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Blue Cross Blue Shield

of Michigan and
Blue Care Network

Custom
Formulary
2011
Custom
Formulary

January 2011
January 2011 Custom Formulary - Chapter Names
1 ANTI-INFECTIVES
1A Penicillins
1B Cephalosporins
1C Tetracyclines
1D Macrolides
1E Quinolones
1F Sulfonamides and Combinations
1G Urinary Tract Agents
1H Antifungals
1I Antivirals
1J Antiretrovirals
1K Antimalarials
1L Antituberculars
1M Antiparasitics/Anthelmintics
1N Miscellaneous Anti-infectives

2 CARDIOVASCULAR, HYPERTENSION, CHOLESTEROL


2A Lipid-lowering Agents
2B Beta Blockers and Combinations
2C ACE Inhibitors and Combinations
2D Angiotensin II Receptor Blockers and Combinations
2E Calcium Channel Blockers and Combinations
2F Diuretics
2G Cardiovascular Treatment
2H Nitrates and Combinations
2I Anticoagulants and Hemostasis Agents
2J Alpha-adrenergic Agents
2K Miscellaneous Antihypertensives

3 CENTRAL NERVOUS SYSTEM


3A Antidepressants
3B Antipsychotics
3C Anxiolytics
3D Sedative/Hypnotics
3E CNS Stimulants
3F Nonsteroidal Anti-inflammatory Drugs
3G Salicylates
3H Narcotics
3I Narcotic/Analgesic Combinations
3J Narcotic Mixed Agonist/Antagonist
3K Narcotic Antagonists
3M Migraine Therapy
3N Antiemetics (see Chapter 4E)
3O Parkinsons Disease and Related Disorders
3P Anticonvulsants
3Q Skeletal Muscle Relaxants
3R Myasthenia Gravis
3S Miscellaneous CNS

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4 GASTROINTESTINAL AGENTS
4A H2-Receptor Antagonists
4B Proton Pump Inhibitors
4C Other Ulcer Therapy
4D Antidiarrheals and Antispasmodics
4E Antiemetics
4F Bile Acids
4G Digestive Enzymes
4H Miscellaneous Gastrointestinal Agents

5 OBSTETRICS AND GYNECOLOGY


5A Oral Contraceptives-Monophasic
5B Oral Contraceptives-Biphasic
5C Oral Contraceptives-Triphasic
5D Contraceptives-Misc.
5E Oral Contraceptives-Postcoital
5F Progestins
5G Estrogens
5H Estrogen/Progestin Combinations
5J Infertility Treatment
5K Vaginal Anti-infective/Antifungal
5L Miscellaneous OB-GYN

6 RHEUMATOLOGY AND MUSCULOSKELETAL


6A Salicylates (see Chapter 3G)
6B Gout Therapy
6C Corticosteroids
6D Miscellaneous Rheumatologic Agents
6E Osteoporosis/Hormonal Treatment
6F Osteoporosis/Bone Resorption

7 ENDOCRINOLOGY
7A Antithyroid Agents
7B Thyroid Hormones
7C Corticosteroids
7D Androgens
7E Miscellaneous Endocrine
7F Insulins
7G Noninsulin Hypoglycemic Agents
7H Growth Hormone and Related Products

8 ANTINEOPLASTICS AND IMMUNOSUPPRESSANTS


8A Alkylating Agents
8B Antimetabolites
8C Immunomodulators
8D Hormonal Agents
8E Miscellaneous Antineoplastic Agents
8F Adjuvant Therapy
8G Kinase Inhibitors and Molecular Target Inhibitors

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9 IMMUNOLOGY AND HEMATOLOGY
9B Hematopoietic Agents
9C Interferons and MS Therapy

10 DERMATOLOGY
10A Very High Potency Corticosteroids
10B High Potency Corticosteroids
10C Medium Potency Corticosteroids
10D Low Potency Corticosteroids
10E Topical Anesthetics
10F Acne Treatment
10G Topical Antibacterials
10H Topical Antifungals
10I Topical Antivirals
10J Wound and Burn Therapy
10K Antipsoriatic/Antiseborrheic
10L Scabicides/Pediculicides
10M Miscellaneous Dermatologicals

11 OPHTHALMOLOGY
11A Ophthalmic Beta Blockers
11B Other Glaucoma Agents
11C Cycloplegic Mydriatics
11D Ophthalmic Anti-inflammatory Agents
11E Ophthalmic Anti-infectives
11F Ophthalmic Steroids
11G Ophthalmic Anti-infective/Steroid Combinations
11H Miscellaneous Ophthalmic Agents

12 OTIC AND NASAL PREPARATIONS


12A Nasal Preparations
12B Otic Preparations

13 RESPIRATORY, COUGH AND COLD


13A Antihistamines
13B Antihistamine/Decongestant Combinations
13C Antitussive Combinations
13D Expectorant Combinations
13E Corticosteroids (see Chapter 7C)
13F Oral Beta-Agonists
13G Inhaled Beta-Agonists
13H Inhaled Steroids
13I Intranasal Steroids
13J Theophyllines
13K Epinephrine
13L Miscellaneous Pulmonary Agents

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14 UROLOGY
14A Urinary Antispasmodics
14B Miscellaneous Urologicals
14C BPH Treatment

15 VITAMINS AND SUPPLEMENTS


15A Vitamins and Minerals
15B Potassium Replacement

16 DIAGNOSTIC AND OTHER MISCELLANEOUS


16A Diagnostics & Other Miscellaneous

17 LIFESTYLE MODIFICATION
17A Impotence
17B Weight Loss Preparations
17C Smoking Cessation

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Introduction

We are pleased to provide the Blue Cross Blue Shield of Michigan and Blue Care Network Custom
Formulary 2011 as a useful reference and educational tool for prescribers, pharmacists and members. Our
formulary is a regularly updated list of medications approved by the U.S. Food and Drug Administration
and reviewed by the BCBSM and BCN Pharmacy and Therapeutics Committee. The list represents the
clinical judgment of Michigan physicians, pharmacists and other experts in the diagnosis and treatment of
disease and the promotion of health. Medications are selected based on clinical effectiveness, safety and
opportunity for cost savings. The Custom Formulary will help in maintaining the quality of care for our
members and containing costs for our clients.

Physicians, pharmacists and members should regularly refer to the Custom Formulary for information
regarding drug coverage and therapeutic options for BCBSM and BCN members. Physicians are
encouraged to prescribe formulary medications whenever possible. The Custom Formulary is divided into
major therapeutic categories by chapter for easy use. Products approved for more than one therapeutic
indication may be included in more than one chapter. Within each chapter, drugs are identified according
to whether they are formulary preferred (Tier 1), formulary options (Tier 2) or nonformulary (Tier 3).

Formulary preferred (Tier 1): These drugs have a proven record of safety and effectiveness and offer the
best value for members. Because they are Tier 1, they require the lowest copayment, making them your
most cost-effective option for treatment. Most generic drugs are formulary preferred.
Formulary options (Tier 2): Our Tier 2 drugs also have a record of safety and effectiveness. However,
because more cost-effective therapies or generic alternatives to these drugs are usually available, most
Tier 2 drugs require a higher copayment.
Nonformulary (Tier 3): Nonformulary drugs are not on our list of approved drugs. These drugs may not
have a proven record for safety or their clinical value may not be as high as the drugs in Tier 1 and Tier 2.
Formulary alternatives are available. Depending on the drug coverage, the member may pay a higher
copayment or even the entire cost of these drugs.

BCBSM and BCN respect the judgment of the dispensing pharmacist. Pharmacists are expected to
contact the prescriber when presented with a prescription for a drug or dose that may not be appropriate
for a patient. We encourage pharmacists to also contact the prescriber, to suggest an alternative when a
BCBSM or BCN member’s prescription is written for a nonformulary drug.

Drug coverage
Coverage and applicable copayment amounts for drugs on the Custom Formulary are based on a
member’s drug plan. Not all drugs included in the Custom Formulary are necessarily covered by each
patient’s plan. Most BCN members do not have coverage for nonformulary drugs unless a BCN-affiliated
provider certifies that the prescription is medically necessary and BCN agrees. Similarly, BCBSM
members with a closed (managed) formulary option do not have coverage for nonformulary drugs.

Some BCBSM and BCN plans may require a different copayment amount or may not cover certain
lifestyle drugs. These may include weight-loss products, drugs for smoking cessation and drugs to treat
sexual dysfunction or infertility. BCN’s coverage for drugs used to treat infertility is based on the member’s
BCN medical plan. Coverage for contraceptives is based on the member’s BCBSM or BCN drug plan.
Some BCN drug plans do not include coverage for proton pump inhibitors.

Members should consult their prescription drug benefit packet or contact a Customer Service
representative to determine specific coverage.

Approved medications
In general, only FDA-approved prescription medications are eligible for coverage under a member’s policy.
When a drug is available in the identical strength and dosage in either a prescription or a nonprescription

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medication, the prescription medication is usually not covered. In these cases, prescribers should refer the
patient to the equivalent over-the-counter product. Certain OTC products, such as loratadine (Claritin®) are
covered for BCN members and for some BCBSM members with a prescription. Other exceptions are
identified in the Custom Formulary.

Certain medications may be excluded from a BCBSM and BCN member’s pharmacy benefits, but may be
covered under the medical benefits. Such medications include serums, vaccines and other medications
that are generally administered in a physician’s office under the supervision of appropriate health care
personnel and not normally dispensed to the patient for self-administration.

Prior authorization and step therapy


Prior authorization may be necessary for coverage of certain medications. In these cases, clinical criteria
must be met based on current medical information and approved by the BCBSM and BCN Pharmacy and
Therapeutics Committee, or other information must be provided before coverage is approved. Drugs
subject to step therapy may require previous treatment with one or more drugs on the formulary before
coverage is approved.

The Blue Care Network Quality Interchange Program (pages seven to 19) and the BCBSM Prior
Authorization and Step-Therapy Program (pages 20 to 31) provide a list of drugs that require prior
authorization or must meet step-therapy requirements prior to coverage. A description of the BCN quality
interchange program and the BCBSM prior authorization and step-therapy program are included in this
Custom Formulary. To view the most recent version, please go to
bcbsm.com/provider/pharmacy_services/index.shtml

For BCBSM members:


Members should consult their prescription drug benefit packet for information on how to obtain prior
authorization or call the Customer Service number on the back of their Blues member ID card for
additional information. Physicians can access the medication request forms on web-DENIS or contact the
Blue Cross Blue Shield of Michigan and Blue Care Network Pharmacy Services Clinical Help Desk at 1-
800-437-3803 and select option 1 for more information and to request coverage.

For BCN members:


The physician or office designee can access the medication request forms through web-DENIS.
Alternatively, physicians can call the Blue Cross Blue Shield of Michigan and Blue Care Network
Pharmacy Services Clinical Help Desk at 1-800-437-3803 and select option 2 to request prior
authorization or a benefit exception, depending on the type of request and the member’s drug benefit.
Urgent requests should be identified as such when calling. The form must be completed in its entirety and
returned to the Pharmacy Services Clinical Help Desk for review. The physician is notified of approved
requests, and the member’s claim will process accordingly. If the request is not approved, BCN provides
written notification to both the member and practitioner. The notification includes the reason for the denial
and an explanation of the appeal rights and the appeals process.

As part of our 2011 focus on efficient service, drugs are listed alphabetically within each tier. The Custom
Formulary is current at the time of publication (January and July) and is subject to change.

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Blue Care Network
Quality Interchange Program
January 2011
The Blue Care Network Quality Interchange Program helps ensure that safe, high-quality cost-effective drug therapy is
prescribed prior to the use of more expensive agents that may not have proven value over current formulary medications.
This program makes use of drug utilization management tools including prior authorization and step therapy. If a drug requires
prior authorization, certain clinical criteria must be met, or other information must be provided, before coverage is approved.
Drugs subject to step therapy require previous treatment with one or more formulary agents prior to coverage. The criteria
for approval are based on current medical information and are approved by the BCBSM/BCN Pharmacy and Therapeutics
Committee.

Most BCN members do not have coverage for nonformulary drugs. Requests for these nonformulary drugs will only
be considered when the following criteria have been met:

• The member has tried and failed to respond to an adequate trial of the available formulary agents from the same drug
class, or the available formulary agents would pose unnecessary risk to the member.
• The member meets any clinical criteria established for the prescribed drug or drug class.
• The prescriber and BCN agree that it is medically necessary.

Authorization requests that do not include documentation of medical necessity and failure of formulary alternatives will be
denied.

Brand-name drugs that physicians prescribe or members request to be dispensed as written (DAW), but are available as
generics, are covered only when determined to be medically necessary by the physician and approved by BCN. The physician
must submit a completed MedWatch form to the FDA with a copy to BCN to document serious adverse events or a quality
issue with the covered generic. Information regarding the FDA MedWatch program and online forms are available at www.
accessdata.fda.gov/scripts/medwatch. If a DAW prescription is not authorized, BCN members are required to pay
the difference in cost between the brand-name and generic versions in addition to their usual brand-name copay amount.

Quantity limits may also apply to certain drugs. Please visit us online at MiBCN.com for more information.

This information applies to members with a BCN commercial drug benefit. Criteria for BCN AdvantageSM and BlueCaid®
members can be viewed on our Web site: MiBCN.com.

(g)=generic available
ANTI-INFECTIVES
Anti-Fungals
Nonformulary: Requires documentation that the member has experienced treatment failure of or intolerance to
Lamisil® Granules at least three months of treatment with griseofulvin (Grifulvin V(g)) suspension.
Miscellaneous Anti-infectives
Nonformulary: Coverage is provided for the treatment of pneumonia in patients with cystic fibrosis.
Cayston®
Quinolones
Formulary: Formulary agents:
Cipro®XR(g) (ciprofloxacin) Cipro XR(g): Approved only for uncomplicated urinary tract infection (cystitis). Alternatives
include Cipro (g) 100-250mg BID x 3 days and Bactrim DS® (g) BID x 3-5 days.

Nonformulary: Nonformulary agents:


Proquin® XR Proquin XR: Approved only for the treatment of uncomplicated urinary tract infection (cystitis)
and requires documentation that member has experienced treatment failure of or intolerance to
formulary Cipro XR(g).
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ANTI-INFECTIVES (Cont.)
Tetracyclines
Nonformulary: Nonformulary agents:
Adoxa®(g), CK, TT; Oracea®, Adoxa(g), CK, TT; Oracea: Requires documentation that the member has experienced
Solodyn®(g) treatment failure of or intolerance to generic doxycycline AND a copy of the completed MedWatch
form (that has been submitted to the FDA) has been submitted to the plan to document treatment
failure of or intolerance to generic doxycycline.
Solodyn(g): Requires documentation that the member has experienced treatment failure of
or intolerance to generic minocycline AND a copy of the completed MedWatch form (that has
been submitted to the FDA) has been submitted to the plan to document treatment failure of or
intolerance to generic minocycline.
ANTINEOPLASTICS & IMMUNOSUPPRESSANTS
Hormonal Agents
Formulary: PA for males only: Approved only for ER-positive breast cancer treatment and other literature
Arimidex®(g) (anastrozole), supported cancer therapies.
Aromasin® (exemestane),
Femara® (letrozole)
Immunomodulators
Formulary: Formulary agent:
Arcalyst™ (rilonacept) Arcalyst: Approved for the treatment of cryopyrin-associated periodic syndrome in members
≥12 years of age.

Nonformulary: Nonformulary agent:


Revlimid® Revlimid: Approved for treatment of transfusion-dependent anemia due to low or
intermediate-1 risk myelodysplastic syndromes (MDS) with deletion 5q abnormality; multiple
myeloma in members whom have experienced treatment failure of or intolerance to or have a
contradindication to thalidomide; or members with documentation of enrollment in a Phase II-IV
investigative study approved by an appropriate Investigational Review Board (IRB). MDS must
be confirmed by FISH analysis or other genetic testing.
Kinase Inhibitors & Molecular Target Inhibitors
Formulary: Formulary agents:
Afinitor® (everolimus), Afinitor: Approved for the treatment of advanced renal cell carcinoma in members who have
Hycamtin® (topotecan), experienced disease progression or recurrence following treatment with Sutent or Nexavar,
Iressa® (gefitinib), OR requires documentation of enrollment in a Phase II-IV investigative study approved by an
Nexavar® (sorafenib), appropriate IRB.
Sprycel® (dasatinib), Hycamtin: Approved for treatment of relapsed small cell lung cancer, OR requires
Sutent® (sunitinib), documentation of enrollment in a Phase II-IV investigative study approved by an appropriate IRB.
Iressa: Approved only for members continuing existing therapy prior to the 09/2005 FDA label
Cont. next page... revisions.
Nexavar: Approved for treatment of advanced or recurrent renal cell carcinoma or
hepatocellular carcinoma, OR requires documentation of enrollment in a Phase II-IV investigative
study approved by an appropriate IRB.
Sprycel: Approved for treatment of chronic myelogenous leukemia in members who have
experienced resistance or intolerance to Gleevec; treatment of Philadelphia chromosome-
positive acute lymphoblastic leukemia in members who have experienced resistance or
intolerance to Gleevec or cytotoxic chemotherapy; OR requires documentation of enrollment in a
Phase II-IV investigative study approved by an appropriate IRB.
Sutent: Approved for treatment of advanced renal cell carcinoma or gastrointestinal stromal
tumor, OR requires documentation of enrollment in a Phase II-IV investigative study approved by
an appropriate IRB. Evidence of disease progression or intolerance to Gleevec must be provided
for members with gastrointestinal stromal tumor.

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ANTINEOPLASTICS & IMMUNOSUPPRESSANTS (Cont.)
Kinase Inhibitors & Molecular Target Inhibitors (cont.)
Formulary: Formulary agents:
Tarceva® (erlotinib), Tarceva: Approved for treatment of non-small cell lung cancer in members who have
Tykerb® (lapatinib), experienced treatment failure with at least one chemotherapy regimen or treatment of pancreatic
VotrientTM (pazopanib) cancer in members who will be receiving Tarceva in combination with gemcitabine, OR requires
documentation of enrollment in a Phase II-IV investigative study approved by an appropriate IRB.
Tykerb: Approved only for treatment of HER2 or HER2/neu positive advanced or metastatic
breast cancer. Evidence of disease progression following treatment with an anthracycline, a
taxane, and trastuzumab (Herceptin) must be provided. The member must be receiving Tykerb
in combination with Xeloda, OR requires documentation of enrollment in phase II-IV investigative
study approved by an appropriate IRB.
Votrient: Approved for treatment of advanced renal cell carcinoma OR requires documentation
of enrollment in phase II-IV investigative study approved by an appropriate IRB.
Miscellaneous Antineoplastic Agents
Formulary: Approved for treatment of cutaneous manifestation of cutaneous T-cell lymphoma and requires
Zolinza™ (vorinostat) documentation of persistent progressive or recurrent disease after trial with two systemic
therapies, such as oral bexarotene (Targretin), α-interferon (Intron-A, Pegasys, PEG-Intron),
denileukin diftitox (Ontak), photochemotherapy (Psoralen plus ultraviolet A (PUVA)), or systemic
chemotherapy, OR requires documentation of enrollment in a Phase II-IV investigative study
approved by an appropriate IRB.
CARDIOVASCULAR, HYPERTENSION, CHOLESTEROL
Angiotensin Converting Enzyme Inhibitors (ACE-Inhibitor)
Nonformulary: Requires documentation that member has experienced failure of or intolerance to Altace(g)
Altace® Tablets capsules.
Angiotensin II Receptor Blockers (ARBS)
Formulary: Formulary agents:
Benicar® (olmesartan medoxomil), Benicar, HCT: Requires documentation that the member has experienced intolerance to an
HCT ACE inhibitor such as Prinivil/Zestril(g), Monopril(g), Lotensin(g), Vasotec(g), Accupril(g), etc.

Nonformulary: Nonformulary agents:


Atacand®, HCT; Avapro®, Avalide®; Atacand, HCT; Avapro, Avalide; Diovan, HCT; Micardis, HCT; Teveten, HCT:
Azor®, Diovan®, HCT; Exforge®, HCT; Requires documentation that the member has experienced intolerance to an ACE inhibitor and
Micardis®, HCT; Teveten®, HCT; experienced treatment failure of or intolerance to a formulary ARB (Cozaar(g), Hyzaar(g);
TribenzorTM, Twynsta®, Valturna® Benicar, HCT)
Azor, Exforge, Tribenzor, Twynsta, Valturna: Requires successful treatment of at
least three months of therapy with the individual agents contained in the requested medication at
the prescribed dosage.
Exforge HCT: Requires inadequate response with at least three months of therapy with
Exforge.
Beta Blockers
Nonformulary: Bystolic: Requires documentation that the member has experienced treatment failure of or
Bystolic®, Coreg CR™ intolerance to at least two unique formulary beta blockers, such as betaxolol, atenolol, acebutolol,
metoprolol, or bisoprolol.
Coreg CR: Requires documentation that the member experienced treatment failure of or
intolerance to both carvedilol immediate-release (Coreg(g)) AND metoprolol succinate (Toprol
XL(g)).
Cardiovascular Treatment
Nonformulary: Ranexa: Requires documentation that the member has experienced treatment failure of or
Ranexa® intolerance to both a beta-blocker and a nitrate. The member must have no history of or high risk
for cancer.

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CARDIOVASCULAR, HYPERTENSION, CHOLESTEROL (Cont.)
Cholesterol-Lowering Agents
Formulary: Formulary agents:
Crestor® (rosuvastatin), Crestor: Requires documentation that member has experienced failure of or intolerance to at
Zetia® (ezetimibe) least one high dose (>40mg) generic statin (Mevacor®(g), Zocor®(g), or Pravachol®(g)).
Zetia: Requires documentation that member has experienced failure of or intolerance to at least
two generic statins (Mevacor(g), Zocor(g), or Pravachol(g)) OR approved when added to a
high dose (> 40mg) generic statin (Mevacor(g), Zocor(g), or Pravachol(g)).

Nonformulary: Nonformulary agents:


Advicor® , Altoprev®, Caduet®, Altoprev, Caduet, Lescol, XL, Lipitor, Livalo, Vytorin: Requires documentation that
Lescol®, XL; Lipitor®, Livalo®, member has experienced treatment failure of or intolerance to at least one high dose (>40mg) generic
Simcor®, TriLipix®, Vytorin® statin (Mevacor(g), Zocor(g), or Pravachol(g)) AND at least one formulary brand agent (Crestor or
Zetia).
Advicor, Simcor: Requires successful treatment of at least three months of therapy with the
individual agents contained in the requested medication at the prescribed dosage.
TriLipix: Requires documentation that the member has experienced treatment failure of or
intolerance to ALL generic fibrates, such as Lofibra(g) and Lopid(g), AND supporting evidence for the
use of this agent. Concomitant use of a statin does not satisfy criteria.
Miscellaneous Antihypertensives
Nonformulary: Tekamlo: Requires successful treatment of at least three months of therapy with the individual
TekamloTM; Tekturna®, HCT agents contained in the requested medication at the prescribed dosage.
Tekturna, HCT: Approved for the treatment of hypertension AND requires documentation
that the member has experienced treatment failure of or intolerance to ALL of the following drug
classes: diuretics, beta-blockers, ACE inhibitors, and angiotensin II receptor blockers (ARBS).
CENTRAL NERVOUS SYSTEM
Anticonvulsants
Nonformulary: Requires documentation that the member has at least one of the following listed diagnoses:
Lyrica® • Seizure disorder that is being treated concurrently with other anticonvulsants
• Neuropathic pain associated with either diabetic peripheral neuropathy or post-herpetic
neuralgia AND the member has experienced treatment failure of or intolerance to:
o Members ≥ 65 years of age: gabapentin 1200 mg per day
o Members ≤ 64 years: gabapentin 1200 mg per day AND a tricyclic antidepressant.
• Fibromyalgia and documentation that the member has experienced intolerance to gabapentin
or inadequate relief from gabapentin 1200 mg per day AND treatment failure of or intolerance to
at least three of the following: a tricyclic antidepressant, an SSRI, an SNRI, cyclobenzaprine, or
tramadol.
Additional criteria:
• Approvals are granted only at the specific strength requested.
• Approved dosage is limited to < 300 mg per day for initial treatment and will not exceed 600 mg
per day if 300 mg/day is tolerated.
• Any previous authorizations are discontinued when a new strength is approved.
Antidepressants
Formulary: Formulary agents: Requires documentation that member has experienced treatment
Lexapro® (escitalopram) failure of or intolerance to at least one generic antidepressant (Prozac(g), Celexa(g), Paxil(g),
Effexor(g), Zoloft(g), or Wellbutrin SR, XL(g)).

Nonformulary: Nonformulary agents:


AplenzinTM Aplenzin: Requires documentation that the member has experienced treatment failure of or
intolerance to at least one generic antidepressant and one brand name formulary antidepressant
Cont. next page... AND documentation that continued use of Wellbutrin SR/XL(g) will adversely affect the
member’s mental health.

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CENTRAL NERVOUS SYSTEM (Cont.)
Antidepressants (cont.)
Nonformulary: Nonformulary agents:
Cymbalta®, Luvox CR®, OleptroTM, Cymbalta: Depression and/or anxiety: Requires documentation that the member
Pexeva®, Pristiq®, Savella® has experienced treatment failure of or intolerance to at least one generic antidepressant
AND one brand name formulary antidepressant. Post-herpetic neuralgia or diabetic
peripheral neuropathy: If older than 65 years, requires treatment failure of or intolerance
to gabapentin 1200 mg per day. If under 65 years, requires treatment failure of or intolerance to
gabapentin 1200 mg per day and a tricyclic antidepressant. Fibromyalgia: Documentation
is required to show that the member has experienced intolerance to gabapentin OR inadequate
relief from gabapentin 1200 mg per day AND treatment failure of or intolerance to at least three of
the following: a tricyclic antidepressant, an SSRI, an SNRI, cyclobenzaprine, or tramadol.
Luvox CR: Requires documentation that the member has experienced treatment failure of or
intolerance to at least one generic antidepressant and one brand name formulary antidepressant
AND documentation that continued use of Luvox(g) will adversely affect the member’s mental
health.
Oleptro: Approved for major depressive disorder in members who have experienced treatment
failure of or intolerance to Desyrel®(g) AND documentation that continued use of Desyrel(g) will
adversely affect the member’s mental health.
Pexeva: Requires documentation that the member has experienced treatment failure of or
intolerance to at least one generic antidepressant and one brand name formulary antidepressant
AND documentation that continued use of Paxil(g) will adversely affect the member’s mental
health.
Pristiq: Requires documentation that the member has experienced treatment failure of or
intolerance to at least one generic antidepressant and one brand name formulary antidepressant
AND documentation that continued use of Effexor(g) or Effexor XR(g) will adversely affect the
member’s mental health.
Savella: Approved for treatment of fibromyalgia AND requires documentation that the member
has experienced intolerance to gabapentin or inadequate relief from gabapentin 1200 mg per day
and treatment failure of or intolerance to at least three of the following: a tricyclic antidepressant,
an SSRI, an SNRI, cyclobenzaprine, or tramadol.
Antipsychotics
Nonformulary: Requires documentation that the member has experienced treatment failure of or intolerance to
Invega®, Seroquel XR® all formulary atypical antipsychotic agents. Maximum dose of Invega is limited to 12 mg per day.
CNS Stimulants
Formulary: Formulary agents:
Adderall XR® (amphet asp/amphet/d- Adderall XR(g): Requires documentation that member has experienced treatment failure of
amphet)(g), Provigil® (modafinil) or intolerance to brand name Adderall XR.
Provigil: Approved only for members with narcolepsy, obstructive sleep apnea, or an indication
supported by peer-reviewed literature. Dosage limited to a maximum of 400mg per day. Shift-
work sleep disorder is not covered since treatment is not medically necessary.

Nonformulary: Nonformulary agents:


Nuvigil®, Procentra™ Nuvigil: Approved for treatment of narcolepsy or obstructive sleep apnea and requires
documentation that member has experienced treatment failure of or intolerance to Provigil.
Cont. next page... Procentra: Requires documentation that member has experienced treatment failure of or
intolerance to both Metadate CD and Adderall XR; both of which may be sprinkled on food.

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CENTRAL NERVOUS SYSTEM (Cont.)
CNS Stimulants (cont.)
Nonformulary: Nonformulary agents:
Strattera™, Vyvanse™ Strattera: Approvable when stimulants are contraindicated by medical history OR the following
criteria by age:
For BCN members age 5 to 20: Requires documentation that the member has
experienced treatment failure of or intolerance to both a methylphenidate (such as Ritalin(g) or
Concerta) AND an amphetamine (such as Adderall(g)).
For BCN members age 21 and older: Requires documentation that the member has
experienced treatment failure of or intolerance to either a methylphenidate OR an amphetamine.
Note: The use of Strattera in members ≤ 4 years of age is not recommended or supported by
literature.
Vyvanse: Requires documentation that the member has experienced treatment failure of or
intolerance to both a methylphenidate (such as Ritalin(g) or Concerta) AND an amphetamine
(such as Adderall(g)).
Migraine Therapy
Formulary: Formulary agents:
Amerge® (g) (naratriptan), Amerge(g): Requires documentation that member has experienced failure of or intolerance to
Maxalt® , MLT® (rizatriptan) both sumatriptan (Imitrex(g)) and Maxalt.
Maxalt, MLT: Requires documentation that member has experienced treatment failure of or
intolerance to sumatriptan (Imitrex(g)).

Nonformulary: Nonformulary agents:


AlsumaTM, Axert® , Frova® , Relpax®, Alsuma, Axert, Frova, Relpax, Sumavel DosePro; Zomig, ZMT, nasal
SumavelTM DoseProTM, Treximet®; spray: Requires documentation that member has experienced failure of or intolerance to both
Zomig® , ZMT® , nasal spray sumatriptan (Imitrex(g)) and Maxalt.
Treximet: Requires documentation that the member has experienced treatment failure of or
intolerance to a combination of sumatriptan (Imitrex(g)) or Maxalt AND naproxen. Documentation
as to why sumatriptan (Imitrex(g)) or Maxalt and naproxen as individual agents do not work for
and/or may be harmful to the member must be provided.
Miscellaneous CNS
Nonformulary: Aricept 23mg: Requires documentation for a progressive-type dementia AND requires
Aricept® 23mg, IntunivTM successful treatment with Aricept 10mg for three months.
Intuniv: Approved for treatment of ADHD and requires documentation that the member has
experienced treatment failure of or intolerance to both a methylphenidate (such as Ritalin(g) or
Concerta), an amphetamine (such as Adderall(g)), generic guanfacine immediate-release, and
clonidine.
Narcotics
Formulary: Formulary agents:
Actiq® (g) (fentanyl citrate), Actiq: Approved for the treatment of breakthrough cancer pain in members that are tolerant
Opana® (g) (oxymorphone HCl) of high dose narcotics and is currently receiving a long-acting narcotic. The member must also
have experienced treatment failure of or intolerance to the use of other oral immediate-release
narcotics for the management of breakthrough pain.
Opana(g): Requires documentation that the member has experienced treatment failure of or
intolerance to morphine sulfate 20mg/mL (Roxanol(g)) or morphine sulfate immediate-release
(MSIR(g)).

Nonformulary: Nonformulary agents:


ButransTM, ExalgoTM Butrans: Coverage is provided for a diagnosis of moderate to severe chronic pain AND
documentation that the member has experienced treatment failure of or intolerance to
methadone, Duragesic(g) AND morphine sulfate (MS Contin(g) or Oramorph SR(g)).
Exalgo: Coverage is provided for the management of moderate to severe pain in opioid
Cont. next page... tolerant patients requiring continuous analgesia for an extended period of time AND
requires documentation that the member has experienced treatment failure of or intolerance
to ALL of the following long-acting formulary agents: methadone, morphine sulfate extended-
release (Oramorph(g), MS Contin(g)), and fentanyl transdermal patch (Duragesic(g)).

Page 12
CENTRAL NERVOUS SYSTEM (Cont.)
Narcotics (cont.)
Nonformulary: Nonformulary agents:
Fentora®, Onsolis®, Nucynta®; Fentora, Onsolis: Approved for the treatment of breakthrough cancer pain in members that
Opana® ER; Oxycontin® are tolerant of high dose narcotics and is currently receiving a long-acting narcotic. The member
must also have experienced treatment failure of or intolerance to the use of other oral immediate-
release narcotics for the management of breakthrough pain. Also requires documentation that the
member has experienced treatment failure of or intolerance to Actiq(g).
Nucynta: Requires documentation that member has experienced treatment failure of or
intolerance to a Ultram(g) or Ultracet(g) AND three formulary immediate-release narcotics. If
use is to exceed 30 days, Nucynta must be used in combination with a long-acting narcotic, such
as methadone, morphine sulfate extended-release (Oramorph(g), MS Contin(g)), and fentanyl
transdermal patch (Duragesic(g)).
Opana ER, Oxycontin: Requires documentation that the member has experienced
treatment failure of or intolerance to ALL of the following long-acting formulary agents:
methadone, morphine sulfate extended-release (Oramorph(g), MS Contin(g)), and fentanyl
transdermal patch (Duragesic(g)).
Narcotic Mixed Agonist/Antagonist
Formulary: Formulary agents:
Suboxone® SL tablets, Film Suboxone SL tabs, Film: Approved only for the treatment of clinically diagnosed opioid
(buprenorphine HCl/naloxone HCl), dependence. Requires documentation of validated screening tools used to identify the opioid
use problem.

Nonformulary: Nonformulary agent:


RybixTM ODT Rybix ODT: Requires documentation that member cannot swallow ANY oral tramadol tablets
OR documentation that the member has had successful treatment with immediate release
tramadol for a minimum of three months AND documentation as to why continued use of generic
tramadol would harm the member.
Non-Steroidal Anti-Inflammatory Drugs
Nonformulary: Arthrotec, Prevacid NapraPAC: Approved for members >60 years of age, receiving
Arthrotec®; Celebrex®, Flector® Patch, anticoagulant or antiplatelet therapy, receiving chronic treatment with oral corticosteroids (≥ 60
PennsaidTM, Prevacid NapraPACTM, days duration), or a history of or current diagnosis of peptic ulcer disease, clinically significant
VimovoTM, Voltaren® Gel gastrointestinal bleeding, and/or alcoholism.
Celebrex: Approved for members >60 years of age whom are not at high risk for
cardiovascular events, and do not have a previous history of stroke, MI, coronary heart disease,
or blood clots. The member must not be receiving concomitant anticoagulant or an antiplatelet
therapy. Approved for members ≤ 60 years of age whom are receiving chronic
treatment with oral corticosteroids (≥ 60 days duration) or have a history of or current diagnosis
of peptic ulcer disease, clinically significant gastrointestinal bleeding, and/or alcoholism. The
member must not be receiving concomitant anticoagulant or antiplatelet therapy AND have no
previous history or evidence of cardiovascular and thromboembolic disease. Note: Lodine®(g)
is more selective than Celebrex for the COX-2 enzyme.
Flector Patch: Approved only for the treatment of acute sprains AND requires treatment
failure of or intolerance to Voltaren(g)/XR(g) tablets AND an OTC topical analgesic (Myoflex OR
Aspercreme).
Pennsaid, Voltaren Gel: Requires treatment failure of or intolerance to Voltaren(g)/XR(g)
tablets AND an OTC topical analgesic (Myoflex OR Aspercreme).
Vimovo: Requires documentation that member has had treatment failure of or intolerance to
Prilosec(g), Protonix(g) and Prevacid(g) at a twice daily, high dose regimen AND meets any
one of the following criteria:
•Greater than 60 years of age
•Receiving anticoagulant or antiplatelet therapy
•Receiving chronic treatment with oral corticosteroids (>= 60 days duration)
•A history or peptic ulcer disease, clinically significant gastrointestinal bleeding, and/or alcoholism.
Parkinson’s Disease and Related Disorders
Nonformulary: Requires a diagnosis of Parkinson’s Disease. Must also try and fail Mirapex IR(g) AND
Mirapex ER® documentation that the continued use of it will adversely afffect the member’s condition.
Page 13
CENTRAL NERVOUS SYSTEM (Cont.)
Sedatives/Hypnotics
Formulary: Requires documentation that member has experienced treatment failure of or intolerance to an
Ambien CR® (g) adequate trial of both zolpidem (Ambien®(g)) and zaleplon (Sonata®(g)).
Nonformulary: Silenor: Requires documentation that member has experienced treatment failure of or
EdluarTM, Lunesta®, Rozerem®, intolerance to Sinequan®(g), Ambien(g), Sonata(g) AND Desyrel®(g).
SilenorTM, ZolpiMistTM
DERMATOLOGY
Acne Treatment
Nonformulary: Requires documentation of medical necessity to identify why individual agents [Cleocin-T®(g)
Ziana™ gel plus Retin-A®(g)] cannot be used.
Antipsoriatic/Antiseborrheic
Formulary: Formulary agents:
Enbrel® (etanercept), Enbrel, Humira:
Humira® (adalimumab) Moderate to Severe Psoriasis: Requires 3 months of previous treatment with topical
corticosteroids and 3 months treatment with PUVA.

Nonformulary agent:
Nonformulary: Taclonex: Requires documentation that the member has experienced treatment failure of
Taclonex, Scalp® or intolerance to at least 30 days of treatment with the combination of a very high potency
corticosteroid [Diprolene ointment(g), Temovate(g), Psorcon(g)] PLUS Dovonex.
Miscellaneous Dermatologicals
Formulary: Formulary agents:
Elidel® (pimecrolimus) Elidel: Approved for members ≥2 years of age with a diagnosis of atopic dermatitis or eczema.

Nonformulary: Nonformulary agent:


Protopic® Protopic: Approved for members ≥2 years of age with a diagnosis of atopic dermatitis or
eczema and documentation that the member has experienced treatment failure of or intolerance
to Elidel®. For members ages 2 to 15, only the 0.03% strength may be used.
Wound & Burn Therapy
Nonformulary: Requires documentation that the member has a diagnosis of diabetic skin ulcer or may be
Regranex® approved for wound therapy per policy criteria.
DIAGNOSTICS & OTHER MISCELLANEOUS
Diagnostic & Other Miscellaneous
Fomulary: Formulary agents:
Carbaglu® (carglumic acid), Kuvan® Carbaglu: Requires documentation that member has a diagnosis of hyperammonemia due to
(sapropterin dihydrochloride), NAGS deficiency.
Xenazine® (tetrabenazine) Kuvan: Requires documentation that member has a diagnosis of phenylketonuria (PKU) and
will be following a phenylalanine-restricted diet in conjunction with Kuvan.
Xenazine: Requires documentation that member has a diagnosis of chorea associated with
Huntingon’s disease.

Nonformulary: Nonformulary agents:


Campral®, Exjade® Campral: Approved for the treatment of alcohol dependence, to maintain abstinence from
alcohol in members who have been abstinent at treatment initiation for at least 5 days post-
detoxification. Members must be enrolled in a comprehensive alcohol management program that
includes psychosocial support.
Exjade: Approved for members ≥2 years of age with a diagnosis of chronic iron overload due
to blood transfusions (transfusional hemosiderosis) and documentation that the member has
experienced treatment failure of or intolerance to Desferal®(g) OR requires documentation that
the member is enrolled in a Phase II-IV investigative study approved by an appropriate IRB.

Page 14
ENDOCRINOLOGY
Growth Hormone & Related Products
Formulary: Formulary agents:
Genotropin® (somatropin), Children (<18 years of age): Requires a diagnosis of growth hormone deficiency, growth
Nutropin®, AQ (somatropin) failure secondary to chronic renal failure/insufficiency in children who have not received a
renal transplant, growth failure in children small for gestational age or with intrauterine growth
retardation, Turner’s Syndrome, Noonan’s Syndrome, Prader-Willi Syndrome, SHOX deficiency,
or for treatment of severe burns covering >40% of the total body surface area. The member’s
current height and weight must be provided. The member must also have open epiphyses.
Initial treatment: For growth hormone deficiency, two growth hormone stimulation tests OR
one GH stimulation test along with a subnormal IGF-1 level and IGFBP-3 level must be provided.
The member’s height must be below the 5th percentile.
To continue: The member must achieve a growth velocity of > 4.5 cm/year while receiving
therapy over the past year. Treatment may continue until final height or epiphyseal closure has
been documented.
Adults (≥18 years of age): Approved for treatment of growth hormone deficiency, AIDS
wasting cachexia, Turner’s Syndrome, and Short Bowel Syndrome. The diagnosis must be made
by an endocrinologist or a nephrologist. Initial diagnosis must be based on two growth hormone
stimulation tests, 3 or more pituitary hormone deficiencies with an IGF-1 below 80ng/ml OR 1
growth hormone and at least 1 pituitary hormone deficiency

Nonformulary: Nonformulary agents: Also requires documentation that the member has experienced
Humatrope®, Norditropin®, treatment failure of or intolerance to formulary agents.
Omnitrope®, Saizen® , Serostim®, Increlex: Approved for treatment of severe IGF-1 deficiency, growth hormone gene deletion,
Tev-Tropin®, Valtropin®, Zorbtive™ and Laron’s syndrome in members <18 years of age, with open epiphyses, and height below the
3rd percentile. Member must have a normal or elevated growth hormone level with an IGF-1 level
Increlex™ 3 or more standard deviations below normal. The prescriber must be a pediatric endocrinologist.
Initial approval is granted for 1 year and renewal can be obtained if member has clinical response
with therapy, as demonstrated by an annual growth velocity of ≥ 2.5cm
Non-Insulin Hypoglycemic Agents
Formulary: Formulary agents:
Actos® (pioglitazone); Actos: Requires documentation that the member has experienced failure with metformin. If the
Actoplus Met® (pioglitazone/ member cannot tolerate metformin or if metformin is contraindicated, physicians are encouraged
metformin), to prescribe a sulfonylurea, unless contraindicated, prior to treatment with a TZD.
Duetact® (pioglitazone/glimepiride) Actoplus Met, Duetact: Requires documentation that the member has experienced
successful treatment with at least three months of therapy with the individual agents that are in
the combination product.

Nonformulary: Nonformulary agents:


Actoplus Met® XR, Avandamet®, Actoplus Met XR, Avandamet, Avandaryl, Janumet, Prandimet: Requires
Avandaryl®, Avandia®, Byetta®, documentation that the member has experienced successful treatment with at least three months
Januvia®, Janumet®, Onglyza™, of therapy with the individual agents that are in the combination product.
Prandimet®, Symlin®, Victoza® Avandia: Requires documentation that the member has had treatment failure of or intolerance
to both Glucophage(g) and Actos.
Byetta, Victoza: Approved for treatment of type 2 diabetes in members with a
contraindication to or have experienced treatment failure of or intolerance to metformin.
The member must currently be taking either metformin, a sulfonylurea, a thiazolidinedione,
a combination of metformin and a sulfonylurea, or a combination of metformin and a
thiazolidinedione. The member must also have tried and failed to achieve desired glucose control
with at least TWO types of oral agents and insulin. Insulin must be discontinued.
Januvia, Onglyza: Requires documentation that member has experienced treatment failure
of or intolerance to the use of three of the following: metformin, basal insulin, sulfonylurea, and a
TZD.
Symlin: Approved for members ≥18 years of age for the treatment of type 1 or 2 diabetes
who are receiving insulin therapy and has not achieved desired glucose control (Hgb A1C >7%)
despite good compliance with optimal insulin therapy.

Page 15
GASTROINTESTINAL AGENTS
Antiemetics
Nonformulary: Sancuso: Requires documentation that the member has experienced treatment failure of or
Sancuso®, Zuplenz® intolerance to both oral Kytril(g) AND Zofran(g), ODT(g).
Zuplenz: Same as above AND documentation that the continued use of Zofran ODT(g) would
adversely affect the member’s condition.
Miscellaneous Gastrointestinal Agents
Formulary: Formulary agent:
Relistor® (methylnaltrexone) Relistor: Approved for the treatment of opioid-induced constipation in members with advanced
illness whom are receiving palliative care and requires documentation that the member
has experienced inadequate response to at least 3 of the following laxatives: bulk laxatives
(polycarbophil, psyllium, methylcellulose), saline laxatives (milk of magnesia/magnesium
hydroxide), osmotic laxatives (Miralax(g)), or stimulant (Dulcolax(g), Senna(g)).

Nonformulary: Nonformulary agents:


Amitiza®, ChenodalTM, Cimzia®, Amitiza: Approved for the treatment of chronic idiopathic constipation (fewer than 3 bowel
Lotronex®, Xifaxan 550® movements/week) or constipation predominant IBS (females only) in members 18 to 65 years of
age whom have tried and failed ALL of the following: dietary advice, trials of bulk laxatives, stool
softeners, and a short course of stimulant laxatives and are NOT taking medications causing
constipation. A total of 12 weeks can be approved, with renewal, only if improvement in bowel
frequency is seen with initial trial.
Chenodal: Approved for dissolution of gallstones only in patients where surgery is not
appropriate. In addition, member must have experience treatment failure of or have an
intolerance to Actigall(g). Member cannot have history of hepatocellular disease.
Cimzia: Approved for the treatment of Crohn’s disease in members ≥18 years of age whom
have experienced treatment failure of or intolerance to Humira.
Lotronex: Approved for the treatment of severe, diarrhea-predominant irritable bowel
syndrome in women at least 18 years of age who have failed to respond to conventional diarrhea
therapy including one OTC product (loperamide, bismuth subsalicylate) and one prescription
agent (diphenoxylate/atropine (Lomotil(g)).
Xifaxan 550: Requires diagnosis of hepatic encephalopathy AND documentation that the
member has had treatment failure of or intolerance to lactulose.
Proton Pump Inhibitors
Formulary: Formulary agents:
Prevacid®(g) capsule (lansoprazole), Prevacid(g), Solutab(g): Requires documentation that the member has experienced
Prevacid SolutabTM (g), failure of or intolerance to Prilosec OTC(g) or Prilosec(g).
Prilosec®(g) (omeprazole) 40mg, Prilosec 40mg(g): Requires documentation that member has experienced treatment failure
Protonix®(g) (pantoprazole), with Prilosec OTC(g) or Prilosec(g) (2 x 20mg).
Zegerid® (g) capsule (omeprazole/ Protonix(g): Requires documentation that member has experienced failure of or intolerance
sodium bicarbonate) to Prilosec OTC(g) or Prilosec(g) unless the member is currently receiving Plavix.
Zegerid(g): Requires documentation that member has experienced failure of or intolerance to
Prilosec OTC(g) or Prilosec(g) AND Prevacid(g) or Prevacid Solutab.

Nonformulary: Nonformulary agents:


Aciphex®, DexilantTM, Nexium®, Aciphex, Zegerid Packet: Requires documentation that the member has experienced
Prilosec suspension, treatment failure of or intolerance to Prilosec OTC or Prilosec(g) AND Prevacid(g) or Prevacid
Protonix suspension, Solutab.
Zegerid® Packet, VimovoTM Dexilant, Nexium: Requires documentation that the member has experienced treatment
failure of or intolerance to both BCN formulary alternatives [either Prilosec OTC or Prilosec(g)
AND Prevacid(g)], one of which is at a twice daily, high dose regimen.
Prilosec suspension, Protonix suspension: Requires documentation that member
has experienced treatment failure of or intolerance to Prevacid Solutab.
Vimovo: Requires documentation that member has had treatment failure of or intolerance to
Prilosec(g), Protonix(g) and Prevacid(g) AND meets any one of the following criteria:
•Greater than 60 years of age
•Receiving anticoagulant or antiplatelet therapy
•Receiving chronic treatment with oral corticosteroids (>= 60 days duration)
•A history or peptic ulcer disease, clinically significant GI bleeding, and/or alcoholism.
Page 16
IMMUNOLOGY & HEMATOLOGY
Hematopoietic Agents
Formulary: Formulary agents:
Procrit® (epoetin alfa) Procrit: Requires documentation that the member has one of the following conditions: anemia
secondary to chronic renal failure, chronic renal insufficiency, HIV infection, HIV therapy,
chemotherapy, myelodysplasia, or chronic hepatitis C therapy, OR prophylaxis prior to surgery
to reduce need for allogenic blood transfusions. A Hgb level of less than 10 g/dL is required for
initial therapy. For continued coverage dose adjustments are required to maintain Hgb between
10 to 12 g/dL. Duration of approval is dependent on the indication.
Promacta® (eltrombopag) Promacta: Approved for treatment of thrombocytopenia with chronic immune
thrombocytopenic purpura, has a platelet count of <400 x 109/L if continuing therapy, and
inadequate response to, intolerance to, or is not a candidate for standard first-line treatments,
such as corticosteroids, immunoglobulins, or splenectomy.

Nonformulary: Nonformulary agents:


Aranesp®, Epogen® Also requires documentation that member has experienced failure of or intolerance to formulary
epoetin alfa (Procrit) and applicable criteria for Procrit.
Hepatitis B & C Therapy
Formulary: Infergen: Approved for the treatment of Hepatitis B.
Infergen (interferon alfacon-1), Intron-A: Approved for the treatment of Hepatitis B, condyloma acuminate, essential
Intron-A (interferon alfa-2B), Pegasys thrombocythemia, hairy cell leukemia, Kaposi’s sarcoma, malignant melanoma, multiple
(peginterferon alfa 2-A), myeloma, non-Hodgkin’s lymphoma, Philadelphia chromosome (Ph) positive chronic phase
Peg-Intron (peginterferon alfa-2B), myelogenous leukemia (CML), and renal cell carcinoma.
ribavirin Peg-Intron, Pegasys: Approved for the treatment of Hepatitis B and Hepatitis C. For
hepatitis C, approval is for members naïve to pegylated interferon therapy only. Genotype,HIV
status, previous therapy and duration must also be provided. The member must receive
peglylated interferon in combination with ribavirin unless contraindicated. For genotypes 2,
3: Approval is for a total of 24 weeks duration. For non-genotypes 2, 3: Approval is for a
total of 48 weeks duration. Members must achieve a ≥2 log decrease in viral load after 12 weeks
of treatment.
Ribavirin: Approved for the treatment of Hepatitis C. Genotype, HIV status, previous therapy
and duration must also be provided.
Interferons and MS Therapy
Nonformulary: Ampyra: Initial treatment: Requires a diagnosis of multiple sclerosis and documentation
AmpyraTM of difficulty walking resulting in significant limitations of instrumental activities of daily living. Also
Betaseron® requires two timed 25-foot walk (T25FW) measurements that must be within 10% variability and
demonstrates that the patient is able to walk 25 feet in 8-45 seconds. To continue: Requires
documentation of improvement in walking speed by at least 10% as assessed by the T25FW
AND that limitations of instrumental activities of daily living has improved as a result of increased
walking speed within the first 2 months of therapy.
Betaseron: Requires documentation that member has experienced failure of or intolerance to
formulary agents (Avonex, Copaxone or Rebif) AND Extavia®.
LIFESTYLE MODIFICATION PRODUCTS
Impotence
Formulary: For men over the age of 34: requires a diagnosis of erectile dysfunction (ED).
Caverject® (alprostadil), Cialis® For men 34 years and younger: requires a diagnosis of ED secondary to a medical cause such
(tadalafil), Muse® (alprostadil), as multiple sclerosis, spinal cord injury, Parkinson’s disease, radiation for prostate or bladder
Viagra® (sildenafil citrate) cancer, and other indications deemed appropriate. The member must not be using nitrates
concomitantly and avoid use of alpha blockers with oral ED agents. Maximum of 6 doses per 28
Nonformulary: days.
Edex®, Levitra®, StaxynTM

Page 17
LIFESTYLE MODIFICATION PRODUCTS (Cont.)
Weight Loss Products
Formulary: Requires verification that member’s Body Mass Index (BMI) is ≥30 kg/m2 or >27 kg/m2 with
phentermine and related products co-morbidities. and concurrent lifestyle modification plan. Initial coverage for all anorexiants and
related drugs is limited to 3 months. Additional coverage requires documentation of weight loss of
Nonformulary: at least 2 pounds per month. Maximum benefit is 12 months of treatment per lifetime; 24 months
Xenical® for Xenical.
OBSTETRICS AND GYNECOLOGY
Infertility treatment
Formulary: Coverage is provided for most BCN female members with an infertility benefit and also in
Bravelle® (urofollitropin), accordance with generally accepted medical practice. BCN does not provide coverage for
Cetrotide® (cetrorelix acetate), infertility drugs to be used as part of assisted reproductive technology treatment, such as in-
FertinexTM (urofollitropin), vitro fertilization (IVF), zygote in vitro fertilization transfer (ZIFT), gamete in vitro fertilization
Ganirelix acetate® (ganirelix transfer (GIFT). Authorization will be provided for one year. Additional coverage will be based
acetate), Gonal-F®, RFF (follitropin on documentation that the member is being treated according to accepted medical practice.
alfa, recomb), Ovidrel® (HCG alfa, Requests are not considered for men.
recomb), Novarel®/Pregnyl®/Profasi®
(gonadotropin, chorionic, human),
Repronex® (menotropins)

Nonformulary:
Follistim® AQ, Luveris®, Menopur®
OTIC & NASAL PREPARATIONS
Intranasal Steroids
Formulary: Formulary agent:
Nasacort AQ® (triamcinolone Nasacort AQ: Requires documentation that member has experienced treatment failure of or
acetonide) intolerance to fluticasone (Flonase(g)) or flunisolide (Nasalide(g)/Nasarel(g)).

Nonformulary: Nonformulary agents: Requires documentation that member has experienced treatment
Beconase AQ®, Nasonex®, Omnaris™, failure of or intolerance to fluticasone (Flonase(g)) or flunisolide (Nasalide(g)/Nasarel(g)) AND
Rhinocort Aqua®, Veramyst™ Nasacort AQ.
RESPIRATORY COUGH & COLD
Antihistamines and Combinations
Formulary: Formulary agent:
Allegra-D®(g) (p-ephed/ Allegra-D(g): Requires documentation that the member has experienced treatment failure of
fexofenadine), or intolerance to OTC loratadine D or OTC cetirizine D
Xyzal® (g) (levocetirizine) Xyzal (g): Requires documentation that the member has experienced treatment failure of
or intolerance to OTC loratadine or OTC cetirizine, AND generic fexofenadine (Allegra(g) or
Allegra-D(g)) in appropriate dosage form for requested drug.

Nonformulary: Nonformulary agents:


Allegra® suspension, Allegra® ODT, Requires documentation that the member has experienced treatment failure of or intolerance
Clarinex®, Clarinex-D®, Clarinex to OTC loratadine or OTC cetirizine, AND generic fexofenadine (Allegra(g) or Allegra-D(g)) in
Reditabs®, Clarinex Syrup®, appropriate dosage form for requested drug.
Semprex-D®, Xyzal® Oral Solution
Inhaled Beta-Agonists
Nonformulary: Requires documentation that the member has experienced treatment failure of or intolerance to
Brovana®, Perforomist™ BOTH Serevent® AND Foradil®.

Page 18
RESPIRATORY COUGH & COLD (Cont.)
Pulmonary Arterial Hypertension
Formulary: Formulary agents:
Letairis™ (ambrisentan), Revatio® Letairis, Revatio, Tracleer, Tyvaso, Ventavis: Approved for the treatment of
(sildenafil), Tracleer® (bosentan), pulmonary arterial hypertension (PAH) WHO Class III or IV symptoms.
TyvasoTM (treprostinil), Ventavis®
(iloprost)

Nonformulary: Nonformulary agent:


Adcirca™ Adcirca: Approved for the treatment of pulmonary arterial hypertension (PAH) WHO Class III
or IV symptoms AND requires documentation that member has experienced treatment failure of
or intolerance to Revatio.
RHEUMATOLOGY & MUSCULOSKELETAL
Gout Therapy
Nonformulary: Approved for the treatment of gout and hyperuricemia in members that have experienced
Uloric® treatment failure of, at appropriate dose, or intolerance to generic allopurinol. Uloric 80mg
requires documentation that the member has had an inadequate response to the 40mg dose.
Miscellaneous Rheumatologic Agents
Formulary: Formulary agents:
Enbrel®(etanercept), Humira® Enbrel, Humira: Requires four month trial with two concurrent disease modifying
(adalimumab) antirheumatic drugs (one must be methotrexate unless contraindicated). Examples of DMARDs
include: methotrexate, sulfasalazine, azathioprine, hydroxychloroquine/chloroquine, cyclosporine,
gold and penicillamine.

Nonformulary: Nonformulary agent:


Cimzia®, Kineret®, SimponiTM Cimzia, Kineret, Simponi: Approved for the treatment of moderate to severe rheumatoid
arthritis and requires documentation that the member has experienced treatment failure of or
intolerance to Enbrel and Humira.
Osteoporosis/Bone Resorption Inhibitors
Formulary: Formulary agents:
Actonel® (risedronate); Actonel® plus Actonel, Actonel plus Calcium: Requires documentation that member has experienced
Calcium treatment failure of or intolerance to alendronate (Fosamax(g)).

Nonformulary: Nonformulary agents:


Boniva®, ForteoTM, Fosamax D™ Boniva, Fosamax D: Requires documentation that member has experienced treatment
failure of or intolerance to both alendronate (Fosamax(g)) and Actonel.
Forteo: Approved for the treatment of osteoporosis (T-score <= -2.5) AND requires
documentation that the member has a contraindication to or experienced treatment failure of or
intolerance to a bisphosphonate.
UROLOGY
BPH Treatment
Nonformulary: Requires successful treatment of at least three months of therapy with the individual agents
JalynTM contained in the requested medication at the prescribed dosage.

Page 19
Blue Cross Blue Shield of MI
Prior Authorization and Step Therapy Program
January 2011
BCBSM monitors the use of certain medications to ensure our members receive the most appropriate and cost-effective drug
therapy. Prior authorization for these drugs means that certain clinical criteria must be met before coverage is provided. In the case
of drugs requiring step therapy, for example, previous treatment with one or more formulary drugs may be required. Drugs that must
meet clinical criteria are identified in the formulary list with (PA) or (ST). Your physician can contact our pharmacy help desk to
request prior authorization for these drugs.

The criteria for authorization are based on current medical information and the recommendations of the Blues’ Pharmacy and
Therapeutics Committee, a group of physicians, pharmacists and other experts. You may be required to pay the full cost of the drug if
your physician does not obtain prior authorization.

When your doctor prescribes a brand-name drug that’s nonformulary, requires prior authorization or is not covered under your drug
rider, it may not be a covered benefit. BCBSM reviews all physician and member requests to determine if the drug is medically
necessary and that there aren’t equally effective alternative drugs on the formulary.

Please call the Customer Service number on the back of your BCBSM ID card if you have questions about your drug coverage, a
drug claim or filing a benefit exception.

Prior Authorization and Step Therapy Drug Categories


(CUSTOM FORMULARY)

MEDICATION/ DRUG CLASS CRITERIA


TM
Adcirca (tadalafil) Approved for members with a diagnosis of Pulmonary Arterial Hypertension (PAH). Coverage
TM ® ®
Nonformulary for Adcirca in combination with bosentan (Tracleer ), epoprostenol (Flolan ), treprostinil
® ®
(Remodulin ) or iloprost (Ventavis ) is provided after monotherapy with one of these agents
has been found to be inadequate in the treatment of the patient’s symptoms. Coverage is
NOT provided for AdcircaTM in situations where patients are receiving nitrate therapy.

Amitiza® (lubiprostone) Patient must be 18 years or older and have a diagnosis of constipation predominant Irritable
Nonformulary Bowel Syndrome (female only) OR chronic idiopathic constipation with documented failure
with one fiber laxative and either a stimulant or osmotic laxative within the last 12 months.
Drug induced constipation must also be ruled out.

TM
Ampyra (dalfampridine Coverage may be provided in patients ≥ 18 years of age when the criteria below are met:
extended release) A. Diagnosis of multiple sclerosis
Nonformulary B. Prescribing physician is a neurologist
C. Patient has documented difficulty walking resulting in significant limitations of instrumental
activities of daily living
D. Ambulatory function assessed with the timed 25-foot walk (T25FW) meeting the following
criteria:
I. Clinical notes documenting two measurements with variability within 10% demonstrating
the patient is able to walk 25 feet in 8-45 seconds. The faster time of the two
measurements will serve as the baseline value.
II. Measurements were not taken within 60 days of an MS exacerbation
III. Clinical notes documenting whether a walking assistive device was used
E. Does not have a history of seizure
F. Does not have moderate to severe renal impairment (CrCl ≤ 50 ml/min)
G. Initial approval length is for 3 months

Coverage may be renewed for 12 months when the following criteria are met:
I. Clinical notes documenting improvement in walking speed by at least 10% as assessed
by the T25FW
II. Clinical documentation indicating that the limitations of instrumental activities of daily
living has resolved as a result of increased speed of ambulation
III. Clinical notes documenting consistency in whether a walking assistive device was used
for all measurements (baseline and re-testing for renewal of therapy)

Page 20
MEDICATION/ DRUG CLASS CRITERIA
TM
Ampyra (dalfampridine Coverage may not be provided for any other uses including, but not limited to:
extended release) continued A. To improve walking ability in any other condition aside from MS
Nonformulary B. Improvement in symptoms related to multiple sclerosis (MS) other than slow ambulation,
including but not limited to: difficulty with balance, fatigue, foot drop, poor stamina and
weakness including, but not limited to upper extremity weakness such as impaired
handwriting
C. Guillain-Barre syndrome
D. Lambert-Eaton Myasthenic Syndrome
E. Spinal cord injury
Anabolic Steroids Oxandrin® [g]:
Oxandrin® [g] (oxandrolone) Approved when used as an adjunct therapy to promote weight gain in patients who have had
extensive surgery, chronic infection, or severe trauma OR for therapy to offset protein
Nonformulary: catabolism associated with prolonged use of corticosteroids OR for bone pain associated with
Anadrol-50® (oxymetholone) osteoporosis OR if prophylactic therapy is needed in patients with hereditary angioedema.
®
Deca-Durabolin (nandrolone
decanoate) Anadrol-50® (oxymetholone) and Deca-Durabolin® (nandrolone decanoate):
Approved for the treatment of clinically diagnosed anemia (documentation must support the
trial of standard supportive measures for treating anemia including: transfusion, correction of
iron, folic acid, vitamin B12, or pyridoxine deficiency, antibacterial therapy, and the appropriate
use of corticosteroids) OR for the treatment of HIV-associated wasting OR if prophylactic
therapy is needed in patients with hereditary angioedema.

Angiotensin II Receptor Approval of a branded formulary ARB requires documentation that the member has
® ®
Blockers (ARBs): experienced failure of or intolerance to Cozaar (losartan)/Hyzaar (g).
® ®
Cozaar (losartan)/Hyzaar (g)
Approval of a nonformulary ARB requires documentation that the member has experienced
® ® ®
Benicar® (olmesartan)/HCT failure of or intolerance to Cozaar (losartan)/Hyzaar (g) AND Benicar (olmesartan)/HCT.

Nonformulary:
Atacand®(candesartan)/HCT
® ®
Avapro (irbesartan)/Avalide
®
Diovan (valsartan)/HCT
Micardis® (telmisartan)/HCT
®
Teveten (eprosartan)/HCT
®
Betaseron® (Interferon beta-1b) Requires trial and failure or intolerance of Extavia
Nonformulary

Bisphosphonates: Approval of Actonel® (risedronate) requires documentation that the member has tried and
®
Fosamax [g] (alendronate) failed/not tolerated treatment with Fosamax® [g].
Fosamax® [g] weekly
Approval of Boniva® (ibandronate) requires documentation that the member has tried and
®
Actonel (risedronate) failed/not tolerated treatment with both Fosamax® [g] and Actonel® (risendronate).
®
Actonel with Calcium

Nonformulary:
®
Boniva (ibandronate)
Fosamax Plus D
Butrans TM (buprenorphine) Coverage will be provided for the management of moderate to severe chronic pain in patients
transdermal system requiring around the clock opioid analgesia for an extended period of time. Criteria also
Nonformulary requires trial and failure, or intolerance to both extended-release morphine and the fentanyl
patch.

Byetta® (exenatide) Approved as adjunctive therapy in combination with at least one of the following medications:
Nonformulary metformin, sulfonylurea or a thiazolidinedione AND being used to improve glycemic control in
patients who have a diagnosis of type II diabetes mellitus AND have tried at least 2 of the
following: metformin, a sulfonylurea or a thiazolidinedione (unless contraindicated) AND the
patient must have documentation of an A1c greater than 7%.

Byetta® is NOT covered for the primary indication of weight loss in patients with or without
diabetes.
Bystolic® (nebivolol) Approval requires documentation that the patient has tried and failed/intolerant to at least 2 of
® ® ®
Nonformulary the formulary cardioselective beta blockers: Kerlone [g], Sectral [g], Tenormin [g],
® ® ®
Zebeta [g], Lopressor [g] OR Toprol XL [g].

Page 21
MEDICATION/ DRUG CLASS CRITERIA
®
Carbaglu (carglumic acid) Covered for the treatment of acute hyperammonemia due to the deficiency of the hepatic
enzyme N-acetylglutamate synthase (NAGS).

Cayston® (aztreonam lysine) Covered for the improvement of respiratory symptoms in cystic fibrosis patients with
Nonformulary Pseudomonas aeruginosa.

ChenodalTM (chenodeoxycholic Coverage approved for patients with radiolucent stones in well-opacifying gallbladders, in
acid) whom selective surgery would be undertaken except for the presence of increased surgical
Nonformulary risk because of systemic disease or age. Requires:
1. trial and failure or intolerance of ursodiol
2. patient is not a candidate for surgery
3. patient has no history of hepatocellular disease
4. if the patient is a woman, required that they are not pregnant and may not become
pregnant.

Coverage is limited to 24 months total of ursodiol plus ChenodalTM.

Cholesterol-lowering Agents Crestor®: Requires documentation that member has experienced failure of or intolerance to at
® ® ® ®
Zocor [g] (simvastatin) least one high dose (>40mg) generic statin (Mevacor [g], Zocor [g], and Pravachol [g]).
Mevacor® [g] (lovastatin)
®
Pravachol [g] (pravastatin) Zetia®: Patient has a documented trial and failure, intolerance, contraindication, or adverse
reaction to Mevacor®[g], Pravachol®[g], or Zocor® [g].
Crestor (rosuvastatin) OR
Zetia (ezetimibe) Patient is currently on statin therapy and unable to reach therapeutic target after trial at
maximum tolerated dose (minimum 40 mg).
Nonformulary:
Altoprev (lovastatin ER) Nonformulary agents:
Lescol,Lescol XL (fluvastatin) Altoprev®, Lescol®, Lipitor®, Livalo®, Vytorin®: Requires documentation that member has
Lipitor (atorvastatin) experienced failure of or intolerance to at least one high dose (>40mg) generic statin
Livalo® (pitavastatin) (Mevacor® [g], Zocor® [g], and Pravachol® [g]) AND one formulary brand agent (Crestor® or
®
Vytorin(simvastatin/ezetimibe) Zetia ).
Advicor(lovastatin/niacin
Advicor®: Requires documentation that member has had at least 3 months of treatment with
extended release)
® lovastatin and niacin extended release as individual agents when used concomitantly.
Simcor (simvastatin/niacin
extended release) ®
Simcor : Requires documentation that member has had at least 3 months of treatment with
simvastatin and niacin extended release as individual agents when used concomitantly.

COX-2 Preferential NSAIDs: Requires age > 60 OR concomitant use of anticoagulants OR oral steroids OR risk of GI bleed
Celebrex (celecoxib) (history of PUD, previous GI bleed, alcoholism).
Nonformulary

®
Cymbalta® (duloxetine) Coverage for Cymbalta will be provided for:
Nonformulary Treatment of major depression
Approval requires trial and failure with two formulary antidepressants including one generic
SSRI/SNRI.
OR
Treatment of diabetic neuropathic pain
If patient equal to or greater than 65 years of age:
After a 30-day trial of gabapentin.

If patient less than 65 years of age:


After a 30-day trial of gabapentin AND a tricyclic antidepressant, such as amitriptyline,
desipramine, or imipramine.
OR

Page 22
MEDICATION/ DRUG CLASS CRITERIA
Treatment of Fibromyalgia
Fibromyalgia characterized by pain in all 4 body quadrants, for at least 3 months, with or
without fatigue and sleep disturbance AND the patient has tried and experienced intolerance
to gabapentin OR had inadequate pain relief at doses of 1200 mg or above AND has tried and
experienced intolerance or inadequate pain relief to three of the following: tricyclic
antidepressant, SSRI, SNRI, cyclobenzaprine, tramadol.

Erythropoiesis Stimulating Information may need to be submitted describing the use and setting of the drug to make the
Agents (ESAs) determination. Approved for use in the following conditions with a hemoglobin less than
Procrit® (epoetin alfa) 12mg/dl: anemia of chronic renal disease (not yet on dialysis), anemia secondary to active
chemotherapy of solid tumors, anemia secondary to active zidovudine (AZT) therapy, anemia
Nonformulary in myelodysplastic disorders and prophylactic use during some major surgeries. Coverage is
Aranesp® (darbepoetin alfa) NOT provided in the following conditions: A. Anemia due to folate, vitamin B-12, and iron
®
Epogen (epoetin alfa) deficiencies, hemolysis, bleeding, or bone marrow fibrosis, B. Anemia associated with
treatment of acute and chronic myelogenous leukemias (CML, AML), or erythroid cancers,
C. Anemia due to cancer treatment in patients with uncontrolled hypertension, D. Anemia not
associated with cancer treatment or renal disease under inclusion criteria, E. Anemia
associated only with radiotherapy, F. Prophylactic use to prevent chemotherapy induced
anemia, G. Prophylactic use to reduce tumor hypoxia, H. Patients with Erythropoietin type
resistance due to neutralizing antibodies.

Coverage duration = 3 months

ExalgoTM (hydromorphone Coverage will be provided for management of moderate to severe pain in opioid tolerant
extended-release) patients requiring continuous, around the clock opioid analgesia for an extended period of
Nonformulary time. Criteria also requires trial and failure, or intolerance to equivalent doses of both
extended-release morphine and the fentanyl patch.

Coverage will not be provided for use as an “as needed” analgesic or for acute pain or
postoperative pain

Flector® (diclofenac patch) For FDA approved indications only. Member must have tried and failed or demonstrated
Nonformulary intolerance to oral diclofenac AND at least two other oral, traditional NSAIDs unless the
patient is unable to take any oral medications.
AND
Coverage will NOT be provided in the presence of concurrent therapy with oral NSAIDs or a
COX II inhibitor.

®
Forteo® (teriparatide) Forteo will be provided for the following guidelines:
Nonformulary
1. For the treatment of postmenopausal women with osteoporosis who are at high risk of
fracture or men with primary or hypogonadal osteoporosis who are at high risk for fracture and
meet the following criteria (a, b and c):

a. Have a bone mineral density (BMD) that is 2.5 standard deviations or more below the mean
(T-score at or below -2.5).

b. Patient has tried and failed a bisphosphonate (formulary agents include Fosamax® [g] and
Actonel®) for a 24 month period except when:
1. contraindication to a bisphosphonate (such as a stricture or achalasia, inability
to stand or sit upright for at least 30 minutes and increased risk of aspiration).
OR
2. documented intolerance to a bisphosphonate

Page 23
MEDICATION/ DRUG CLASS CRITERIA
c. Coverage will NOT be provided in the following situations:
1. Concurrent treatment with a bisphosphonate
2. Hypercalcemia
3. Paget’s disease
4. Bone metastases or a history of skeletal malignancies
5. Metabolic bone disease other than osteoporosis
6. Pediatric patients or young adults with open epiphyses
7. Prior radiation therapy involving the skeleton

2. Forteo will be approved for a maximum of two years.

Growth Hormone Coverage will be provided for:


Genotropin (somatropin) Pediatric Growth Hormone Deficiency
Nutropin (somatropin) Children (M < 16 years old, F < 15 years old):
th
Initial Treatment: Req. > 6 months of initial height measurements, Ht < 5 percentile for age
Nonformulary: (based on initial evaluation), abnormal growth velocity based on > 6 mo. of measurement,
th
Humatrope® < 50 percentile for age with growth hormone therapy, initial subnormal blood test for
Norditropin
®
growth hormone.
®
Omnitrope
Saizen
®
To continue treatment: must have a documented growth velocity of > 2.5 cm/year during the
Serostim® first 6 mo. of therapy & documented growth of > 4.5 cm/year for each succeeding 6 month
Tev-Tropin
®
review period. Treatment may continue until final height or epiphyseal closure has been
Zorbtive™ documented or patient has reached age 16 years (M) or 15 years (F).

Adults: Diagnosis of growth hormone deficiency confirmed by laboratory testing (e.g.


provocative stimulation), known indication for pituitary disease and multiple pituitary hormone
deficiencies. Multiple stimulation tests may be required in certain clinical circumstances. May
be approved for AIDS-wasting cachexia and Turner’s Syndrome. Growth hormone therapy is
NOT covered for anti-aging, obesity or athletic enhancement.
HizentraTM (immune globulin Requires appropriate diagnosis for coverage and other criteria may apply depending on
subcutaneous) diagnosis.
Nonformulary

H.P. Acthar Gel® (repository Coverage will be provided for the treatment of infantile spasms, OR for the diagnostic testing
corticotropin) of adrenocortical function only if use of cosyntropin is contraindicated.
Nonformulary
Use of H.P. Acthar Gel® is NOT considered medically necessary as treatment of steroid-
responsive conditions, unless there are medical contraindications or intolerance to
®
corticosteroids that are not also expected to occur with use of H.P. Acthar Gel .

Increlex® (mecasermin) Approval will require the following:


Nonformulary 1. Medication to be prescribed by a pediatric endocrinologist AND
2. Diagnosis of one of the following:
Severe primary IGF-1 deficiency or growth hormone gene deletion or genetic mutation
of growth hormone receptor (Laron Syndrome) AND
rd
3. Current height measurement at less than 3 percentile for age and sex AND
4. IGF-1 level greater than or equal to 3 standard deviations below normal AND
5. Normal or elevated growth hormone levels based on at least one growth hormone
stimulation test AND
6. Open growth plates

Authorizations shall be reviewed at least annually to confirm that current medical necessity
criteria are met and that the medication is effective. Continued authorization in children may
be given for up to 12 months until any one of the following conditions occurs:
1. Growth velocity is less than 2.5 cm/year
OR
0/12
2. Bone age in males exceeds 16 years of age
OR
3. Bone age in females exceeds 14 0/12 years of age
®
Increlex is considered investigational for all other indications, including, but not limited to:
Page 24
MEDICATION/ DRUG CLASS CRITERIA
a. Amyotrophic lateral sclerosis (ALS)
b. Children less than two years of age
c. Combination treatment with growth hormone
d. Diabetes
e. Individuals with closed growth plates
f. Secondary forms of IGF-1 deficiency, such as growth hormone deficiency, malnutrition,
hypothyroidism or chronic treatment with steroids
g. Idiopathic short stature
h. Growth failure due to other identifiable causes (including, but not limited to Prader-Willi
syndrome, Russell-Silver syndrome, Turner syndrome, Noonan syndrome)
i. Less severe forms of IGF-1 deficiency

Intranasal Steroids Approval of Nasacort AQ® requires trial and failure/intolerance to Flonase® [g] OR Nasarel®
®
Flonase [g] (fluticasone) [g].
®
Nasarel [g] (flunisolide)
Approval of nonformulary agents requires trial and failure/intolerance to generic fluticasone
®
Nasacort AQ (triamcinolone) (Flonase®) OR generic flunisolide (Nasarel®) AND trial and failure/intolerance to Nasacort
®
AQ .
Nonformulary:
Beconase® AQ (beclomethasone)
®
Nasonex (mometasone)
®
Omnaris (ciclesonide)
®
Rhinocort AQ (budesonide)
®
Veramyst (fluticasone)
IntunivTM (guanfacine extended- Requires diagnosis of ADHD AND therapeutic failure, intolerance or contraindication to BOTH
release) an amphetamine-type product AND a methylphenidate product.
Nonformulary
Lotronex® (alosetron Approved for treatment of women > 18 years old with severe, diarrhea-predominant Irritable
hydrochloride) Bowel Syndrome (IBS) who have failed to respond to conventional IBS therapy.
Nonformulary
Lyrica® (pregabalin) Coverage of Lyrica® will be provided for:
Nonformulary Adjunctive treatment for adult patients with partial onset of seizures
OR
Treatment of diabetic neuropathic pain or post-herpetic neuralgia
If patient equal to or greater than 65 years of age: After a 30-day trial of gabapentin.

If patient less than 65 years of age: After a 30-day trial of gabapentin AND a tricyclic
antidepressant, such as amitriptyline, desipramine, or imipramine.
OR
Treatment of Fibromyalgia
Fibromyalgia characterized by pain in all 4 body quadrants, for at least 3 months, with or
without fatigue and sleep disturbance AND the patient has tried and experienced intolerance
to gabapentin OR had inadequate pain relief at doses of 1200 mg or above AND has tried and
experienced intolerance or inadequate pain relief to three of the following: tricyclic
antidepressant, SSRI, SNRI, cyclobenzaprine, tramadol.
® TM
Mirapex ER (pramipexole Coverage approved for the treatment of Parkinson's. Requires trial and failure of
extended release) Mirapex® (g).
Nonformulary
Narcotics Requires appropriate diagnosis for coverage and tolerance to high doses of narcotics.
Actiq® [g] (fentanyl citrate)

Nonformulary:
Fentora™ (fentanyl citrate)
OnsolisTM (fentanyl citrate)
Non-Sedating Antihistamines: Clarinex/Clarinex-D and Xyzal
Claritin/-D™ OTC Requires failure of or intolerance to OTC loratadine/loratadine-D AND OTC
(loratadine/pseudoephedrine) cetirizine/cetirizine-D, AND fexofenadine/fexofenadine-D.
Zyrtec/-D™ OTC
(cetirizine/pseudoephedrine) Allegra® Suspension and Allegra® ODT
Allegra [g] (fexofenadine) Requires failure or intolerance to loratadine AND cetirizine
Allegra-D 12hr [g]
(fexofenadine/pseudoephedrine)
Allegra-D 24hr
(fexofenadine/pseudoephedrine)

Nonformulary:
Page 25
MEDICATION/ DRUG CLASS CRITERIA
Allegra Suspension
(fexofenadine) Allegra
ODT (fexofenadine)
®
Clarinex/-D
(desloratadine/pseudoephedrine)
Xyzal (levocetirizine)
OleptroTM (trazodone extended Coverage approved for the treament of major depressive disorder. Requires trial and failure
release) of Desyrel (g) and documentation why the long acting would be more efficacious.
Nonformulary
Pennsaid® topical solution For FDA approved indications only. Member must have tried and failed or demonstrated
(diclofenac sodium) intolerance to oral diclofenac AND at least two other oral, traditional NSAIDs unless the
Nonformulary patient is unable to take any oral medications.
AND
Coverage will NOT be provided in the presence of concurrent therapy with oral NSAIDs or a
COX II inhibitor.
Promacta® (eltrombopag) Initial approval for coverage requires all of the following:
1, Age greater than 18 years old AND
2. Diagnosis of chronic immune thrombocytopenia (ITP) and persistent thrombocytopenia
(platelet count < 150,000 mcL) for > 2 months AND
3. Prescribed by a hematologist or in consultation with a hematologist AND
4. Inadequate response or patient must not be a candidate for corticosteroids,
immunoglobulins, or splenectomy AND
5. Current platelet count is < 50, 000 mcL AND
6. Dose is < 75mg/day
®
Renewal approval for Promacta requires recent platelet count of 30,000-150, 000 mcL AND
dose is < 75mg/day.

Proton Pump Inhibitors (PPI’s): Approval of nonformulary medications requires failure of or intolerance to all formulary
alternatives: Prilosec [g] OR Prilosec OTC [g] AND Protonix [g] AND

Prilosec OTC™ [g] (omeprazole)
®
Prilosec [g] (omeprazole) Prevacid® [SoluTab™[g]
Protonix [g] (pantoprazole)
Prevacid® [g] (lansoprazole)
®
Prevacid SoluTab™(g)
(lansoprazole)
Zegerid® (capsule (g)
omeprazole/sodium bicarbinate

Nonformulary:
Aciphex (rabeprazole)
DexilantTM (dexlansoprazole)
Nexium (esomeprazole)
Zegerid® powder for oral
suspension(omeprazole/sodium
bicarbonate
TM
RelistorTM (methylnaltrexone Coverage of Relistor will be provided for:
bromide) injection 1. The treatment of opioid-induced constipation in patients with advanced illness who
are receiving palliative care, when response to laxative therapy has not been
sufficient.
2. Patients shall be on stable doses of opioids for greater than 2 weeks.
3. Duration of methylnaltrexone therapy shall be limited to 3 months.
4. Previous history of treatment for constipation shall include fluids, stool softeners, bulk
laxatives, saline laxatives and osmotic laxatives. Laxatives trials shall be of at least 5
days duration.
5. Maximum initial regimen shall be 1 box (7 doses). Monthly doses shall not exceed
14.
6. Patients experiencing withdrawal symptoms while taking methylnaltrexone should
consider using an alternate form of therapy.

Page 26
MEDICATION/ DRUG CLASS CRITERIA
®
Revatio (sildenafil citrate) tablet Approved for members with a diagnosis of Pulmonary Arterial Hypertension (PAH). Coverage
® ® ®
for sildenafil (Revatio ) in combination with bosentan (Tracleer ), epoprostenol (Flolan ),
® ®
treprostinil (Remodulin ) or iloprost (Ventavis ) is provided after monotherapy with one of
these agents has been found to be inadequate in the treatment of the patient’s symptoms.
Coverage is NOT provided for sildenafil (Revatio®) in situations where patients are receiving
nitrate therapy.

®
Sancuso® (granisetron) Coverage of Sancuso will be provided for:
Nonformulary 1. Indication for prevention and/or treatment of nausea/vomiting associated with
chemotherapy and/or radiation therapy AND
2. Documented treatment/failure with generic ondansetron (Zofran®) AND generic granisetron
®
(Kytril ) AND
3. Not a candidate for IV granisetron therapy

Sandostatin® (octreotide) [g] Sandostatin® [g]


®
Sandostatin LAR Approval requires one of the following (1, 2 or 3):
1. Clinically diagnosed acromegaly AND one of the following (a, b, or c)
a. failure to respond to surgery or radiation OR
b. not a candidate for surgery or radiation OR
c. use to shrink tumor prior to surgery

2. Diagnosis of metastatic carcinoid tumor

3. Diagnosis of vasoactive intestinal peptide tumors (VIPomas)

Sandostatin LAR®
Approval requires member to have previously tried, responded and tolerated immediate-
release octreotide injection AND one of the following (1,2 or 3):
1. Clinically diagnosed acromegaly AND one of the following (a,b or c)
a. failure to respond to surgery or radiation OR
b. not a candidate for surgery or radiation OR
c. use to shrink tumor prior to surgery

2. Diagnosis of metastatic carcinoid tumor

3. Diagnosis of vasoactive intestinal peptide tumors (VIPomas)

SavellaTM (milnacipran) Treatment of Fibromyalgia


Nonformulary Fibromyalgia characterized by pain in all 4 body quadrants, for at least 3 months, with or
without fatigue and sleep disturbance AND the patient has tried and experienced intolerance
to gabapentin OR had inadequate pain relief at doses of 1200 mg or above AND has tried and
experienced intolerance or inadequate pain relief to three of the following: tricyclic
antidepressant, SSRI, SNRI, cyclobenzaprine, tramadol.

Sedative/Hypnotics Ambien CR® [g], LunestaTM and RozeremTM require documentation that member has
Ambien® [g] (zolpidem) experienced failure of or intolerance to Ambien® [g] OR Sonata® [g].
®
Ambien CR [g] (zolpidem)
Sonata® [g] (zaleplon) Edluar™ and Zolpimist® require trial and failure, or intolerance, to Ambien® (zolpidem) AND
Sonata® (zaleplon) AND documentation of medical necessity.
Nonformulary:
Edluar™ (zolpidem sublingual)
Lunesta™ (eszopiclone)
Rozerem™ (ramelteon)
Zolpimist® (zolpidem tartrate oral
spray)

Page 27
MEDICATION/ DRUG CLASS CRITERIA

Selective Reuptake Inhibitor – Lexapro requires step therapy with at least one of the following generic formulary
antidepressants: alternatives; Celexa [g], Effexor/XR®[g], Luvox [g], Paxil/CR [g], Prozac [g], Remeron
[g], Wellbutrin/SR [g], Wellbutrin XL [g], or Zoloft [g].
®
Celexa [g] (citalopram)
Effexor/XR®[g] capsule
(venlafaxine) Aplenzin®; requires trial/failure of at least 2 formulary agents plus documentation that
continued use of Wellbutrin® [g] will adversely affect the member’s mental health.
Luvox [g] (fluvoxamine)
Luvox CR; requires trial/failure of at least 2 formulary agents plus documentation that
Paxil [g] (paroxetine)
continued use of Luvox® [g] will adversely affect the member’s mental health.
Paxil CR® [g] (paroxetine)
Pexeva; requires trial/failure of at least two of the above formulary agents PLUS
Prozac [g] (fluoxetine)
documentation that continued use of Paxil® [g] will adversely affect the member’s health.
Prozac Weekly [g] (fluoxetine)
Pristiq; requires trial/failure of at least 2 formulary agents.
Remeron [g] (mirtazapine)
Venlafaxine ER [g] tablet
Wellbutrin SR [g] (bupropion)
Wellbutrin XL® [g] (bupropion)
Zoloft [g] (sertraline)

Lexapro (escitalopram)
Nonformulary:
®
Aplenzin (bupropion
hydrobromide)
Luvox® CR (fluvoxamine)
Pexeva (paroxetine)
Pristiq (desvenlafaxine)

SilenorTM (doxepin) Requires trial and failure of Ambien (g) AND Sonata (g)
Nonformulary

Somavert® (pegvisomant) For the treatment of acromegaly in patients who have had an inadequate response to surgery
and/or radiation therapy and/or other medical therapies, or for whom these therapies are not
appropriate.

Strattera® (atomoxetine) For members age 5-21: Requires documentation that member has experienced failure of or
Nonformulary intolerance to BOTH a methylphenidate product (such as Ritalin® [g] or Concerta®) AND an
amphetamine (such as Adderall® [g]).
For members age >21: Requires documentation that the member has experienced failure of
or intolerance to EITHER a methylphenidate product OR an amphetamine.

Approvable when stimulants are contraindicated by medical history.

Tekturna® (aliskiren) Requires documentation that the member has tried standard effective doses and not reached
Nonformulary therapeutic goals or could not tolerate therapy with ALL of the following drug classes:
1. Diuretic
2. Beta-blocker
3. ACE-Inhibitor
Angiotension II Receptor Blocker (ARB)

Page 28
MEDICATION/ DRUG CLASS CRITERIA
® ®
TNF-alpha agents and related Enbrel and Humira :
products: Rheumatoid arthritis, juvenile RA, or psoriatic arthritis: Requires three-month trial with two
Enbrel (etanercept) concurrent DMARDs, (one must be methotrexate unless contraindicated). Examples of
Humira (adalimumab) DMARDs include: methotrexate, sulfasalazine, azathioprine, hydroxychloroquine/chloroquine,
cyclosporine, gold and penicillamine.
Nonformulary:
Cimzia (certolizumab pegol Ankylosing spondylitis: requires therapy is being supervised by a Rheumatologist.
injection)
Kineret (anakinra) Moderate to severe psoriasis: Requires 3 months of previous treatment with topical
SimponiTM (golimumab) corticosteroids AND 3 months treatment with PUVA (unless PUVA is contraindicated) AND
therapy must be supervised by a Dermatologist.

Crohn’s Disease: Coverage for patients age 18 years and older, with a diagnosis of
moderately to severely active Crohn’s disease with a history of inadequate response to
conventional therapy. Applies to Humira® only.
®
Cimzia :
®
The following criteria are used in reviewing medical exceptions for Cimzia
A. OR B.

A. Age 18 or older and for the treatment of acute exacerbation of moderate to severe Crohn’s
disease when the following criteria are met (1 AND 2):
1) Treatment with an adequate course of systemic corticosteroids has been ineffective or is
contraindicated or patient has been unable to taper or patient is experiencing breakthrough
disease while stabilized on an immunomodulatory medication for at least 2 months.

AND

2) Previous trial/failure/contraindication of Humira®.

OR

B. Age 18 or older and for the treatment of rheumatoid arthritis when the following criteria are
met (1 AND 2)
1) Treatment failure with a three month trial with two concurrent DMARDs (one must be
methotrexate unless contraindicated)

AND
®
2) Treatment failure or documented intolerance to Adalimumab ( Humira ) and
®
Etanercept (Enbrel )

®
Kineret :
Rheumatoid arthritis in adults: Requires three-month trial with two concurrent DMARDs, (one
must be methotrexate unless contraindicated) AND treatment failure or intolerance to Enbrel
and Humira. Examples of DMARDs include: methotrexate, sulfasalazine, azathioprine,
hydroxychloroquine/chloroquine, cyclosporine, gold and penicillamine.

SimponiTM:

18 years of age or older and A OR B


A. Rheumatoid arthritis and psoriatic arthritis: Requires a 3-month trial on two concurrent
Disease Modifying Anti-Rheumatic Drugs (DMARDs), one of which must be methotrexate
®
unless contraindicated AND treatment failure or contraindication to both Enbrel AND
®
Humira .

OR

B. Ankylosing spondylitis: Requires a treatment failure or contraindication


® ®
to both Enbrel AND Humira .

TreximetTM Requires prior use of Imitrex® [g] and Naprosyn® [g] in combination AND documentation
(sumatriptan/naproxen sodium) indicating why use of the individual agents is harmful to the member AND documentation of
Nonformulary trial and failure of formulary option Maxalt®.

Page 29
MEDICATION/ DRUG CLASS CRITERIA
TM
TriLipix (fenofibric acid) Requires trial and failure of gemfibrozil [g] AND fenofibrate [g].
Nonformulary

Triptans: The formulary option Maxalt® will require trial and failure of the generic formulary alternative
®
Imitrex [g].
Amerge® (g) (naratriptan)
® ® ® ® ®
Imitrex [g] (sumatriptan) Approval of the nonformulary triptans, Axert , Frova , Relpax , Zomig , will require trial and
® ® ®
Maxalt (rizatriptan) failure of both the formulary options Imitrex [g] AND Maxalt .

Nonformulary Approval of the nonformulary triptans AlsumaTM and SumavelTM DoseProTM will require trial
AlsumaTM (sumatriptan) and failure of both formulary options Imitrex (g) injection AND Maxalt MLT®
Axert® (almotriptan)
®
Frova (frovatriptan)
Relpax® (eletriptan)
SumavelTM DoseProTM
(sumatriptan needle-free injection)
Zomig® (zolmitriptan)

Uloric® (febuxostat) Requires treatment failure, intolerance or contraindication with formulary alternative generic
allopurinol.

Victoza® (liraglutide) Approved as adjunctive therapy in combination with at least one of the following medications:
Nonformulary metformin, sulfonylurea or a thiazolidinedione AND being used to improve glycemic control in
patients who have a diagnosis of type II diabetes mellitus AND have tried at least 2 of the
following: metformin, a sulfonylurea or a thiazolidinedione (unless contraindicated) AND the
patient must have documentation of an A1c greater than 7%.
®
Victoza is NOT covered for the primary indication of weight loss in patients with or without
diabetes.

VimovoTM Approval requires trial and failure of Prilosec (g) AND Protonix (g) AND Prevacid (g) AND one
(naproxen/esomeprazole) of the following criteria:
Nonformulary Member is >60 years of age or
receiving anticoagulant or antiplatelet therapy or
receiving chronic treatment with oral corticosteroids (>60 days duration) or
has a history of or current diagnosis of peptic ulcer disease, clinically significant
gastrointestinal bleeding and/or alcoholism.

Voltaren Gel® (diclofenac gel) For FDA approved indications only. Member must have tried and failed or demonstrated
Nonformulary intolerance to oral diclofenac AND at least two other oral, traditional NSAIDs unless the
patient is unable to take any oral medications.
AND
Coverage will NOT be provided in the presence of concurrent therapy with oral NSAIDs or a
COX II inhibitor.

Vyvanse™ (lisdexamfetamine) Covered for the treatment of ADHD in children and adults 6 years of age and older who have
Nonformulary experienced therapeutic failure or intolerance to BOTH an amphetamine-type product AND a
methylphenidate product. Maximum dose approved per day will be 70 mg.

Page 30
MEDICATION/ DRUG CLASS CRITERIA
®
Xenazine (tetrabenazine) Approval will require diagnosis of chorea associated with Huntington’s disease
AND for doses above 50mg per day, documentation of the CYP2D6 genotype of the patient
will be required.

Tetrabenazine is considered investigational when used for all other conditions, including, but
not limited to:
A. Chorea not associated with Huntington’s disease
B. Tardive dyskinesia
C. Dystonia, tics and other dyskinesias
D. Hyperkinetic or involuntary movement disorders
E. Tourette’s syndrome
F. Athetoid cerebral palsy

Xyrem® (sodium oxybate) Requires a diagnosis of narcolepsy and A OR B:


Nonformulary A. Cataplexy demonstrated by supporting chart documentation or sleep studies
OR
B. Excessive daytime sleepiness demonstrated by supporting chart documentation or
sleep studies when (1 AND 2):
1. Modafinil in doses up to 400mg daily has been ineffective, not tolerated, or
contraindicated.
AND

2. At least one other formulary/preferred treatment, such as methylphenidate


or dextroamphetamine, has been ineffective, not tolerated, or
contraindicated.
®
Xyrem will NOT be approved if:
1. Patient is being treated with sedative hypnotic agents, other CNS depressants, or
using alcohol
2. Patient has a history of drug abuse
3. Patient has succinic semialdehyde dehydrogenase deficiency

Xyrem® is NOT considered medically necessary for the following condition(s):


1. Alcohol dependence and withdrawal
2. Fibromyalgia

Xyrem® is considered investigational for all other conditions or applications, including, but not
limited to, the treatment of:
1. Opioid dependence and withdrawal
2. Parkinsonism
3. Night eating syndrome
4. Myoclonus and essential tremor
ZuplenzTM (ondansetron) Requires documentation that the member has experienced treatment failure or intolerance to
oral soluble film Zofran ODT (g) AND oral Kyrtril (g). Documentation must be provided as to why continued
Nonformulary use of Zofran ODT will harm the patient.

[g] = generic available

Page 31
Possible brand alternatives

Some medications are produced by more than one pharmaceutical manufacturer, under different brand names.
In some cases, only one of the brand-name products is listed in the Blue Cross Blue Shield of Michigan and
Blue Care Network Custom Formulary 2011. The other brands are considered nonformulary. We encourage
prescribers to select the preferred product to help patients save out-of-pocket costs.

Possible brand alternatives


Nonformulary Formulary alternative
Epogen® Procrit®
Follistim® Gonal-F®
Humatrope®, Norditropin® , Omnitrope®, Saizen®, Serostim®, Genotropin®, Nutropin®
® ®
Tev-Tropin , Zorbtive
Ritalin LA® Metadate CD®

Generic drug substitution


Generic drug substitution is when a generic equivalent is dispensed rather than the brand-name product.
Products designated in the formulary with “(g)” after the name are available as generics approved by the U.S.
Food and Drug Administration. BCN members are required to use generic substitution. For BCN members, if a
brand-name drug is requested when a generic version is available, members will pay their Tier 2 copayment
plus the difference in cost between the brand and generic versions. Prescribers may request authorization for
the brand-name version, based on medical necessity. A completed MedWatch form is required.

BCBSM members are encouraged to receive the generic equivalent, if available, or they may be required to
pay the difference in cost between the brand dispensed and the generic equivalent, in addition to the
applicable copay.

The maximum allowable cost list sets ceiling prices for reimbursement of certain generic prescription drugs.
The drugs on the MAC list are commonly prescribed and dispensed, and have undergone the FDA’s review
and approval process, which ensures:

o Generic drugs contain the same active ingredients and are the same strengths and dosage forms as
their brand-name counterparts.

o The FDA has given the generics an “A” rating and have determined they are the equivalent of their
brand-name counterparts. Or the BCBSM and BCN Pharmacy and Therapeutics Committee has
reviewed the products and found them to be acceptable generic substitutes.

When the above two criteria are met, generics can be substituted with the full expectation that they will
produce the same clinical effects and have the same safety profiles as the prescribed brand-name products.

Possible therapeutic alternatives


The BCBSM-BCN Formulary Alternatives – January 2011 list represents possible options to nonformulary
drugs. These alternative medications can generally be prescribed without approval from BCBSM or BCN, and
can be dispensed with lesser copayments for members. Therapeutic alternatives may represent a different
drug class, contain different ingredients or may be available in different strengths or dosage forms than the
prescribed branded products. Pharmacists must obtain authorization from a patient’s physician to dispense an
alternative product.

Listed below are examples of the therapeutic alternatives a patient’s physician should consider when
determining appropriate treatment for the patient. The physician should consider individual drug product
characteristics and patient factors such as coexisting disease states, contraindications, therapeutic history,
concurrent medications and other relevant circumstances. This list is also available at
bcbsm.com/provider/pharmacy_services/index.shtml.

Page 32
BCBSM/BCN Formulary Alternatives - January 2011
NonFormulary Formulary Alternative NonFormulary Formulary Alternative
ACIPHEX Prilosec OTC**; Prevacid(g)*, ARTHROTEC Lodine(g), Mobic(g), Motrin(g),
Solutab(g)*; Prilosec 20mg(g), Naprosyn(g), Voltaren(g), etc. plus
Protonix(g)*, Zegerid(g)* Cytotec(g)
ACTIVELLA 0.5- Activella(g); Estratest(g), H.S.(g) ATACAND, HCT Cozaar(g), Hyzaar(g), Benicar*, HCT*
0.1MG AVALIDE, AVAPRO Cozaar(g), Hyzaar(g), Benicar*, HCT*
ACTOPLUS MET Glucophage(g) plus Actos*; ActoPlus AVANDAMET ActoPlus Met*
XR Met*
AVANDARYL Duetact*
ACUVAIL Acular, LS(g); Voltaren(g)
AVANDIA Glucophage(g); Insulin or a
ACZONE Topical OTC benzoyl peroxide, sulfonylurea (Glucotrol, XL(g);
clindamycin, erythromycin Micronase(g), Amaryl(g)), Actos*
ADCIRCA Revatio* AVC Diflucan(g) oral, Terazol(g) vaginal
ADOXA, CK, TT Monodox(g), Vibramycin(g) AVINZA Methadone(g), MSIR(g), MS
ADVICOR Mevacor(g), Pravachol(g), Zocor(g), Contin(g), Oramorph SR(g)
Crestor*; plus Niaspan AXERT Amerge(g)*, Imitrex(g); Maxalt*,
AEROBID, M Alvesco, Asmanex, Azmacort, MLT*
Flovent, Pulmicort, QVAR AZASITE Ciloxan(g), Vigamox
AGGRENOX Persantine(g) plus ASA OTC, Plavix AZELEX Retin-A(g)
AKNE-MYCIN Erythromycin topical solution & gel(g) AZILECT Eldepryl(g)
ALAMAST Zaditor OTC(g), Alomide, Patanol AZOR Generic ACE (lisinopril, benazepril,
ALLEGRA ODT, Claritin Syr OTC(g)**, Zyrtec Syr etc.), Benicar*, or Cozaar(g) PLUS
SUSP OTC(g)** Norvasc(g)
ALREX Decadron ophth(g), Pred Forte(g), BECONASE AQ Flonase(g), Nasalide(g), Nasarel(g),
Pred Mild Nasacort AQ*
ALTABAX Triple Antibiotic OTC, Bactroban(g) BENZACLIN Individual agents (BPO and
ALTACE TABLETS Altace capsules(g) clindamycin)
ALTOPREV Mevacor(g), Pravachol(g), Zocor(g), BENZASHAVE OTC benzoyl peroxide
Crestor*, Zetia* BEPREVE Zaditor OTC(g), Patanol
AMITIZA OTC laxatives and stool softeners, BESIVANCE Ciloxan(g), Ocuflox(g), Vigamox
Glycolax(g), Lactulose(g) BETASERON Avonex, Copaxone, Rebif
AMRIX Flexeril(g) BETIMOL Betagan(g), Betoptic(g), Timoptic(g)
ANADROL-50 Androxy(g), Depo-testosterone(g), BEYAZ Yasmin(g), Yaz(g) PLUS Folic Acid
Androderm, Delatestryl 1MG
ANDROGEL Androderm BONIVA Fosamax(g), Actonel*
ANGELIQ FemHRT, Prempro/Premphase, or BROVANA Foradil, Serevent Diskus
Estradiol plus Progestin
BUTISOL SODIUM Ambien(g), Prosom(g), Restoril(g),
ANTARA Lofibra(g), Lopid(g), Tricor Sonata(g)
ANZEMET Kytril(g); Zofran(g), ODT(g) BUTRANS Duragesic(g), Methadone(g), MS
APHTHASOL Kenalog in Orabase(g) Contin(g), Oramorph(g)
APLENZIN Generic SSRI/SNRI (Celexa(g), BYETTA Insulin, Glucophage(g),
Prozac(g), Zoloft (g), Effexor(g), Sulfonylurea's, TZD's
Effexor XR(g); Wellbutrin, SR, XL(g), BYSTOLIC Blocadren(g), Lopressor(g),
etc.) Tenormin(g), Toprol XL(g), etc.
APRISO Azulfidine(g), Azulfidine En-Tab(g), CADUET Mevacor(g), Pravachol(g), Zocor(g),
Asacol, HD; Pentasa Crestor*; plus Norvasc(g), Zetia*
ARANESP Procrit* CAMPRAL Revia(g), Antabuse
ARICEPT 23MG Aricept 5, 10mg(g) CANTIL Bentyl(g), Donnatal(g), Robinul(g)
ARIXTRA Lovenox(g) CARAC Efudex(g)
ARMOUR Synthroid(g) CARBATROL Tegretol(g), XR(g)
THYROID
CARDENE SR Cardene(g), Norvasc(g), Procardia
XL(g)
* Prior Authorization or Step Therapy may be required. ** Covered with a prescription for BCN members and certain BCBSM members.
Most BCN members and some BCBSM members do not have coverage for nonformulary agents. Please use this list as a guide when selecting alternatives.
Page 33
NonFormulary Formulary Alternative NonFormulary Formulary Alternative
CARDURA XL Cardura(g), Flomax(g), Hytrin(g), DIPENTUM Azulfidine(g), Azulfidine En-Tab(g),
Avodart, Uroxatral Asacol, HD; Pentasa
CARMOL HC Hydrocortisone plus Aquaphor OTC, DONNATAL Bentyl(g), Donnatal(g), Robinul(g)
Hydrocortisone plus Eucerin OTC EXTENTABS
CAYSTON Tobi DORAL Ambien(g), Halcion(g), Prosom(g),
CEDAX Ceclor(g), Ceftin(g), Duricef(g), Restoril(g), Sonata(g)
Keflex(g), Omnicef(g) DORYX Vibramycin(g)
CELEBREX Lodine(g), Mobic(g), Motrin(g), DUAC CS Individual agents (Cleocin(g) topical
Naprosyn(g), Voltaren(g), etc. and OTC BPO)
CENESTIN Estrace(g), Ogen(g), Premarin DUREZOL Decadron ophth(g); Inflamase,
CESAMET Kytril(g); Zofran(g), ODT(g) Forte(g); Pred Forte(g), etc.
CHENODAL Actigall(g), Urso(g) DYNACIRC CR Cardene(g), Dynacirc(g), Norvasc(g),
Procardia XL(g)
CIMZIA SYRINGE Enbrel*, Humira*
EDEX Caverject*, Cialis*, Muse*, Viagra*
CLARIFOAM EF Plexion(g), Sulfacet-R(g)
EDLUAR Ambien(g), Sonata(g)
CLARINEX (ALL) Claritin OTC(g)**, Zyrtec OTC(g)**,
Allegra(g), Allegra-D 12 hour(g)*, EFUDEX Efudex(g)
Allegra-D 24 hour*, Astelin(g) OCCLUSION
CLEOCIN Cleocin Vaginal Cream(g) ELESTAT Zaditor OTC(g), Alomide, Patanol
VAGINAL OVULES ELESTRIN Climara(g), Estrace(g), Ogen(g),
CLIMARA PRO Climara(g), Vivelle-DOT, or Vivelle-DOT, Estraderm
Estraderm plus a progestin ELIGARD Lupron, Depot;Trelstar, Depot
CLINAC BPO Individual agents (Cleocin(g) topical ELLA Plan B(g)
and OTC BPO) EMADINE Zaditor OTC(g), Alomide, Patanol
CLINDESSE Cleocin vaginal cream(g) EMBEDA Methadone(g), MSIR(g), MS
CLOBEX, SPRAY Diprolene(g), Psorcon(g), Contin(g), Oramorph SR(g)
Temovate(g), Ultravate(g) EMSAM Celexa(g), Effexor(g), Effexor XR(g),
COGNEX Razadyne, ER(g); Aricept, ODT(g); Paxil(g), Prozac(g), Wellbutrin, SR,
Namenda XL(g); Venlafaxine ER(g), Lexapro*
COLESTID Colestid(g), Questran(g), Questran ENABLEX Ditropan(g), XL(g), Detrol, LA
FLAVORED Light(g) ENJUVIA Premarin
COLY-MYCIN S Cortisporin(g), Floxin(g) Otic, Cipro ENTOCORT EC Prednisone(g), Prednisolone(g),
HC Hydrocortisone(g), etc.
COMBIPATCH Climara(g), Vivelle-DOT, Estraderm EPIDUO Individual agents: Differin plus OTC
plus Progestin BPO
COREG CR Coreg(g), Toprol XL(g) EPOGEN Procrit*
CORTISPORIN-TC Cortisporin(g), Floxin(g) Otic, Cipro EQUETRO Tegretol, XR(g)
Otic HC
ERTACZO Lamisil AT(g) OTC; Lotrimin(g), Ultra
CYMBALTA Generic SSRI/SNRI (Celexa(g), OTC; Monistat-Derm(g), Nizoral
Effexor(g), Effexor XR(g), Prozac(g), cream(g), Spectazole(g)
Zoloft(g), etc.)
ESTRACE Premarin Vaginal Cream
DAYTRANA Adderall, XR(g)*; Ritalin, SR(g); VAGINAL CREAM
Concerta, Metadate CD
ESTRASORB Climara(g), Estrace(g), Ogen(g),
DENAVIR Zovirax 5% cream/ointment Estraderm, Vivelle-DOT
DEPEN Cuprimine ESTROGEL Climara(g), Estrace(g), Ogen(g),
DERMA- Elocon(g), Locoid(g), Synalar Estraderm, Vivelle-DOT
SMOOTHE/FS solution(g), Capex EVAMIST Climara(g), Estrace(g), Ogen(g),
DESONATE Elocon(g), Locoid(g), Synalar Estraderm, Vivelle-DOT
solution(g), Capex EVOXAC Bethanechol(g), Salagen(g)
DEXILANT Prilosec OTC**; Prevacid(g)*, EXALGO Duragesic(g), Methadone(g), MS
Solutab(g)*; Prilosec 20mg(g), Contin(g), Oramorph(g)
Protonix(g)*, Zegerid(g)*
DIOVAN, HCT Cozaar(g), Hyzaar(g), Benicar*, HCT*

* Prior Authorization or Step Therapy may be required. ** Covered with a prescription for BCN members and certain BCBSM members.
Most BCN members and some BCBSM members do not have coverage for nonformulary agents. Please use this list as a guide when selecting alternatives.
Page 34
NonFormulary Formulary Alternative NonFormulary Formulary Alternative
EXFORGE Lotrel(g), Generic ACE Inhibitor INVEGA Clozaril(g), Risperdal(g), Abilify,
(lisinopril, benazepril, etc.), Benicar*, Geodon, Seroquel, Zyprexa
or Cozaar(g) PLUS Norvasc(g) IOPIDINE Alphagan(g), Alphagan P
EXFORGE HCT Lotrel(g) plus HCTZ(g) IQUIX Ciloxan(g), Ocuflox(g), Vigamox
EXJADE Desferal(g) JALYN Cardura(g), Flomax(g), Hytrin(g),
EXTAVIA Avonex, Betaseron, Copaxone, Rebif Avodart, Uroxatral
EXTINA Nizoral(g) JANUMET Glucophage(g); Insulin or a
FACTIVE Erythromycin(g), Vibramycin(g), Sulfonylurea (Glucotrol, XL(g);
Zithromax(g), Avelox Micronase(g), Amaryl(g)), Actos*
FANAPT Clozaril(g), Risperdal(g), Abilify, JANUVIA Glucophage(g); Insulin or a
Geodon, Seroquel, Zyprexa Sulfonylurea (Glucotrol, XL(g);
Micronase(g), Amaryl(g)), Actos*
FAZACLO Clozaril(g), Risperdal(g), Abilify,
Geodon, Seroquel, Zyprexa KADIAN Methadone(g), MSIR(g), MS
Contin(g), Oramorph SR(g)
FEMCON FE Loestrin Fe(g) [NOT 24], Estrostep
Fe(g) KAOCHLOR-EFF Potassium Chloride(g) liquid,
capsules or tablets
FEMRING Estring
KEFLEX 750MG Keflex(g)
FEMTRACE Estrace(g), Ogen(g), Premarin
KEPPRA XR Keppra(g)
FENOGLIDE Lofibra(g), Lopid(g), Tricor
KETEK Erythromycin(g), Zithromax(g)
FENTORA Actiq(g)*, MSIR(g), MS Contin(g),
Oramorph SR(g), Roxanol(g) KINERET Enbrel*, Humira*
FEXMID Flexeril(g) LAMICTAL ODT, Lamictal(g), Disper tabs(g),
XR Tegretol(g)
FINACEA, PLUS Metrogel topical(g), Metrolotion(g),
Retin-A(g) LAMISIL Lamisil(g)
GRANULES
FLECTOR PATCH Topical OTC analgesic balms, i.e.
trolamine salicylate; Voltaren oral(g) LESCOL, XL Mevacor(g), Pravachol(g), Zocor(g),
Crestor*, Zetia*
FLOXIN OTIC Floxin(g)
SINGLES LEVAQUIN Vibramycin(g), Avelox
FOCALIN XR Adderall, XR(g)*, Focalin(g); Ritalin, LEVATOL Inderal(g), Inderal LA(g),
SR; Concerta, Metadate CD Lopressor(g), Sectral(g),
Tenormin(g), Toprol XL(g)
FOLLISTIM AQ Gonal-F, Gonal RFF
LEVITRA Cialis*, Viagra*
FORTAMET Glucophage(g)
LIALDA Azulfidine(g); Asacol, HD; Pentasa
FORTEO Fosamax(g), Miacalcin Nasal
Spray(g), Actonel* LIDODERM PATCH Topical lidocaine, EMLA(g)
FOSAMAX PLUS D Fosamax(g) plus OTC Vitamin D LIPITOR Mevacor(g), Pravachol(g), Zocor(g),
Crestor*, Zetia*
FOSRENOL Tums OTC, Phoslo(g), Renagel,
Renvela LIPOFEN Lofibra(g), Lopid(g), Tricor
FRAGMIN Lovenox(g) LIVALO Mevacor(g), Pravachol(g), Zocor(g),
Crestor*, Zetia*
FROVA Amerge(g)*, Imitrex(g); Maxalt*,
MLT* LOCOID Aristocort(g), Elocon(g), Locoid(g),
LIPOCREAM Synalar(g), Topicort(g)
GALZIN OTC zinc supplements
LOESTRIN 24 FE Loestrin(g), Loestrin Fe(g)
GELNIQUE Ditropan, XL(g); Detrol, LA
LOPROX Nizoral Shampoo 2%(g)
GILENYA Avonex, Copaxone, Rebif SHAMPOO
GLUMETZA Glucophage(g) LOSEASONIQUE Generic biphasic contraceptives
GLYSET Precose(g) LOTEMAX Decadron ophth(g), Pred Forte(g),
GYNAZOLE-1 Lotrimin OTC, Monistat OTC, Pred Mild
Diflucan 150mg(g), Terazol(g) LOTRONEX OTC Anti-diarrheals; Levbid(g);
HALFLYTELY Colyte(g) plus bisacodyl OTC Levsin, SL(g); Levsinex(g); Lomotil(g)
HECTOROL Rocaltrol(g) LOVAZA OTC Omega products, Lofibra(g),
HUMATROPE Genotropin*; Nutropin*, AQ* Lopid(g), Tricor
INNOPRAN XL Inderal(g), Inderal LA(g), Inderide(g) LUNESTA Ambien(g), Halcion(g), Prosom(g),
Restoril(g), Sonata(g)
INTUNIV Catapres(g), Tenex(g)
* Prior Authorization or Step Therapy may be required. ** Covered with a prescription for BCN members and certain BCBSM members.
Most BCN members and some BCBSM members do not have coverage for nonformulary agents. Please use this list as a guide when selecting alternatives.
Page 35
NonFormulary Formulary Alternative NonFormulary Formulary Alternative
LUVERIS Repronex NOROXIN Bactrim DS/Septra DS(g); Cipro(g),
LUVOX CR Luvox(g) immediate release XR(g)*
LUXIQ Aristocort(g), Elocon(g), Locoid(g), NUCYNTA Ultram(g); MSIR(g), oxycodone IR(g)
Synalar(g), Topicort(g) NUVARING Oral contraceptives, Ortho Evra
LYRICA Effexor(g), Effexor XR(g), Flexeril(g), NUVIGIL Provigil*
Neurontin(g), SSRI's(g), TCA's(g), OLEPTRO Desyrel(g)
Ultram(g)
OLUX-E Diprolene(g), Psorcon(g),
MAGNACET Percocet(g), Tylox(g) Temovate(g), Ultravate(g)
MARPLAN Parnate(g), Nardil OMNARIS Flonase(g), Nasalide(g), Nasarel(g),
MAXIDEX Decadron ophth(g) Nasacort AQ*
MEGACE ES Megace(g) OMNITROPE Genotropin*, Nutropin*, AQ*
MENEST Estradiol (various), Ogen(g) ONGLYZA Glucophage(g); Insulin or a
MENOPUR Repronex Sulfonylurea (Glucotrol, XL(g);
Micronase(g), Amaryl(g)), Actos*
MENOSTAR Climara(g), Estrace(g), Ogen(g),
Vivelle-DOT, Estraderm ONSOLIS Actiq(g)*, MSIR(g), MS Contin(g),
Oramorph SR(g), Roxanol(g)
MENTAX Lamisil AT(g), OTC; Lotrimin(g),
Ultra OTC; Monistat-Derm(g), OPANA, ER Methadone(g), Morphine(g), MS
Nizoral cream(g), Spectazole(g) Contin(g), Oramorph SR(g)
METHITEST Androxy(g), Depo-Testosterone(g), ORACEA Monodox(g), Vibramycin(g)
Oxandrin(g), Androderm, Delatestryl ORAPRED ODT Orapred(g)
METHYLIN CHEW Adderall XR(g)*, Metadate CD (Both ORAXYL Vibramycin(g)
of which may be "sprinkled" on food) ORTHO-PREFEST Use FemHRT, Prempro/Premphase,
METOZOLV ODT Reglan(g) or Estradiol plus progestin
MICARDIS, HCT Cozaar(g), Hyzaar(g), Benicar*, HCT* OSMOPREP Fleet's Phospho Soda OTC, Colyte(g)
MIRAPEX ER Mirapex(g) OVCON-50, FE Modicon(g), Ortho-Cyclen(g), Ortho-
MONUROL Bactrim(g), DS(g); Macrobid(g), Novum(g), Ovcon-35(g)
Cipro(g) OXISTAT Lamisil AT(g), OTC; Lotrimin(g),
MOVIPREP Colyte(g), Nulytely(g) Ultra OTC; Monistat-Derm(g),
Nizoral cream(g), Spectazole(g)
MOXATAG Amoxil capsules(g)
OXYCONTIN Duragesic(g), Methadone(g), MS
MYFORTIC Cellcept(g) Contin(g), Oramorph(g)
MYTELASE Mestinon(g), Prostigmin OXYTROL Ditropan, XL(g); Detrol, LA
NAFTIN Lotrimin(g), Monistat(g), Nystatin(g) PANCRECARB Pancrease MT - 16(g), Viokase
NAMENDA XR Razadyne, ER(g); Aricept, ODT(g); MS - 16
Namenda PANCRECARB Pancrease MT - 4(g), Pancrealipase
NAPRELAN Mobic(g); Motrin(g); Naprosyn, MS - 4 EC
EC(g); etc* PANDEL Aristocort(g), Elocon(g), Locoid(g),
NASCOBAL SPRAY Cyanocobalamin tabs OTC, Synalar(g), Topicort(g), Cloderm,
Cyanocobalamin injection Cordran
NASONEX Flonase(g), Nasalide(g), Nasarel(g), PANIXINE Keflex(g)
Nasacort AQ* PAREMYD Atropine(g), Cyclogyl(g), Mydriacyl(g)
NATAZIA Yasmin(g), Yaz(g) PATADAY Zaditor OTC(g), Alocril, Alomide,
NEULASTA Neupogen Patanol
NEVANAC Ocufen(g), Voltaren ophth(g) PATANASE Flonase(g), Nasalide(g), Nasarel(g),
NEXIUM Prilosec OTC**; Prevacid(g)*, Astelin(g), Nasacort AQ*
Solutab(g)*; Prilosec 20mg(g), PCE Biaxin(g), Erythromycin(g),
Protonix(g)* Zithromax(g)
NICOTROL, NS Nicotine gum(g), lozenge(g), patch(g) PENNSAID Topical OTC analgesic balms, i.e.
NORDITROPIN, Genotropin*; Nutropin*, AQ* trolamine salicylate; Voltaren oral(g)
NORDIFLEX PERANEX HC Anusol HC(g), Proctocream HC(g)
NORITATE MetroCream(g) PERFOROMIST Serevent Diskus, Foradil MDI

* Prior Authorization or Step Therapy may be required. ** Covered with a prescription for BCN members and certain BCBSM members.
Most BCN members and some BCBSM members do not have coverage for nonformulary agents. Please use this list as a guide when selecting alternatives.
Page 36
NonFormulary Formulary Alternative NonFormulary Formulary Alternative
PEXEVA Generic SSRI/SNRI (Celexa(g), SANCTURA XR Ditropan, XL(g); Sanctura(g); Detrol,
Prozac(g), Paxil(g), Zoloft (g), etc.) LA
PLAN B ONE-STEP Plan B(g) SANCUSO PATCH Kytril(g); Zofran, ODT(g)
PRANDIMET Individual agents: Prandin and SAPHRIS Clozaril(g), Risperdal(g), Abilify,
Glucophage(g) Geodon, Seroquel, Zyprexa
PRED-G Garamycin(g), Pred Forte(g) SARAFEM TABLET Sarafem capsule(g)
PREVACID Prilosec OTC**; Prevacid(g)*, SAVELLA Effexor(g), Effexor XR(g), Flexeril(g),
NAPRAPAC Solutab(g)*; Prilosec 20mg(g), PLUS Neurontin(g), SSRI(g), TCA's(g),
Naprosyn(g) Ultram(g)
PRILOSEC Prilosec OTC**; Prevacid(g)*, SEASONIQUE Generic biphasic contraceptives
SUSPENSION Solutab(g)*; Prilosec 20 mg(g), SEMPREX D Claritin OTC(g)**, Zyrtec OTC(g)**,
Protonix(g)* Allegra(g), Allegra-D 12 hour(g)*,
PRISTIQ Generic SSRI/SNRI (Celexa(g), Allegra-D 24 hour*, Astelin(g)
Prozac(g), Zoloft (g), Effexor(g), SEROQUEL XR Clozaril(g), Risperdal(g), Abilify,
Effexor XR(g), etc.) Geodon, Zyprexa, Seroquel(IR)
PROCENTRA Adderall XR(g)*, Metadate CD (Both SEROSTIM Genotropin*, Nutropin*, AQ*
of which may be "sprinkled" on food)
SERZONE(g) Generic SSRI/SNRI (Celexa(g),
PROQUIN XR Bactrim DS/Septra DS(g), Cipro(g), Prozac(g), Paxil(g), Zoloft(g), etc.)
XR(g) *
SILENOR Ambien(g), Desyrel(g), Sinequan(g),
PROTONIX SUSP Prilosec OTC**; Prevacid(g)*, Sonata(g)
Solutab(g)*; Prilosec 20mg(g);
Protonix(g)* SIMCOR Individual agents (Zocor(g) PLUS
Niaspan)
PROTOPIC Topical corticosteroids, Elidel*
SIMPONI Enbrel*, Humira*
PROVENTIL HFA Proair HFA, Ventolin HFA
SOLARAZE Efudex(g)
PYLERA Use Tetracycline(g) plus Flagyl(g)
plus Bismuth; or Helidac or SOLODYN Monodox(g), Vibramycin(g)
PREVPAC SOLTAMOX Nolvadex(g)
QUALAQUIN Aralen(g), Lariam(g), Plaquenil(g) SOMA 250 Soma(g)
QUIXIN Ciloxan(g), Vigamox STAXYN Cialis*, Viagra*
RANEXA Long-acting nitrate, plus a beta- STRATTERA Adderall, XR(g)*; Focalin(g),
blocker or calcium channel blocker Ritalin(g), Concerta, Metadate CD
RANICLOR Ceclor(g), Ceftin(g), Duricef(g), STRIANT Androxy(g), Depo-testosterone(g),
Keflex(g), Omnicef(g) Oxandrin(g), Androderm, Delatestryl
RAPAFLO Cardura(g), Flomax(g), Hytrin(g), SUMAVEL Amerge(g)*, Imitrex(g); Maxalt*,
Avodart, Uroxatral DOSEPRO MLT*
REGRANEX Ethezyme(g), Granulex(g) SUPRAX Ceclor(g), Ceftin(g), Duricef(g),
RELPAX Amerge(g)*, Imitrex(g); Maxalt*, Keflex(g), Omnicef(g)
MLT* SYMBYAX Use Zyprexa plus Prozac(g)
REQUIP XL Requip(g) SYMLIN Insulin
REVLIMID Thalomid TACLONEX, Use Dovonex plus
RHINOCORT Flonase(g), Nasalide(g), Nasarel(g), SCALP Diprosone/Diprolene(g)
AQUA Nasacort AQ* TASMAR Comtan
RIOMET Glucophage(g) TEKAMLO Lotrel(g), Generic ACE Inhibitor
RITALIN LA Adderall, XR(g)*; Ritalin(g), (lisinopril, benazepril, etc.), Benicar*,
Concerta, Metadate CD or Cozaar(g) PLUS Norvasc(g)
ROZEREM Ambien(g), Halcion(g), Prosom(g), TEKTURNA, HCT Generic ACE Inhibitors (benazapril,
Restoril(g), Sonata(g) enalapril, lisinopril, etc.)
RYBIX ODT Ultram(g) TESTIM Androderm
RYTHMOL SR Rythmol(g) TESTRED, Androxy(g), Depo-testosterone(g),
ANDROID Oxandrin(g), Androderm, Delatestryl
RYZOLT Ultram(g)
TEVETEN, HCT Cozaar(g), Hyzaar(g), Benicar*, HCT*
SAIZEN Genotropin*; Nutropin*, AQ*
TEV-TROPIN Genotropin*; Nutropin*, AQ*

* Prior Authorization or Step Therapy may be required. ** Covered with a prescription for BCN members and certain BCBSM members.
Most BCN members and some BCBSM members do not have coverage for nonformulary agents. Please use this list as a guide when selecting alternatives.
Page 37
NonFormulary Formulary Alternative NonFormulary Formulary Alternative
TIROSINT Synthroid(g) XYREM Ambien(g), Halcion(g), Prosom(g),
TOVIAZ Ditropan, XL(g); Detrol, LA Restoril(g)
TRANXENE SD Ativan(g), Buspar(g), Serax(g), XYZAL SOLUTION Claritin OTC(g)**, Zyrtec OTC(g)**,
Tranxene(g), Valium(g), Xanax(g) Allegra(g)
TREXIMET Individual agents (Imitrex(g) PLUS ZANAFLEX(g) Dantrium(g), Flexeril(g), Lioresal(g)
naproxen); Amerge(g)*; Maxalt, MLT* ZANTAC Zantac, OTC(g); Pepcid(g)
TRIBENZOR Cozaar(g), HCTZ(g), Hyzaar(g), EFFERDOSE
PLUS Norvasc(g) ZAVESCA Ceredase, Cerezyme (medical
TRIGLIDE Lofibra(g), Lopid(g), Tricor benefit)
TRILIPIX Lofibra(g), Lopid(g), Tricor ZEGERID PACKET Prilosec OTC**; Prevacid(g)*,
Solutab(g)*; Prilosec 20mg(g),
TWYNSTA Lotrel(g), Generic ACE Inhibitor Protonix(g)*, Zegerid(g)*
(lisinopril, benazepril, etc.), Benicar*,
or Cozaar(g) PLUS Norvasc(g) ZELAPAR Eldepryl(g)
TYZEKA Baraclude, Epivir HBV, Hepsera ZEMPLAR Rocaltrol(g)
ULORIC Zyloprim(g) ZIANA GEL Individual agents: Cleocin topical(g)
and Retin-A(g)*
ULTRAM ER Ultram(g)
300MG ZIPSOR Mobic(g), Motrin(g), Naprosyn,
EC(g); Voltaren(g), etc*
VAGIFEM Climara(g), Ogen(g), Vivelle-DOT,
Estraderm, Estring, Premarin Vaginal ZMAX Zithromax(g)
VALTURNA Generic ACE Inhibitors (benazapril, ZOLPIMIST Ambien(g), Sonata(g)
enalapril, lisinopril, etc.) ZOMIG, ZMT, Amerge(g)*, Imitrex(g); Maxalt*,
VANOS 0.1% CR Diprolene(g), Psorcon(g), NASAL SPRAY MLT*
Temovate(g), Ultravate(g) ZORBTIVE Genotropin*; Nutropin*, AQ*
VECTICAL Dovonex ZUPLENZ Kytril(g); Zofran, ODT(g)
VERAMYST Flonase(g), Nasalide(g), Nasarel(g), ZYCLARA Aldara(g)
Nasacort AQ* ZYDONE Lortab(g), Tylenol with Codeine(g),
VERDESO Elocon(g), Locoid(g), Synalar Vicodin(g)
solution(g), Capex ZYFLO CR Accolate(g), Inhaled Steroids,
VEREGEN Condylox Solution(g), Gel Singulair
VESICARE Ditropan, XL(g); Detrol, LA ZYLET Maxitrol(g), Tobradex(g),
VICTOZA Insulin, Glucophage(g), Vasocidin(g)
Sulfonylurea's, TZD's ZYMAR Ciloxan(g), Vigamox
VISICOL Fleet's Phospho Soda OTC, Colyte(g) ZYMAXID Ciloxan(g), Ocuflox(g)
VOLTAREN GEL Topical OTC analgesic balms, i.e.
trolamine salicylate; Voltaren oral(g)
VUSION OTC diaper rash products
VYTORIN Mevacor(g), Pravachol(g), Zocor(g),
Crestor*; plus Zetia*
VYVANSE Adderall, XR(g)*; Ritalin, SR(g);
Concerta, Metadate CD
XENICAL Alli OTC, Bontril(g)*, Didrex(g)*,
Phentermine(g)*, Tenuate(g)*
XERESE Zovirax cream PLUS HC cream
XIBROM Ocufen(g), Voltaren (ophthalmic)(g)
XIFAXAN 220MG Bactrim DS(g), Vibramycin(g)
XIFAXAN 550MG Lactulose
XODOL Vicodin(g)
XOLEGEL Nizoral(g)
XOPENEX, HFA Albuterol(g); Maxair; Proair HFA,
Ventolin HFA

* Prior Authorization or Step Therapy may be required. ** Covered with a prescription for BCN members and certain BCBSM members.
Most BCN members and some BCBSM members do not have coverage for nonformulary agents. Please use this list as a guide when selecting alternatives.
Page 38
Dose Optimization and Quantity Limits

The Blue Cross Blue Shield of Michigan and Blue Care Network dose optimization programs encourage
appropriate prescribing of medications intended for once-daily administration. Quantities of these
medications are limited to single daily doses of appropriate strengths. Michigan Blues pharmacists work
closely with physicians and community pharmacists to achieve this goal, which promotes patient
compliance and more cost-effective therapy. Examples of some drugs include certain cholesterol-lowering,
diabetes, antidepressant and antihypertensive medications.

Quantity limits also apply to both BCBSM and BCN for other medications, based on manufacturer
recommendations, available package size and other criteria. These drugs are identified with a Quantity
Limit (#) indicator. A complete list of medications subject to quantity limits is available at:
bcbsm.com/provider/pharmacy_services/index.shtml.

Copayments
A member’s benefit plan design determines applicable copayments for covered prescriptions.

Symbols used throughout the document


(g) Use generic equivalent
(#) Quantity limits may apply
[PA] Prior authorization required for some members
[ST] Step therapy required prior to use for some members
<s> Specialty drug
BE Drugs offered a Tier 0 copayment for Blue EssentialsSM Rx benefit

Editor’s note:
Please send us your comments and suggestions regarding this custom formulary. Your input is vital to its
continued success. We review and consider all responses. Please send your comments to:

Drug Information Services — Mail Code B773


Blue Cross Blue Shield of Michigan
600 E. Lafayette Boulevard
Detroit, MI 48226-2998
or

Pharmacy Services — Mail Code C303


Blue Care Network of Michigan
20500 Civic Center Drive
Southfield, MI 48076-5043

Page 39
1. ANTI-INFECTIVES

1A. Penicillins

Formulary Preferred
Trade Name Generic Name Utilization Management
AMOXIL (g) AMOXICILLIN TRIHYDRATE
AMPICILLIN (g) AMPICILLIN TRIHYDRATE
AUGMENTIN, ES, XR (g) AMOX TR/POTASSIUM CLAVULANATE
DICLOXACILLIN (g) DICLOXACILLIN SODIUM
PENICILLIN VK (g) PENICILLIN V POTASSIUM
Formulary Options
Trade Name Generic Name Utilization Management
NONE
Nonformulary
Trade Name Generic Name Utilization Management
MOXATAG AMOXICILLIN TRIHYDRATE
1B. Cephalosporins

Formulary Preferred
Trade Name Generic Name Utilization Management
CECLOR (g) CEFACLOR
CECLOR ER (g) CEFACLOR
CEFTIN (g) CEFUROXIME AXETIL
CEFZIL (g) CEFPROZIL
DURICEF (g) CEFADROXIL HYDRATE
KEFLEX (g) CEPHALEXIN MONOHYDRATE
OMNICEF (g) CEFDINIR
SPECTRACEF (g) CEFDITOREN PIVOXIL [QL]
VANTIN (g) CEFPODOXIME PROXETIL
Formulary Options
Trade Name Generic Name Utilization Management
NONE
Nonformulary
Trade Name Generic Name Utilization Management
CEDAX CEFTIBUTEN DIHYDRATE
KEFLEX 750MG CEPHALEXIN MONOHYDRATE
RANICLOR CEFACLOR
SUPRAX CEFIXIME

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 40
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
1C. Tetracyclines

Formulary Preferred
Trade Name Generic Name Utilization Management
ADOXA (g) DOXYCYCLINE MONOHYDRATE [PA]
MINOCIN, DYNACIN (g) MINOCYCLINE HCL
MONODOX (g) DOXYCYCLINE MONOHYDRATE
PERIOSTAT (g) DOXYCYCLINE HYCLATE
SOLODYN 45, 90, 135MG(g) MINOCYCLINE HCL [PA]
TETRACYCLINE (g) TETRACYCLINE HCL
VIBRAMYCIN, VIBRATABS (g) DOXYCYCLINE HYCLATE
Formulary Options
Trade Name Generic Name Utilization Management
NONE
Nonformulary
Trade Name Generic Name Utilization Management
ADOXA 150MG CAPSULE DOXYCYCLINE MONOHYDRATE [PA]
ADOXA CK, TT DOXYCYCLINE MONOHY/SKIN CLNSR9 [PA]
DORYX DOXYCYCLINE HYCLATE [PA]
ORACEA DOXYCYCLINE MONOHYDRATE [PA]
ORAXYL DOXYCYCLINE HYCLATE
SOLODYN 55, 65, 80, 105, 115MG MINOCYCLINE HCL [PA]
1D. Macrolides

Formulary Preferred
Trade Name Generic Name Utilization Management
BIAXIN, XL (g) CLARITHROMYCIN
ERYTHROMYCIN (g) ERYTHROMYCIN ETHYLSUCCINATE
ERYTHROMYCIN STEARATE, BASE (g) ERYTHROMYCIN BASE
PEDIAZOLE (g) ERY E-SUCC/SULFISOXAZOLE
ZITHROMAX (g) AZITHROMYCIN
Formulary Options
Trade Name Generic Name Utilization Management
NONE
Nonformulary
Trade Name Generic Name Utilization Management
KETEK TELITHROMYCIN
PCE ERYTHROMYCIN BASE
ZMAX AZITHROMYCIN

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 41
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
1E. Quinolones

Formulary Preferred
Trade Name Generic Name Utilization Management
CIPRO (g) CIPROFLOXACIN HCL
CIPRO XR (g) CIPROFLOXACIN HCL-BETAINE COMB [PA] [QL]
FLOXIN (g) OFLOXACIN
Formulary Options
Trade Name Generic Name Utilization Management
AVELOX, ABC MOXIFLOXACIN HCL
Nonformulary
Trade Name Generic Name Utilization Management
FACTIVE GEMIFLOXACIN MESYLATE
LEVAQUIN LEVOFLOXACIN
NOROXIN NORFLOXACIN
PROQUIN XR CIPROFLOXACIN HCL [PA] [QL]
1F. Sulfonamides and Combinations

Formulary Preferred
Trade Name Generic Name Utilization Management
BACTRIM, DS, SEPTRA, DS (g) SULFAMETHOXAZOLE/TRIMETHOPRIM
PEDIAZOLE (g) ERY E-SUCC/SULFISOXAZOLE
SULFADIAZINE (g) SULFADIAZINE
Formulary Options
Trade Name Generic Name Utilization Management
NONE
Nonformulary
Trade Name Generic Name Utilization Management
NONE
1G. Urinary Tract Agents

Formulary Preferred
Trade Name Generic Name Utilization Management
HIPREX/UREX (g) METHENAMINE HIPPURATE
MACROBID (g) NITROFURANTOIN/NITROFURAN MAC
MACRODANTIN (g) NITROFURANTOIN MACROCRYSTAL
MANDELAMINE (g) METHENAMINE MANDELATE
PYRIDIUM (g) PHENAZOPYRIDINE HCL
TRIMETHOPRIM (g) TRIMETHOPRIM
Formulary Options
Trade Name Generic Name Utilization Management
NONE
Nonformulary
Trade Name Generic Name Utilization Management
MONUROL FOSFOMYCIN TROMETHAMINE

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 42
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
1H. Antifungals

Formulary Preferred
Trade Name Generic Name Utilization Management
DIFLUCAN (g) FLUCONAZOLE
GRIFULVIN V SUSP (g) GRISEOFULVIN,MICROSIZE
LAMISIL TABLETS (g) TERBINAFINE HCL
MYCELEX TROCHE (g) CLOTRIMAZOLE
NIZORAL (g) KETOCONAZOLE
NYSTATIN (g) NYSTATIN
SPORANOX CAPS (g) ITRACONAZOLE
Formulary Options
Trade Name Generic Name Utilization Management
ANCOBON FLUCYTOSINE
GRIFULVIN V 500MG GRISEOFULVIN,MICROSIZE
GRIS PEG GRISEOFULVIN ULTRAMICROSIZE
NOXAFIL POSACONAZOLE
SPORANOX SOLN ITRACONAZOLE
VFEND VORICONAZOLE
Nonformulary
Trade Name Generic Name Utilization Management
LAMISIL GRANULES TERBINAFINE HCL [PA]
ORAVIG MICONAZOLE [QL]
1I. Antivirals

Formulary Preferred
Trade Name Generic Name Utilization Management
COPEGUS (g) RIBAVIRIN [PA] <s>
CYTOVENE (g) GANCICLOVIR
FAMVIR (g) FAMCICLOVIR [QL]
FLUMADINE (g) RIMANTADINE HCL
REBETOL (g) RIBAVIRIN [PA] <s>
SYMMETREL (g) AMANTADINE HCL
VALTREX (g) VALACYCLOVIR HCL [QL]
ZOVIRAX (g) ACYCLOVIR
Formulary Options
Trade Name Generic Name Utilization Management
BARACLUDE ENTECAVIR <s>
EPIVIR HBV LAMIVUDINE
HEPSERA ADEFOVIR DIPIVOXIL <s>
REBETOL SOLUTION RIBAVIRIN [PA] <s>
RELENZA ZANAMIVIR [QL]
TAMIFLU CAP, SUSP OSELTAMIVIR PHOSPHATE [QL]
VALCYTE VALGANCICLOVIR HYDROCHLORIDE
Nonformulary
Trade Name Generic Name Utilization Management
TYZEKA TELBIVUDINE <s>

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 43
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
1J. Antiretrovirals

Formulary Preferred
Trade Name Generic Name Utilization Management
RETROVIR (g) ZIDOVUDINE
VIDEX EC (g) DIDANOSINE
ZERIT (g) STAVUDINE
Formulary Options
Trade Name Generic Name Utilization Management
APTIVUS(MUST BE USED WITH NORVIR) TIPRANAVIR
ATRIPLA EFAVIRENZ/EMTRICITAB/TENOFOVIR
COMBIVIR LAMIVUDINE/ZIDOVUDINE
CRIXIVAN INDINAVIR SULFATE
EMTRIVA EMTRICITABINE
EPIVIR LAMIVUDINE
EPZICOM ABACAVIR SULFATE/LAMIVUDINE
FUZEON ENFUVIRTIDE <s>
INTELENCE ETRAVIRINE
INVIRASE SAQUINAVIR MESYLATE
ISENTRESS RALTEGRAVIR POTASSIUM
KALETRA RITONAVIR/LOPINAVIR
LEXIVA FOSAMPRENAVIR CALCIUM
NORVIR RITONAVIR
PREZISTA(MUST BE USED WITH NORVIR) DARUNAVIR ETHANOLATE
RESCRIPTOR DELAVIRDINE MESYLATE
REYATAZ ATAZANAVIR SULFATE
SELZENTRY MARAVIROC
SUSTIVA EFAVIRENZ
TRIZIVIR ABACAVIR/LAMIVUDINE/ZIDOVUDINE
TRUVADA EMTRICITABINE/TENOFOVIR
VIDEX DIDANOSINE
VIRACEPT NELFINAVIR MESYLATE
VIRAMUNE NEVIRAPINE
VIREAD TENOFOVIR DISOPROXIL FUMARATE
ZIAGEN ABACAVIR SULFATE
Nonformulary
Trade Name Generic Name Utilization Management
NONE

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 44
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
1K. Antimalarials

Formulary Preferred
Trade Name Generic Name Utilization Management
ARALEN (g) CHLOROQUINE PHOSPHATE
LARIAM (g) MEFLOQUINE HCL
PLAQUENIL (g) HYDROXYCHLOROQUINE SULFATE
Formulary Options
Trade Name Generic Name Utilization Management
COARTEM ARTEMETHER/LUMEFANTRINE [QL]
DARAPRIM PYRIMETHAMINE
MALARONE ATOVAQUONE/PROGUANIL HCL
PRIMAQUINE PRIMAQUINE PHOSPHATE
Nonformulary
Trade Name Generic Name Utilization Management
QUALAQUIN QUININE SULFATE
1L. Antituberculars

Formulary Preferred
Trade Name Generic Name Utilization Management
ETHAMBUTOL (g) ETHAMBUTOL HCL
ISONIAZID (g) ISONIAZID
PYRAZINAMIDE (g) PYRAZINAMIDE
RIFADIN (g) RIFAMPIN
RIFAMATE (g) RIFAMPIN/ISONIAZID
Formulary Options
Trade Name Generic Name Utilization Management
DAPSONE DAPSONE
MYCOBUTIN RIFABUTIN
SEROMYCIN CYCLOSERINE
Nonformulary
Trade Name Generic Name Utilization Management
PRIFTIN RIFAPENTINE
RIFATER RIFAMPIN/INH/PYRAZINAMIDE
TRECATOR ETHIONAMIDE

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 45
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
1M. Antiparasitics/Anthelmintics

Formulary Preferred
Trade Name Generic Name Utilization Management
FLAGYL (g) METRONIDAZOLE
HUMATIN (g) PAROMOMYCIN SULFATE
VERMOX (g) MEBENDAZOLE [QL]
Formulary Options
Trade Name Generic Name Utilization Management
ALINIA NITAZOXANIDE
BILTRICIDE PRAZIQUANTEL
FLAGYL ER METRONIDAZOLE
MEPRON ATOVAQUONE
NEBUPENT AEROSOL PENTAMIDINE ISETHIONATE
STROMECTROL - SINGLE DOSE IVERMECTIN [QL]
TINDAMAX TINIDAZOLE [QL]
Nonformulary
Trade Name Generic Name Utilization Management
ALBENZA ALBENDAZOLE
1N. Miscellaneous Anti-infectives

Formulary Preferred
Trade Name Generic Name Utilization Management
CLEOCIN (g) CLINDAMYCIN HCL
NEOMYCIN (g) NEOMYCIN SULFATE
Formulary Options
Trade Name Generic Name Utilization Management
TOBI TOBRAMYCIN/0.25 NORMAL SALINE [QL] <s>
VANCOCIN HCL VANCOMYCIN HCL
ZYVOX LINEZOLID
Nonformulary
Trade Name Generic Name Utilization Management
CAYSTON AZTREONAM LYSINE [PA] [QL] <s>
XIFAXAN 200MG RIFAXIMIN [QL]
XIFAXAN 550MG RIFAXIMIN [PA] [QL]

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 46
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
2. CARDIOVASCULAR, HYPERTENSION, CHOLESTEROL

2A. Lipid-lowering Agents

Formulary Preferred
Trade Name Generic Name Utilization Management
COLESTID (g) COLESTIPOL HCL
FIBRICOR (g) FENOFIBRIC ACID
LOFIBRA (g) FENOFIBRATE,MICRONIZED BE
LOPID (g) GEMFIBROZIL BE
MEVACOR (g) LOVASTATIN [QL] BE
PRAVACHOL (g) PRAVASTATIN SODIUM [QL] BE
QUESTRAN, QUESTRAN LIGHT (g) CHOLESTYRAMINE
ZOCOR (g) SIMVASTATIN [QL] BE
Formulary Options
Trade Name Generic Name Utilization Management
CRESTOR ROSUVASTATIN CALCIUM [ST] [QL]
NIASPAN NIACIN BE
TRICOR FENOFIBRATE NANOCRYSTALLIZED [QL]
WELCHOL COLESEVELAM HCL
ZETIA EZETIMIBE [ST] [QL]
Nonformulary
Trade Name Generic Name Utilization Management
ADVICOR NIACIN/LOVASTATIN [PA] [QL]
ALTOPREV LOVASTATIN [PA] [QL]
ANTARA FENOFIBRATE,MICRONIZED
CADUET AMLODIPINE/ATORVAST CAL [PA] [QL]
COLESTID FLAVORED COLESTIPOL HCL
FENOGLIDE FENOFIBRATE
LESCOL, XL FLUVASTATIN SODIUM [PA] [QL]
LIPITOR ATORVASTATIN CALCIUM [PA] [QL]
LIPOFEN FENOFIBRATE [QL]
LIVALO PITAVASTATIN CALCIUM [ST] [QL]
LOVAZA OMEGA-3 ACID ETHYL ESTERS
SIMCOR NIACIN/SIMVASTATIN [ST]
TRIGLIDE FENOFIBRATE NANOCRYSTALLIZED
TRILIPIX FENOFIBRIC ACID [PA] [QL]
VYTORIN EZETIMIBE/SIMVASTATIN [PA] [QL]

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 47
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
2B. Beta Blockers and Combinations

Formulary Preferred
Trade Name Generic Name Utilization Management
BETAPACE, AF (g) SOTALOL HCL BE
BLOCADREN (g) TIMOLOL MALEATE BE
COREG (g) CARVEDILOL BE
CORGARD (g) NADOLOL BE
CORZIDE (g) NADOLOL/BENDROFLUMETHIAZIDE BE
INDERAL (g) PROPRANOLOL HCL BE
INDERAL LA (g) PROPRANOLOL HCL [QL] BE
INDERIDE (g) PROPRANOLOL/HYDROCHLOROTHIAZIDE BE
KERLONE (g) BETAXOLOL HCL BE
LOPRESSOR (g) METOPROLOL TARTRATE BE
LOPRESSOR HCT (g) METOPROLOL/HYDROCHLOROTHIAZIDE BE
NORMODYNE (g) LABETALOL HCL BE
PINDOLOL (g) PINDOLOL BE
SECTRAL (g) ACEBUTOLOL HCL BE
TENORETIC (g) ATENOLOL/CHLORTHALIDONE BE
TENORMIN (g) ATENOLOL BE
TOPROL XL (g) METOPROLOL SUCCINATE BE
ZEBETA (g) BISOPROLOL FUMARATE BE
ZIAC (g) BISOPROL/HYDROCHLOROTHIAZIDE BE
Formulary Options
Trade Name Generic Name Utilization Management
NONE
Nonformulary
Trade Name Generic Name Utilization Management
BYSTOLIC NEBIVOLOL HCL [PA] [QL]
COREG CR CARVEDILOL PHOSPHATE [PA] [QL]
INNOPRAN XL PROPRANOLOL HCL
LEVATOL PENBUTOLOL SULFATE

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 48
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
2C. ACE-Inhibitors and Combinations

Formulary Preferred
Trade Name Generic Name Utilization Management
ACCUPRIL (g) QUINAPRIL HCL BE
ACCURETIC (g) QUINAPRIL/HYDROCHLOROTHIAZIDE BE
ACEON (g) PERINDOPRIL ERBUMINE
ALTACE CAPSULE (g) RAMIPRIL BE
CAPOTEN (g) CAPTOPRIL BE
CAPOZIDE (g) CAPTOPRIL/HYDROCHLOROTHIAZIDE BE
LOTENSIN (g) BENAZEPRIL HCL BE
LOTENSIN HCT (g) BENAZEPRIL/HYDROCHLOROTHIAZIDE BE
LOTREL (g) AMLODIPINE BESYLATE/BENAZEPRIL BE
MAVIK (g) TRANDOLAPRIL BE
MONOPRIL (g) FOSINOPRIL SODIUM BE
MONOPRIL HCT (g) FOSINOPRIL/HYDROCHLOROTHIAZIDE BE
PRINIVIL, ZESTRIL (g) LISINOPRIL BE
PRINZIDE, ZESTORETIC (g) LISINOPRIL/HYDROCHLOROTHIAZIDE BE
TARKA (g) TRANDOLAPRIL/VERAPAMIL HCL [QL]
UNIRETIC (g) MOEXIPRIL/HYDROCHLOROTHIAZIDE BE
UNIVASC (g) MOEXIPRIL HCL BE
VASERETIC (g) ENALAPRIL/HYDROCHLOROTHIAZIDE BE
VASOTEC (g) ENALAPRIL MALEATE BE
Formulary Options
Trade Name Generic Name Utilization Management
LOTREL 5/40, 10/40 AMLODIPINE BESYLATE/BENAZEPRIL [QL]
Nonformulary
Trade Name Generic Name Utilization Management
ALTACE TABLET RAMIPRIL [PA] [QL]

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 49
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
2D. Angiotensin II Receptor Blockers and Combinations

Formulary Preferred
Trade Name Generic Name Utilization Management
COZAAR (g) LOSARTAN POTASSIUM [QL] BE
HYZAAR (g) LOSARTAN/HYDROCHLOROTHIAZIDE [QL] BE
Formulary Options
Trade Name Generic Name Utilization Management
BENICAR OLMESARTAN MEDOXOMIL [ST] [QL]
BENICAR HCT OLMESARTAN/HYDROCHLOROTHIAZIDE [ST] [QL]
Nonformulary
Trade Name Generic Name Utilization Management
ATACAND CANDESARTAN CILEXETIL [PA] [QL]
ATACAND HCT CANDESARTAN/HYDROCHLOROTHIAZID [PA]
AVALIDE IRBESARTAN/HYDROCHLOROTHIAZIDE [PA] [QL]
AVAPRO IRBESARTAN [PA] [QL]
AZOR AMLODIPINE BES/OLMESARTAN MED [PA] [QL]
DIOVAN VALSARTAN [PA]
DIOVAN HCT VALSARTAN/HYDROCHLOROTHIAZIDE [PA] [QL]
EXFORGE AMLODIPINE/VALSARTAN [PA]
EXFORGE HCT AMLODIPINE/VALSARTAN/HCTZ [PA] [QL]
MICARDIS TELMISARTAN [PA] [QL]
MICARDIS HCT TELMISARTAN/HYDROCHLOROTHIAZID [PA] [QL]
TEVETEN EPROSARTAN MESYLATE [PA]
TEVETEN HCT EPROSARTAN/HYDROCHLOROTHIAZIDE [PA]
TRIBENZOR OLMESARTAN MED/AMLODIPINE/HCTZ [ST] [QL]
TWYNSTA TELMISARTAN/AMLODIPINE [PA] [QL]
VALTURNA ALISKIREN/VALSARTAN [PA] [QL]

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 50
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
2E. Calcium Channel Blockers and Combinations

Formulary Preferred
Trade Name Generic Name Utilization Management
CALAN SR/ISOPTIN SR (g) VERAPAMIL HCL
CARDENE (g) NICARDIPINE HCL
CARDIZEM LA (g) DILTIAZEM HCL
CARDIZEM, SR, CD (g) DILTIAZEM HCL
DYNACIRC (g) ISRADIPINE
LOTREL (g) AMLODIPINE BESYLATE/BENAZEPRIL BE
NORVASC (g) AMLODIPINE BESYLATE BE
PLENDIL (g) FELODIPINE
PROCARDIA, XL;ADALAT CC (g) NIFEDIPINE [QL]
SULAR (g) NISOLDIPINE
TARKA (g) TRANDOLAPRIL/VERAPAMIL HCL [QL]
TIAZAC (g) DILTIAZEM HCL
VERELAN (g) VERAPAMIL HCL
VERELAN PM (g) VERAPAMIL HCL
Formulary Options
Trade Name Generic Name Utilization Management
COVERA-HS VERAPAMIL HCL
LOTREL 5/40, 10/40 AMLODIPINE BESYLATE/BENAZEPRIL [QL]
Nonformulary
Trade Name Generic Name Utilization Management
AZOR AMLODIPINE BES/OLMESARTAN MED [PA] [QL]
CADUET AMLODIPINE/ATORVAST CAL [PA] [QL]
CARDENE SR NICARDIPINE HCL
CARDIZEM LA DILTIAZEM HCL
DYNACIRC CR ISRADIPINE
EXFORGE AMLODIPINE/VALSARTAN [PA]
EXFORGE HCT AMLODIPINE/VALSARTAN/HCTZ [PA] [QL]
SULAR 8.5, 17, 25.5, 34MG NISOLDIPINE
TEKAMLO ALISKIREN/AMLODIPINE [ST] [QL]
TRIBENZOR OLMESARTAN MED/AMLODIPINE/HCTZ [ST] [QL]
TWYNSTA TELMISARTAN/AMLODIPINE [PA] [QL]

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 51
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
2F. Diuretics

Formulary Preferred
Trade Name Generic Name Utilization Management
ALDACTAZIDE (g) SPIRONOLACT/HYDROCHLOROTHIAZID BE
ALDACTONE (g) SPIRONOLACTONE BE
BUMEX (g) BUMETANIDE BE
DEMADEX (g) TORSEMIDE BE
DIAMOX (g) ACETAZOLAMIDE
DIAMOX SEQUELS (g) ACETAZOLAMIDE
DIURIL (g) CHLOROTHIAZIDE BE
HYDRODIURIL, MICROZIDE (g) HYDROCHLOROTHIAZIDE BE
HYGROTON, THALITONE (g) CHLORTHALIDONE BE
INSPRA (g) EPLERENONE BE
LASIX (g) FUROSEMIDE BE
LOZOL (g) INDAPAMIDE BE
MAXZIDE, DYAZIDE (g) TRIAMTERENE/HYDROCHLOROTHIAZID BE
MIDAMOR (g) AMILORIDE HCL BE
MODURETIC (g) AMILORIDE/HYDROCHLOROTHIAZIDE BE
ZAROXOLYN (g) METOLAZONE BE
Formulary Options
Trade Name Generic Name Utilization Management
DYRENIUM TRIAMTERENE
EDECRIN ETHACRYNIC ACID
Nonformulary
Trade Name Generic Name Utilization Management
NONE
2G. Cardiovascular Treatment

Formulary Preferred
Trade Name Generic Name Utilization Management
BETAPACE, AF (g) SOTALOL HCL BE
CORDARONE (g) AMIODARONE HCL
DIGOXIN ELIXIR (g) DIGOXIN
DIGOXIN TABS (g) DIGOXIN
MEXITIL (g) MEXILETINE HCL
NORPACE (g) DISOPYRAMIDE PHOSPHATE
PROAMATINE (g) MIDODRINE HCL
PRONESTYL, SR (g) PROCAINAMIDE HCL
QUINIDEX (g) QUINIDINE SULFATE
QUINIDINE GLUCONATE SA (g) QUINIDINE GLUCONATE
RYTHMOL (g) PROPAFENONE HCL
TAMBOCOR (g) FLECAINIDE ACETATE
Formulary Options
Trade Name Generic Name Utilization Management
MULTAQ DRONEDARONE HYDROCHLORIDE [QL]
NORPACE CR DISOPYRAMIDE PHOSPHATE
TIKOSYN DOFETILIDE
Nonformulary
Trade Name Generic Name Utilization Management
RANEXA RANOLAZINE [PA]
RYTHMOL SR PROPAFENONE HCL
(g) Use generic equivalent
[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 52
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
2H. Nitrates and Combinations

Formulary Preferred
Trade Name Generic Name Utilization Management
IMDUR (g) ISOSORBIDE MONONITRATE
ISMO, MONOKET (g) ISOSORBIDE MONONITRATE
ISORDIL (g) ISOSORBIDE DINITRATE
NITROGLYCERIN PATCH (g) NITROGLYCERIN
NITROGLYCERIN SA CAP (g) NITROGLYCERIN
Formulary Options
Trade Name Generic Name Utilization Management
DILATRATE-SR ISOSORBIDE DINITRATE
NITRO-BID OINTMENT NITROGLYCERIN
NITROLINGUAL SPRAY NITROGLYCERIN
NITROMIST NITROGLYCERIN
NITROSTAT NITROGLYCERIN
Nonformulary
Trade Name Generic Name Utilization Management
NONE
2I. Anticoagulants and Hemostasis Agents

Formulary Preferred
Trade Name Generic Name Utilization Management
AGRYLIN (g) ANAGRELIDE HCL
AMICAR (g) AMINOCAPROIC ACID
COUMADIN (g) WARFARIN SODIUM BE
HEPARIN (g) HEPARIN SODIUM,PORCINE <s>
LOVENOX (g) ENOXAPARIN SODIUM <s>
PERSANTINE (g) DIPYRIDAMOLE
PLETAL (g) CILOSTAZOL
TICLID (g) TICLOPIDINE HCL
TRENTAL (g) PENTOXIFYLLINE
Formulary Options
Trade Name Generic Name Utilization Management
EFFIENT PRASUGREL HYDROCHLORIDE [QL]
MEPHYTON PHYTONADIONE
PLAVIX CLOPIDOGREL BISULFATE
Nonformulary
Trade Name Generic Name Utilization Management
AGGRENOX ASPIRIN/DIPYRIDAMOLE
ARIXTRA FONDAPARINUX SODIUM <s>
FRAGMIN DALTEPARIN SODIUM,PORCINE <s>
INNOHEP TINZAPARIN SODIUM,PORCINE <s>

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 53
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
2J. Alpha-adrenergic Agents

Formulary Preferred
Trade Name Generic Name Utilization Management
ALDOMET (g) METHYLDOPA
ALDORIL (g) METHYLDOPA/HYDROCHLOROTHIAZIDE
CARDURA (g) DOXAZOSIN MESYLATE
CATAPRES (g) CLONIDINE HCL
CATAPRES-TTS (g) CLONIDINE HCL
HYTRIN (g) TERAZOSIN HCL
MINIPRESS (g) PRAZOSIN HCL
RESERPINE (g) RESERPINE
TENEX (g) GUANFACINE HCL
Formulary Options
Trade Name Generic Name Utilization Management
NONE
Nonformulary
Trade Name Generic Name Utilization Management
NONE
2K. Miscellaneous Antihypertensives

Formulary Preferred
Trade Name Generic Name Utilization Management
APRESOLINE (g) HYDRALAZINE HCL
LONITEN (g) MINOXIDIL
PAPAVERINE CAPS (g) PAPAVERINE HCL
VASODILAN (g) ISOXSUPRINE HCL
Formulary Options
Trade Name Generic Name Utilization Management
NONE
Nonformulary
Trade Name Generic Name Utilization Management
TEKAMLO ALISKIREN/AMLODIPINE [ST] [QL]
TEKTURNA ALISKIREN HEMIFUMARATE [PA]
TEKTURNA HCT ALISKIREN/HYDROCHLOROTHIAZIDE [PA]
VALTURNA ALISKIREN/VALSARTAN [PA] [QL]

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 54
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
3. CENTRAL NERVOUS SYSTEM

3A. Antidepressants

Formulary Preferred
Trade Name Generic Name Utilization Management
AMOXAPINE (g) AMOXAPINE
ANAFRANIL (g) CLOMIPRAMINE HCL BE
CELEXA (g) CITALOPRAM HYDROBROMIDE BE
DESYREL (g) TRAZODONE HCL BE
EFFEXOR (g) VENLAFAXINE HCL BE
EFFEXOR XR (g) VENLAFAXINE HCL [QL] BE
ELAVIL (g) AMITRIPTYLINE HCL BE
ETRAFON (g) AMITRIPTYLINE HCL/PERPHENAZINE
FLUVOXAMINE MALEATE (g) FLUVOXAMINE MALEATE BE
LIMBITROL, DS (g) AMITRIP HCL/CHLORDIAZEPOXIDE
MAPROTILINE HCL (g) MAPROTILINE HCL BE
NORPRAMIN (g) DESIPRAMINE HCL BE
PAMELOR, AVENTYL (g) NORTRIPTYLINE HCL BE
PARNATE (g) TRANYLCYPROMINE SULFATE
PAXIL (g) PAROXETINE HCL BE
PAXIL CR (g) PAROXETINE HCL
PROZAC WEEKLY (g) FLUOXETINE HCL [QL]
PROZAC, SARAFEM (g) FLUOXETINE HCL BE
REMERON (g) MIRTAZAPINE BE
REMERON SOLTAB (g) MIRTAZAPINE BE
SINEQUAN, ADAPIN (g) DOXEPIN HCL BE
SURMONTIL (g) TRIMIPRAMINE MALEATE
TOFRANIL (g) IMIPRAMINE HCL BE
TOFRANIL-PM (g) IMIPRAMINE PAMOATE
VENLAFAXINE HCL ER (g) VENLAFAXINE HCL [QL] BE
VIVACTIL (g) PROTRIPTYLINE HCL
WELLBUTRIN XL (g) BUPROPION HCL [QL]
WELLBUTRIN, SR (g) BUPROPION HCL BE
ZOLOFT (g) SERTRALINE HCL BE
Formulary Options
Trade Name Generic Name Utilization Management
LEXAPRO ESCITALOPRAM OXALATE [ST] [QL]
NARDIL PHENELZINE SULFATE
SURMONTIL 100MG TRIMIPRAMINE MALEATE
Nonformulary
Trade Name Generic Name Utilization Management
APLENZIN BUPROPRION HBR [PA]
CYMBALTA DULOXETINE HCL [PA] [QL]
EMSAM SELEGILINE [QL]
LUVOX CR FLUVOXAMINE MALEATE [ST] [QL]
MARPLAN ISOCARBOXAZID
OLEPTRO ER TRAZODONE HCL [PA] [QL]
PEXEVA PAROXETINE MESYLATE [PA] [QL]
PRISTIQ DESVENLAFAXINE SUCCINATE [ST] [QL]
SARAFEM TABLET FLUOXETINE HCL
SERZONE (g) NEFAZODONE HCL

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 55
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
3B. Antipsychotics

Formulary Preferred
Trade Name Generic Name Utilization Management
CLOZARIL (g) CLOZAPINE BE
HALDOL (g) HALOPERIDOL BE
LOXITANE (g) LOXAPINE SUCCINATE
MELLARIL (g) THIORIDAZINE HCL BE
NAVANE (g) THIOTHIXENE
PERPHENAZINE (g) PERPHENAZINE
PROLIXIN (g) FLUPHENAZINE HCL BE
RISPERDAL (g) (TIER 0-BCN ONLY) RISPERIDONE BE
RISPERDAL M-TAB (g) RISPERIDONE BE
STELAZINE (g) TRIFLUOPERAZINE HCL BE
THORAZINE (g) CHLORPROMAZINE HCL BE
Formulary Options
Trade Name Generic Name Utilization Management
ABILIFY, DISCMELT, SOLUTION ARIPIPRAZOLE
GEODON ZIPRASIDONE HCL
ORAP PIMOZIDE
SEROQUEL QUETIAPINE FUMARATE
ZYPREXA, ZYDIS OLANZAPINE
Nonformulary
Trade Name Generic Name Utilization Management
FANAPT ILOPERIDONE
FAZACLO CLOZAPINE
INVEGA PALIPERIDONE [PA] [QL]
SAPHRIS ASENAPINE [QL]
SEROQUEL XR QUETIAPINE FUMARATE [PA] [QL]
SYMBYAX OLANZAPINE/FLUOXETINE HCL
3C. Anxiolytics

Formulary Preferred
Trade Name Generic Name Utilization Management
ATIVAN (g) LORAZEPAM
BUSPAR (g) BUSPIRONE HCL
LIBRIUM (g) CHLORDIAZEPOXIDE HCL
MILTOWN, EQUANIL (g) MEPROBAMATE
NIRAVAM (g) ALPRAZOLAM
SERAX (g) OXAZEPAM
TRANXENE (g) CLORAZEPATE DIPOTASSIUM
VALIUM (g) DIAZEPAM
XANAX, XR (g) ALPRAZOLAM
Formulary Options
Trade Name Generic Name Utilization Management
NONE
Nonformulary
Trade Name Generic Name Utilization Management
TRANXENE SD CLORAZEPATE DIPOTASSIUM

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 56
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
3D. Sedative/Hypnotics

Formulary Preferred
Trade Name Generic Name Utilization Management
AMBIEN (g) ZOLPIDEM TARTRATE [QL]
AMBIEN CR (g) ZOLPIDEM TARTRATE [PA] [QL]
CHLORAL HYDRATE (g) CHLORAL HYDRATE
DALMANE (g) FLURAZEPAM HCL [QL]
HALCION (g) TRIAZOLAM [QL]
PROSOM (g) ESTAZOLAM [QL]
RESTORIL (g) TEMAZEPAM [QL]
SONATA (g) ZALEPLON [QL]
Formulary Options
Trade Name Generic Name Utilization Management
NONE
Nonformulary
Trade Name Generic Name Utilization Management
BUTISOL SODIUM BUTABARBITAL SODIUM
DORAL QUAZEPAM [QL]
EDLUAR ZOLPIDEM TARTRATE [PA] [QL]
LUNESTA ESZOPICLONE [PA] [QL]
ROZEREM RAMELTEON [PA] [QL]
SILENOR DOXEPIN HCL [PA] [QL]
ZOLPIMIST ZOLPIDEM TARTRATE [PA] [QL]
3E. CNS Stimulants

Formulary Preferred
Trade Name Generic Name Utilization Management
ADDERALL (g) AMPHET ASP/AMPHET/D-AMPHET [QL]
ADDERALL XR (BRAND-BCN ONLY) AMPHET ASP/AMPHET/D-AMPHET [QL]
ADDERALL XR (g) (BCBSM ONLY) AMPHET ASP/AMPHET/D-AMPHET [QL]
DESOXYN (g) METHAMPHETAMINE HCL [QL]
DEXEDRINE (g) D-AMPHETAMINE SULFATE [QL]
FOCALIN (g) DEXMETHYLPHENIDATE HCL [QL]
METHYLIN SOLN (g) METHYLPHENIDATE HCL [QL]
RITALIN, SR; METHYLIN, ER (g) METHYLPHENIDATE HCL [QL]
Formulary Options
Trade Name Generic Name Utilization Management
CONCERTA METHYLPHENIDATE HCL [QL]
METADATE CD METHYLPHENIDATE HCL [QL]
PROVIGIL MODAFINIL [PA] [QL]
Nonformulary
Trade Name Generic Name Utilization Management
DAYTRANA METHYLPHENIDATE [QL]
FOCALIN XR DEXMETHYLPHENIDATE HCL [QL]
METHYLIN CHEW METHYLPHENIDATE HCL [QL]
NUVIGIL ARMODAFINIL [PA] [QL]
PROCENTRA D-AMPHETAMINE SULFATE [PA]
RITALIN LA METHYLPHENIDATE HCL [QL]
STRATTERA ATOMOXETINE HCL [PA] [QL]
VYVANSE LISDEXAMFETAMINE DIMESYLATE [PA] [QL]

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 57
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
3F. Nonsteroidal Anti-inflammatory Drugs

Formulary Preferred
Trade Name Generic Name Utilization Management
ANAPROX, DS (g) NAPROXEN SODIUM
ANSAID (g) FLURBIPROFEN
CATAFLAM (g) DICLOFENAC POTASSIUM
CLINORIL (g) SULINDAC
DAYPRO (g) OXAPROZIN
EC-NAPROSYN (g) NAPROXEN
FELDENE (g) PIROXICAM
INDOCIN, SR (g) INDOMETHACIN
KETOPROFEN (g) KETOPROFEN
LODINE (g) ETODOLAC
LODINE XL (g) ETODOLAC
MECLOMEN (g) MECLOFENAMATE SODIUM
MOBIC (g) MELOXICAM
MOTRIN (g) IBUPROFEN
NAPROSYN (g) NAPROXEN
RELAFEN (g) NABUMETONE
TOLECTIN, DS (g) TOLMETIN SODIUM
TORADOL (g) KETOROLAC TROMETHAMINE [QL]
VOLTAREN (g) DICLOFENAC SODIUM
VOLTAREN-XR (g) DICLOFENAC SODIUM
Formulary Options
Trade Name Generic Name Utilization Management
INDOCIN SUPPOSITORY INDOMETHACIN
PONSTEL MEFENAMIC ACID
Nonformulary
Trade Name Generic Name Utilization Management
ARTHROTEC DICLOFENAC SODIUM/MISOPROSTOL [PA]
CAMBIA DICLOFENAC POTASSIUM [PA] [QL]
CELEBREX CELECOXIB [PA] [QL]
FLECTOR PATCH DICLOFENAC EPOLAMINE [PA] [QL]
NAPRELAN NAPROXEN SODIUM
NAPRELAN CR DOSEPAK NAPROXEN SODIUM
PENNSAID DICLOFENAC SODIUM [PA] [QL]
PREVACID NAPRAPAC LANSOPRAZOLE/NAPROXEN [PA]
VIMOVO NAPROXEN/ESOMEPRAZOLE MAG [PA] [QL]
VOLTAREN GEL DICLOFENAC SODIUM [PA] [QL]
ZIPSOR DICLOFENAC POTASSIUM

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 58
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
3G. Salicylates

Formulary Preferred
Trade Name Generic Name Utilization Management
DISALCID, SALFLEX (g) SALSALATE
DOLOBID (g) DIFLUNISAL
TRILISATE (g) CHOLINE MAGNESIUM TRISALICYLATE
Formulary Options
Trade Name Generic Name Utilization Management
ZORPRIN ASPIRIN
Nonformulary
Trade Name Generic Name Utilization Management
NONE
3H. Narcotics

Formulary Preferred
Trade Name Generic Name Utilization Management
ACTIQ (g) FENTANYL CITRATE [PA] [QL]
CODEINE SULFATE (g) CODEINE SULFATE(g)
DEMEROL (g) MEPERIDINE HCL
DILAUDID (g) HYDROMORPHONE HCL
DURAGESIC (g) FENTANYL [QL]
METHADONE (g) METHADONE HCL
MS CONTIN/ORAMORPH SR (g) MORPHINE SULFATE
MSIR (g) MORPHINE SULFATE
OPANA (g) OXYMORPHONE HCL [PA] [QL]
OXYCODONE IMMEDIATE RELEASE (g) OXYCODONE HCL
RMS SUPPOSITORY (g) MORPHINE SULFATE
ROXANOL (g) MORPHINE SULFATE
Formulary Options
Trade Name Generic Name Utilization Management
NONE
Nonformulary
Trade Name Generic Name Utilization Management
AVINZA MORPHINE SULFATE [QL]
EMBEDA MORPHINE SULFATE/NALTREXONE [QL]
EXALGO HYDROMORPHONE HCL [PA] [QL]
FENTORA FENTANYL CITRATE [PA] [QL]
KADIAN MORPHINE SULFATE
NUCYNTA TAPENTADOL HYDROCHLORIDE [PA] [QL]
ONSOLIS FENTANYL CITRATE [PA] [QL]
OPANA ER OXYMORPHONE HCL [PA] [QL]
OXYCONTIN OXYCODONE HCL [PA] [QL]

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 59
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
3I. Narcotic/Analgesic Combinations

Formulary Preferred
Trade Name Generic Name Utilization Management
ASPIRIN W/CODEINE (g) CODEINE PHOS/ASPIRIN
FIORICET W/CODEINE (g) CODEINE/BUTALBUT/ACETAMIN/CAFF
FIORICET;ESGIC, PLUS (g) BUTALB/ACETAMINOPHEN/CAFFEINE
FIORINAL (g) BUTALBITAL/ASPIRIN/CAFFEINE
FIORINAL W/CODEINE (g) CODEINE/BUTALBITAL/ASA/CAFFEIN
PERCOCET (g) OXYCODONE HCL/ACETAMINOPHEN
PERCODAN (g) OXYCODONE HCL/ASPIRIN
PHRENILIN (g) BUTALBITAL/ACETAMINOPHEN
TYLENOL W/CODEINE (g) CODEINE PHOS/ACETAMINOPHEN
TYLOX (g) OXYCODONE HCL/ACETAMINOPHEN
VICODIN, LORTAB (g) HYDROCODONE BIT/ACETAMINOPHEN
VICOPROFEN (g) HYDROCODONE/IBUPROFEN
ZEBUTAL (g) BUTALB/ACETAMINOPHEN/CAFFEINE
Formulary Options
Trade Name Generic Name Utilization Management
PHRENILIN FORTE BUTALBITAL/ACETAMINOPHEN
SYNALGOS-DC DIHYDROCODEINE/ASPIRIN/CAFFEIN
Nonformulary
Trade Name Generic Name Utilization Management
MAGNACET OXYCODONE HCL/ACETAMINOPHEN
XODOL HYDROCODONE BIT/ACETAMINOPHEN
ZYDONE HYDROCODONE BIT/ACETAMINOPHEN
3J. Narcotic Mixed Agonist/Antagonist

Formulary Preferred
Trade Name Generic Name Utilization Management
STADOL NS (g) BUTORPHANOL TARTRATE
TALACEN (g) PENTAZOCINE HCL/ACETAMINOPHEN
TALWIN NX (g) PENTAZOCINE HCL/NALOXONE HCL
ULTRACET (g) TRAMADOL HCL/ACETAMINOPHEN
ULTRAM (g) TRAMADOL HCL
ULTRAM ER 100MG, 200MG (g) TRAMADOL HCL
Formulary Options
Trade Name Generic Name Utilization Management
SUBOXONE FILM, TABS BUPRENORPHINE HCL/NALOXONE HCL [PA]
Nonformulary
Trade Name Generic Name Utilization Management
BUTRANS BUPRENORPHINE [PA] [QL]
RYBIX ODT TRAMADOL HCL [PA] [QL]
RYZOLT TRAMADOL HCL [QL]
ULTRAM ER 300MG TRAMADOL HCL

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 60
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
3K. Narcotic Antagonists

Formulary Preferred
Trade Name Generic Name Utilization Management
REVIA (g) NALTREXONE HCL
Formulary Options
Trade Name Generic Name Utilization Management
RELISTOR METHYLNALTREXONE [PA] [QL]
Nonformulary
Trade Name Generic Name Utilization Management
NONE
3M. Migraine Therapy

Formulary Preferred
Trade Name Generic Name Utilization Management
AMERGE (g) NARATRIPTAN HCL [ST] [QL]
BUPAP (g) BUTALBITAL/ACETAMINOPHEN
CAFERGOT (g) ERGOTAMINE TARTRATE/CAFFEINE [QL]
D.H.E.45 (g) DIHYDROERGOTAMINE MESYLATE [QL]
FIORICET;ESGIC, PLUS (g) BUTALB/ACETAMINOPHEN/CAFFEINE
FIORINAL (g) BUTALBITAL/ASPIRIN/CAFFEINE
FIORINAL W/CODEINE (g) CODEINE/BUTALBITAL/ASA/CAFFEIN
IMITREX INJECTION (g) SUMATRIPTAN SUCCINATE [QL]
IMITREX NASAL SPRAY (g) SUMATRIPTAN [QL]
IMITREX TABLETS (g) SUMATRIPTAN SUCCINATE [QL]
MIDRIN (g) ISOMETHEPTENE/APAP/DICHLPHEN
PHRENILIN (g) BUTALBITAL/ACETAMINOPHEN
STADOL NS (g) BUTORPHANOL TARTRATE
ZEBUTAL (g) BUTALB/ACETAMINOPHEN/CAFFEINE
Formulary Options
Trade Name Generic Name Utilization Management
ERGOMAR ERGOTAMINE TARTRATE [QL]
MAXALT, MLT RIZATRIPTAN BENZOATE [ST] [QL]
MIGRANAL DIHYDROERGOTAMINE MESYLATE [QL]
PHRENILIN FORTE BUTALBITAL/ACETAMINOPHEN
Nonformulary
Trade Name Generic Name Utilization Management
ALSUMA SUMATRIPTAN SUCCINATE [ST] [QL]
AXERT ALMOTRIPTAN MALATE [ST] [QL]
CAMBIA DICLOFENAC POTASSIUM [PA] [QL]
FROVA FROVATRIPTAN SUCCINATE [ST] [QL]
RELPAX ELETRIPTAN HYDROBROMIDE [ST] [QL]
SUMAVEL DOSEPRO SUMATRIPTAN SUCCINATE [ST] [QL]
TREXIMET SUMATRIPTAN SUCC/NAPROXEN SOD [PA] [QL]
ZOMIG NASAL SPRAY ZOLMITRIPTAN [ST] [QL]
ZOMIG, ZMT ZOLMITRIPTAN [ST] [QL]

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 61
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
3O. Parkinsons Disease and Related Disorders

Formulary Preferred
Trade Name Generic Name Utilization Management
ARTANE (g) TRIHEXYPHENIDYL HCL
COGENTIN (g) BENZTROPINE MESYLATE
DOSTINEX (g) CABERGOLINE
ELDEPRYL(g) SELEGILINE HCL
MIRAPEX (g) PRAMIPEXOLE DI-HCL
PARCOPA (g) CARBIDOPA/LEVODOPA
PARLODEL (g) BROMOCRIPTINE MESYLATE
REQUIP (g) ROPINIROLE HCL
SINEMET (g) CARBIDOPA/LEVODOPA
SINEMET CR (g) CARBIDOPA/LEVODOPA
SYMMETREL (g) AMANTADINE HCL
Formulary Options
Trade Name Generic Name Utilization Management
APOKYN APOMORPHINE HCL <s>
COMTAN ENTACAPONE
STALEVO CARBIDOPA/LEVODOPA/ENTACAPONE
Nonformulary
Trade Name Generic Name Utilization Management
AZILECT RASAGILINE MESYLATE
MIRAPEX ER PRAMIPEXOLE DI-HCL [PA] [QL]
REQUIP XL ROPINIROLE HCL [QL]
TASMAR TOLCAPONE
ZELAPAR SELEGILINE HCL [QL]

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 62
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
3P. Anticonvulsants

Formulary Preferred
Trade Name Generic Name Utilization Management
DEPAKENE (g) VALPROATE SODIUM
DEPAKOTE (g) DIVALPROEX SODIUM
DEPAKOTE ER (g) DIVALPROEX SODIUM
DEPAKOTE SPRINKLES (g) DIVALPROEX SODIUM
DIAMOX (g) ACETAZOLAMIDE
DIASTAT 2.5MG (g) DIAZEPAM
DILANTIN (g) PHENYTOIN SODIUM EXTENDED
KEPPRA (g) LEVETIRACETAM
KLONOPIN, WAFER (g) CLONAZEPAM
LAMICTAL DISPERTABS (g) LAMOTRIGINE
LAMICTAL TABS (g) LAMOTRIGINE
MEBARAL (g) MEPHOBARBITAL
MYSOLINE (g) PRIMIDONE
NEURONTIN (g) GABAPENTIN
PHENOBARBITAL (g) PHENOBARBITAL
TEGRETOL (g) CARBAMAZEPINE
TEGRETOL XR (g) CARBAMAZEPINE
TOPAMAX (g) TOPIRAMATE
TOPAMAX SPRINKLE (g) TOPIRAMATE
TRILEPTAL (g) OXCARBAZEPINE
TRILEPTAL SUSP (g) OXCARBAZEPINE
ZARONTIN (g) ETHOSUXIMIDE
ZONEGRAN (g) ZONISAMIDE
Formulary Options
Trade Name Generic Name Utilization Management
BANZEL RUFINAMIDE
CELONTIN METHSUXIMIDE
DIASTAT DIAZEPAM
DILANTIN CHEW TABS PHENYTOIN
FELBATOL FELBAMATE
GABITRIL TIAGABINE HCL
NEURONTIN SOLUTION GABAPENTIN
PEGANONE ETHOTOIN
SABRIL VIGABATRIN <s>
TEGRETOL XR 100MG CARBAMAZEPINE
VIMPAT LACOSAMIDE
Nonformulary
Trade Name Generic Name Utilization Management
CARBATROL CARBAMAZEPINE
EQUETRO CARBAMAZEPINE
KEPPRA XR LEVETIRACETAM
LAMICTAL ODT LAMOTRIGINE [QL]
LAMICTAL XR LAMOTRIGINE [QL]
LYRICA PREGABALIN [PA] [QL]

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 63
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
3Q. Skeletal Muscle Relaxants

Formulary Preferred
Trade Name Generic Name Utilization Management
DANTRIUM (g) DANTROLENE SODIUM
FLEXERIL (g) CYCLOBENZAPRINE HCL
LIORESAL (g) BACLOFEN
NORFLEX (g) ORPHENADRINE CITRATE
NORGESIC, FORTE (g) ORPHENADRINE/ASPIRIN/CAFFEINE
PARAFLEX, PARAFON FORTE DSC (g) CHLORZOXAZONE
ROBAXIN (g) METHOCARBAMOL
SKELAXIN (g) METAXALONE
SOMA (g) CARISOPRODOL
SOMA COMPOUND (g) CARISOPRODOL/ASPIRIN
SOMA COMPOUND W/CODEINE (g) CODEINE PHOS/CARISOPRODOL/ASA
VALIUM (g) DIAZEPAM
Formulary Options
Trade Name Generic Name Utilization Management
NONE
Nonformulary
Trade Name Generic Name Utilization Management
AMRIX CYCLOBENZAPRINE HCL [QL]
FEXMID CYCLOBENZAPRINE HCL
ZANAFLEX CAPS TIZANIDINE HCL
ZANAFLEX TABS (g) TIZANIDINE HCL
3R. Myesthenia Gravis

Formulary Preferred
Trade Name Generic Name Utilization Management
MESTINON (g) PYRIDOSTIGMINE BROMIDE
Formulary Options
Trade Name Generic Name Utilization Management
MESTINON TIMESPAN, SYRUP PYRIDOSTIGMINE BROMIDE
PROSTIGMIN NEOSTIGMINE BROMIDE
Nonformulary
Trade Name Generic Name Utilization Management
MYTELASE AMBENONIUM CHLORIDE

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 64
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
3S. Miscellaneous CNS

Formulary Preferred
Trade Name Generic Name Utilization Management
ARICEPT, ODT (g) DONEPEZIL HCL
ESKALITH (g) LITHIUM CARBONATE
ESKALITH CR (g) LITHIUM CARBONATE
EXELON (g) RIVASTIGMINE TARTRATE [QL]
LITHIUM CITRATE (g) LITHIUM CITRATE
LITHOBID (g) LITHIUM CARBONATE
NIMOTOP (g) NIMODIPINE
RAZADYNE SOLUTION (g) GALANTAMINE HYDROBROMIDE
RAZADYNE, ER (g) GALANTAMINE HYDROBROMIDE
Formulary Options
Trade Name Generic Name Utilization Management
EXELON RIVASTIGMINE TARTRATE [QL]
NAMENDA, SOLN MEMANTINE HCL
RILUTEK RILUZOLE
Nonformulary
Trade Name Generic Name Utilization Management
ARICEPT 23MG DONEPEZIL HCL [ST]
COGNEX TACRINE HCL
INTUNIV GUANFACINE HCL [PA] [QL]
SAVELLA MILNACIPRAN HCL [PA] [QL]
XYREM SODIUM OXYBATE [PA] [QL]

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 65
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
4. GASTROINTESTINAL AGENTS

4A. H2-Receptor Antagonists

Formulary Preferred
Trade Name Generic Name Utilization Management
AXID (RX ONLY) (g) NIZATIDINE
PEPCID (RX ONLY) (g) FAMOTIDINE
TAGAMET (RX ONLY) (g) CIMETIDINE
ZANTAC (RX ONLY) (g) RANITIDINE HCL
Formulary Options
Trade Name Generic Name Utilization Management
NONE
Nonformulary
Trade Name Generic Name Utilization Management
ZANTAC EFFERDOSE RANITIDINE HCL
4B. Proton Pump Inhibitors

Formulary Preferred
Trade Name Generic Name Utilization Management
OMEPRAZOLE OTC (g) OMEPRAZOLE
PREVACID (g) LANSOPRAZOLE [ST]
PREVACID SOLUTAB (g) LANSOPRAZOLE [PA]
PRILOSEC (g) OMEPRAZOLE
PRILOSEC 40MG OMEPRAZOLE [PA]
PRILOSEC OTC OMEPRAZOLE MAGNESIUM
PROTONIX (g) PANTOPRAZOLE SODIUM [PA]
ZEGERID CAP (Rx Only) (g) OMEPRAZOLE/SODIUM BICARBONATE [PA] [QL]
Formulary Options
Trade Name Generic Name Utilization Management
NONE
Nonformulary
Trade Name Generic Name Utilization Management
ACIPHEX RABEPRAZOLE SODIUM [PA]
DEXILANT DEXLANSOPRAZOLE [PA][ST] [QL]
NEXIUM ESOMEPRAZOLE MAG TRIHYDRATE [PA][ST]
PRILOSEC SUSPENSION OMEPRAZOLE MAGNESIUM [PA]
PROTONIX SUSPENSION PANTOPRAZOLE SODIUM [ST]
VIMOVO NAPROXEN/ESOMEPRAZOLE MAG [PA] [QL]
ZEGERID PACKET OMEPRAZOLE/SODIUM BICARBONATE [PA] [QL]

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 66
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
4C. Other Ulcer Therapy

Formulary Preferred
Trade Name Generic Name Utilization Management
CARAFATE SUSP (g) SUCRALFATE
CARAFATE TABS (g) SUCRALFATE
CYTOTEC (g) MISOPROSTOL
Formulary Options
Trade Name Generic Name Utilization Management
HELIDAC TETRACYC HCL/BIS SS/METRONID
PREVPAC LANSOPRAZOLE/AMOX TR/CLARITH
Nonformulary
Trade Name Generic Name Utilization Management
PYLERA BISMUTH/METRONID/TETRACYCLINE
4D. Antidiarrheals and Antispasmodics

Formulary Preferred
Trade Name Generic Name Utilization Management
BELLAMINE/BELLASPAS (g) ERGOTAMINE TART/BELLAD ALK/PB
BENTYL (g) DICYCLOMINE HCL
DONNATAL (g) BELLADONNA ALKALOIDS/PHENOBARB
LEVBID (g) HYOSCYAMINE SULFATE
LEVSIN, SL (g) HYOSCYAMINE SULFATE
LEVSINEX (g) HYOSCYAMINE SULFATE
LIBRAX (g) CLIDINIUM BR/CHLORDIAZEPOXIDE
LOMOTIL (g) DIPHENOXYLATE HCL/ATROP SULF
PAREGORIC (g) PAREGORIC
PRO-BANTHINE 15MG (g) PROPANTHELINE BROMIDE
ROBINUL, FORTE (g) GLYCOPYRROLATE
Formulary Options
Trade Name Generic Name Utilization Management
NONE
Nonformulary
Trade Name Generic Name Utilization Management
CANTIL MEPENZOLATE BROMIDE
DONNATAL EXTENTABS BELLADONNA ALKALOIDS/PHENOBARB

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 67
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
4E. Antiemetics

Formulary Preferred
Trade Name Generic Name Utilization Management
ANTIVERT (g) MECLIZINE HCL
COMPAZINE (g) PROCHLORPERAZINE MALEATE
KYTRIL (g) GRANISETRON HCL [QL]
MARINOL (g) DRONABINOL [QL]
PHENERGAN (g) PROMETHAZINE HCL
TIGAN (g) TRIMETHOBENZAMIDE HCL
ZOFRAN (g) ONDANSETRON HCL
ZOFRAN ODT (g) ONDANSETRON
Formulary Options
Trade Name Generic Name Utilization Management
EMEND 80,125MG CAPSULES APREPITANT [QL]
TRANSDERM-SCOP SCOPOLAMINE HYDROBROMIDE
Nonformulary
Trade Name Generic Name Utilization Management
ANZEMET DOLASETRON MESYLATE [QL]
CESAMET NABILONE
SANCUSO GRANISETRON [ST] [QL]
ZUPLENZ ONDANSETRON [ST] [QL]
4F. Bile Acids

Formulary Preferred
Trade Name Generic Name Utilization Management
ACTIGALL (g) URSODIOL
URSO (g) URSODIOL
URSO FORTE (g) URSODIOL
Formulary Options
Trade Name Generic Name Utilization Management
NONE
Nonformulary
Trade Name Generic Name Utilization Management
CHENODAL CHENODIOL [PA]

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 68
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
4G. Digestive Enzymes

Formulary Preferred
Trade Name Generic Name Utilization Management
DYGASE (g) AMYLASE/LIPASE/PROTEASE
LAPASE (g) AMYLASE/LIPASE/PROTEASE
PANCREASE MT 10, 16, 20 (g) AMYLASE/LIPASE/PROTEASE
Formulary Options
Trade Name Generic Name Utilization Management
CREON AMYLASE/LIPASE/PROTEASE
LIPRAM-UL20 AMYLASE/LIPASE/PROTEASE
PANCREASE MT 4 AMYLASE/LIPASE/PROTEASE
PANCRELIPASE EC AMYLASE/LIPASE/PROTEASE
PANGESTYME UL 12 AMYLASE/LIPASE/PROTEASE
ULTRASE MT AMYLASE/LIPASE/PROTEASE
VIOKASE AMYLASE/LIPASE/PROTEASE
Nonformulary
Trade Name Generic Name Utilization Management
PANCREAZE LIPASE/PROTEASE/AMYLASE
PANCRECARB MS AMYLASE/LIPASE/PROTEASE
ZENPEP AMYLASE/LIPASE/PROTEASE

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 69
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
4H. Miscellaneous Gastrointestinal Agents

Formulary Preferred
Trade Name Generic Name Utilization Management
ANALPRAM HC (g) HC ACETATE/PRAMOXINE HCL
ANAMANTLE HC (g) LIDOCAINE HCL/HC
ANNUSOL HC, PROCTOCREAM HC (g) HYDROCORTISONE
AZULFIDINE EN-TAB (g) SULFASALAZINE
AZULFIDINE TAB (g) SULFASALAZINE
COLAZAL (g) BALSALAZIDE DISODIUM
CORTENEMA (g) HYDROCORTISONE ACETATE
GLYCOLAX (g) POLYETHYLENE GLYCOL 3350
LACTULOSE (g) LACTULOSE
PRAMOSONE (g) HC ACETATE/PRAMOXINE HCL
PROCTOCORT SUPPOSITORY (g) HYDROCORTISONE ACETATE
REGLAN TAB, SOLUTION (g) METOCLOPRAMIDE HCL
ROWASA ENEMA (g) MESALAMINE
Formulary Options
Trade Name Generic Name Utilization Management
ASACOL MESALAMINE
ASACOL HD MESALAMINE
CANASA MESALAMINE
CORTIFOAM HYDROCORTISONE ACETATE
PENTASA MESALAMINE
RELISTOR METHYLNALTREXONE [PA] [QL]
Nonformulary
Trade Name Generic Name Utilization Management
AMITIZA LUBIPROSTONE [PA] [QL]
APRISO MESALAMINE
CIMZIA SYRINGE CERTOLIZUMAB [PA] [QL] <s>
DIPENTUM OLSALAZINE SODIUM
LIALDA MESALAMINE [QL]
LOTRONEX ALOSETRON HCL [PA] [QL]
METOZOLV ODT METOCLOPRAMIDE HCL
PERANEX HC HC ACETATE/LIDOCAINE HCL
PRAMOSONE LOTION HC ACETATE/PRAMOXINE HCL

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 70
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
5. OBSTETRICS AND GYNECOLOGY

5A. Contraceptives-Monophasic

Formulary Preferred
Trade Name Generic Name Utilization Management
ALESSE (g), LEVLITE (g) LEVONORGESTREL-ETH ESTRA
DEMULEN (g) ETHYNODIOL D-ETHINYL ESTRADIOL
DESOGEN (g), ORTHO-CEPT (g) DESOGESTREL-ETHINYL ESTRADIOL
LO/OVRAL (g) NORGESTREL-ETHINYL ESTRADIOL
LOESTRIN, FE (g) NORETH A-ET ESTRA/FE FUMARATE
MODICON (g) NORETHINDRONE-ETHINYL ESTRAD
NORDETTE, LEVLEN (g) LEVONORGESTREL-ETH ESTRA
NORINYL 1/35 (g), ORTHO-NOVUM 1/35 (g) NORETHINDRONE-MESTRANOL
NORINYL 1/50 (g), ORTHO-NOVUM 1/50 (g) NORETHINDRONE-ETHINYL ESTRAD
ORTHO-CYCLEN (g) NORGESTIMATE-ETHINYL ESTRADIOL
OVCON 35 (g) NORETHINDRONE-ETHINYL ESTRAD
OVRAL (g) NORGESTREL-ETHINYL ESTRADIOL
SEASONALE (g) LEVONORGESTREL-ETH ESTRA [QL]
YASMIN 28 (g) ETHINYL ESTRADIOL/DROSPIRENONE
YAZ (g) ETHINYL ESTRADIOL/DROSPIRENONE
Formulary Options
Trade Name Generic Name Utilization Management
LYBREL LEVONORGESTREL-ETH ESTRA
Nonformulary
Trade Name Generic Name Utilization Management
FEMCON FE NORETH-ETHINYL ESTRADIOL/IRON
LOESTRIN 24 FE NORETH A-ET ESTRA/FE FUMARATE
OVCON-50, FE NORETHINDRONE-ETHINYL ESTRAD
5B. Contraceptives-Biphasic

Formulary Preferred
Trade Name Generic Name Utilization Management
MIRCETTE (g) DESOG-ET ESTRA/ETHIN ESTRA
NECON 10/11 (g) NORETHINDRONE-ETHINYL ESTRAD
Formulary Options
Trade Name Generic Name Utilization Management
NONE
Nonformulary
Trade Name Generic Name Utilization Management
LOSEASONIQUE L-NORGEST-ETH ESTR/ETHIN ESTRA [QL]
SEASONIQUE L-NORGEST-ETH ESTR/ETHIN ESTRA [QL]

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 71
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
5C. Contraceptives-Triphasic

Formulary Preferred
Trade Name Generic Name Utilization Management
CYCLESSA (g) DESOGESTREL-ETHINYL ESTRADIOL
ESTROSTEP FE (g) NORETH A-ET ESTRA/FE FUMARATE
ORTHO TRI-CYCLEN (g) NORGESTIMATE-ETHINYL ESTRADIOL
ORTHO-NOVUM 7/7/7 (g) NORETHINDRONE-ETHINYL ESTRAD
TRI-NORINYL (g) NORETHINDRONE-ETHINYL ESTRAD
TRIPHASIL, TRILEVLEN (g) LEVONORGESTREL-ETH ESTRA
Formulary Options
Trade Name Generic Name Utilization Management
ORTHO TRI-CYCLEN LO NORGESTIMATE-ETHINYL ESTRADIOL
Nonformulary
Trade Name Generic Name Utilization Management
NONE
5D. Contraceptives-Misc.

Formulary Preferred
Trade Name Generic Name Utilization Management
ORTHO MICRONOR (g), NOR-QD (g) NORETHINDRONE
Formulary Options
Trade Name Generic Name Utilization Management
ORTHO EVRA ETHINYL ESTRADIOL/NORELGEST [QL]
Nonformulary
Trade Name Generic Name Utilization Management
BEYAZ DROSPIR/ETH ESTRA/LEVOMEFOL CA
NATAZIA ESTRADIOL VALERATE/DIENOGEST
NUVARING ETONOGESTREL/ETHINYL ESTRADIOL [QL]
5E. Contraceptives-Postcoital

Formulary Preferred
Trade Name Generic Name Utilization Management
PLAN B (g) LEVONORGESTREL
Formulary Options
Trade Name Generic Name Utilization Management
NONE
Nonformulary
Trade Name Generic Name Utilization Management
ELLA ULIPRISTAL ACETATE [QL]
PLAN B ONE-STEP LEVONORGESTREL

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 72
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
5F. Progestins

Formulary Preferred
Trade Name Generic Name Utilization Management
AYGESTIN (g) NORETHINDRONE ACETATE
DEPO-PROVERA 150MG (g) MEDROXYPROGESTERONE ACET
PROGESTERONE IN OIL (INJ) (g) PROGESTERONE
PROVERA (g) MEDROXYPROGESTERONE ACET
Formulary Options
Trade Name Generic Name Utilization Management
CRINONE PROGESTERONE,MICRONIZED
DEPO-SUBQ PROVERA 104 MEDROXYPROGESTERONE ACET
ENDOMETRIN PROGESTERONE, MICRONIZED
PROCHIEVE PROGESTERONE,MICRONIZED
PROMETRIUM PROGESTERONE,MICRONIZED
Nonformulary
Trade Name Generic Name Utilization Management
NONE
5G. Estrogens

Formulary Preferred
Trade Name Generic Name Utilization Management
CLIMARA (g) ESTRADIOL [QL]
ESTRACE (g) ESTRADIOL
OGEN, ORTHO-EST (g) ESTROPIPATE
VIVELLE (g) ESTRADIOL [QL]
Formulary Options
Trade Name Generic Name Utilization Management
ALORA ESTRADIOL [QL]
ESTRADERM ESTRADIOL [QL]
ESTRING ESTRADIOL [QL]
PREMARIN CREAM ESTROGENS,CONJUGATED
PREMARIN, PREMARIN LOW DOSE ESTROGENS,CONJUGATED
VIVELLE-DOT ESTRADIOL [QL]
Nonformulary
Trade Name Generic Name Utilization Management
CENESTIN ESTROGENS,CONJ.,SYNTHETIC A
DIVIGEL ESTRADIOL
ELESTRIN ESTRADIOL [QL]
ENJUVIA ESTROGENS,CONJ.,SYNTHETIC B [QL]
ESTRACE VAGINAL CREAM ESTRADIOL
ESTRASORB ESTRADIOL [QL]
ESTROGEL ESTRADIOL [QL]
EVAMIST ESTRADIOL TRANSDERMAL SPRAY [QL]
FEMRING ESTRADIOL ACETATE [QL]
FEMTRACE ESTRADIOL ACETATE
MENEST ESTROGENS,ESTERIFIED
MENOSTAR ESTRADIOL [QL]
VAGIFEM ESTRADIOL

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 73
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
5H. Estrogen/Progestin Combinations

Formulary Preferred
Trade Name Generic Name Utilization Management
ACTIVELLA (g) ESTRADIOL/NORETH AC
ESTRATEST, H.S. (g) ESTROGEN,ESTER/ME-TESTOSTERONE
Formulary Options
Trade Name Generic Name Utilization Management
FEMHRT ETHINYL ESTRADIOL/NORETH AC
PREMPRO, LOW DOSE/PREMPHASE ESTROGEN,CON/M-PROGEST ACET
Nonformulary
Trade Name Generic Name Utilization Management
ACTIVELLA 0.5-0.1MG ESTRADIOL/NORETH AC
ANGELIQ ESTRADIOL/DROSPIRENONE
CLIMARA PRO ESTRADIOL/LEVONORGESTREL [QL]
COMBIPATCH ESTRADIOL/NORETH AC [QL]
ORTHO-PREFEST ESTRADIOL/NORGESTIMATE
5J. Infertility Treatment

Formulary Preferred
Trade Name Generic Name Utilization Management
CLOMID (g) CLOMIPHENE CITRATE
LUPRON (g) LEUPROLIDE ACETATE [PA] <s>
Formulary Options
Trade Name Generic Name Utilization Management
BRAVELLE UROFOLLITROPIN (FSH) [PA] <s>
CETROTIDE CETRORELIX ACETATE [PA] <s>
FERTINEX UROFOLLITROPIN (FSH) [PA] <s>
GANIRELIX ACETATE GANIRELIX ACETATE [PA] <s>
GONAL-F, RFF FOLLITROPIN ALPHA,RECOMB [PA] <s>
NOVAREL, PREGNYL, PROFASI GONADOTROPIN,CHORIONIC,HUMAN [PA] <s>
OVIDREL HCG ALPHA,RECOMBINANT [PA] <s>
PROFASI 5000UNITS GONADOTROPIN,CHORIONIC,HUMAN [PA] <s>
REPRONEX MENOTROPINS [PA] <s>
Nonformulary
Trade Name Generic Name Utilization Management
FOLLISTIM AQ FOLLITROPIN BETA,RECOMB [PA] <s>
LUVERIS LUTROPIN ALPHA [PA] <s>
MENOPUR MENOTROPINS [PA] <s>

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 74
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5K. Vaginal Anti-infective/Antifungal

Formulary Preferred
Trade Name Generic Name Utilization Management
CLEOCIN VAG CREAM (g) CLINDAMYCIN PHOSPHATE
DIFLUCAN (g) FLUCONAZOLE
METROGEL-VAGINAL (g) METRONIDAZOLE
NYSTATIN (g) NYSTATIN
TERAZOL- 3, 7 (g) TERCONAZOLE
Formulary Options
Trade Name Generic Name Utilization Management
NONE
Nonformulary
Trade Name Generic Name Utilization Management
AVC SULFANILAMIDE
CLEOCIN VAGINAL OVULES CLINDAMYCIN PHOSPHATE
CLINDESSE CLINDAMYCIN PHOSPHATE
GYNAZOLE-1 BUTOCONAZOLE NITRATE
5L. Miscellaneous OB-GYN

Formulary Preferred
Trade Name Generic Name Utilization Management
NONE
Formulary Options
Trade Name Generic Name Utilization Management
LUPRON DEPOT LEUPROLIDE ACETATE <s>
METHERGINE METHYLERGONOVINE MALEATE
SYNAREL NAFARELIN ACETATE
Nonformulary
Trade Name Generic Name Utilization Management
LYSTEDA TRANEXAMIC ACID [QL]

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 75
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
6. RHEUMATOLOGY AND MUSCULOSKELETAL

6A. Salicylates

Formulary Preferred
Trade Name Generic Name Utilization Management
SALICYLATES AND NSAIDS SEE CHAPTERS 3F & 3G
Formulary Options
Trade Name Generic Name Utilization Management
NONE
Nonformulary
Trade Name Generic Name Utilization Management
NONE
6B. Gout Therapy

Formulary Preferred
Trade Name Generic Name Utilization Management
COLBENEMID (g) COLCHICINE/PROBENECID
PROBENECID (g) PROBENECID
ZYLOPRIM (g) ALLOPURINOL
Formulary Options
Trade Name Generic Name Utilization Management
COLCRYS COLCHICINE
ULORIC FEBUXOSTAT [PA] [QL]
Nonformulary
Trade Name Generic Name Utilization Management
NONE
6C. Corticosteroids

Formulary Preferred
Trade Name Generic Name Utilization Management
CORTICOSTEROIDS SEE CHAPTER 7C
Formulary Options
Trade Name Generic Name Utilization Management
NONE
Nonformulary
Trade Name Generic Name Utilization Management
NONE

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 76
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
6D. Miscellaneous Rheumatologic Agents

Formulary Preferred
Trade Name Generic Name Utilization Management
ARAVA (g) LEFLUNOMIDE [QL]
AZULFIDINE EN-TAB (g) SULFASALAZINE
AZULFIDINE TAB (g) SULFASALAZINE
IMURAN (g) AZATHIOPRINE
METHOTREXATE (g) METHOTREXATE SODIUM/PF
PLAQUENIL (g) HYDROXYCHLOROQUINE SULFATE
Formulary Options
Trade Name Generic Name Utilization Management
CUPRIMINE PENICILLAMINE
ENBREL ETANERCEPT [PA] [QL] <s>
HUMIRA ADALIMUMAB [PA] [QL] <s>
RHEUMATREX, TREXALL METHOTREXATE SODIUM
RIDAURA AURANOFIN
Nonformulary
Trade Name Generic Name Utilization Management
CIMZIA SYRINGE CERTOLIZUMAB [PA] [QL] <s>
DEPEN PENICILLAMINE
KINERET ANAKINRA [PA] [QL] <s>
SIMPONI GOLIMUMAB [PA] [QL] <s>
6E. Osteoporosis/Hormonal Treatment

Formulary Preferred
Trade Name Generic Name Utilization Management
CLIMARA (g) ESTRADIOL [QL]
ESTRACE (g) ESTRADIOL
ESTRATEST, H.S. (g) ESTROGEN,ESTER/ME-TESTOSTERONE
OGEN, ORTHO-EST (g) ESTROPIPATE
VIVELLE (g) ESTRADIOL [QL]
Formulary Options
Trade Name Generic Name Utilization Management
ALORA ESTRADIOL [QL]
ESTRADERM ESTRADIOL [QL]
FEMHRT ETHINYL ESTRADIOL/NORETH AC
PREMARIN CREAM ESTROGENS,CONJUGATED
PREMARIN, PREMARIN LOW DOSE ESTROGENS,CONJUGATED
PREMPRO, LOW DOSE/PREMPHASE ESTROGEN,CON/M-PROGEST ACET
VIVELLE-DOT ESTRADIOL [QL]
Nonformulary
Trade Name Generic Name Utilization Management
CENESTIN ESTROGENS,CONJ.,SYNTHETIC A
ENJUVIA ESTROGENS,CONJ.,SYNTHETIC B [QL]
FORTEO TERIPARATIDE [PA] [QL] <s>
MENEST ESTROGENS,ESTERIFIED

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 77
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
6F. Osteoporosis/Bone Resorption

Formulary Preferred
Trade Name Generic Name Utilization Management
DIDRONEL (g) ETIDRONATE DISODIUM [QL]
ESTROGENS FIRST-LINE THERAPY WHEN APPROPRIATE
FOSAMAX (g) ALENDRONATE SODIUM BE
FOSAMAX WEEKLY (g) ALENDRONATE SODIUM [QL] BE
MIACALCIN NASAL SPRAY (g) CALCITONIN,SALMON,SYNTHETIC
Formulary Options
Trade Name Generic Name Utilization Management
ACTONEL WITH CALCIUM RISEDRON SOD/CALCIUM CARBONATE [ST] [QL]
ACTONEL, WEEKLY, 150MG RISEDRONATE SODIUM [ST] [QL]
EVISTA RALOXIFENE HCL
MIACALCIN INJECTION CALCITONIN,SALMON,SYNTHETIC
Nonformulary
Trade Name Generic Name Utilization Management
BONIVA IBANDRONATE SODIUM [ST] [QL]
FOSAMAX PLUS D ALENDRONATE SODIUM/VITAMIN D3 [ST] [QL]

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 78
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
7. ENDOCRINOLOGY

7A. Antithyroid Agents

Formulary Preferred
Trade Name Generic Name Utilization Management
PROPYLTHIOURACIL (g) PROPYLTHIOURACIL
SSKI (g) POTASSIUM IODIDE
TAPAZOLE (g) METHIMAZOLE
Formulary Options
Trade Name Generic Name Utilization Management
NONE
Nonformulary
Trade Name Generic Name Utilization Management
NONE
7B. Thyroid Hormones

Formulary Preferred
Trade Name Generic Name Utilization Management
CYTOMEL (g) LIOTHYRONINE SODIUM
LEVOTHYROXINE (g) LEVOTHYROXINE SODIUM
Formulary Options
Trade Name Generic Name Utilization Management
THYROLAR LIOTRIX
Nonformulary
Trade Name Generic Name Utilization Management
ARMOUR THYROID THYROID
TIROSINT LEVOTHYROXINE SODIUM
7C. Corticosteroids

Formulary Preferred
Trade Name Generic Name Utilization Management
CORTEF, HYDROCORTISONE (g) HYDROCORTISONE
CORTISONE ACETATE (g) CORTISONE ACETATE
DECADRON (g) DEXAMETHASONE
FLORINEF (g) FLUDROCORTISONE ACETATE
MEDROL, DOSEPAK (g) METHYLPREDNISOLONE
ORAPRED (g) PREDNISOLONE SOD PHOSPHATE
PREDNISOLONE, TABS, SYRUP (g) PREDNISOLONE
PREDNISONE (g) PREDNISONE
Formulary Options
Trade Name Generic Name Utilization Management
NONE
Nonformulary
Trade Name Generic Name Utilization Management
ENTOCORT EC BUDESONIDE
ORAPRED ODT PREDNISOLONE SOD PHOSPHATE

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 79
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
7D. Androgens

Formulary Preferred
Trade Name Generic Name Utilization Management
ANDROXY 10MG (g) FLUOXYMESTERONE
DANOCRINE (g) DANAZOL
DEPO-TESTOSTERONE (g) TESTOSTERONE CYPIONATE
OXANDRIN (g) OXANDROLONE [PA]
Formulary Options
Trade Name Generic Name Utilization Management
ANDRODERM TESTOSTERONE [QL]
DELATESTRYL TESTOSTERONE ENANTHATE
Nonformulary
Trade Name Generic Name Utilization Management
ANADROL-50 OXYMETHOLONE [PA]
ANDROGEL TESTOSTERONE [QL]
METHITEST METHYLTESTOSTERONE [PA]
STRIANT TESTOSTERONE [QL]
TESTIM TESTOSTERONE [QL]
TESTRED, ANDROID METHYLTESTOSTERONE
7E. Miscellaneous Endocrine

Formulary Preferred
Trade Name Generic Name Utilization Management
CALCIFEROL (g) ERGOCALCIFEROL
DDAVP SPRAY (g) DESMOPRESSIN ACETATE
DDAVP TABS (g) DESMOPRESSIN ACETATE
DOSTINEX (g) CABERGOLINE
MIACALCIN NASAL SPRAY (g) CALCITONIN,SALMON,SYNTHETIC
PROSCAR (g) FINASTERIDE
ROCALTROL (g) CALCITRIOL
SANDOSTATIN (g) OCTREOTIDE ACETATE [PA] <s>
Formulary Options
Trade Name Generic Name Utilization Management
DDAVP SOLN DESMOPRESSIN ACETATE
GLUCAGON EMERGENCY KIT GLUCAGON,HUMAN RECOMBINANT
LUPRON DEPOT-PED LEUPROLIDE ACETATE <s>
MIACALCIN INJECTION CALCITONIN,SALMON,SYNTHETIC
SANDOSTATIN LAR OCTREOTIDE ACETATE [PA] <s>
SENSIPAR CINACALCET HCL <s>
SOMATULINE DEPOT LANREOTIDE ACETATE <s>
SOMAVERT PEGVISOMANT [PA] <s>
STIMATE DESMOPRESSIN ACETATE
SYNAREL NAFARELIN ACETATE
Nonformulary
Trade Name Generic Name Utilization Management
HECTOROL DOXERCALCIFEROL
ZEMPLAR PARICALCITOL

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 80
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
7F. Insulins

Formulary Preferred
Trade Name Generic Name Utilization Management
NONE
Formulary Options
Trade Name Generic Name Utilization Management
APIDRA (PEN/CARTRIDGE) INSULIN GLULISINE
APIDRA (VIAL) INSULIN GLULISINE
HUMALOG, MIX (PEN/CARTRIDGE) INSULIN LISPRO,HUMAN REC.ANLOG
HUMALOG, MIX (VIAL) INSULIN NPL/INSULIN LISPRO BE
HUMULIN 70/30 (PEN/CARTRIDGE) HUMULIN
HUMULIN 70/30 (VIAL) HUMULIN BE
HUMULIN N (PEN/CARTRIDGE) NPH, HUMAN INSULIN ISOPHANE
HUMULIN N (VIAL) NPH, HUMAN INSULIN ISOPHANE BE
HUMULIN R (VIAL) INSULIN REGULAR HUMAN REC BE
LANTUS (PEN/CARTRIDGE) INSULIN GLARGINE,HUM.REC.ANLOG
LANTUS (VIAL) INSULIN GLARGINE,HUM.REC.ANLOG
LEVEMIR (PEN) INSULIN DETEMIR
LEVEMIR (VIAL) INSULIN DETEMIR
NOVOLIN (PEN/CARTRIDGE) INSULIN REGULAR HUMAN REC
NOVOLIN (VIAL) INSULIN REGULAR HUMAN REC BE
NOVOLOG (PEN/CARTRIDGE) INSULIN ASPART
NOVOLOG (VIAL) INSULIN ASPART BE
NOVOLOG MIX (PEN/CARTRIDGE) INSULN ASP PRT/INSULIN ASPART
Nonformulary
Trade Name Generic Name Utilization Management
NONE

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 81
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
7G. Non-insulin Hypoglycemic Agents

Formulary Preferred
Trade Name Generic Name Utilization Management
AMARYL (g) GLIMEPIRIDE BE
DIABETA, MICRONASE (g) GLYBURIDE BE
DIABINESE (g) CHLORPROPAMIDE BE
GLUCOPHAGE (g) METFORMIN HCL BE
GLUCOPHAGE XR (g) METFORMIN HCL BE
GLUCOTROL (g) GLIPIZIDE BE
GLUCOTROL XL (g) GLIPIZIDE BE
GLUCOVANCE (g) GLYBURIDE/METFORMIN HCL BE
GLYNASE (g) GLYBURIDE,MICRONIZED BE
METAGLIP (g) GLIPIZIDE/METFORMIN HCL BE
ORINASE (g) TOLBUTAMIDE
PRECOSE (g) ACARBOSE
STARLIX (g) NATEGLINIDE
TOLINASE (g) TOLAZAMIDE
Formulary Options
Trade Name Generic Name Utilization Management
ACTOPLUS MET PIOGLITAZONE HCL/METFORMIN HCL [ST] [QL]
ACTOS PIOGLITAZONE HCL [ST] [QL]
DUETACT PIOGLITAZONE/GLIMEPIRIDE [ST] [QL]
PRANDIN REPAGLINIDE
Nonformulary
Trade Name Generic Name Utilization Management
ACTOPLUS MET XR PIOGLITAZONE HCL/METFORMIN HCL [ST] [QL]
AVANDAMET ROSIGLITAZONE/METFORMIN HCL [ST] [QL]
AVANDARYL ROSIGLITAZONE MALEATE/GLIMEPIR [ST]
AVANDIA ROSIGLITAZONE MALEATE [ST] [QL]
BYETTA EXENATIDE [PA] [QL]
FORTAMET METFORMIN HCL
GLUMETZA METFORMIN HCL
GLYSET MIGLITOL
JANUMET SITAGLIPTIN PHOS/METFORMIN HCL [PA]
JANUVIA SITAGLIPTIN PHOSPHATE [PA] [QL]
ONGLYZA SAXAGLIPTIN HYDROCHLORIDE [PA] [QL]
PRANDIMET REPAGLINIDE/METFORMIN HCL [PA]
RIOMET METFORMIN HCL
SYMLIN PRAMLINTIDE ACETATE [ST] [QL]
VICTOZA LIRAGLUTIDE [PA] [QL]

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 82
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
7H. Growth Hormone and Related Products

Formulary Preferred
Trade Name Generic Name Utilization Management
NONE
Formulary Options
Trade Name Generic Name Utilization Management
GENOTROPIN SOMATROPIN [PA] <s>
NUTROPIN SOMATROPIN [PA] <s>
NUTROPIN AQ SOMATROPIN [PA] <s>
NUTROPIN AQ NUSPIN SOMATROPIN [PA] <s>
Nonformulary
Trade Name Generic Name Utilization Management
HUMATROPE SOMATROPIN [PA] <s>
INCRELEX MECASERMIN [PA] <s>
NORDITROPIN NORDIFLEX SOMATROPIN [PA] <s>
OMNITROPE SOMATROPIN [PA] <s>
SAIZEN SOMATROPIN [PA] <s>
SEROSTIM SOMATROPIN [PA] <s>
TEV-TROPIN SOMATROPIN [PA] <s>
ZORBTIVE SOMATROPIN [PA] <s>

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 83
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
8. ANTINEOPLASTICS AND IMMUNOSUPPRESANTS

8A. Alkylating Agents

Formulary Preferred
Trade Name Generic Name Utilization Management
CYTOXAN (g) CYCLOPHOSPHAMIDE
Formulary Options
Trade Name Generic Name Utilization Management
ALKERAN MELPHALAN
CEENU LOMUSTINE
LEUKERAN CHLORAMBUCIL
MYLERAN BUSULFAN
TEMODAR TEMOZOLOMIDE <s>
Nonformulary
Trade Name Generic Name Utilization Management
NONE
8B. Antimetabolites

Formulary Preferred
Trade Name Generic Name Utilization Management
METHOTREXATE (g) METHOTREXATE SODIUM/PF
PURINETHOL (g) MERCAPTOPURINE
Formulary Options
Trade Name Generic Name Utilization Management
OFORTA FLUDARABINE PHOSPHATE [QL] <s>
THIOGUANINE THIOGUANINE
XELODA CAPECITABINE <s>
Nonformulary
Trade Name Generic Name Utilization Management
NONE

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 84
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
8C. Immunomodulators

Formulary Preferred
Trade Name Generic Name Utilization Management
CELLCEPT (g) MYCOPHENOLATE MOFETIL <s>
IMURAN (g) AZATHIOPRINE
NEORAL (g) CYCLOSPORINE, MODIFIED <s>
PREDNISONE (g) PREDNISONE
PROGRAF (g) TACROLIMUS ANHYDROUS <s>
Formulary Options
Trade Name Generic Name Utilization Management
ARCALYST RILONACEPT [PA] <s>
CELLCEPT SUSPENSION MYCOPHENOLATE MOFETIL <s>
RAPAMUNE TABS, SOLUTION SIROLIMUS <s>
SANDIMMUNE CYCLOSPORINE <s>
THALOMID THALIDOMIDE <s>
Nonformulary
Trade Name Generic Name Utilization Management
MYFORTIC MYCOPHENOLATE SODIUM <s>
REVLIMID LENALIDOMIDE [PA] [QL] <s>
8D. Hormonal Agents

Formulary Preferred
Trade Name Generic Name Utilization Management
ARIMIDEX (g) ANASTROZOLE [PA] <s>
CASODEX (g) BICALUTAMIDE <s>
EULEXIN (g) FLUTAMIDE
LUPRON (g) LEUPROLIDE ACETATE <s>
MEGACE (g) MEGESTROL ACETATE
TAMOXIFEN CITRATE (g) TAMOXIFEN CITRATE
Formulary Options
Trade Name Generic Name Utilization Management
AROMASIN EXEMESTANE [PA] <s>
DEPO-PROVERA 400MG MEDROXYPROGESTERONE ACET
FARESTON TOREMIFENE CITRATE
FASLODEX FULVESTRANT
FEMARA LETROZOLE [PA] <s>
LUPRON DEPOT LEUPROLIDE ACETATE <s>
NILANDRON NILUTAMIDE
TRELSTAR DEPOT, LA TRIPTORELIN PAMOATE <s>
ZOLADEX GOSERELIN ACETATE [QL] <s>
Nonformulary
Trade Name Generic Name Utilization Management
ELIGARD LEUPROLIDE ACETATE <s>
MEGACE ES MEGESTROL ACETATE

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 85
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
8E. Miscellaneous Antineoplastic Agents

Formulary Preferred
Trade Name Generic Name Utilization Management
HYDREA (g) HYDROXYUREA
SANDOSTATIN (g) OCTREOTIDE ACETATE [PA] <s>
VEPESID (g) ETOPOSIDE
Formulary Options
Trade Name Generic Name Utilization Management
DROXIA HYDROXYUREA
EMCYT ESTRAMUSTINE PHOSPHATE SODIUM
HEXALEN ALTRETAMINE
HYCAMTIN TOPOTECAN HCL [PA] <s>
LYSODREN MITOTANE
MATULANE PROCARBAZINE HCL
SANDOSTATIN LAR OCTREOTIDE ACETATE [PA] <s>
VESANOID TRETINOIN
ZOLINZA VORINOSTAT [PA] <s>
Nonformulary
Trade Name Generic Name Utilization Management
TARGRETIN ORAL BEXAROTENE <s>
8F. Adjuvant Therapy

Formulary Preferred
Trade Name Generic Name Utilization Management
LEUCOVORIN (g) LEUCOVORIN CALCIUM
Formulary Options
Trade Name Generic Name Utilization Management
LEUKINE SARGRAMOSTIM <s>
MESNEX MESNA
NEUPOGEN FILGRASTIM <s>
PROCRIT EPOETIN ALFA [PA] <s>
Nonformulary
Trade Name Generic Name Utilization Management
ARANESP DARBEPOETIN ALFA IN ALBUMN SOL [PA] <s>
EPOGEN EPOETIN ALFA [PA] <s>
NEULASTA PEGFILGRASTIM [QL] <s>

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 86
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
8G. Kinase Inhibitors and Molecular Target Inhibitors

Formulary Preferred
Trade Name Generic Name Utilization Management
NONE
Formulary Options
Trade Name Generic Name Utilization Management
AFINITOR EVEROLIMUS [PA] [QL] <s>
GLEEVEC IMATINIB MESYLATE <s>
IRESSA GEFITINIB [PA] <s>
NEXAVAR SORAFENIB TOSYLATE [PA] [QL] <s>
SPRYCEL DASATINIB [PA] <s>
SUTENT SUNITINIB MALATE [PA] [QL] <s>
TARCEVA ERLOTINIB HCL [PA] <s>
TASIGNA NILOTINIB HYDROCHLORIDE <s>
TYKERB LAPATINIB DITOSYLATE [PA] <s>
VOTRIENT PAZOPANIB HYDROCHLORIDE [PA] <s>
ZORTRESS EVEROLIMUS [QL] <s>
Nonformulary
Trade Name Generic Name Utilization Management
NONE

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 87
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
9. IMMUNOLOGY AND HEMATOLOGY

9B. Hematopoietic Agents

Formulary Preferred
Trade Name Generic Name Utilization Management
NONE
Formulary Options
Trade Name Generic Name Utilization Management
LEUKINE SARGRAMOSTIM <s>
NEUMEGA OPRELVEKIN <s>
NEUPOGEN FILGRASTIM <s>
PROCRIT EPOETIN ALFA [PA] <s>
PROMACTA ELTROMBOPAG OLAMINE [PA] [QL] <s>
Nonformulary
Trade Name Generic Name Utilization Management
ARANESP DARBEPOETIN ALFA IN ALBUMN SOL [PA] <s>
EPOGEN EPOETIN ALFA [PA] <s>
NEULASTA PEGFILGRASTIM [QL] <s>
9C. Interferons and MS Therapy

Formulary Preferred
Trade Name Generic Name Utilization Management
NONE
Formulary Options
Trade Name Generic Name Utilization Management
ACTIMMUNE INTERFERON GAMMA-1B,RECOMB. <s>
ALFERON N INTERFERON ALFA-N3
AVONEX INTERFERON BETA-1A <s>
COPAXONE GLATIRAMER ACETATE <s>
INFERGEN INTERFERON ALFACON-1 [PA] <s>
INTRON A INTERFERON ALFA-2B,RECOMB. [PA] <s>
PEGASYS PEGINTERFERON ALFA-2A [PA] [QL] <s>
PEG-INTRON, REDIPEN PEGINTERFERON ALFA-2B [PA] [QL] <s>
REBIF INTERFERON BETA-1A/ALBUMIN <s>
Nonformulary
Trade Name Generic Name Utilization Management
AMPYRA FAMPRIDINE (4-AMINOPYRIDINE) [PA] [QL] <s>
BETASERON INTERFERON BETA-1B [PA] <s>
EXTAVIA INTERFERON BETA-1B <s>
GILENYA FINGOLIMOD HYDROCHLORIDE [PA] [QL] <s>

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 88
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
10. DERMATOLOGY

10A. Very High Potency Corticosteriods

Formulary Preferred
Trade Name Generic Name Utilization Management
DIPROLENE OINTMENT (g) BETAMET DIPROP/PROP GLY
OLUX (g) CLOBETASOL PROPIONATE
PSORCON, FLORONE (g) DIFLORASONE DIACETATE
TEMOVATE (g), CLOBEVATE (g) CLOBETASOL PROPIONATE
ULTRAVATE (g) HALOBETASOL PROPIONATE
Formulary Options
Trade Name Generic Name Utilization Management
NONE
Nonformulary
Trade Name Generic Name Utilization Management
CLOBEX, SPRAY CLOBETASOL PROPIONATE
OLUX-E CLOBETASOL PROPIONATE/EMOLL
ULTRAVATE PAC HALOBETASOL PROP/AMMONIUM LAC
VANOS 0.1% CR FLUOCINONIDE
10B. High Potency Corticosteroids

Formulary Preferred
Trade Name Generic Name Utilization Management
ARISTOCORT, KENALOG 0.5% CR (g) TRIAMCINOLONE ACETONIDE
CYCLOCORT (g) AMCINONIDE
DIPROLENE AF, GEL, CR, LOT (g) BETAMET DIPROP/PROP GLY
DIPROSONE (g), MAXIVATE (g) BETAMETHASONE DIPROPIONATE
LIDEX, E (g) FLUOCINONIDE
PSORCON, FLORONE (g) DIFLORASONE DIACETATE
TOPICORT CR, GEL, OINT (g) DESOXIMETASONE
VALISONE CR, LOTION, OINT (g) BETAMETHASONE VALERATE
Formulary Options
Trade Name Generic Name Utilization Management
NONE
Nonformulary
Trade Name Generic Name Utilization Management
APEXICON E DIFLORASONE DIACETATE/EMOLL
HALOG HALCINONIDE

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 89
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
10C. Medium Potency Corticosteroids

Formulary Preferred
Trade Name Generic Name Utilization Management
ARISTOCORT, KENALOG (g) TRIAMCINOLONE ACETONIDE
CUTIVATE (g) FLUTICASONE PROPIONATE
DERMATOP (g) PREDNICARBATE
ELOCON (g) MOMETASONE FUROATE
LOCOID CM, OINT, SOLN (g) HYDROCORTISONE BUTYRATE
LOCOID LIPOCREAM (g) HYDROCORTISONE BUTYRATE/EMOLL
SYNALAR 0.025% CREAM, OINT (g) FLUOCINOLONE ACETONIDE
TOPICORT LP (g) DESOXIMETASONE
VALISONE CR, LOTION, OINT (g) BETAMETHASONE VALERATE
WESTCORT (g) HYDROCORTISONE VALERATE
Formulary Options
Trade Name Generic Name Utilization Management
CLODERM CLOCORTOLONE PIVALATE
CORDRAN, TAPE, SP FLURANDRENOLIDE
Nonformulary
Trade Name Generic Name Utilization Management
CUTIVATE LOTION FLUTICASONE PROPIONATE
LOCOID LOTION HYDROCORTISONE BUTYRATE
LUXIQ BETAMETHASONE VALERATE
PANDEL HYDROCORTISONE PROBUTATE
10D. Low Potency Corticosteroids

Formulary Preferred
Trade Name Generic Name Utilization Management
ACLOVATE (g) ALCLOMETASONE DIPROPIONATE
DERMACORT, HYTONE (Rx Only) (g) HYDROCORTISONE
DESOWEN, TRIDESILON (g) DESONIDE
SYNALAR CREAM, SOLN (g) FLUOCINOLONE ACETONIDE
Formulary Options
Trade Name Generic Name Utilization Management
CAPEX SHAMPOO FLUOCINOLONE ACETONIDE
Nonformulary
Trade Name Generic Name Utilization Management
DERMA-SMOOTHE/FS FLUOCINOLONE ACETONIDE
DESONATE DESONIDE [ST]
VERDESO DESONIDE [ST]

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 90
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
10E. Topical Anesthetics

Formulary Preferred
Trade Name Generic Name Utilization Management
EMLA (g) LIDOCAINE/PRILOCAINE
XYLOCAINE (Rx Only) (g) LIDOCAINE HCL
XYLOCAINE VISCOUS (g) LIDOCAINE HCL
Formulary Options
Trade Name Generic Name Utilization Management
NONE
Nonformulary
Trade Name Generic Name Utilization Management
LIDODERM PATCH LIDOCAINE

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 91
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
10F. Acne Treatment

Formulary Preferred
Trade Name Generic Name Utilization Management
ACCUTANE (REQ DERM CONSULT) (g) ISOTRETINOIN
BENZAMYCIN (g) ERYTHROMYCIN BASE/BENZ PER
BENZOYL PEROXIDE-RX (g) BENZOYL PEROXIDE
BREVOXYL GEL (g) BENZOYL PEROXIDE
CLEOCIN T (g) CLINDAMYCIN PHOSPHATE
DIFFERIN 0.1% CREAM, GEL (g) ADAPALENE
DIFFERIN LOTION ADAPALENE
ERYTHROMYCIN TOPICAL SOLN, GEL (g) ERYTHROMYCIN BASE/ETHANOL
EVOCLIN FOAM(g) CLINDAMYCIN PHOSPHATE
METROCREAM, GEL, LOTION (g) METRONIDAZOLE
NEOBENZ MICRO BENZOYL PEROXIDE MICROSPHERES
PLEXION, TS (g) SULFACETAMIDE SODIUM/SULFUR
RETIN-A, AVITA (g) TRETINOIN
ROSULA CLEANSER (g) SULFACETAMIDE SOD/SULFUR/UREA
SULFACET-R (g) SULFACETAMIDE SODIUM/SULFUR
Formulary Options
Trade Name Generic Name Utilization Management
DIFFERIN 0.3% GEL ADAPALENE
METROGEL TOPICAL 1% METRONIDAZOLE
RETIN-A MICRO TRETINOIN MICROSPHERES
TAZORAC TAZAROTENE
Nonformulary
Trade Name Generic Name Utilization Management
ACZONE DAPSONE [QL]
AKNE-MYCIN ERYTHROMYCIN BASE
ALTABAX RETAPAMULIN
AZELEX AZELAIC ACID
BENZACLIN CLINDAMYCIN PHOSPHATE/BENZ PER
BENZASHAVE BENZOYL PEROXIDE
CLINAC BPO BENZOYL PEROXIDE
DUAC, CS CLINDAMYCIN PHOSPHATE/BENZ PER
EPIDUO ADAPALENE/BENZOYL PEROXIDE
FINACEA AZELAIC ACID
NORITATE METRONIDAZOLE
ROSULA FOAM SULFACETAMIDE SODIUM/SULFUR
ZIANA GEL CLINDAMYCIN/TRETINOIN [PA]
10G. Topical Antibacterials

Formulary Preferred
Trade Name Generic Name Utilization Management
BACTROBAN OINTMENT (g) MUPIROCIN
GENTAMICIN CR, OINT (g) GENTAMICIN SULFATE
Formulary Options
Trade Name Generic Name Utilization Management
BACTROBAN CREAM, NASAL MUPIROCIN CALCIUM
Nonformulary
Trade Name Generic Name Utilization Management
ALTABAX RETAPAMULIN
(g) Use generic equivalent
[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 92
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
10H. Topical Antifungals

Formulary Preferred
Trade Name Generic Name Utilization Management
LOPROX CR, LOTION, GEL (g) CICLOPIROX OLAMINE
LOPROX SHAMPOO (g) CICLOPIROX
LOTRIMIN (g) CLOTRIMAZOLE
LOTRISONE CR, LOTION (g) CLOTRIMAZOLE/BETAMET DIPROP
MONISTAT-DERM (g) MICONAZOLE NITRATE
MYCOSTATIN (g) NYSTATIN
NIZORAL CREAM (g) KETOCONAZOLE
NIZORAL SHAMPOO 2% (g) KETOCONAZOLE
NYSTATIN W/TRIAMCINOLONE (g) NYSTATIN/TRIAMCIN
PENLAC (g) CICLOPIROX
SPECTAZOLE (g) ECONAZOLE NITRATE
Formulary Options
Trade Name Generic Name Utilization Management
CNL 8 CICLOPIROX/NAIL LACQUER REMOVR
Nonformulary
Trade Name Generic Name Utilization Management
ERTACZO SERTACONAZOLE NITRATE
EXELDERM SOLN, CR SULCONAZOLE NITRATE
EXTINA KETOCONAZOLE
MENTAX BUTENAFINE HCL
NAFTIN NAFTIFINE HCL
OXISTAT OXICONAZOLE NITRATE
VUSION MICONAZOLE NITRATE/ZINC OXIDE
XOLEGEL KETOCONAZOLE
XOLEGEL COREPAK KETOCONAZOLE/HYDROCORTISONE
10I. Topical Antivirals

Formulary Preferred
Trade Name Generic Name Utilization Management
NONE
Formulary Options
Trade Name Generic Name Utilization Management
ZOVIRAX CREAM, OINT ACYCLOVIR
Nonformulary
Trade Name Generic Name Utilization Management
DENAVIR PENCICLOVIR
XERESE ACYCLOVIR/HYDROCORTISONE

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 93
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
10J. Wound and Burn Therapy

Formulary Preferred
Trade Name Generic Name Utilization Management
ACCUZYME, ETHEZYME, GLADASE (g) PAPAIN/UREA
GRANULEX (g) TRYPSIN/BALSAM PERU/CASTOR OIL
SILVADENE (g) SILVER SULFADIAZINE
Formulary Options
Trade Name Generic Name Utilization Management
SANTYL COLLAGENASE
Nonformulary
Trade Name Generic Name Utilization Management
REGRANEX BECAPLERMIN [PA]
10K. Antipsoriatic/Antiseborrheic

Formulary Preferred
Trade Name Generic Name Utilization Management
DOVONEX OINT(g) CALCIPOTRIENE
DOVONEX SOLUTION (g) CALCIPOTRIENE
DRITHOCREME HP (g) ANTHRALIN
SELSUN RX (g) SELENIUM SULFIDE
Formulary Options
Trade Name Generic Name Utilization Management
DOVONEX CREAM CALCIPOTRIENE
DRITHO-SCALP ANTHRALIN
ENBREL ETANERCEPT [PA] [QL] <s>
HUMIRA ADALIMUMAB [PA] [QL] <s>
OXSORALEN, ULTRA METHOXSALEN, RAPID
SORIATANE ACITRETIN [QL]
Nonformulary
Trade Name Generic Name Utilization Management
TACLONEX, SCALP BETAMET DIPROP/CALCIPOTRIENE [PA]
VECTICAL CALCITRIOL
10L. Scabicides/Pediculicides

Formulary Preferred
Trade Name Generic Name Utilization Management
ELIMITE (g) PERMETHRIN
OVIDE (g) MALATHION
Formulary Options
Trade Name Generic Name Utilization Management
EURAX CROTAMITON
LINDANE LINDANE
Nonformulary
Trade Name Generic Name Utilization Management
NONE

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 94
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
10M. Miscellaneous Dermatologicals

Formulary Preferred
Trade Name Generic Name Utilization Management
ALDARA (g) IMIQUIMOD [QL]
CONDYLOX SOLN (g) PODOFILOX
DRYSOL (g) ALUMINUM CHLORIDE
EFUDEX (g) FLUOROURACIL
Formulary Options
Trade Name Generic Name Utilization Management
CONDYLOX GEL PODOFILOX
ELIDEL PIMECROLIMUS [PA]
PANRETIN ALITRETINOIN
ZONALON, PRUDOXIN DOXEPIN HCL
Nonformulary
Trade Name Generic Name Utilization Management
CARAC FLUOROURACIL
CARMOL HC HYDROCORTISONE ACETATE/UREA
EFUDEX OCCLUSION FLUOROURACIL/ADHESIVE BANDAGE
PROTOPIC TACROLIMUS [ST]
SOLARAZE DICLOFENAC SODIUM
TARGRETIN GEL BEXAROTENE <s>
VEREGEN SINECATECHINS
ZYCLARA IMIQUIMOD [QL]

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 95
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
11. OPHTHALMOLOGY

11A. Ophthalmic Beta Blockers

Formulary Preferred
Trade Name Generic Name Utilization Management
BETAGAN (g) LEVOBUNOLOL HCL
BETOPTIC SOLN (g) BETAXOLOL HCL
OCUPRESS (g) CARTEOLOL HCL
OPTIPRANOLOL (g) METIPRANOLOL
TIMOPTIC - XE (g) TIMOLOL MALEATE
TIMOPTIC (g) TIMOLOL MALEATE
Formulary Options
Trade Name Generic Name Utilization Management
BETOPTIC S BETAXOLOL HCL
ISTALOL TIMOLOL MALEATE
Nonformulary
Trade Name Generic Name Utilization Management
BETIMOL TIMOLOL
11B. Other Glaucoma Agents

Formulary Preferred
Trade Name Generic Name Utilization Management
ALPHAGAN (g) BRIMONIDINE TARTRATE
ALPHAGAN P 0.15% (g) BRIMONIDINE TARTRATE
COSOPT (g) TIMOLOL MALEATE/DORZOLAM HCL
IOPIDINE DROPS (g) APRACLONIDINE HCL
PILOCAR, ISOPTO-CARPINE (g) PILOCARPINE HCL
TRUSOPT (g) DORZOLAMIDE HCL
Formulary Options
Trade Name Generic Name Utilization Management
ALPHAGAN P 0.1% BRIMONIDINE TARTRATE
AZOPT BRINZOLAMIDE
ISOPTO CARBACHOL CARBACHOL
LUMIGAN BIMATOPROST
PHOSPHOLINE IODIDE ECHOTHIOPHATE IODIDE
PILOPINE HS PILOCARPINE HCL
PROPINE DIPIVEFRIN HCL
TRAVATAN, Z TRAVOPROST
XALATAN LATANOPROST
Nonformulary
Trade Name Generic Name Utilization Management
COMBIGAN BRIMONIDINE TARTRATE/TIMOLOL
IOPIDINE DROPERETTE APRACLONIDINE HCL

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 96
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
11C. Cycloplegic Mydriatics

Formulary Preferred
Trade Name Generic Name Utilization Management
CYCLOGYL (g) CYCLOPENTOLATE HCL
ISOPTO ATROPINE (g) ATROPINE SULFATE
ISOPTO HOMATROPINE (g) HOMATROPINE HBR
MYDRIACYL (g) TROPICAMIDE
Formulary Options
Trade Name Generic Name Utilization Management
ISOPTO HYOSCINE SCOPOLAMINE HYDROBROMIDE
Nonformulary
Trade Name Generic Name Utilization Management
PAREMYD HYDROXYAMPHETAMINE/TROPICAMIDE
11D. Ophthalmic Anti-inflammatory Agents

Formulary Preferred
Trade Name Generic Name Utilization Management
ACULAR, LS (g) KETOROLAC TROMETHAMINE
OCUFEN (g) FLURBIPROFEN SODIUM
VOLTAREN (g) DICLOFENAC SODIUM
Formulary Options
Trade Name Generic Name Utilization Management
NONE
Nonformulary
Trade Name Generic Name Utilization Management
ACUVAIL KETOROLAC TROMETHAMINE
NEVANAC NEPAFENAC
XIBROM BROMFENAC SODIUM

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 97
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
11E. Ophthalmic Anti-infectives

Formulary Preferred
Trade Name Generic Name Utilization Management
BACITRACIN (g) BACITRACIN
BLEPH-10, SODIUM SULAMYDE (g) SULFACETAMIDE SODIUM
CILOXAN DROPS (g) CIPROFLOXACIN HCL
GARAMYCIN (g) GENTAMICIN SULFATE
ILOTYCIN (g) ERYTHROMYCIN BASE
NEOSPORIN OPHTH SOLN (g) NEOMYCIN/GRAMICIDIN/POLYMYXN B
NEOSPORIN OPTH OINT (g) NEOMY SULF/BACITRA/POLYMYXIN B
OCUFLOX (g) OFLOXACIN
POLYSPORIN (g) BACITRACIN/POLYMYXIN B SULFATE
POLYTRIM (g) POLYMYXIN B SULFATE/TMP
TOBREX (g) TOBRAMYCIN SULFATE
VIROPTIC (g) TRIFLURIDINE
Formulary Options
Trade Name Generic Name Utilization Management
CILOXAN OINT CIPROFLOXACIN HCL
NATACYN NATAMYCIN
VIGAMOX MOXIFLOXACIN HCL
ZIRGAN GANCICLOVIR
Nonformulary
Trade Name Generic Name Utilization Management
AZASITE AZITHROMYCIN
BESIVANCE BESIFLOXACIN HYDROCHLORIDE
IQUIX IQUIX
QUIXIN LEVOFLOXACIN
ZYMAR GATIFLOXACIN
ZYMAXID GATIFLOXACIN
11F. Ophthalmic Steroids

Formulary Preferred
Trade Name Generic Name Utilization Management
DECADRON OPTH (g) DEXAMETHASONE SOD PHOSPHATE
FML (g) FLUOROMETHOLONE
INFLAMASE, FORTE (g) PREDNISOLONE SOD PHOSPHATE
PRED FORTE (g) PREDNISOLONE ACETATE
Formulary Options
Trade Name Generic Name Utilization Management
FML FORTE, S.O.P. FLUOROMETHOLONE
PRED MILD PREDNISOLONE ACETATE
VEXOL RIMEXOLONE
Nonformulary
Trade Name Generic Name Utilization Management
ALREX LOTEPREDNOL ETABONATE
DUREZOL DIFLUPREDNATE
LOTEMAX LOTEPREDNOL ETABONATE
MAXIDEX DEXAMETHASONE

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 98
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
11G. Ophthalmic Anti-infective/Steroid Combinations

Formulary Preferred
Trade Name Generic Name Utilization Management
CORTISPORIN (g) NEOMY SULF/POLYMYX B SULF/HC
MAXITROL (g) NEO/POLYMYX B SULF/DEXAMETH
TOBRADEX (g) TOBRAMYCIN SULFATE/DEXAMETH
VASOCIDIN (g) NA SULFACETM/PREDNIS SP
Formulary Options
Trade Name Generic Name Utilization Management
BLEPHAMIDE DROPS, OINT NA SULFACETM/PREDNISOL AC
POLY-PRED NEOMY SULF/POLYMYX B SULF/PRED
TOBRADEX OINT TOBRAMYCIN SULFATE/DEXAMETH
Nonformulary
Trade Name Generic Name Utilization Management
PRED-G GENTAMICIN/PREDNISOL AC
ZYLET TOBRAMYCIN/LOTEPRED ETAB
11H. Miscellaneous Ophthalmic Agents

Formulary Preferred
Trade Name Generic Name Utilization Management
ALBALON (g) NAPHAZOLINE HCL
NEO-SYNEPHRINE (g) PHENYLEPHRINE HCL
OPTICROM (g) CROMOLYN SODIUM
OPTIVAR (g) AZELASTINE HCL
Formulary Options
Trade Name Generic Name Utilization Management
ALOCRIL NEDOCROMIL SODIUM
ALOMIDE LODOXAMIDE TROMETHAMINE
LACRISERT HYDROXYPROPYL CELLULOSE
PATANOL OLOPATADINE HCL
RESTASIS CYCLOSPORINE
Nonformulary
Trade Name Generic Name Utilization Management
ALAMAST PEMIROLAST POTASSIUM
BEPREVE BEPOTASTINE BESILATE
ELESTAT EPINASTINE HCL
EMADINE EMEDASTINE DIFUMARATE
PATADAY OLOPATADINE HCL

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 99
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
12. OTIC & NASAL PREPARATIONS

12A. Nasal Preparations

Formulary Preferred
Trade Name Generic Name Utilization Management
ASTELIN NASAL SPRAY(g) AZELASTINE HCL
ATROVENT NASAL SPRAY (g) IPRATROPIUM BROMIDE
FLONASE (g) FLUTICASONE PROPIONATE
NASALIDE (g) FLUNISOLIDE 0.025% SPRAY
NASAREL (g) FLUNISOLIDE
Formulary Options
Trade Name Generic Name Utilization Management
ASTEPRO NASAL SPRAY AZELASTINE HCL
NASACORT AQ TRIAMCINOLONE ACETONIDE [ST]
Nonformulary
Trade Name Generic Name Utilization Management
BECONASE AQ BECLOMETHASONE DIPROPIONATE [ST]
NASONEX MOMETASONE FUROATE [ST]
OMNARIS CICLESONIDE [ST]
PATANASE OLOPATADINE HCL
RHINOCORT AQUA BUDESONIDE [ST]
VERAMYST FLUTICASONE FUROATE [ST]
12B. Otic Preparations

Formulary Preferred
Trade Name Generic Name Utilization Management
ACETASOL, HC/VOSOL, HC (g) ACETIC ACID/HYDROCORTISONE
AURALGAN (g) AA/ANTPY/BCAINE/POLICO/AL ACET
CORTISPORIN (g) NEOMY SULF/POLYMYX B SULF/HC
DOMEBORO OTIC (g) ACETIC ACID/ALUMINUM ACETATE
FLOXIN OTIC (g) OFLOXACIN
Formulary Options
Trade Name Generic Name Utilization Management
CIPRO HC CIPROFLOXACIN HCL/HC
CIPRODEX CIPROFLOXACIN HCL/DEXAMETH
Nonformulary
Trade Name Generic Name Utilization Management
COLY-MYCIN S NEOMYCIN SULFATE/COLIST SUL/HC
CORTISPORIN-TC NEOMY SULF/COLIST SUL/HC/THONZ
FLOXIN OTIC SINGLES OFLOXACIN

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 100
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13. RESPIRATORY, COUGH & COLD

13A. Antihistamines

Formulary Preferred
Trade Name Generic Name Utilization Management
ALLEGRA (g) FEXOFENADINE HCL
ASTELIN NASAL SPRAY(g) AZELASTINE HCL
ATARAX, VISTARIL (g) HYDROXYZINE
BENADRYL (g) DIPHENHYDRAMINE HCL
CLARITIN, ALAVERT(OTC) (g) LORATADINE
PERIACTIN (g) CYPROHEPTADINE HCL
PHENERGAN (g) PROMETHAZINE HCL
POLARAMINE (g) DEXCHLORPHENIRAMINE MALEATE
TAVIST RX (2.68MG, SYRUP) (g) CLEMASTINE FUMARATE
XYZAL TABS (g) LEVOCETIRIZINE DIHYDROCHLORIDE [ST] [QL]
ZYRTEC (OTC) (g) CETIRIZINE HCL
Formulary Options
Trade Name Generic Name Utilization Management
ASTEPRO NASAL SPRAY AZELASTINE HCL
Nonformulary
Trade Name Generic Name Utilization Management
ALLEGRA ODT FEXOFENADINE HCL [ST]
ALLEGRA SUSP FEXOFENADINE HCL [ST]
CLARINEX (ALL) DESLORATADINE [PA] [QL]
PATANASE OLOPATADINE HCL
XYZAL SOLUTION LEVOCETIRIZINE DIHYDROCHLORIDE [PA] [QL]
13B. Antihistamine/Decongestant Combinations

Formulary Preferred
Trade Name Generic Name Utilization Management
ALLEGRA-D 12 HOUR (g) P-EPHED HCL/FEXOFENADINE HCL [ST] [QL]
BROMFED, PD (g) P-EPHED HCL/BROMPHENIRAMIN
CLARITIN-D 12HR, 24HR(OTC) (g) P-EPHED SUL/LORATADINE
DECONAMINE SYRUP, SR (g) PSEUDOEPHEDRINE HCL/CHLOR-MAL
RONDEC (g) PHENYLEPHRINE HCL/CHLOR-MAL
RYNATAN (g) PHENYLEPHRINE/CHLOR-TAN
RYNATAN PED SUSP (g) PHENYLEPHRINE/CHLOR-TAN
ZYRTEC-D(OTC) (g) P-EPHED HCL/CETIRIZINE HCL
Formulary Options
Trade Name Generic Name Utilization Management
ALLEGRA-D 24 HOUR P-EPHED HCL/FEXOFENADINE HCL [ST] [QL]
DECONAMINE SR PSEUDOEPHEDRINE HCL/CHLOR-MAL
Nonformulary
Trade Name Generic Name Utilization Management
CLARINEX-D P-EPHED SUL/DESLORATADINE [PA] [QL]
SEMPREX-D PSEUDOEPHEDRINE HCL/ACRIVAS [ST]

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
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13C. Antitussive combinations

Formulary Preferred
Trade Name Generic Name Utilization Management
BROMFED-DM (g) D-METHORPHAN HB/P-EPD HCL/BPM
DECONAMINE CX, SR (g) GUAIFENESIN/P-EPHED HCL/HCOD
HUMABID DM (g) GUAIFENESIN/D-METHORPHAN HB
PHENERGAN DM (g) D-METHORPHAN HB/PROMETH HCL
PHENERGAN W/CODEINE (g) CODEINE/PROMETHAZINE HCL
RONDEC-DM (g) D-METHORPHAN HB/PE/CHLORPHENIR
TESSALON, PERLES (g) BENZONATATE
TUSSIONEX (g) HYDROCODONE/CHLORPHEN POLIS
Formulary Options
Trade Name Generic Name Utilization Management
TUSSICAPS HYDROCODONE/CHLORPHEN POLIS
Nonformulary
Trade Name Generic Name Utilization Management
NONE
13D. Expectorant combinations

Formulary Preferred
Trade Name Generic Name Utilization Management
GUAIFED, ENTEX PSE (g) GUAIFENESIN/P-EPHED HCL
GUAIFED-PD (g) GUAIFENESIN/PHENYLEPHRINE HCL
PHENERGAN VC (g) PHENYLEPHRINE HCL/PROMETH HCL
Formulary Options
Trade Name Generic Name Utilization Management
NONE
Nonformulary
Trade Name Generic Name Utilization Management
NONE
13F. Oral Beta-Agonists

Formulary Preferred
Trade Name Generic Name Utilization Management
ALUPENT (g) METAPROTERENOL SULFATE
BRETHINE (g) TERBUTALINE SULFATE
PROVENTIL SOLUTION (g) ALBUTEROL SULFATE
VOSPIRE ER (g) ALBUTEROL SULFATE
Formulary Options
Trade Name Generic Name Utilization Management
NONE
Nonformulary
Trade Name Generic Name Utilization Management
NONE

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 102
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13G. Inhaled Beta-Agonists

Formulary Preferred
Trade Name Generic Name Utilization Management
ACCUNEB (g) ALBUTEROL SULFATE
ALBUTEROL NEBULIZER SOLN (g) ALBUTEROL SULFATE
METAPROTERENOL SOLN (g) METAPROTERENOL SULFATE
XOPENEX 1.25MG/0.5ML (g) LEVALBUTEROL HCL
Formulary Options
Trade Name Generic Name Utilization Management
FORADIL FORMOTEROL FUMARATE
MAXAIR AUTOHALER PIRBUTEROL ACETATE
PROAIR HFA, VENTOLIN HFA ALBUTEROL
SEREVENT DISKUS SALMETEROL XINAFOATE
Nonformulary
Trade Name Generic Name Utilization Management
BROVANA ARFORMOTEROL TARTRATE [PA] [QL]
PERFOROMIST FORMOTEROL FUMARATE [PA] [QL]
PROVENTIL HFA ALBUTEROL
XOPENEX HFA LEVALBUTEROL TARTRATE
XOPENEX SOLUTION LEVALBUTEROL HCL
13H. Inhaled Steroids

Formulary Preferred
Trade Name Generic Name Utilization Management
PULMICORT 0.25MG, 0.5MG/2ML (g) BUDESONIDE BE
Formulary Options
Trade Name Generic Name Utilization Management
ALVESCO (TIER 1-BCN ONLY) CICLESONIDE BE
ASMANEX (TIER 1-BCN ONLY) MOMETASONE FUROATE BE
AZMACORT (TIER 1-BCN ONLY) TRIAMCINOLONE ACETONIDE BE
FLOVENT HFA, DISKUS (TIER 1-BCN ONLY) FLUTICASONE PROPIONATE BE
PULMICORT 1MG/2ML (TIER 1-BCN ONLY) BUDESONIDE
PULMICORT INH (TIER 1-BCN ONLY) BUDESONIDE BE
QVAR (TIER 1-BCN ONLY) BECLOMETHASONE DIPROPIONATE BE
Nonformulary
Trade Name Generic Name Utilization Management
AEROBID, M FLUNISOLIDE/MENTHOL

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 103
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13I. Intranasal Steroids

Formulary Preferred
Trade Name Generic Name Utilization Management
FLONASE (g) FLUTICASONE PROPIONATE
NASALIDE (g) FLUNISOLIDE 0.025% SPRAY
NASAREL (g) FLUNISOLIDE
Formulary Options
Trade Name Generic Name Utilization Management
NASACORT AQ TRIAMCINOLONE ACETONIDE [ST]
Nonformulary
Trade Name Generic Name Utilization Management
BECONASE AQ BECLOMETHASONE DIPROPIONATE [ST]
NASONEX MOMETASONE FUROATE [ST]
OMNARIS CICLESONIDE [ST]
RHINOCORT AQUA BUDESONIDE [ST]
VERAMYST FLUTICASONE FUROATE [ST]
13J. Theophyllines

Formulary Preferred
Trade Name Generic Name Utilization Management
THEOPHYLLINE ANHYDROUS (g) THEOPHYLLINE ANHYDROUS
UNIPHYL (g) THEOPHYLLINE ANHYDROUS
Formulary Options
Trade Name Generic Name Utilization Management
THEO-24 THEOPHYLLINE ANHYDROUS
Nonformulary
Trade Name Generic Name Utilization Management
NONE
13K. Epinephrine

Formulary Preferred
Trade Name Generic Name Utilization Management
NONE
Formulary Options
Trade Name Generic Name Utilization Management
EPIPEN, JR EPINEPHRINE
Nonformulary
Trade Name Generic Name Utilization Management
NONE

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 104
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
13L. Miscellaneous Pulmonary Agents

Formulary Preferred
Trade Name Generic Name Utilization Management
ACCOLATE(g) ZAFIRLUKAST [QL]
ATROVENT NASAL SPRAY (g) IPRATROPIUM BROMIDE
ATROVENT SOLN (g) IPRATROPIUM BROMIDE
DUONEB (g) IPRATROPIUM/ALBUTEROL SULFATE
INTAL SOLUTION (g) CROMOLYN SODIUM
MUCOMYST (g) ACETYLCYSTEINE
Formulary Options
Trade Name Generic Name Utilization Management
ADVAIR FLUTICASONE/SALMETEROL
ATROVENT INHALER IPRATROPIUM BROMIDE
COMBIVENT ALBUTEROL SULFATE/IPRATROPIUM
DULERA MOMETASONE/FORMOTEROL [QL]
LETAIRIS AMBRISENTAN [PA] [QL] <s>
PULMOZYME DORNASE ALFA <s>
REVATIO SILDENAFIL CITRATE [PA] [QL] <s>
SINGULAIR MONTELUKAST SODIUM [QL]
SPIRIVA TIOTROPIUM BROMIDE
SYMBICORT BUDESONIDE/FORMOTEROL FUMARATE
TRACLEER BOSENTAN [PA] <s>
TYVASO TREPROSTINIL [PA] [QL] <s>
VENTAVIS ILOPROST [PA] [QL] <s>
Nonformulary
Trade Name Generic Name Utilization Management
ADCIRCA TADALAFIL [PA] [QL] <s>
ZYFLO, CR ZILEUTON [QL]

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 105
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14. UROLOGY

14A. Urinary Antispasmodics

Formulary Preferred
Trade Name Generic Name Utilization Management
BENTYL (g) DICYCLOMINE HCL
DITROPAN (g) OXYBUTYNIN CHLORIDE
DITROPAN XL (g) OXYBUTYNIN CHLORIDE
LEVBID (g) HYOSCYAMINE SULFATE
LEVSIN, SL (g) HYOSCYAMINE SULFATE
LEVSINEX (g) HYOSCYAMINE SULFATE
PRO-BANTHINE 15MG (g) PROPANTHELINE BROMIDE
SANCTURA (g) TROSPIUM CHLORIDE
URISPAS (g) FLAVOXATE HCL
Formulary Options
Trade Name Generic Name Utilization Management
DETROL TOLTERODINE TARTRATE
DETROL LA TOLTERODINE TARTRATE
Nonformulary
Trade Name Generic Name Utilization Management
ENABLEX DARIFENACIN HYDROBROMIDE
GELNIQUE OXYBUTYNIN CHLORIDE [QL]
OXYTROL OXYBUTYNIN [QL]
SANCTURA XR TROSPIUM CHLORIDE [QL]
TOVIAZ FESOTERODINE FUMARATE [QL]
VESICARE SOLIFENACIN SUCCINATE
14B. Miscellaneous Urologicals

Formulary Preferred
Trade Name Generic Name Utilization Management
CYTRA-2, 3, K (g) CITRIC ACID/POTASSIUM CITRATE
K-PHOS NEUTRAL (g) PHOSPHORUS #1
POLYCITRA (g) SOD/POTASS/K CIT/SOD CIT/CA
PYRIDIUM (g) PHENAZOPYRIDINE HCL
URECHOLINE (g) BETHANECHOL CHLORIDE
UROCIT-K (g) POTASSIUM CITRATE
Formulary Options
Trade Name Generic Name Utilization Management
ELMIRON PENTOSAN POLYSULFATE SODIUM
RENACIDIN MAG CARB/CITRIC ACID/G-LACTONE
URETRON D-S MTH/ME BLUE/BA/SALICY/ATP/HYOS
Nonformulary
Trade Name Generic Name Utilization Management
NONE

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 106
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14C. BPH Treatment

Formulary Preferred
Trade Name Generic Name Utilization Management
CARDURA (g) DOXAZOSIN MESYLATE
FLOMAX (g) TAMSULOSIN HCL
HYTRIN (g) TERAZOSIN HCL
PROSCAR (g) FINASTERIDE
Formulary Options
Trade Name Generic Name Utilization Management
AVODART DUTASTERIDE
UROXATRAL ALFUZOSIN HCL
Nonformulary
Trade Name Generic Name Utilization Management
CARDURA XL DOXAZOSIN MESYLATE
JALYN DUTASTERIDE/TAMSULOSIN HCL [ST] [QL]
RAPAFLO SILODOSIN [QL]

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 107
BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit
15. VITAMINS AND SUPPLEMENTS

15A. Vitamins and Minerals

Formulary Preferred
Trade Name Generic Name Utilization Management
CALCIFEROL (g) ERGOCALCIFEROL
CYANOCOBALAMIN INJ (g) CYANOCOBALAMIN
FOLVITE (g) FOLIC ACID
LURIDE (g) SODIUM FLUORIDE
POLY-VI-FLOR (g) FLUORIDE ION/MULTIVITAMINS
PRENATAL VITS (g) PRENATAL VIT/IRON,CARB/DOSS/FA
PREVIDENT (g) SODIUM FLUORIDE
ROCALTROL (g) CALCITRIOL
TRI-VI-FLOR (g) FLUORIDE ION/VIT A,C&D
Formulary Options
Trade Name Generic Name Utilization Management
MEPHYTON PHYTONADIONE
Nonformulary
Trade Name Generic Name Utilization Management
GALZIN ZINC ACETATE
HECTOROL DOXERCALCIFEROL
NASCOBAL SPRAY CYANOCOBALAMIN
NIFEREX GOLD IRON ASPGLY&PS/C/B12/FA/CA/SUC
SUPERVITE LYSINE HCL/VIT B COMP/FA/ZINC
ZEMPLAR PARICALCITOL
15B. Potassium Replacement

Formulary Preferred
Trade Name Generic Name Utilization Management
KAYCIEL, KAON-CL, KAON LIQUID (g) POTASSIUM CHLORIDE
K-LOR, KLOR-CON (g) POTASSIUM CHLORIDE
K-LYTE, KLOR-CON/EF (g) POTASSIUM BICARBONATE/CIT AC
K-TAB, K-DUR, SLOW-K, KAON CL (g) POTASSIUM CHLORIDE
MICRO-K(g) POTASSIUM CHLORIDE
Formulary Options
Trade Name Generic Name Utilization Management
NONE
Nonformulary
Trade Name Generic Name Utilization Management
KAOCHLOR-EFF POTASSIUM CHLORIDE/POT BICARB

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 108
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16. DIAGNOSTIC AND OTHER MISCELLANEOUS

16A. Diagnostics and Other Miscellaneous

Formulary Preferred
Trade Name Generic Name Utilization Management
CARNITOR (g) LEVOCARNITINE
COLYTE (g) SOD SULF/SOD/NAHCO3/KCL/PEG'S
DESFERAL (g) DEFEROXAMINE MESYLATE
GOLYTELY (g) PEG 3350/NA SULF,BICARB,CL/KCL
KAYEXALATE (g) SODIUM POLYSTYRENE SULFONATE
NULYTELY (g) SOD SULF/SOD/NAHCO3/KCL/PEG'S
PERIDEX (g) CHLORHEXIDINE GLUCONATE
PHOSLO (g) CALCIUM ACETATE
REVIA (g) NALTREXONE HCL
SALAGEN (g) PILOCARPINE HCL
Formulary Options
Trade Name Generic Name Utilization Management
ANTABUSE DISULFIRAM
CARBAGLU CARGLUMIC ACID [PA] <s>
CUPRIMINE PENICILLAMINE
GOLYTELY PACKET PEG 3350/NA SULF,BICARB,CL/KCL
KUVAN SAPROPTERIN DIHYDROCHLORIDE [PA] <s>
ORFADIN NITISINONE <s>
RADIOGARDASE PRUSSIAN BLUE [QL]
RENAGEL SEVELAMER HCL
RENVELA PACKET 2.4G SEVELAMER CARBONATE
RENVELA TABLET SEVELAMER CARBONATE
SAMSCA TOLVAPTAN <s>
SYPRINE TRIENTINE HCL <s>
XENAZINE TETRABENAZINE [PA] [QL] <s>
Nonformulary
Trade Name Generic Name Utilization Management
APHTHASOL AMLEXANOX
CAMPRAL ACAMPROSATE CALCIUM [PA]
EVOXAC CEVIMELINE HCL
EXJADE DEFERASIROX [PA] <s>
FOSRENOL LANTHANUM CARBONATE
HALFLYTELY BISAC/NACL/NAHCO3/KCL/PEG 3350 [QL]
MOVIPREP PEG3350/SOD SUL/NACL/ASB/C/KCL
OSMOPREP, VISICOL NAPHOS M-B M-H/NA PHOS,DI-BA
RENVELA PACKET 0.8G SEVELAMER CARBONATE
ZAVESCA MIGLUSTAT

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 109
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17. LIFESTYLE MODIFICATION

17A. Impotence

Formulary Preferred
Trade Name Generic Name Utilization Management
YOHIMBINE HCL (g) YOHIMBINE HCL
Formulary Options
Trade Name Generic Name Utilization Management
CAVERJECT ALPROSTADIL [PA] [QL]
CIALIS TADALAFIL [PA] [QL]
MUSE ALPROSTADIL [PA] [QL]
VIAGRA SILDENAFIL CITRATE [PA] [QL]
Nonformulary
Trade Name Generic Name Utilization Management
EDEX ALPROSTADIL [PA] [QL]
LEVITRA VARDENAFIL HCL [PA] [QL]
STAXYN VARDENAFIL HCL [PA] [QL]
17B. Weight Loss Preparations

Formulary Preferred
Trade Name Generic Name Utilization Management
ADIPEX-P (g) PHENTERMINE HCL [PA] [QL]
BONTRIL (g) PHENDIMETRAZINE TARTRATE [PA] [QL]
DIDREX (g) BENZPHETAMINE HCL [PA] [QL]
TENUATE (g) DIETHYLPROPION HCL [PA] [QL]
Formulary Options
Trade Name Generic Name Utilization Management
IONAMIN PHENTERMINE RESIN [PA] [QL]
Nonformulary
Trade Name Generic Name Utilization Management
XENICAL ORLISTAT [PA] [QL]
17C. Smoking Cessation

Formulary Preferred
Trade Name Generic Name Utilization Management
COMMIT LOZENGE OTC (g) (BCN ONLY) NICOTINE POLACRILEX [QL] BE
NICOTINE GUM, NICORETTE (g) (BCN ONLY) NICOTINE POLACRILEX [QL] BE
NICOTINE PATCH (g) NICOTINE [QL] BE
ZYBAN (g) BUPROPION HCL BE
Formulary Options
Trade Name Generic Name Utilization Management
CHANTIX VARENICLINE TARTRATE [QL]
Nonformulary
Trade Name Generic Name Utilization Management
NICOTROL, NS NICOTINE [QL]

(g) Use generic equivalent


[PA] Prior authorization may be required
[ST] Step therapy may be required
[QL] Quantity limits may apply
<s> Specialty Drug
Page 110
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Index
Trade Name Page Trade Name Page
ABILIFY, DISCMELT, SOLUTION 56 ALLEGRA ODT 101
ACCOLATE(g) 105 ALLEGRA SUSP 101
ACCUNEB (g) 103 ALLEGRA-D 12 HOUR (g) 101
ACCUPRIL (g) 49 ALLEGRA-D 24 HOUR 101
ACCURETIC (g) 49 ALOCRIL 99
ACCUTANE (REQ DERM CONSULT) (g) 92 ALOMIDE 99
ACCUZYME, ETHEZYME, GLADASE (g) 94 ALORA 73
ACEON (g) 49 ALORA 77
ACETASOL, HC/VOSOL, HC (g) 100 ALPHAGAN (g) 96
ACIPHEX 66 ALPHAGAN P 0.1% 96
ACLOVATE (g) 90 ALPHAGAN P 0.15% (g) 96
ACTIGALL (g) 68 ALREX 98
ACTIMMUNE 88 ALSUMA 61
ACTIQ (g) 59 ALTABAX 92
ACTIVELLA (g) 74 ALTABAX 92
ACTIVELLA 0.5-0.1MG 74 ALTACE CAPSULE (g) 49
ACTONEL WITH CALCIUM 78 ALTACE TABLET 49
ACTONEL, WEEKLY, 150MG 78 ALTOPREV 47
ACTOPLUS MET 82 ALUPENT (g) 102
ACTOPLUS MET XR 82 ALVESCO (TIER 1-BCN ONLY) 103
ACTOS 82 AMARYL (g) 82
ACULAR, LS (g) 97 AMBIEN (g) 57
ACUVAIL 97 AMBIEN CR (g) 57
ACZONE 92 AMERGE (g) 61
ADCIRCA 105 AMICAR (g) 53
ADDERALL (g) 57 AMITIZA 70
ADDERALL XR (BRAND-BCN ONLY) 57 AMOXAPINE (g) 55
ADDERALL XR (g) (BCBSM ONLY) 57 AMOXIL (g) 40
ADIPEX-P (g) 110 AMPICILLIN (g) 40
ADOXA (g) 41 AMPYRA 88
ADOXA 150MG CAPSULE 41 AMRIX 64
ADOXA CK, TT 41 ANADROL-50 80
ADVAIR 105 ANAFRANIL (g) 55
ADVICOR 47 ANALPRAM HC (g) 70
AEROBID, M 103 ANAMANTLE HC (g) 70
AFINITOR 87 ANAPROX, DS (g) 58
AGGRENOX 53 ANCOBON 43
AGRYLIN (g) 53 ANDRODERM 80
AKNE-MYCIN 92 ANDROGEL 80
ALAMAST 99 ANDROXY 10MG (g) 80
ALBALON (g) 99 ANGELIQ 74
ALBENZA 46 ANNUSOL HC, PROCTOCREAM HC (g) 70
ALBUTEROL NEBULIZER SOLN (g) 103 ANSAID (g) 58
ALDACTAZIDE (g) 52 ANTABUSE 109
ALDACTONE (g) 52 ANTARA 47
ALDARA (g) 95 ANTIVERT (g) 68
ALDOMET (g) 54 ANZEMET 68
ALDORIL (g) 54 APEXICON E 89
ALESSE (g), LEVLITE (g) 71 APHTHASOL 109
ALFERON N 88 APIDRA (PEN/CARTRIDGE) 81
ALINIA 46 APIDRA (VIAL) 81
ALKERAN 84 APLENZIN 55
ALLEGRA (g) 101 APOKYN 62
Trade Name Page Trade Name Page
APRESOLINE (g) 54 AZOPT 96
APRISO 70 AZOR 51
APTIVUS(MUST BE USED WITH NORVIR) 44 AZOR 50
ARALEN (g) 45 AZULFIDINE EN-TAB (g) 70
ARANESP 88 AZULFIDINE EN-TAB (g) 77
ARANESP 86 AZULFIDINE TAB (g) 77
ARAVA (g) 77 AZULFIDINE TAB (g) 70
ARCALYST 85 BACITRACIN (g) 98
ARICEPT 23MG 65 BACTRIM, DS, SEPTRA, DS (g) 42
ARICEPT, ODT (g) 65 BACTROBAN CREAM, NASAL 92
ARIMIDEX (g) 85 BACTROBAN OINTMENT (g) 92
ARISTOCORT, KENALOG (g) 90 BANZEL 63
ARISTOCORT, KENALOG 0.5% CR (g) 89 BARACLUDE 43
ARIXTRA 53 BECONASE AQ 100
ARMOUR THYROID 79 BECONASE AQ 104
AROMASIN 85 BELLAMINE/BELLASPAS (g) 67
ARTANE (g) 62 BENADRYL (g) 101
ARTHROTEC 58 BENICAR 50
ASACOL 70 BENICAR HCT 50
ASACOL HD 70 BENTYL (g) 106
ASMANEX (TIER 1-BCN ONLY) 103 BENTYL (g) 67
ASPIRIN W/CODEINE (g) 60 BENZACLIN 92
ASTELIN NASAL SPRAY(g) 100 BENZAMYCIN (g) 92
ASTELIN NASAL SPRAY(g) 101 BENZASHAVE 92
ASTEPRO NASAL SPRAY 100 BENZOYL PEROXIDE-RX (g) 92
ASTEPRO NASAL SPRAY 101 BEPREVE 99
ATACAND 50 BESIVANCE 98
ATACAND HCT 50 BETAGAN (g) 96
ATARAX, VISTARIL (g) 101 BETAPACE, AF (g) 52
ATIVAN (g) 56 BETAPACE, AF (g) 48
ATRIPLA 44 BETASERON 88
ATROVENT NASAL SPRAY (g) 105 BETIMOL 96
ATROVENT NASAL SPRAY (g) 100 BETOPTIC S 96
ATROVENT INHALER 105 BETOPTIC SOLN (g) 96
ATROVENT SOLN (g) 105 BEYAZ 72
AUGMENTIN, ES, XR (g) 40 BIAXIN, XL (g) 41
AURALGAN (g) 100 BILTRICIDE 46
AVALIDE 50 BLEPH-10, SODIUM SULAMYDE (g) 98
AVANDAMET 82 BLEPHAMIDE DROPS, OINT 99
AVANDARYL 82 BLOCADREN (g) 48
AVANDIA 82 BONIVA 78
AVAPRO 50 BONTRIL (g) 110
AVC 75 BRAVELLE 74
AVELOX, ABC 42 BRETHINE (g) 102
AVINZA 59 BREVOXYL GEL (g) 92
AVODART 107 BROMFED, PD (g) 101
AVONEX 88 BROMFED-DM (g) 102
AXERT 61 BROVANA 103
AXID (RX ONLY) (g) 66 BUMEX (g) 52
AYGESTIN (g) 73 BUPAP (g) 61
AZASITE 98 BUSPAR (g) 56
AZELEX 92 BUTISOL SODIUM 57
AZILECT 62 BUTRANS 60
AZMACORT (TIER 1-BCN ONLY) 103 BYETTA 82
Trade Name Page Trade Name Page
BYSTOLIC 48 CIALIS 110
CADUET 51 CILOXAN DROPS (g) 98
CADUET 47 CILOXAN OINT 98
CAFERGOT (g) 61 CIMZIA SYRINGE 77
CALAN SR/ISOPTIN SR (g) 51 CIMZIA SYRINGE 70
CALCIFEROL (g) 80 CIPRO (g) 42
CALCIFEROL (g) 108 CIPRO HC 100
CAMBIA 58 CIPRO XR (g) 42
CAMBIA 61 CIPRODEX 100
CAMPRAL 109 CLARINEX (ALL) 101
CANASA 70 CLARINEX-D 101
CANTIL 67 CLARITIN, ALAVERT(OTC) (g) 101
CAPEX SHAMPOO 90 CLARITIN-D 12HR, 24HR(OTC) (g) 101
CAPOTEN (g) 49 CLEOCIN (g) 46
CAPOZIDE (g) 49 CLEOCIN T (g) 92
CARAC 95 CLEOCIN VAG CREAM (g) 75
CARAFATE SUSP (g) 67 CLEOCIN VAGINAL OVULES 75
CARAFATE TABS (g) 67 CLIMARA (g) 77
CARBAGLU 109 CLIMARA (g) 73
CARBATROL 63 CLIMARA PRO 74
CARDENE (g) 51 CLINAC BPO 92
CARDENE SR 51 CLINDESSE 75
CARDIZEM LA 51 CLINORIL (g) 58
CARDIZEM LA (g) 51 CLOBEX, SPRAY 89
CARDIZEM, SR, CD (g) 51 CLODERM 90
CARDURA (g) 107 CLOMID (g) 74
CARDURA (g) 54 CLOZARIL (g) 56
CARDURA XL 107 CNL 8 93
CARMOL HC 95 COARTEM 45
CARNITOR (g) 109 CODEINE SULFATE (g) 59
CASODEX (g) 85 COGENTIN (g) 62
CATAFLAM (g) 58 COGNEX 65
CATAPRES (g) 54 COLAZAL (g) 70
CATAPRES-TTS (g) 54 COLBENEMID (g) 76
CAVERJECT 110 COLCRYS 76
CAYSTON 46 COLESTID (g) 47
CECLOR (g) 40 COLESTID FLAVORED 47
CECLOR ER (g) 40 COLY-MYCIN S 100
CEDAX 40 COLYTE (g) 109
CEENU 84 COMBIGAN 96
CEFTIN (g) 40 COMBIPATCH 74
CEFZIL (g) 40 COMBIVENT 105
CELEBREX 58 COMBIVIR 44
CELEXA (g) 55 COMMIT LOZENGE OTC (g) (BCN ONLY) 110
CELLCEPT (g) 85 COMPAZINE (g) 68
CELLCEPT SUSPENSION 85 COMTAN 62
CELONTIN 63 CONCERTA 57
CENESTIN 73 CONDYLOX GEL 95
CENESTIN 77 CONDYLOX SOLN (g) 95
CESAMET 68 COPAXONE 88
CETROTIDE 74 COPEGUS (g) 43
CHANTIX 110 CORDARONE (g) 52
CHENODAL 68 CORDRAN, TAPE, SP 90
CHLORAL HYDRATE (g) 57 COREG (g) 48
Trade Name Page Trade Name Page
COREG CR 48 DEPAKENE (g) 63
CORGARD (g) 48 DEPAKOTE (g) 63
CORTEF, HYDROCORTISONE (g) 79 DEPAKOTE ER (g) 63
CORTENEMA (g) 70 DEPAKOTE SPRINKLES (g) 63
CORTICOSTEROIDS 76 DEPEN 77
CORTIFOAM 70 DEPO-PROVERA 150MG (g) 73
CORTISONE ACETATE (g) 79 DEPO-PROVERA 400MG 85
CORTISPORIN (g) 99 DEPO-SUBQ PROVERA 104 73
CORTISPORIN (g) 100 DEPO-TESTOSTERONE (g) 80
CORTISPORIN-TC 100 DERMACORT, HYTONE (Rx Only) (g) 90
CORZIDE (g) 48 DERMA-SMOOTHE/FS 90
COSOPT (g) 96 DERMATOP (g) 90
COUMADIN (g) 53 DESFERAL (g) 109
COVERA-HS 51 DESOGEN (g), ORTHO-CEPT (g) 71
COZAAR (g) 50 DESONATE 90
CREON 69 DESOWEN, TRIDESILON (g) 90
CRESTOR 47 DESOXYN (g) 57
CRINONE 73 DESYREL (g) 55
CRIXIVAN 44 DETROL 106
CUPRIMINE 77 DETROL LA 106
CUPRIMINE 109 DEXEDRINE (g) 57
CUTIVATE (g) 90 DEXILANT 66
CUTIVATE LOTION 90 DIABETA, MICRONASE (g) 82
CYANOCOBALAMIN INJ (g) 108 DIABINESE (g) 82
CYCLESSA (g) 72 DIAMOX (g) 63
CYCLOCORT (g) 89 DIAMOX (g) 52
CYCLOGYL (g) 97 DIAMOX SEQUELS (g) 52
CYMBALTA 55 DIASTAT 63
CYTOMEL (g) 79 DIASTAT 2.5MG (g) 63
CYTOTEC (g) 67 DICLOXACILLIN (g) 40
CYTOVENE (g) 43 DIDREX (g) 110
CYTOXAN (g) 84 DIDRONEL (g) 78
CYTRA-2, 3, K (g) 106 DIFFERIN 0.1% CREAM, GEL (g) 92
D.H.E.45 (g) 61 DIFFERIN 0.3% GEL 92
DALMANE (g) 57 DIFFERIN LOTION 92
DANOCRINE (g) 80 DIFLUCAN (g) 75
DANTRIUM (g) 64 DIFLUCAN (g) 43
DAPSONE 45 DIGOXIN ELIXIR (g) 52
DARAPRIM 45 DIGOXIN TABS (g) 52
DAYPRO (g) 58 DILANTIN (g) 63
DAYTRANA 57 DILANTIN CHEW TABS 63
DDAVP SOLN 80 DILATRATE-SR 53
DDAVP SPRAY (g) 80 DILAUDID (g) 59
DDAVP TABS (g) 80 DIOVAN 50
DECADRON (g) 79 DIOVAN HCT 50
DECADRON OPTH (g) 98 DIPENTUM 70
DECONAMINE CX, SR (g) 102 DIPROLENE AF, GEL, CR, LOT (g) 89
DECONAMINE SR 101 DIPROLENE OINTMENT (g) 89
DECONAMINE SYRUP, SR (g) 101 DIPROSONE (g), MAXIVATE (g) 89
DELATESTRYL 80 DISALCID, SALFLEX (g) 59
DEMADEX (g) 52 DITROPAN (g) 106
DEMEROL (g) 59 DITROPAN XL (g) 106
DEMULEN (g) 71 DIURIL (g) 52
DENAVIR 93 DIVIGEL 73
Trade Name Page Trade Name Page
DOLOBID (g) 59 ENBREL 77
DOMEBORO OTIC (g) 100 ENDOMETRIN 73
DONNATAL (g) 67 ENJUVIA 77
DONNATAL EXTENTABS 67 ENJUVIA 73
DORAL 57 ENTOCORT EC 79
DORYX 41 EPIDUO 92
DOSTINEX (g) 62 EPIPEN, JR 104
DOSTINEX (g) 80 EPIVIR 44
DOVONEX CREAM 94 EPIVIR HBV 43
DOVONEX OINT(g) 94 EPOGEN 88
DOVONEX SOLUTION (g) 94 EPOGEN 86
DRITHOCREME HP (g) 94 EPZICOM 44
DRITHO-SCALP 94 EQUETRO 63
DROXIA 86 ERGOMAR 61
DRYSOL (g) 95 ERTACZO 93
DUAC, CS 92 ERYTHROMYCIN (g) 41
DUETACT 82 ERYTHROMYCIN STEARATE, BASE (g) 41
DULERA 105 ERYTHROMYCIN TOPICAL SOLN, GEL (g) 92
DUONEB (g) 105 ESKALITH (g) 65
DURAGESIC (g) 59 ESKALITH CR (g) 65
DUREZOL 98 ESTRACE (g) 77
DURICEF (g) 40 ESTRACE (g) 73
DYGASE (g) 69 ESTRACE VAGINAL CREAM 73
DYNACIRC (g) 51 ESTRADERM 73
DYNACIRC CR 51 ESTRADERM 77
DYRENIUM 52 ESTRASORB 73
EC-NAPROSYN (g) 58 ESTRATEST, H.S. (g) 77
EDECRIN 52 ESTRATEST, H.S. (g) 74
EDEX 110 ESTRING 73
EDLUAR 57 ESTROGEL 73
EFFEXOR (g) 55 ESTROGENS 78
EFFEXOR XR (g) 55 ESTROSTEP FE (g) 72
EFFIENT 53 ETHAMBUTOL (g) 45
EFUDEX (g) 95 ETRAFON (g) 55
EFUDEX OCCLUSION 95 EULEXIN (g) 85
ELAVIL (g) 55 EURAX 94
ELDEPRYL(g) 62 EVAMIST 73
ELESTAT 99 EVISTA 78
ELESTRIN 73 EVOCLIN FOAM(g) 92
ELIDEL 95 EVOXAC 109
ELIGARD 85 EXALGO 59
ELIMITE (g) 94 EXELDERM SOLN, CR 93
ELLA 72 EXELON 65
ELMIRON 106 EXELON (g) 65
ELOCON (g) 90 EXFORGE 51
EMADINE 99 EXFORGE 50
EMBEDA 59 EXFORGE HCT 51
EMCYT 86 EXFORGE HCT 50
EMEND 80,125MG CAPSULES 68 EXJADE 109
EMLA (g) 91 EXTAVIA 88
EMSAM 55 EXTINA 93
EMTRIVA 44 FACTIVE 42
ENABLEX 106 FAMVIR (g) 43
ENBREL 94 FANAPT 56
Trade Name Page Trade Name Page
FARESTON 85 GABITRIL 63
FASLODEX 85 GALZIN 108
FAZACLO 56 GANIRELIX ACETATE 74
FELBATOL 63 GARAMYCIN (g) 98
FELDENE (g) 58 GELNIQUE 106
FEMARA 85 GENOTROPIN 83
FEMCON FE 71 GENTAMICIN CR, OINT (g) 92
FEMHRT 74 GEODON 56
FEMHRT 77 GILENYA 88
FEMRING 73 GLEEVEC 87
FEMTRACE 73 GLUCAGON EMERGENCY KIT 80
FENOGLIDE 47 GLUCOPHAGE (g) 82
FENTORA 59 GLUCOPHAGE XR (g) 82
FERTINEX 74 GLUCOTROL (g) 82
FEXMID 64 GLUCOTROL XL (g) 82
FIBRICOR (g) 47 GLUCOVANCE (g) 82
FINACEA 92 GLUMETZA 82
FIORICET W/CODEINE (g) 60 GLYCOLAX (g) 70
FIORICET;ESGIC, PLUS (g) 60 GLYNASE (g) 82
FIORICET;ESGIC, PLUS (g) 61 GLYSET 82
FIORINAL (g) 60 GOLYTELY (g) 109
FIORINAL (g) 61 GOLYTELY PACKET 109
FIORINAL W/CODEINE (g) 61 GONAL-F, RFF 74
FIORINAL W/CODEINE (g) 60 GRANULEX (g) 94
FLAGYL (g) 46 GRIFULVIN V 500MG 43
FLAGYL ER 46 GRIFULVIN V SUSP (g) 43
FLECTOR PATCH 58 GRIS PEG 43
FLEXERIL (g) 64 GUAIFED, ENTEX PSE (g) 102
FLOMAX (g) 107 GUAIFED-PD (g) 102
FLONASE (g) 100 GYNAZOLE-1 75
FLONASE (g) 104 HALCION (g) 57
FLORINEF (g) 79 HALDOL (g) 56
FLOVENT HFA, DISKUS (TIER 1-BCN ONLY) 103 HALFLYTELY 109
FLOXIN (g) 42 HALOG 89
FLOXIN OTIC (g) 100 HECTOROL 80
FLOXIN OTIC SINGLES 100 HECTOROL 108
FLUMADINE (g) 43 HELIDAC 67
FLUVOXAMINE MALEATE (g) 55 HEPARIN (g) 53
FML (g) 98 HEPSERA 43
FML FORTE, S.O.P. 98 HEXALEN 86
FOCALIN (g) 57 HIPREX/UREX (g) 42
FOCALIN XR 57 HUMABID DM (g) 102
FOLLISTIM AQ 74 HUMALOG, MIX (PEN/CARTRIDGE) 81
FOLVITE (g) 108 HUMALOG, MIX (VIAL) 81
FORADIL 103 HUMATIN (g) 46
FORTAMET 82 HUMATROPE 83
FORTEO 77 HUMIRA 94
FOSAMAX (g) 78 HUMIRA 77
FOSAMAX PLUS D 78 HUMULIN 70/30 (PEN/CARTRIDGE) 81
FOSAMAX WEEKLY (g) 78 HUMULIN 70/30 (VIAL) 81
FOSRENOL 109 HUMULIN N (PEN/CARTRIDGE) 81
FRAGMIN 53 HUMULIN N (VIAL) 81
FROVA 61 HUMULIN R (VIAL) 81
FUZEON 44 HYCAMTIN 86
Trade Name Page Trade Name Page
HYDREA (g) 86 KEPPRA (g) 63
HYDRODIURIL, MICROZIDE (g) 52 KEPPRA XR 63
HYGROTON, THALITONE (g) 52 KERLONE (g) 48
HYTRIN (g) 107 KETEK 41
HYTRIN (g) 54 KETOPROFEN (g) 58
HYZAAR (g) 50 KINERET 77
ILOTYCIN (g) 98 KLONOPIN, WAFER (g) 63
IMDUR (g) 53 K-LOR, KLOR-CON (g) 108
IMITREX INJECTION (g) 61 K-LYTE, KLOR-CON/EF (g) 108
IMITREX NASAL SPRAY (g) 61 K-PHOS NEUTRAL (g) 106
IMITREX TABLETS (g) 61 K-TAB, K-DUR, SLOW-K, KAON CL (g) 108
IMURAN (g) 77 KUVAN 109
IMURAN (g) 85 KYTRIL (g) 68
INCRELEX 83 LACRISERT 99
INDERAL (g) 48 LACTULOSE (g) 70
INDERAL LA (g) 48 LAMICTAL DISPERTABS (g) 63
INDERIDE (g) 48 LAMICTAL ODT 63
INDOCIN SUPPOSITORY 58 LAMICTAL TABS (g) 63
INDOCIN, SR (g) 58 LAMICTAL XR 63
INFERGEN 88 LAMISIL GRANULES 43
INFLAMASE, FORTE (g) 98 LAMISIL TABLETS (g) 43
INNOHEP 53 LANTUS (PEN/CARTRIDGE) 81
INNOPRAN XL 48 LANTUS (VIAL) 81
INSPRA (g) 52 LAPASE (g) 69
INTAL SOLUTION (g) 105 LARIAM (g) 45
INTELENCE 44 LASIX (g) 52
INTRON A 88 LESCOL, XL 47
INTUNIV 65 LETAIRIS 105
INVEGA 56 LEUCOVORIN (g) 86
INVIRASE 44 LEUKERAN 84
IONAMIN 110 LEUKINE 88
IOPIDINE DROPERETTE 96 LEUKINE 86
IOPIDINE DROPS (g) 96 LEVAQUIN 42
IQUIX 98 LEVATOL 48
IRESSA 87 LEVBID (g) 67
ISENTRESS 44 LEVBID (g) 106
ISMO, MONOKET (g) 53 LEVEMIR (PEN) 81
ISONIAZID (g) 45 LEVEMIR (VIAL) 81
ISOPTO ATROPINE (g) 97 LEVITRA 110
ISOPTO CARBACHOL 96 LEVOTHYROXINE (g) 79
ISOPTO HOMATROPINE (g) 97 LEVSIN, SL (g) 106
ISOPTO HYOSCINE 97 LEVSIN, SL (g) 67
ISORDIL (g) 53 LEVSINEX (g) 106
ISTALOL 96 LEVSINEX (g) 67
JALYN 107 LEXAPRO 55
JANUMET 82 LEXIVA 44
JANUVIA 82 LIALDA 70
KADIAN 59 LIBRAX (g) 67
KALETRA 44 LIBRIUM (g) 56
KAOCHLOR-EFF 108 LIDEX, E (g) 89
KAYCIEL, KAON-CL, KAON LIQUID (g) 108 LIDODERM PATCH 91
KAYEXALATE (g) 109 LIMBITROL, DS (g) 55
KEFLEX (g) 40 LINDANE 94
KEFLEX 750MG 40 LIORESAL (g) 64
Trade Name Page Trade Name Page
LIPITOR 47 MAGNACET 60
LIPOFEN 47 MALARONE 45
LIPRAM-UL20 69 MANDELAMINE (g) 42
LITHIUM CITRATE (g) 65 MAPROTILINE HCL (g) 55
LITHOBID (g) 65 MARINOL (g) 68
LIVALO 47 MARPLAN 55
LO/OVRAL (g) 71 MATULANE 86
LOCOID CM, OINT, SOLN (g) 90 MAVIK (g) 49
LOCOID LIPOCREAM (g) 90 MAXAIR AUTOHALER 103
LOCOID LOTION 90 MAXALT, MLT 61
LODINE (g) 58 MAXIDEX 98
LODINE XL (g) 58 MAXITROL (g) 99
LOESTRIN 24 FE 71 MAXZIDE, DYAZIDE (g) 52
LOESTRIN, FE (g) 71 MEBARAL (g) 63
LOFIBRA (g) 47 MECLOMEN (g) 58
LOMOTIL (g) 67 MEDROL, DOSEPAK (g) 79
LONITEN (g) 54 MEGACE (g) 85
LOPID (g) 47 MEGACE ES 85
LOPRESSOR (g) 48 MELLARIL (g) 56
LOPRESSOR HCT (g) 48 MENEST 77
LOPROX CR, LOTION, GEL (g) 93 MENEST 73
LOPROX SHAMPOO (g) 93 MENOPUR 74
LOSEASONIQUE 71 MENOSTAR 73
LOTEMAX 98 MENTAX 93
LOTENSIN (g) 49 MEPHYTON 53
LOTENSIN HCT (g) 49 MEPHYTON 108
LOTREL (g) 49 MEPRON 46
LOTREL (g) 51 MESNEX 86
LOTREL 5/40, 10/40 49 MESTINON (g) 64
LOTREL 5/40, 10/40 51 MESTINON TIMESPAN, SYRUP 64
LOTRIMIN (g) 93 METADATE CD 57
LOTRISONE CR, LOTION (g) 93 METAGLIP (g) 82
LOTRONEX 70 METAPROTERENOL SOLN (g) 103
LOVAZA 47 METHADONE (g) 59
LOVENOX (g) 53 METHERGINE 75
LOXITANE (g) 56 METHITEST 80
LOZOL (g) 52 METHOTREXATE (g) 77
LUMIGAN 96 METHOTREXATE (g) 84
LUNESTA 57 METHYLIN CHEW 57
LUPRON (g) 74 METHYLIN SOLN (g) 57
LUPRON (g) 85 METOZOLV ODT 70
LUPRON DEPOT 75 METROCREAM, GEL, LOTION (g) 92
LUPRON DEPOT 85 METROGEL TOPICAL 1% 92
LUPRON DEPOT-PED 80 METROGEL-VAGINAL (g) 75
LURIDE (g) 108 MEVACOR (g) 47
LUVERIS 74 MEXITIL (g) 52
LUVOX CR 55 MIACALCIN INJECTION 80
LUXIQ 90 MIACALCIN INJECTION 78
LYBREL 71 MIACALCIN NASAL SPRAY (g) 80
LYRICA 63 MIACALCIN NASAL SPRAY (g) 78
LYSODREN 86 MICARDIS 50
LYSTEDA 75 MICARDIS HCT 50
MACROBID (g) 42 MICRO-K(g) 108
MACRODANTIN (g) 42 MIDAMOR (g) 52
Trade Name Page Trade Name Page
MIDRIN (g) 61 NEORAL (g) 85
MIGRANAL 61 NEOSPORIN OPHTH SOLN (g) 98
MILTOWN, EQUANIL (g) 56 NEOSPORIN OPTH OINT (g) 98
MINIPRESS (g) 54 NEO-SYNEPHRINE (g) 99
MINOCIN, DYNACIN (g) 41 NEULASTA 88
MIRAPEX (g) 62 NEULASTA 86
MIRAPEX ER 62 NEUMEGA 88
MIRCETTE (g) 71 NEUPOGEN 86
MOBIC (g) 58 NEUPOGEN 88
MODICON (g) 71 NEURONTIN (g) 63
MODURETIC (g) 52 NEURONTIN SOLUTION 63
MONISTAT-DERM (g) 93 NEVANAC 97
MONODOX (g) 41 NEXAVAR 87
MONOPRIL (g) 49 NEXIUM 66
MONOPRIL HCT (g) 49 NIASPAN 47
MONUROL 42 NICOTINE GUM, NICORETTE (g) (BCN ONLY 110
MOTRIN (g) 58 NICOTINE PATCH (g) 110
MOVIPREP 109 NICOTROL, NS 110
MOXATAG 40 NIFEREX GOLD 108
MS CONTIN/ORAMORPH SR (g) 59 NILANDRON 85
MSIR (g) 59 NIMOTOP (g) 65
MUCOMYST (g) 105 NIRAVAM (g) 56
MULTAQ 52 NITRO-BID OINTMENT 53
MUSE 110 NITROGLYCERIN PATCH (g) 53
MYCELEX TROCHE (g) 43 NITROGLYCERIN SA CAP (g) 53
MYCOBUTIN 45 NITROLINGUAL SPRAY 53
MYCOSTATIN (g) 93 NITROMIST 53
MYDRIACYL (g) 97 NITROSTAT 53
MYFORTIC 85 NIZORAL (g) 43
MYLERAN 84 NIZORAL CREAM (g) 93
MYSOLINE (g) 63 NIZORAL SHAMPOO 2% (g) 93
MYTELASE 64 NORDETTE, LEVLEN (g) 71
NAFTIN 93 NORDITROPIN NORDIFLEX 83
NAMENDA, SOLN 65 NORFLEX (g) 64
NAPRELAN 58 NORGESIC, FORTE (g) 64
NAPRELAN CR DOSEPAK 58 NORINYL 1/35 (g), ORTHO-NOVUM 1/35 (g) 71
NAPROSYN (g) 58 NORINYL 1/50 (g), ORTHO-NOVUM 1/50 (g) 71
NARDIL 55 NORITATE 92
NASACORT AQ 100 NORMODYNE (g) 48
NASACORT AQ 104 NOROXIN 42
NASALIDE (g) 100 NORPACE (g) 52
NASALIDE (g) 104 NORPACE CR 52
NASAREL (g) 104 NORPRAMIN (g) 55
NASAREL (g) 100 NORVASC (g) 51
NASCOBAL SPRAY 108 NORVIR 44
NASONEX 100 NOVAREL, PREGNYL, PROFASI 74
NASONEX 104 NOVOLIN (PEN/CARTRIDGE) 81
NATACYN 98 NOVOLIN (VIAL) 81
NATAZIA 72 NOVOLOG (PEN/CARTRIDGE) 81
NAVANE (g) 56 NOVOLOG (VIAL) 81
NEBUPENT AEROSOL 46 NOVOLOG MIX (PEN/CARTRIDGE) 81
NECON 10/11 (g) 71 NOXAFIL 43
NEOBENZ MICRO 92 NUCYNTA 59
NEOMYCIN (g) 46 NULYTELY (g) 109
Trade Name Page Trade Name Page
NUTROPIN 83 OXYCONTIN 59
NUTROPIN AQ 83 OXYTROL 106
NUTROPIN AQ NUSPIN 83 PAMELOR, AVENTYL (g) 55
NUVARING 72 PANCREASE MT 10, 16, 20 (g) 69
NUVIGIL 57 PANCREASE MT 4 69
NYSTATIN (g) 43 PANCREAZE 69
NYSTATIN (g) 75 PANCRECARB MS 69
NYSTATIN W/TRIAMCINOLONE (g) 93 PANCRELIPASE EC 69
OCUFEN (g) 97 PANDEL 90
OCUFLOX (g) 98 PANGESTYME UL 12 69
OCUPRESS (g) 96 PANRETIN 95
OFORTA 84 PAPAVERINE CAPS (g) 54
OGEN, ORTHO-EST (g) 77 PARAFLEX, PARAFON FORTE DSC (g) 64
OGEN, ORTHO-EST (g) 73 PARCOPA (g) 62
OLEPTRO ER 55 PAREGORIC (g) 67
OLUX (g) 89 PAREMYD 97
OLUX-E 89 PARLODEL (g) 62
OMEPRAZOLE OTC (g) 66 PARNATE (g) 55
OMNARIS 104 PATADAY 99
OMNARIS 100 PATANASE 101
OMNICEF (g) 40 PATANASE 100
OMNITROPE 83 PATANOL 99
ONGLYZA 82 PAXIL (g) 55
ONSOLIS 59 PAXIL CR (g) 55
OPANA (g) 59 PCE 41
OPANA ER 59 PEDIAZOLE (g) 41
OPTICROM (g) 99 PEDIAZOLE (g) 42
OPTIPRANOLOL (g) 96 PEGANONE 63
OPTIVAR (g) 99 PEGASYS 88
ORACEA 41 PEG-INTRON, REDIPEN 88
ORAP 56 PENICILLIN VK (g) 40
ORAPRED (g) 79 PENLAC (g) 93
ORAPRED ODT 79 PENNSAID 58
ORAVIG 43 PENTASA 70
ORAXYL 41 PEPCID (RX ONLY) (g) 66
ORFADIN 109 PERANEX HC 70
ORINASE (g) 82 PERCOCET (g) 60
ORTHO EVRA 72 PERCODAN (g) 60
ORTHO MICRONOR (g), NOR-QD (g) 72 PERFOROMIST 103
ORTHO TRI-CYCLEN (g) 72 PERIACTIN (g) 101
ORTHO TRI-CYCLEN LO 72 PERIDEX (g) 109
ORTHO-CYCLEN (g) 71 PERIOSTAT (g) 41
ORTHO-NOVUM 7/7/7 (g) 72 PERPHENAZINE (g) 56
ORTHO-PREFEST 74 PERSANTINE (g) 53
OSMOPREP, VISICOL 109 PEXEVA 55
OVCON 35 (g) 71 PHENERGAN (g) 68
OVCON-50, FE 71 PHENERGAN (g) 101
OVIDE (g) 94 PHENERGAN DM (g) 102
OVIDREL 74 PHENERGAN VC (g) 102
OVRAL (g) 71 PHENERGAN W/CODEINE (g) 102
OXANDRIN (g) 80 PHENOBARBITAL (g) 63
OXISTAT 93 PHOSLO (g) 109
OXSORALEN, ULTRA 94 PHOSPHOLINE IODIDE 96
OXYCODONE IMMEDIATE RELEASE (g) 59 PHRENILIN (g) 61
Trade Name Page Trade Name Page
PHRENILIN (g) 60 PRISTIQ 55
PHRENILIN FORTE 60 PROAIR HFA, VENTOLIN HFA 103
PHRENILIN FORTE 61 PROAMATINE (g) 52
PILOCAR, ISOPTO-CARPINE (g) 96 PRO-BANTHINE 15MG (g) 106
PILOPINE HS 96 PRO-BANTHINE 15MG (g) 67
PINDOLOL (g) 48 PROBENECID (g) 76
PLAN B (g) 72 PROCARDIA, XL;ADALAT CC (g) 51
PLAN B ONE-STEP 72 PROCENTRA 57
PLAQUENIL (g) 45 PROCHIEVE 73
PLAQUENIL (g) 77 PROCRIT 88
PLAVIX 53 PROCRIT 86
PLENDIL (g) 51 PROCTOCORT SUPPOSITORY (g) 70
PLETAL (g) 53 PROFASI 5000UNITS 74
PLEXION, TS (g) 92 PROGESTERONE IN OIL (INJ) (g) 73
POLARAMINE (g) 101 PROGRAF (g) 85
POLYCITRA (g) 106 PROLIXIN (g) 56
POLY-PRED 99 PROMACTA 88
POLYSPORIN (g) 98 PROMETRIUM 73
POLYTRIM (g) 98 PRONESTYL, SR (g) 52
POLY-VI-FLOR (g) 108 PROPINE 96
PONSTEL 58 PROPYLTHIOURACIL (g) 79
PRAMOSONE (g) 70 PROQUIN XR 42
PRAMOSONE LOTION 70 PROSCAR (g) 107
PRANDIMET 82 PROSCAR (g) 80
PRANDIN 82 PROSOM (g) 57
PRAVACHOL (g) 47 PROSTIGMIN 64
PRECOSE (g) 82 PROTONIX (g) 66
PRED FORTE (g) 98 PROTONIX SUSPENSION 66
PRED MILD 98 PROTOPIC 95
PRED-G 99 PROVENTIL HFA 103
PREDNISOLONE, TABS, SYRUP (g) 79 PROVENTIL SOLUTION (g) 102
PREDNISONE (g) 85 PROVERA (g) 73
PREDNISONE (g) 79 PROVIGIL 57
PREMARIN CREAM 73 PROZAC WEEKLY (g) 55
PREMARIN CREAM 77 PROZAC, SARAFEM (g) 55
PREMARIN, PREMARIN LOW DOSE 73 PSORCON, FLORONE (g) 89
PREMARIN, PREMARIN LOW DOSE 77 PSORCON, FLORONE (g) 89
PREMPRO, LOW DOSE/PREMPHASE 77 PULMICORT 0.25MG, 0.5MG/2ML (g) 103
PREMPRO, LOW DOSE/PREMPHASE 74 PULMICORT 1MG/2ML (TIER 1-BCN ONLY) 103
PRENATAL VITS (g) 108 PULMICORT INH (TIER 1-BCN ONLY) 103
PREVACID (g) 66 PULMOZYME 105
PREVACID NAPRAPAC 58 PURINETHOL (g) 84
PREVACID SOLUTAB (g) 66 PYLERA 67
PREVIDENT (g) 108 PYRAZINAMIDE (g) 45
PREVPAC 67 PYRIDIUM (g) 42
PREZISTA(MUST BE USED WITH NORVIR) 44 PYRIDIUM (g) 106
PRIFTIN 45 QUALAQUIN 45
PRILOSEC (g) 66 QUESTRAN, QUESTRAN LIGHT (g) 47
PRILOSEC 40MG 66 QUINIDEX (g) 52
PRILOSEC OTC 66 QUINIDINE GLUCONATE SA (g) 52
PRILOSEC SUSPENSION 66 QUIXIN 98
PRIMAQUINE 45 QVAR (TIER 1-BCN ONLY) 103
PRINIVIL, ZESTRIL (g) 49 RADIOGARDASE 109
PRINZIDE, ZESTORETIC (g) 49 RANEXA 52
Trade Name Page Trade Name Page
RANICLOR 40 ROCALTROL (g) 108
RAPAFLO 107 RONDEC (g) 101
RAPAMUNE TABS, SOLUTION 85 RONDEC-DM (g) 102
RAZADYNE SOLUTION (g) 65 ROSULA CLEANSER (g) 92
RAZADYNE, ER (g) 65 ROSULA FOAM 92
REBETOL (g) 43 ROWASA ENEMA (g) 70
REBETOL SOLUTION 43 ROXANOL (g) 59
REBIF 88 ROZEREM 57
REGLAN TAB, SOLUTION (g) 70 RYBIX ODT 60
REGRANEX 94 RYNATAN (g) 101
RELAFEN (g) 58 RYNATAN PED SUSP (g) 101
RELENZA 43 RYTHMOL (g) 52
RELISTOR 61 RYTHMOL SR 52
RELISTOR 70 RYZOLT 60
RELPAX 61 SABRIL 63
REMERON (g) 55 SAIZEN 83
REMERON SOLTAB (g) 55 SALAGEN (g) 109
RENACIDIN 106 SALICYLATES AND NSAIDS 76
RENAGEL 109 SAMSCA 109
RENVELA PACKET 0.8G 109 SANCTURA (g) 106
RENVELA PACKET 2.4G 109 SANCTURA XR 106
RENVELA TABLET 109 SANCUSO 68
REPRONEX 74 SANDIMMUNE 85
REQUIP (g) 62 SANDOSTATIN (g) 86
REQUIP XL 62 SANDOSTATIN (g) 80
RESCRIPTOR 44 SANDOSTATIN LAR 86
RESERPINE (g) 54 SANDOSTATIN LAR 80
RESTASIS 99 SANTYL 94
RESTORIL (g) 57 SAPHRIS 56
RETIN-A MICRO 92 SARAFEM TABLET 55
RETIN-A, AVITA (g) 92 SAVELLA 65
RETROVIR (g) 44 SEASONALE (g) 71
REVATIO 105 SEASONIQUE 71
REVIA (g) 109 SECTRAL (g) 48
REVIA (g) 61 SELSUN RX (g) 94
REVLIMID 85 SELZENTRY 44
REYATAZ 44 SEMPREX-D 101
RHEUMATREX, TREXALL 77 SENSIPAR 80
RHINOCORT AQUA 100 SERAX (g) 56
RHINOCORT AQUA 104 SEREVENT DISKUS 103
RIDAURA 77 SEROMYCIN 45
RIFADIN (g) 45 SEROQUEL 56
RIFAMATE (g) 45 SEROQUEL XR 56
RIFATER 45 SEROSTIM 83
RILUTEK 65 SERZONE (g) 55
RIOMET 82 SILENOR 57
RISPERDAL (g) (TIER 0-BCN ONLY) 56 SILVADENE (g) 94
RISPERDAL M-TAB (g) 56 SIMCOR 47
RITALIN LA 57 SIMPONI 77
RITALIN, SR; METHYLIN, ER (g) 57 SINEMET (g) 62
RMS SUPPOSITORY (g) 59 SINEMET CR (g) 62
ROBAXIN (g) 64 SINEQUAN, ADAPIN (g) 55
ROBINUL, FORTE (g) 67 SINGULAIR 105
ROCALTROL (g) 80 SKELAXIN (g) 64
Trade Name Page Trade Name Page
SOLARAZE 95 TAMBOCOR (g) 52
SOLODYN 45, 90, 135MG(g) 41 TAMIFLU CAP, SUSP 43
SOLODYN 55, 65, 80, 105, 115MG 41 TAMOXIFEN CITRATE (g) 85
SOMA (g) 64 TAPAZOLE (g) 79
SOMA COMPOUND (g) 64 TARCEVA 87
SOMA COMPOUND W/CODEINE (g) 64 TARGRETIN GEL 95
SOMATULINE DEPOT 80 TARGRETIN ORAL 86
SOMAVERT 80 TARKA (g) 49
SONATA (g) 57 TARKA (g) 51
SORIATANE 94 TASIGNA 87
SPECTAZOLE (g) 93 TASMAR 62
SPECTRACEF (g) 40 TAVIST RX (2.68MG, SYRUP) (g) 101
SPIRIVA 105 TAZORAC 92
SPORANOX CAPS (g) 43 TEGRETOL (g) 63
SPORANOX SOLN 43 TEGRETOL XR (g) 63
SPRYCEL 87 TEGRETOL XR 100MG 63
SSKI (g) 79 TEKAMLO 51
STADOL NS (g) 61 TEKAMLO 54
STADOL NS (g) 60 TEKTURNA 54
STALEVO 62 TEKTURNA HCT 54
STARLIX (g) 82 TEMODAR 84
STAXYN 110 TEMOVATE (g), CLOBEVATE (g) 89
STELAZINE (g) 56 TENEX (g) 54
STIMATE 80 TENORETIC (g) 48
STRATTERA 57 TENORMIN (g) 48
STRIANT 80 TENUATE (g) 110
STROMECTROL - SINGLE DOSE 46 TERAZOL- 3, 7 (g) 75
SUBOXONE FILM, TABS 60 TESSALON, PERLES (g) 102
SULAR (g) 51 TESTIM 80
SULAR 8.5, 17, 25.5, 34MG 51 TESTRED, ANDROID 80
SULFACET-R (g) 92 TETRACYCLINE (g) 41
SULFADIAZINE (g) 42 TEVETEN 50
SUMAVEL DOSEPRO 61 TEVETEN HCT 50
SUPERVITE 108 TEV-TROPIN 83
SUPRAX 40 THALOMID 85
SUPRINE 109 THEO-24 104
SURMONTIL (g) 55 THEOPHYLLINE ANHYDROUS (g) 104
SURMONTIL 100MG 55 THIOGUANINE 84
SUSTIVA 44 THORAZINE (g) 56
SUTENT 87 THYROLAR 79
SYMBICORT 105 TIAZAC (g) 51
SYMBYAX 56 TICLID (g) 53
SYMLIN 82 TIGAN (g) 68
SYMMETREL (g) 43 TIKOSYN 52
SYMMETREL (g) 62 TIMOPTIC - XE (g) 96
SYNALAR 0.025% CREAM, OINT (g) 90 TIMOPTIC (g) 96
SYNALAR CREAM, SOLN (g) 90 TINDAMAX 46
SYNALGOS-DC 60 TIROSINT 79
SYNAREL 80 TOBI 46
SYNAREL 75 TOBRADEX (g) 99
TACLONEX, SCALP 94 TOBRADEX OINT 99
TAGAMET (RX ONLY) (g) 66 TOBREX (g) 98
TALACEN (g) 60 TOFRANIL (g) 55
TALWIN NX (g) 60 TOFRANIL-PM (g) 55
Trade Name Page Trade Name Page
TOLECTIN, DS (g) 58 URETRON D-S 106
TOLINASE (g) 82 URISPAS (g) 106
TOPAMAX (g) 63 UROCIT-K (g) 106
TOPAMAX SPRINKLE (g) 63 UROXATRAL 107
TOPICORT CR, GEL, OINT (g) 89 URSO (g) 68
TOPICORT LP (g) 90 URSO FORTE (g) 68
TOPROL XL (g) 48 VAGIFEM 73
TORADOL (g) 58 VALCYTE 43
TOVIAZ 106 VALISONE CR, LOTION, OINT (g) 89
TRACLEER 105 VALISONE CR, LOTION, OINT (g) 90
TRANSDERM-SCOP 68 VALIUM (g) 56
TRANXENE (g) 56 VALIUM (g) 64
TRANXENE SD 56 VALTREX (g) 43
TRAVATAN, Z 96 VALTURNA 50
TRECATOR 45 VALTURNA 54
TRELSTAR DEPOT, LA 85 VANCOCIN HCL 46
TRENTAL (g) 53 VANOS 0.1% CR 89
TREXIMET 61 VANTIN (g) 40
TRIBENZOR 50 VASERETIC (g) 49
TRIBENZOR 51 VASOCIDIN (g) 99
TRICOR 47 VASODILAN (g) 54
TRIGLIDE 47 VASOTEC (g) 49
TRILEPTAL (g) 63 VECTICAL 94
TRILEPTAL SUSP (g) 63 VENLAFAXINE HCL ER (g) 55
TRILIPIX 47 VENTAVIS 105
TRILISATE (g) 59 VEPESID (g) 86
TRIMETHOPRIM (g) 42 VERAMYST 104
TRI-NORINYL (g) 72 VERAMYST 100
TRIPHASIL, TRILEVLEN (g) 72 VERDESO 90
TRI-VI-FLOR (g) 108 VEREGEN 95
TRIZIVIR 44 VERELAN (g) 51
TRUSOPT (g) 96 VERELAN PM (g) 51
TRUVADA 44 VERMOX (g) 46
TUSSICAPS 102 VESANOID 86
TUSSIONEX (g) 102 VESICARE 106
TWYNSTA 50 VEXOL 98
TWYNSTA 51 VFEND 43
TYKERB 87 VIAGRA 110
TYLENOL W/CODEINE (g) 60 VIBRAMYCIN, VIBRATABS (g) 41
TYLOX (g) 60 VICODIN, LORTAB (g) 60
TYVASO 105 VICOPROFEN (g) 60
TYZEKA 43 VICTOZA 82
ULORIC 76 VIDEX 44
ULTRACET (g) 60 VIDEX EC (g) 44
ULTRAM (g) 60 VIGAMOX 98
ULTRAM ER 100MG, 200MG (g) 60 VIMOVO 66
ULTRAM ER 300MG 60 VIMOVO 58
ULTRASE MT 69 VIMPAT 63
ULTRAVATE (g) 89 VIOKASE 69
ULTRAVATE PAC 89 VIRACEPT 44
UNIPHYL (g) 104 VIRAMUNE 44
UNIRETIC (g) 49 VIREAD 44
UNIVASC (g) 49 VIROPTIC (g) 98
URECHOLINE (g) 106 VIVACTIL (g) 55
Trade Name Page Trade Name Page
VIVELLE (g) 77 ZEMPLAR 80
VIVELLE (g) 73 ZENPEP 69
VIVELLE-DOT 73 ZERIT (g) 44
VIVELLE-DOT 77 ZETIA 47
VOLTAREN (g) 97 ZIAC (g) 48
VOLTAREN (g) 58 ZIAGEN 44
VOLTAREN GEL 58 ZIANA GEL 92
VOLTAREN-XR (g) 58 ZIPSOR 58
VOSPIRE ER (g) 102 ZIRGAN 98
VOTRIENT 87 ZITHROMAX (g) 41
VUSION 93 ZMAX 41
VYTORIN 47 ZOCOR (g) 47
VYVANSE 57 ZOFRAN (g) 68
WELCHOL 47 ZOFRAN ODT (g) 68
WELLBUTRIN XL (g) 55 ZOLADEX 85
WELLBUTRIN, SR (g) 55 ZOLINZA 86
WESTCORT (g) 90 ZOLOFT (g) 55
XALATAN 96 ZOLPIMIST 57
XANAX, XR (g) 56 ZOMIG NASAL SPRAY 61
XELODA 84 ZOMIG, ZMT 61
XENAZINE 109 ZONALON, PRUDOXIN 95
XENICAL 110 ZONEGRAN (g) 63
XERESE 93 ZORBTIVE 83
XIBROM 97 ZORPRIN 59
XIFAXAN 200MG 46 ZORTRESS 87
XIFAXAN 550MG 46 ZOVIRAX (g) 43
XODOL 60 ZOVIRAX CREAM, OINT 93
XOLEGEL 93 ZUPLENZ 68
XOLEGEL COREPAK 93 ZYBAN (g) 110
XOPENEX 1.25MG/0.5ML (g) 103 ZYCLARA 95
XOPENEX HFA 103 ZYDONE 60
XOPENEX SOLUTION 103 ZYFLO, CR 105
XYLOCAINE (Rx Only) (g) 91 ZYLET 99
XYLOCAINE VISCOUS (g) 91 ZYLOPRIM (g) 76
XYREM 65 ZYMAR 98
XYZAL SOLUTION 101 ZYMAXID 98
XYZAL TABS (g) 101 ZYPREXA, ZYDIS 56
YASMIN 28 (g) 71 ZYRTEC (OTC) (g) 101
YAZ (g) 71 ZYRTEC-D(OTC) (g) 101
YOHIMBINE HCL (g) 110 ZYVOX 46
ZANAFLEX CAPS 64
ZANAFLEX TABS (g) 64
ZANTAC (RX ONLY) (g) 66
ZANTAC EFFERDOSE 66
ZARONTIN (g) 63
ZAROXOLYN (g) 52
ZAVESCA 109
ZEBETA (g) 48
ZEBUTAL (g) 61
ZEBUTAL (g) 60
ZEGERID CAP (Rx Only) (g) 66
ZEGERID PACKET 66
ZELAPAR 62
ZEMPLAR 108
CB 2870 NOV 10 104277BCNM