 2% (Nizoral –brand is NF)

mupirocin (Bactroban – brand is NF)

nystatin topical

silver sulfadiazine (Silvadene – brandis NF)

Corticosteroids

alclometasone (Aclovate – brand isNF)

amcinonide crm

betamethasone dipropionate

betamethasone dipropionate,augmented (Diprolene – brand is NF)

betamethasone valerate

clobetasol (Clobex, Olux, Temovate –brands are NF)

desonide (Desowen – brand is NF)

desoximetasone crm, 0.25%; gel;oint, 0.25% (Topicort – brand is NF)

diflorasone oint

2014


Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

fluocinolone (Derma-Smoothe/FS,Synalar – brands are NF)

fluocinonide

fluticasone propionate (Cutivate –brand is NF)

halobetasol (Ultravate – brand is NF)

hydrocortisone topical

hydrocortisone valerate (Westcort –brand is NF)

mometasone (Elocon – brand is NF)

nystatin/triamcinolone crm

triamcinolone crm; lotn; oint,0.025%, 0.1%

Other Skin Products

acitretin (Soriatane – brand is NF)

aluminum chloride (Drysol – brand isNF)

calcipotriene (Dovonex – brand is NF)

CARAC

ELIDEL

FLUOROPLEX

fluorouracil (Efudex – brand is NF)

imiquimod (Aldara – brand is NF) •lidocaine patches (Lidoderm – brand is

NF)

lidocaine topical, NF = lotn (Xylocaine– brand is NF)

lidocaine/prilocaine crm (Emla –brand is NF)

lindane

malathion (Ovide – brand is NF)

permethrin (Elimite – brand is NF)

podofilox (Condylox – brand is NF)

PROTOPIC

selenium sulfide

SOLARAZE

VOLTAREN

Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

XERAC AC

ZYCLARA •ZYCLARA PUMP •MISCELLANEOUS CATEGORIES

DIABETIC SUPPLIES

INSULIN PEN NEEDLES – BDULTRAFINE, NOVOFINE,NOVOTWIST

•

INSULIN SYRINGES – BD •LANCETS – BAYER FINGERSTIX,

MICROLET, SINGLE-LET

LANCETS – BD MICROTAINER,ULTRAFINE

LANCETS – ROCHE ACCU-CHEKFASTCLIX, MULTICLIX, SOFTTOUCH, SOFTCLIX

TEST STRIPS – BAYER ASCENSIAAUTODISC, BREEZE 2, CONTOUR,CONTOUR NEXT

•

TEST STRIPS – ROCHE ACCU-CHEKACTIVE, AVIVA, AVIVA PLUS,COMFORT CURVE, COMPACT,SMARTVIEW

•

TEST STRIPS – ROCHEACCUTREND

•

MEDICAL DEVICES

BREATHERITE

MISCELLANEOUS DRUGS

azathioprine (Imuran – brand is NF)

CELLCEPT

CHEMET

CUPRIMINE •cyclosporine (Sandimmune – brand is

NF)

cyclosporine modified caps, 25 mg,100 mg; soln (Neoral – brand is NF)

CYCLOSPORINE MODIFIED caps,50 mg

mycophenolate mofetil (Cellcept)

2014


Drug Name Spe

cial

ty

Prio

r A

utho

rizat

ion

Dis

pens

ing

Lim

its

Ste

p T

hera

py

MYFORTIC

PROGRAF

RAPAMUNE

REVLIMID • •sodium polystyrene sulfonate

tacrolimus (Prograf)

THALOMID • •ZORTRESS

2014


INDEX

A

abacavir tabs...................................................................2acarbose.......................................................................... 4acebutolol........................................................................ 6acetaminophen/codeine............................................... 11acetaminophen/isometheptene/dichloralphenazone 12acetazolamide 250 mg................................................... 7acetazolamide ext-release............................................. 7acetic acid ear soln......................................................15acetylcysteine................................................................. 8acitretin.......................................................................... 17ACTONEL......................................................................... 5acyclovir.......................................................................... 2adapalene...................................................................... 16ADCIRCA..........................................................................7adefovir............................................................................ 2ADVAIR DISKUS..............................................................8ADVAIR HFA.................................................................... 8ADVATE..........................................................................14AFINITOR, NF = DISPERZ..............................................3ALBENZA..........................................................................2albuterol 0.63 mg/3 mL, 1.25 mg/3 mL......................... 8albuterol inhal soln, 0.083%, 0.5%................................8albuterol syrup, tabs...................................................... 8alclometasone............................................................... 16alendronate tabs, 5 mg, 10 mg, 35 mg, 70 mg............. 5alfuzosin ext-release...................................................... 9ALKERAN tabs................................................................. 3allopurinol......................................................................12ALPHAGAN P 0.1%....................................................... 15ALPHANATE...................................................................14ALPHANINE SD............................................................. 14alprazolam..................................................................... 10alprazolam ext-release................................................. 10aluminum chloride........................................................17amantadine, NF = tabs.................................................13amcinonide crm............................................................ 16amiloride.......................................................................... 7amiloride/hydrochlorothiazide.......................................7amiodarone......................................................................7amitriptyline...................................................................10amlodipine....................................................................... 6amlodipine/benazepril.................................................... 6amoxicillin, NF = chew tabs.......................................... 1amoxicillin/potassium clavulanate................................1amoxicillin/potassium clavulanate ext-release............1amphetamine/dextroamphetamine..............................11amphetamine/dextroamphetamine ext-release..........11ampicillin caps................................................................1anagrelide...................................................................... 14anastrozole...................................................................... 3ANDRODERM.................................................................. 4

ANDROGEL......................................................................4ANDROXY........................................................................ 4APOKYN......................................................................... 13APTIVUS...........................................................................2ARANESP.......................................................................14ASACOL HD.....................................................................9ASMANEX........................................................................ 8ASTEPRO.........................................................................7atenolol............................................................................ 6atenolol/chlorthalidone.................................................. 6atorvastatin......................................................................6atovaquone/proguanil 250-100 mg............................... 2ATRIPLA........................................................................... 2atropine sulfate eye soln............................................. 15ATROVENT HFA..............................................................8AVODART.........................................................................9azathioprine...................................................................17azelastine.........................................................................8azelastine eye soln.......................................................15AZILECT......................................................................... 13azithromycin susp.......................................................... 1azithromycin tabs........................................................... 1AZOPT............................................................................ 15

B

bacitracin/polymyxin B eye oint................................. 14BACITRACIN eye oint.................................................... 14baclofen......................................................................... 13balsalazide.......................................................................9BARACLUDE.................................................................... 2BEBULIN.........................................................................14BEBULIN VH.................................................................. 14benazepril........................................................................ 5benazepril/hydrochlorothiazide.....................................5BENEFIX.........................................................................14BENICAR.......................................................................... 6BENICAR HCT................................................................. 6benzocaine/antipyrine ear soln................................... 16benztropine....................................................................13betamethasone dipropionate.......................................16betamethasone dipropionate, augmented................. 16betamethasone valerate...............................................16BETASERON..................................................................11bicalutamide.................................................................... 3BILTRICIDE...................................................................... 2bisoprolol.........................................................................6bisoprolol/hydrochlorothiazide..................................... 6BREATHERITE...............................................................17BREO ELLIPTA................................................................ 8brimonidine eye soln, 0.15%....................................... 15brimonidine eye soln, 0.2%......................................... 15bromocriptine................................................................13budesonide......................................................................8budesonide ext-release..................................................3bumetanide......................................................................7buprenorphine...............................................................11

2014


buprenorphine/naloxone SL tabs............................... 11bupropion...................................................................... 10bupropion ext-release.................................................. 10bupropion ext-release.................................................. 11buspirone.......................................................................10butalbital/acetaminophen.............................................11butalbital/acetaminophen/caffeine.............................. 11butalbital/aspirin/caffeine/codeine.............................. 11butalbital/aspirin/caffeine caps................................... 11

C

cabergoline......................................................................5caffeine citrate.............................................................. 11calcipotriene..................................................................17calcitonin-salmon........................................................... 5calcitriol........................................................................... 5calcium acetate...............................................................9CANASA........................................................................... 9captopril...........................................................................5CARAC........................................................................... 17carbamazepine.............................................................. 12carbamazepine ext-release..........................................12carbidopa/levodopa...................................................... 13carbidopa/levodopa ext-release.................................. 13carteolol eye soln.........................................................15carvedilol......................................................................... 6cefaclor caps...................................................................1cefadroxil......................................................................... 1cefdinir............................................................................. 1cefpodoxime....................................................................1cefprozil........................................................................... 1ceftriaxone.......................................................................1cefuroxime.......................................................................1CELEBREX.....................................................................12CELLCEPT..................................................................... 17CELONTIN......................................................................12cephalexin, NF = tabs.................................................... 1cetirizine syrup............................................................... 7cevimeline......................................................................16CHANTIX........................................................................ 11CHEMET.........................................................................17CHENODAL...................................................................... 9chlorhexidine oral rinse...............................................16chloroquine phosphate..................................................2chlorothiazide..................................................................7chlorpromazine............................................................. 10chlorzoxazone............................................................... 13cholestyramine................................................................6chorionic gonadotropin................................................. 4CIALIS...............................................................................7ciclopirox crm, gel, shampoo, susp........................... 16ciclopirox soln.............................................................. 16cilostazol........................................................................14cimetidine........................................................................ 8CIPRODEX..................................................................... 16ciprofloxacin....................................................................1

ciprofloxacin ext-release................................................1ciprofloxacin eye soln..................................................14citalopram......................................................................10clarithromycin................................................................. 1clarithromycin ext-release............................................. 1CLEOCIN supp.................................................................9clindamycin..................................................................... 2clindamycin................................................................... 16clindamycin/benzoyl peroxide.....................................16clindamycin crm............................................................. 9clobetasol...................................................................... 16clomiphene...................................................................... 4clomipramine.................................................................10clonazepam................................................................... 12clonidine.......................................................................... 7clopidogrel.....................................................................14clotrimazole troche.......................................................16clozapine........................................................................10CODEINE SULFATE 15 mg...........................................11COLCRYS.......................................................................12colestipol......................................................................... 6COMBIPATCH.................................................................. 4COMBIVENT.....................................................................8COMBIVENT RESPIMAT.................................................8COPAXONE....................................................................11CORIFACT......................................................................14CORTIFOAM.................................................................. 16CORTISONE.....................................................................3CREON............................................................................. 9CRESTOR........................................................................ 6CRINONE......................................................................... 9CRIXIVAN......................................................................... 2cromolyn eye soln........................................................15cromolyn inhal soln....................................................... 8CUPRIMINE....................................................................17cyanocobalamin inj...................................................... 14cyclobenzaprine............................................................13cyclopentolate eye soln...............................................15CYCLOPHOSPHAMIDE tabs...........................................3cyclosporine..................................................................17cyclosporine modified caps, 25 mg, 100 mg; soln.... 17CYCLOSPORINE MODIFIED caps, 50 mg....................17cyproheptadine............................................................... 7CYSTAGON......................................................................9

D

danazol.............................................................................4dantrolene......................................................................13DAPSONE........................................................................ 2DARAPRIM....................................................................... 2DELZICOL........................................................................ 9demeclocycline............................................................... 1desipramine...................................................................10desmopressin..................................................................5desonide........................................................................ 16desoximetasone crm, 0.25%; gel; oint, 0.25%........... 16

2014


DETROL LA......................................................................9dexamethasone elixir; tabs, 0.5 mg, 0.75 mg, 1.5 mg,4 mg, 6 mg.................................................................... 3

dexamethasone sodium phosphate eye soln............ 15DEXAMETHASONE soln, 0.5 mg/5 mL........................... 3dextroamphetamine......................................................11dextroamphetamine ext-release..................................11DIASTAT.........................................................................13DIAZEPAM oral soln, 1 mg/mL...................................... 10diazepam tabs...............................................................10DIBENZYLINE.................................................................. 7diclofenac eye soln...................................................... 15diclofenac potassium...................................................12diclofenac sodium delayed-release............................ 12diclofenac sodium ext-release.................................... 12dicloxacillin..................................................................... 1dicyclomine caps, tabs.................................................. 8didanosine delayed-release...........................................2DIFFERIN gel, 0.3%.......................................................16diflorasone oint.............................................................16digoxin tabs.................................................................... 7DILANTIN 30 mg............................................................13diltiazem...........................................................................6diltiazem ext-release...................................................... 6diphenoxylate/atropine tabs.......................................... 9dipyridamole..................................................................14disopyramide...................................................................7disulfiram.......................................................................11divalproex delayed-release..........................................13divalproex ext-release..................................................13DIVIGEL............................................................................4donepezil....................................................................... 11dorzolamide/timolol maleate eye soln........................15dorzolamide eye soln...................................................15doxazosin........................................................................ 7doxepin, NF = caps, 75 mg..........................................10doxycycline hyclate........................................................1doxycycline monohydrate............................................. 1DROXIA.......................................................................... 14DULERA........................................................................... 8

E

econazole.......................................................................16ELIDEL............................................................................17ELLA................................................................................. 4EMCYT............................................................................. 3EMEND caps.................................................................... 9EMTRIVA.......................................................................... 2enalapril........................................................................... 5enalapril/hydrochlorothiazide........................................5ENBREL..........................................................................12ENJUVIA...........................................................................4enoxaparin.....................................................................14entacapone.................................................................... 13EPIPEN.............................................................................7EPIPEN-JR....................................................................... 7

EPIVIR soln...................................................................... 2eplerenone.......................................................................7EPOGEN.........................................................................14EPZICOM..........................................................................2ergocalciferol................................................................ 13erythromycin/benzoyl peroxide...................................16erythromycin/sulfisoxazole............................................2erythromycin delayed-release caps..............................1erythromycin eye oint.................................................. 14erythromycin pads, soln..............................................16escitalopram..................................................................10estazolam.......................................................................10ESTRACE crm..................................................................9estradiol/norethindrone acetate.................................... 4estradiol patches............................................................ 4estradiol tabs.................................................................. 4estropipate, NF = 3 mg.................................................. 4ethambutol.......................................................................1ethosuximide.................................................................13etodolac......................................................................... 12EVISTA............................................................................. 5EXELON patches, soln...................................................11exemestane..................................................................... 3

F

famciclovir....................................................................... 2famotidine........................................................................8FARESTON...................................................................... 3FEIBA NF....................................................................... 14FEIBA VH IMMUNO....................................................... 14felodipine ext-release.....................................................6fenofibrate....................................................................... 6fenofibrate micronized................................................... 6fenofibric acid delayed-release..................................... 6fentanyl.......................................................................... 11fentanyl lollipop............................................................ 11FINACEA........................................................................ 16finasteride........................................................................9FIRAZYR...........................................................................8flecainide......................................................................... 7FLOVENT DISKUS...........................................................8FLOVENT HFA.................................................................8fluconazole...................................................................... 1flucytosine....................................................................... 1fludrocortisone................................................................3flunisolide........................................................................ 8fluocinolone...................................................................17fluocinonide...................................................................17fluorometholone eye susp...........................................15FLUOROPLEX................................................................17fluorouracil.................................................................... 17fluoxetine, NF = 60 mg.................................................10FLUPHENAZINE HCL conc, elixir..................................10fluphenazine hcl tabs...................................................10flurbiprofen....................................................................12flurbiprofen eye soln....................................................15

2014


flutamide.......................................................................... 3fluticasone propionate................................................... 8fluticasone propionate................................................. 17fluvoxamine................................................................... 10folic acid 1 mg..............................................................14FOLLISTIM AQ.................................................................4FORADIL AEROLIZER.....................................................8FORTEO........................................................................... 5fosinopril..........................................................................5fosinopril/hydrochlorothiazide...................................... 5furosemide, NF = soln, 8 mg/mL...................................7FUZEON........................................................................... 2

G

gabapentin.....................................................................13GABITRIL 12 mg, 16 mg................................................13galantamine................................................................... 11galantamine ext-release...............................................11GANIRELIX ACETATE.....................................................4gemfibrozil.......................................................................6gentamicin eye oint, soln............................................ 14GLEEVEC......................................................................... 3glimepiride.......................................................................4glipizide............................................................................4glipizide/metformin......................................................... 4glipizide ext-release....................................................... 4GLUCAGON EMERGENCY KIT...................................... 4glyburide..........................................................................4glyburide/metformin....................................................... 4glyburide micronized..................................................... 4glycopyrrolate................................................................. 8granisetron...................................................................... 9griseofulvin microsize....................................................1guanfacine....................................................................... 7

H

halobetasol.................................................................... 17haloperidol decanoate..................................................10haloperidol lactate oral conc.......................................10haloperidol tabs............................................................10HELIXATE FS.................................................................14HEMOFIL M....................................................................14homatropine eye soln.................................................. 15HUMALOG........................................................................5HUMALOG MIX 50/50, 75/25...........................................5HUMATE-P..................................................................... 14HUMIRA..........................................................................12HUMULIN 70/30............................................................... 5HUMULIN N......................................................................5HUMULIN R......................................................................5hydralazine...................................................................... 7hydrochlorothiazide caps.............................................. 7hydrochlorothiazide tabs...............................................7hydrocodone/acetaminophen, NF = tabs, 2.5-325mg.................................................................................11

hydrocodone/ibuprofen................................................11

hydrocortisone................................................................3hydrocortisone/acetic acid ear soln........................... 16hydrocortisone acetate rectal crm, supp................... 16hydrocortisone enema................................................. 16hydrocortisone topical.................................................17hydrocortisone valerate...............................................17hydromorphone soln, tabs.......................................... 12hydroxychloroquine....................................................... 2hydroxyurea.................................................................... 3hydroxyzine hcl............................................................ 10hydroxyzine pamoate 25 mg, 50 mg...........................10hyoscyamine................................................................... 8hyoscyamine ext-release............................................... 8

I

ibandronate..................................................................... 5ibuprofen....................................................................... 12imipramine hcl.............................................................. 10imiquimod......................................................................17IMITREX nasal spray..................................................... 12INCIVEK............................................................................2INCRELEX........................................................................ 5indapamide...................................................................... 7indomethacin.................................................................12INNOPRAN XL................................................................. 6INSULIN PEN NEEDLES – BD ULTRAFINE,NOVOFINE, NOVOTWIST........................................... 17

INSULIN SYRINGES – BD............................................ 17INTELENCE......................................................................2INTUNIV..........................................................................11INVIRASE......................................................................... 2ipratropium/albuterol......................................................8ipratropium inhal soln....................................................8ipratropium nasal........................................................... 8irbesartan.........................................................................6irbesartan/hydrochlorothiazide..................................... 6ISENTRESS......................................................................2isoniazid/rifampin........................................................... 1isoniazid tabs..................................................................1isosorbide dinitrate, NF = SL tabs................................6isosorbide mononitrate..................................................6isosorbide mononitrate ext-release..............................6isotretinoin, NF = 30 mg.............................................. 16itraconazole..................................................................... 1

J

JANUMET......................................................................... 4JANUMET XR...................................................................4JANUVIA...........................................................................4JUVISYNC........................................................................ 4

K

KADIAN...........................................................................12KALETRA..........................................................................2KALYDECO...................................................................... 8ketoconazole crm......................................................... 16

2014


ketoconazole shampoo, 2%.........................................16ketoprofen..................................................................... 12ketorolac eye soln........................................................ 15KOATE-DVI.....................................................................14KOGENATE FS.............................................................. 14KOGENATE FS BIO-SET.............................................. 14KOMBIGLYZE XR............................................................ 4K-PHOS.......................................................................... 14

L

labetalol........................................................................... 6lactulose.......................................................................... 8lactulose.......................................................................... 9lamivudine....................................................................... 2lamivudine/zidovudine................................................... 2lamotrigine.....................................................................13LANCETS – BAYER FINGERSTIX, MICROLET,SINGLE-LET................................................................. 17

LANCETS – BD MICROTAINER, ULTRAFINE.............. 17LANCETS – ROCHE ACCU-CHEK FASTCLIX,MULTICLIX, SOFT TOUCH, SOFTCLIX...................... 17

lansoprazole delayed-release........................................8LANTUS............................................................................5latanoprost eye soln.................................................... 15leflunomide....................................................................12LETAIRIS.......................................................................... 7letrozole........................................................................... 3LEUCOVORIN CALCIUM tabs, 10 mg, 15 mg.................3leucovorin calcium tabs, 5 mg, 25 mg......................... 3LEUKERAN.......................................................................3LEVEMIR.......................................................................... 5levetiracetam................................................................. 13levobunolol eye soln, 0.5%..........................................15levocarnitine....................................................................5levofloxacin..................................................................... 1levonorgestrel................................................................. 4levothyroxine...................................................................5LEXIVA............................................................................. 2LIALDA..............................................................................9lidocaine/prilocaine crm...............................................17lidocaine patches......................................................... 17lidocaine topical, NF = lotn......................................... 17lidocaine viscous..........................................................16lindane........................................................................... 17liothyronine..................................................................... 5lisinopril........................................................................... 5lisinopril/hydrochlorothiazide........................................5lithium carbonate..........................................................10lithium carbonate ext-release 300 mg........................ 10lithium carbonate ext-release 450 mg........................ 10loperamide.......................................................................9lorazepam...................................................................... 10lorazepam conc............................................................ 10losartan............................................................................ 6losartan/hydrochlorothiazide.........................................6LOTEMAX.......................................................................15

lovastatin......................................................................... 6loxapine......................................................................... 10LUMIGAN........................................................................15LYRICA caps.................................................................. 13

M

MALARONE 62.5-25 mg.................................................. 2malathion....................................................................... 17meclizine..........................................................................9medroxyprogesterone acetate...................................... 4medroxyprogesterone acetate inj, 150 mg/mL............ 4mefloquine.......................................................................2megestrol.........................................................................3MEKINIST......................................................................... 3meloxicam tabs.............................................................12MEPHYTON....................................................................13mercaptopurine...............................................................3mesalamine..................................................................... 9MESNEX tabs...................................................................3MESTINON syrup...........................................................13MESTINON TIMESPAN................................................. 13metaxalone.................................................................... 13metformin........................................................................ 4metformin ext-release.................................................... 4metformin ext-release OSM...........................................4methadone conc........................................................... 12methadone soln............................................................ 12methadone tabs............................................................ 12methazolamide................................................................ 7methimazole.................................................................... 5methocarbamol............................................................. 13methotrexate................................................................... 3methscopolamine........................................................... 8methyldopa......................................................................7methylergonovine........................................................... 5methylphenidate ext-release caps; tabs, 20 mg........ 11methylphenidate tabs...................................................11methylprednisolone........................................................3metipranolol eye soln.................................................. 15metoclopramide.............................................................. 9metolazone...................................................................... 7metoprolol succinate ext-release..................................6metoprolol tartrate..........................................................6metronidazole..................................................................9metronidazole tabs.........................................................3metronidazole topical...................................................16mexiletine........................................................................ 7midodrine.........................................................................7MIGRANAL..................................................................... 12minocycline..................................................................... 1minoxidil.......................................................................... 7mirtazapine, NF = 7.5 mg.............................................10misoprostol..................................................................... 8modafinil........................................................................ 11moexipril.......................................................................... 5moexipril/hydrochlorothiazide.......................................5

2014


mometasone..................................................................17MONOCLATE-P..............................................................14MONONINE.................................................................... 14montelukast.....................................................................8morphine sulfate conc, soln........................................12morphine sulfate ext-release.......................................12morphine sulfate ext-release.......................................12MORPHINE SULFATE supp, tabs................................. 12MULTAQ........................................................................... 7mupirocin.......................................................................16MYCOBUTIN.................................................................... 1mycophenolate mofetil.................................................17MYFORTIC..................................................................... 18MYLERAN.........................................................................3

N

nabumetone...................................................................12nadolol............................................................................. 6naltrexone......................................................................11naproxen........................................................................12naproxen delayed-release............................................12naproxen sodium..........................................................12naratriptan..................................................................... 12NASONEX........................................................................ 8NATACYN.......................................................................14nateglinide....................................................................... 4neomycin/polymyxin B/bacitracin/hydrocortisoneeye oint........................................................................ 15

neomycin/polymyxin B/bacitracin eye oint................ 14neomycin/polymyxin B/dexamethasone eye oint,susp..............................................................................15

neomycin/polymyxin B/gramicidin eye soln.............. 15neomycin/polymyxin B/hydrocortisone ear soln,susp..............................................................................16

neomycin sulfate............................................................ 1NEULASTA..................................................................... 14NEUPOGEN................................................................... 14nevirapine tabs............................................................... 2NEXAVAR.........................................................................3NEXIUM............................................................................ 8niacin ext-release........................................................... 6NICOTROL INHALER.................................................... 11NICOTROL NS............................................................... 11nifedipine ext-release.....................................................6NILANDRON.....................................................................3nitrofurantoin.................................................................. 9nitrofurantoin macrocrystalline.....................................9nitrofurantoin monohydrate/macrocrystalline.............9nitroglycerin.................................................................... 6NITROSTAT......................................................................6norethindrone acetate....................................................4nortriptyline caps......................................................... 10NORVIR............................................................................ 2NOVOLIN 70/30............................................................... 5NOVOLIN N......................................................................5NOVOLIN R......................................................................5

NOVOLOG........................................................................5NOVOLOG MIX 70/30......................................................5NOVOSEVEN RT........................................................... 14NOXAFIL...........................................................................1NUCYNTA ER................................................................ 12NUEDEXTA.................................................................... 11NUVARING....................................................................... 4nystatin/triamcinolone crm..........................................17nystatin oral.................................................................... 1nystatin susp................................................................ 16nystatin topical............................................................. 16

O

octreotide.........................................................................5ofloxacin ear soln.........................................................16ofloxacin eye soln........................................................ 15ofloxacin tabs................................................................. 1olanzapine..................................................................... 10omeprazole delayed-release..........................................8OMNITROPE.................................................................... 5ondansetron.................................................................... 9ondansetron 24 mg........................................................ 9ONGLYZA.........................................................................4oral contraceptives – all generics.................................4ORAP..............................................................................11ORFADIN..........................................................................5orphenadrine/aspirin/caffeine 25-385-30 mg..............13orphenadrine citrate ext-release................................. 13ORTHO EVRA..................................................................4oxaprozin....................................................................... 12oxcarbazepine............................................................... 13oxybutynin.......................................................................9oxybutynin ext-release...................................................9oxycodone..................................................................... 12oxycodone/acetaminophen..........................................12oxycodone/aspirin........................................................ 12oxycodone caps, conc, soln....................................... 12OXYCONTIN...................................................................12

P

pantoprazole delayed-release....................................... 8paricalcitol....................................................................... 5paromomycin.................................................................. 1paroxetine hcl............................................................... 10paroxetine hcl ext-release........................................... 10PATADAY....................................................................... 15pediatric multivitamins.................................................13pediatric vitamins ADC................................................ 13PEGASYS.........................................................................2PEG – electrolytes for soln........................................... 8penicillin v potassium....................................................1PENTASA......................................................................... 9pentoxifylline ext-release.............................................14perindopril....................................................................... 5permethrin..................................................................... 17perphenazine.................................................................10

2014


phenelzine..................................................................... 10phenobarbital soln; tabs, 16.2 mg, 32.4 mg............... 10phenytoin chew tabs....................................................13phenytoin sodium ext-release.....................................13phenytoin susp............................................................. 13pilocarpine.....................................................................16pilocarpine eye soln.....................................................15pioglitazone..................................................................... 4pioglitazone/metformin.................................................. 4piroxicam....................................................................... 12podofilox........................................................................17polymyxin B/trimethoprim eye soln............................15potassium bicarbonate/chloride effervescent tabs,25 mEq......................................................................... 14

potassium chloride ext-release...................................14potassium chloride ext-release caps..........................14potassium chloride packets; soln, 10%..................... 14POTASSIUM CITRATE.................................................... 9potassium citrate/citric acid powder............................ 9potassium phosphate/sodium phosphates................14pramipexole...................................................................13pravastatin.......................................................................7prazosin........................................................................... 7prednisolone................................................................... 3prednisolone acetate eye susp................................... 15PREDNISOLONE SODIUM PHOSPHATE eye soln,1%................................................................................. 15

prednisolone sodium soln.............................................3PREDNISONE INTENSOL...............................................3PREDNISONE soln, 5 mg/5 mL; tabs, 50 mg.................. 3prednisone tabs, 1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg... 3PRENAPLUS.................................................................. 13PRENATABS FA............................................................ 13PRENATAL 19, PRENATAL LOW IRON, PRENATALPLUS.............................................................................13

PRENATAL VITAMINS PLUS........................................ 13PREZISTA........................................................................ 2PRIFTIN............................................................................ 1PRIMAQUINE................................................................... 2primidone.......................................................................13PROAIR HFA....................................................................8probenecid.....................................................................12probenecid/colchicine.................................................. 12prochlorperazine...........................................................10PROCRIT........................................................................14PROFILNINE SD............................................................ 14progesterone micronized...............................................4PROGRAF...................................................................... 18promethazine, NF = supp, 50 mg..................................7propafenone.................................................................... 7propafenone ext-release................................................ 7propranolol ext-release..................................................6PROPRANOLOL soln.......................................................6propranolol tabs............................................................. 6propylthiouracil...............................................................5PROTOPIC..................................................................... 17

PULMOZYME................................................................... 8pyrazinamide................................................................... 1pyridostigmine.............................................................. 13

Q

quetiapine...................................................................... 10quinapril...........................................................................5quinapril/hydrochlorothiazide....................................... 5quinidine gluconate ext-release....................................7quinidine sulfate, NF = ext-release............................... 7QVAR................................................................................8

R

ramipril.............................................................................5ranitidine..........................................................................8RAPAMUNE....................................................................18REBIF............................................................................. 11RECOMBINATE..............................................................14RENVELA......................................................................... 9repaglinide.......................................................................4REPRONEX......................................................................4RESCRIPTOR.................................................................. 2REVLIMID....................................................................... 18REYATAZ......................................................................... 2ribavirin............................................................................2rifampin............................................................................1riluzole........................................................................... 13risperidone.................................................................... 10rivastigmine caps......................................................... 11RIXUBIS..........................................................................14rizatriptan.......................................................................12ropinirole....................................................................... 13

S

SABRIL........................................................................... 13salsalate.........................................................................11selegiline caps.............................................................. 13selegiline tabs...............................................................13selenium sulfide........................................................... 17SELZENTRY.....................................................................2SE-NATAL 19................................................................. 14SENSIPAR........................................................................5SEROQUEL XR..............................................................10sertraline........................................................................10sildenafil.......................................................................... 7silver sulfadiazine.........................................................16SIMBRINZA.................................................................... 15simvastatin...................................................................... 7sodium citrate/citric acid............................................... 9sodium fluoride.............................................................16sodium fluoride chew tabs, soln.................................14sodium polystyrene sulfonate.....................................18SOLARAZE.....................................................................17sotalol.............................................................................. 7SPIRIVA HANDIHALER................................................... 8spironolactone................................................................ 7

2014


spironolactone/hydrochlorothiazide.............................7SPRYCEL......................................................................... 3stavudine......................................................................... 2STIMATE.......................................................................... 5STRIBILD..........................................................................2STROMECTOL................................................................. 2SUBOXONE film.............................................................12sucralfate......................................................................... 8sulfacetamide sodium..................................................16sulfacetamide sodium/prednisolone eye soln........... 15sulfacetamide sodium/sulfur, NF = susp, 10-5%....... 16sulfacetamide sodium eye soln.................................. 15sulfamethoxazole/trimethoprim.....................................3sulfasalazine....................................................................9sulfasalazine delayed-release....................................... 9sulindac......................................................................... 12sumatriptan inj, tabs.................................................... 12SUPRAX tabs................................................................... 1SUSTIVA...........................................................................2SUTENT............................................................................3SYLATRON.......................................................................3SYMBICORT.....................................................................8

T

TABLOID...........................................................................3tacrolimus......................................................................18TAFINLAR.........................................................................3tamoxifen......................................................................... 3tamsulosin....................................................................... 9TARCEVA......................................................................... 3TASIGNA.......................................................................... 3TAZORAC.......................................................................16TECFIDERA....................................................................11TEGRETOL-XR 100 mg.................................................13temazepam.................................................................... 11temozolomide..................................................................3terazosin.......................................................................... 7terbinafine........................................................................1terbutaline........................................................................8terconazole...................................................................... 9testosterone cypionate.................................................. 4testosterone enanthate.................................................. 4TEST STRIPS – BAYER ASCENSIA AUTODISC,BREEZE 2, CONTOUR, CONTOUR NEXT..................17

TEST STRIPS – ROCHE ACCU-CHEK ACTIVE,AVIVA, AVIVA PLUS, COMFORT CURVE, COMPACT,SMARTVIEW................................................................ 17

TEST STRIPS – ROCHE ACCUTREND........................17THALOMID..................................................................... 18theophylline ext-release.................................................8thiothixene.....................................................................10timolol maleate eye soln..............................................15TIMOLOL tabs.................................................................. 6TIVICAY............................................................................ 2tizanidine....................................................................... 13TOBI, NF = Podhaler....................................................... 1

TOBRADEX eye oint...................................................... 15tobramycin/dexamethasone eye susp........................15tobramycin eye soln.....................................................15tolterodine....................................................................... 9topiramate......................................................................13torsemide.........................................................................7TRACLEER.......................................................................7tramadol.........................................................................12tramadol/acetaminophen............................................. 12trandolapril...................................................................... 5tranylcypromine............................................................ 10TRAVATAN Z................................................................. 15trazodone.......................................................................10tretinoin..........................................................................16tretinoin caps.................................................................. 3tretinoin microsphere...................................................16TREXALL.......................................................................... 3triamcinolone.................................................................. 8triamcinolone crm; lotn; oint, 0.025%, 0.1%.............. 17triamcinolone dental paste..........................................16triamterene/hydrochlorothiazide................................... 7trifluoperazine............................................................... 10trifluridine eye soln...................................................... 15trihexyphenidyl............................................................. 13trimethobenzamide......................................................... 9trimethoprim....................................................................3TRIZIVIR........................................................................... 2tropicamide eye soln....................................................15TRUVADA.........................................................................2

U

ursodiol............................................................................9

V

VAGIFEM..........................................................................9valacyclovir..................................................................... 2VALCYTE..........................................................................1valproic acid..................................................................13valsartan/hydrochlorothiazide.......................................6vancomycin..................................................................... 3venlafaxine.................................................................... 10venlafaxine ext-release caps....................................... 10venlafaxine ext-release tabs, NF = 225 mg................ 10VENTOLIN HFA............................................................... 8verapamil, NF = 40 mg...................................................6verapamil ext-release..................................................... 6VESICARE........................................................................9VICTOZA.......................................................................... 4VICTRELIS....................................................................... 2VIDEX............................................................................... 2VIGAMOX....................................................................... 15VIRACEPT........................................................................ 2VIRAMUNE susp.............................................................. 2VIRAMUNE XR.................................................................2VIREAD.............................................................................2VIVELLE-DOT...................................................................4

2014


VOLTAREN.....................................................................17voriconazole.................................................................... 1VOTRIENT........................................................................3VYVANSE....................................................................... 11

W

warfarin.......................................................................... 14WELCHOL........................................................................ 7WILATE...........................................................................14

X

XALKORI.......................................................................... 3XARELTO....................................................................... 14XELODA........................................................................... 3XERAC AC..................................................................... 17XIFAXAN 550 mg.............................................................3XYNTHA......................................................................... 14XYNTHA SOLOFUSE.................................................... 14

Y

Z

zafirlukast........................................................................ 8zaleplon..........................................................................11ZELBORAF....................................................................... 3ZENPEP............................................................................9ZIAGEN soln.....................................................................2zidovudine....................................................................... 2ziprasidone.................................................................... 10ZITHROMAX packets....................................................... 1zolpidem........................................................................ 11zolpidem ext-release.................................................... 11zonisamide.................................................................... 13ZORTRESS.................................................................... 18ZYCLARA....................................................................... 17ZYCLARA PUMP............................................................17ZYLET.............................................................................15ZYTIGA............................................................................. 3ZYVOX..............................................................................3

Date post:	26-Apr-2018
Category:	Documents
Upload:	doxuyen
View:	218 times
Download:	1 times

January 2014 Standard Drug Formulary - Blue Cross … 2014 Standard Drug Formulary . ... example,...

Documents