Blue Cross Blue Shield of Michigan and

Blue Care Network

Custom Formulary

2011

Custom Formulary

January 2011

January 2011 Custom Formulary - Chapter Names 1 ANTI-INFECTIVES 1A Penicillins

1B Cephalosporins

1C Tetracyclines

1D Macrolides

1E Quinolones

1F Sulfonamides and Combinations

1G Urinary Tract Agents

1H Antifungals

1I Antivirals

1J Antiretrovirals

1K Antimalarials

1L Antituberculars

1M Antiparasitics/Anthelmintics

1N Miscellaneous Anti-infectives

2 CARDIOVASCULAR, HYPERTENSION, CHOLESTEROL 2A Lipid-lowering Agents

2B Beta Blockers and Combinations

2C ACE Inhibitors and Combinations

2D Angiotensin II Receptor Blockers and Combinations

2E Calcium Channel Blockers and Combinations

2F Diuretics

2G Cardiovascular Treatment

2H Nitrates and Combinations

2I Anticoagulants and Hemostasis Agents

2J Alpha-adrenergic Agents

2K Miscellaneous Antihypertensives

3 CENTRAL NERVOUS SYSTEM 3A Antidepressants

3B Antipsychotics

3C Anxiolytics

3D Sedative/Hypnotics

3E CNS Stimulants

3F Nonsteroidal Anti-inflammatory Drugs

3G Salicylates

3H Narcotics

3I Narcotic/Analgesic Combinations

3J Narcotic Mixed Agonist/Antagonist

3K Narcotic Antagonists

3M Migraine Therapy

3N Antiemetics (see Chapter 4E)

3O Parkinsons Disease and Related Disorders

3P Anticonvulsants

3Q Skeletal Muscle Relaxants

3R Myasthenia Gravis

3S Miscellaneous CNS

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4 GASTROINTESTINAL AGENTS 4A H2-Receptor Antagonists

4B Proton Pump Inhibitors

4C Other Ulcer Therapy

4D Antidiarrheals and Antispasmodics

4E Antiemetics

4F Bile Acids

4G Digestive Enzymes

4H Miscellaneous Gastrointestinal Agents

5 OBSTETRICS AND GYNECOLOGY 5A Oral Contraceptives-Monophasic

5B Oral Contraceptives-Biphasic

5C Oral Contraceptives-Triphasic

5D Contraceptives-Misc.

5E Oral Contraceptives-Postcoital

5F Progestins

5G Estrogens

5H Estrogen/Progestin Combinations

5J Infertility Treatment

5K Vaginal Anti-infective/Antifungal

5L Miscellaneous OB-GYN

6 RHEUMATOLOGY AND MUSCULOSKELETAL 6A Salicylates (see Chapter 3G)

6B Gout Therapy

6C Corticosteroids

6D Miscellaneous Rheumatologic Agents

6E Osteoporosis/Hormonal Treatment

6F Osteoporosis/Bone Resorption

7 ENDOCRINOLOGY 7A Antithyroid Agents

7B Thyroid Hormones

7C Corticosteroids

7D Androgens

7E Miscellaneous Endocrine

7F Insulins

7G Noninsulin Hypoglycemic Agents

7H Growth Hormone and Related Products

8 ANTINEOPLASTICS AND IMMUNOSUPPRESSANTS 8A Alkylating Agents

8B Antimetabolites

8C Immunomodulators

8D Hormonal Agents

8E Miscellaneous Antineoplastic Agents

8F Adjuvant Therapy

8G Kinase Inhibitors and Molecular Target Inhibitors

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9 IMMUNOLOGY AND HEMATOLOGY 9B Hematopoietic Agents

9C Interferons and MS Therapy

10 DERMATOLOGY 10A Very High Potency Corticosteroids

10B High Potency Corticosteroids

10C Medium Potency Corticosteroids

10D Low Potency Corticosteroids

10E Topical Anesthetics

10F Acne Treatment

10G Topical Antibacterials

10H Topical Antifungals

10I Topical Antivirals

10J Wound and Burn Therapy

10K Antipsoriatic/Antiseborrheic

10L Scabicides/Pediculicides

10M Miscellaneous Dermatologicals

11 OPHTHALMOLOGY 11A Ophthalmic Beta Blockers

11B Other Glaucoma Agents

11C Cycloplegic Mydriatics

11D Ophthalmic Anti-inflammatory Agents

11E Ophthalmic Anti-infectives

11F Ophthalmic Steroids

11G Ophthalmic Anti-infective/Steroid Combinations

11H Miscellaneous Ophthalmic Agents

12 OTIC AND NASAL PREPARATIONS

12A Nasal Preparations

12B Otic Preparations

13 RESPIRATORY, COUGH AND COLD

13A Antihistamines

13B Antihistamine/Decongestant Combinations

13C Antitussive Combinations

13D Expectorant Combinations

13E Corticosteroids (see Chapter 7C)

13F Oral Beta-Agonists

13G Inhaled Beta-Agonists

13H Inhaled Steroids

13I Intranasal Steroids

13J Theophyllines

13K Epinephrine

13L Miscellaneous Pulmonary Agents

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14 UROLOGY

14A Urinary Antispasmodics

14B Miscellaneous Urologicals

14C BPH Treatment

15 VITAMINS AND SUPPLEMENTS 15A Vitamins and Minerals

15B Potassium Replacement

16 DIAGNOSTIC AND OTHER MISCELLANEOUS 16A Diagnostics & Other Miscellaneous

17 LIFESTYLE MODIFICATION

17A Impotence

17B Weight Loss Preparations

17C Smoking Cessation

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Introduction We are pleased to provide the Blue Cross Blue Shield of Michigan and Blue Care Network Custom Formulary 2011 as a useful reference and educational tool for prescribers, pharmacists and members. Our formulary is a regularly updated list of medications approved by the U.S. Food and Drug Administration and reviewed by the BCBSM and BCN Pharmacy and Therapeutics Committee. The list represents the clinical judgment of Michigan physicians, pharmacists and other experts in the diagnosis and treatment of disease and the promotion of health. Medications are selected based on clinical effectiveness, safety and opportunity for cost savings. The Custom Formulary will help in maintaining the quality of care for our members and containing costs for our clients. Physicians, pharmacists and members should regularly refer to the Custom Formulary for information regarding drug coverage and therapeutic options for BCBSM and BCN members. Physicians are encouraged to prescribe formulary medications whenever possible. The Custom Formulary is divided into major therapeutic categories by chapter for easy use. Products approved for more than one therapeutic indication may be included in more than one chapter. Within each chapter, drugs are identified according to whether they are formulary preferred (Tier 1), formulary options (Tier 2) or nonformulary (Tier 3). Formulary preferred (Tier 1): These drugs have a proven record of safety and effectiveness and offer the best value for members. Because they are Tier 1, they require the lowest copayment, making them your most cost-effective option for treatment. Most generic drugs are formulary preferred.

Formulary options (Tier 2): Our Tier 2 drugs also have a record of safety and effectiveness. However, because more cost-effective therapies or generic alternatives to these drugs are usually available, most Tier 2 drugs require a higher copayment.

Nonformulary (Tier 3): Nonformulary drugs are not on our list of approved drugs. These drugs may not have a proven record for safety or their clinical value may not be as high as the drugs in Tier 1 and Tier 2. Formulary alternatives are available. Depending on the drug coverage, the member may pay a higher copayment or even the entire cost of these drugs. BCBSM and BCN respect the judgment of the dispensing pharmacist. Pharmacists are expected to contact the prescriber when presented with a prescription for a drug or dose that may not be appropriate for a patient. We encourage pharmacists to also contact the prescriber, to suggest an alternative when a BCBSM or BCN member’s prescription is written for a nonformulary drug. Drug coverage Coverage and applicable copayment amounts for drugs on the Custom Formulary are based on a member’s drug plan. Not all drugs included in the Custom Formulary are necessarily covered by each patient’s plan. Most BCN members do not have coverage for nonformulary drugs unless a BCN-affiliated provider certifies that the prescription is medically necessary and BCN agrees. Similarly, BCBSM members with a closed (managed) formulary option do not have coverage for nonformulary drugs. Some BCBSM and BCN plans may require a different copayment amount or may not cover certain lifestyle drugs. These may include weight-loss products, drugs for smoking cessation and drugs to treat sexual dysfunction or infertility. BCN’s coverage for drugs used to treat infertility is based on the member’s BCN medical plan. Coverage for contraceptives is based on the member’s BCBSM or BCN drug plan. Some BCN drug plans do not include coverage for proton pump inhibitors. Members should consult their prescription drug benefit packet or contact a Customer Service representative to determine specific coverage. Approved medications In general, only FDA-approved prescription medications are eligible for coverage under a member’s policy. When a drug is available in the identical strength and dosage in either a prescription or a nonprescription

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medication, the prescription medication is usually not covered. In these cases, prescribers should refer the patient to the equivalent over-the-counter product. Certain OTC products, such as loratadine (Claritin®) are covered for BCN members and for some BCBSM members with a prescription. Other exceptions are identified in the Custom Formulary. Certain medications may be excluded from a BCBSM and BCN member’s pharmacy benefits, but may be covered under the medical benefits. Such medications include serums, vaccines and other medications that are generally administered in a physician’s office under the supervision of appropriate health care personnel and not normally dispensed to the patient for self-administration. Prior authorization and step therapy Prior authorization may be necessary for coverage of certain medications. In these cases, clinical criteria must be met based on current medical information and approved by the BCBSM and BCN Pharmacy and Therapeutics Committee, or other information must be provided before coverage is approved. Drugs subject to step therapy may require previous treatment with one or more drugs on the formulary before coverage is approved. The Blue Care Network Quality Interchange Program (pages seven to 19) and the BCBSM Prior Authorization and Step-Therapy Program (pages 20 to 31) provide a list of drugs that require prior authorization or must meet step-therapy requirements prior to coverage. A description of the BCN quality interchange program and the BCBSM prior authorization and step-therapy program are included in this Custom Formulary. To view the most recent version, please go to bcbsm.com/provider/pharmacy_services/index.shtml For BCBSM members: Members should consult their prescription drug benefit packet for information on how to obtain prior authorization or call the Customer Service number on the back of their Blues member ID card for additional information. Physicians can access the medication request forms on web-DENIS or contact the Blue Cross Blue Shield of Michigan and Blue Care Network Pharmacy Services Clinical Help Desk at 1-800-437-3803 and select option 1 for more information and to request coverage. For BCN members: The physician or office designee can access the medication request forms through web-DENIS. Alternatively, physicians can call the Blue Cross Blue Shield of Michigan and Blue Care Network Pharmacy Services Clinical Help Desk at 1-800-437-3803 and select option 2 to request prior authorization or a benefit exception, depending on the type of request and the member’s drug benefit. Urgent requests should be identified as such when calling. The form must be completed in its entirety and returned to the Pharmacy Services Clinical Help Desk for review. The physician is notified of approved requests, and the member’s claim will process accordingly. If the request is not approved, BCN provides written notification to both the member and practitioner. The notification includes the reason for the denial and an explanation of the appeal rights and the appeals process. As part of our 2011 focus on efficient service, drugs are listed alphabetically within each tier. The Custom Formulary is current at the time of publication (January and July) and is subject to change.

Blue Care NetworkQuality Interchange Program

January 2011

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

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

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

• The prescriber and BCN agree that it is medically necessary.

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

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

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

This information applies to members with a BCN commercial drug benefit. Criteria for BCN AdvantageSM and BlueCaid®

members can be viewed on our Web site: MiBCN.com.

(g)=generic availableANTI-INFECTIVESAnti-FungalsNonformulary:Lamisil® Granules

Requires documentation that the member has experienced treatment failure of or intolerance to at least three months of treatment with griseofulvin (Grifulvin V(g)) suspension.

Miscellaneous Anti-infectivesNonformulary: Cayston®

Coverage is provided for the treatment of pneumonia in patients with cystic fibrosis.

QuinolonesFormulary: Cipro®XR(g) (ciprofloxacin)

Nonformulary:Proquin® XR

Formulary agents:Cipro XR(g): Approved only for uncomplicated urinary tract infection (cystitis). Alternatives include Cipro (g) 100-250mg BID x 3 days and Bactrim DS® (g) BID x 3-5 days.

Nonformulary agents: Proquin XR: Approved only for the treatment of uncomplicated urinary tract infection (cystitis) and requires documentation that member has experienced treatment failure of or intolerance to formulary Cipro XR(g).

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ANTI-INFECTIVES (Cont.)TetracyclinesNonformulary: Adoxa®(g), CK, TT; Oracea®, Solodyn®(g)

Nonformulary agents:Adoxa(g), CK, TT; Oracea: Requires documentation that the member has experienced treatment failure of or intolerance to generic doxycycline AND a copy of the completed MedWatch form (that has been submitted to the FDA) has been submitted to the plan to document treatment failure of or intolerance to generic doxycycline.Solodyn(g): Requires documentation that the member has experienced treatment failure of or intolerance to generic minocycline AND a copy of the completed MedWatch form (that has been submitted to the FDA) has been submitted to the plan to document treatment failure of or intolerance to generic minocycline.

ANTINEOPLASTICS & IMMUNOSUPPRESSANTSHormonal AgentsFormulary:Arimidex®(g) (anastrozole), Aromasin® (exemestane), Femara® (letrozole)

PA for males only: Approved only for ER-positive breast cancer treatment and other literature supported cancer therapies.

ImmunomodulatorsFormulary:Arcalyst™ (rilonacept)

Nonformulary:Revlimid®

Formulary agent:Arcalyst: Approved for the treatment of cryopyrin-associated periodic syndrome in members ≥12 years of age.

Nonformulary agent:Revlimid: Approved for treatment of transfusion-dependent anemia due to low or intermediate-1 risk myelodysplastic syndromes (MDS) with deletion 5q abnormality; multiple myeloma in members whom have experienced treatment failure of or intolerance to or have a contradindication to thalidomide; or members with documentation of enrollment in a Phase II-IV investigative study approved by an appropriate Investigational Review Board (IRB). MDS must be confirmed by FISH analysis or other genetic testing.

Kinase Inhibitors & Molecular Target InhibitorsFormulary:Afinitor® (everolimus), Hycamtin® (topotecan), Iressa® (gefitinib),Nexavar® (sorafenib), Sprycel® (dasatinib), Sutent® (sunitinib),

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Formulary agents:Afinitor: Approved for the treatment of advanced renal cell carcinoma in members who have experienced disease progression or recurrence following treatment with Sutent or Nexavar, OR requires documentation of enrollment in a Phase II-IV investigative study approved by an appropriate IRB.Hycamtin: Approved for treatment of relapsed small cell lung cancer, OR requires documentation of enrollment in a Phase II-IV investigative study approved by an appropriate IRB.Iressa: Approved only for members continuing existing therapy prior to the 09/2005 FDA label revisions.Nexavar: Approved for treatment of advanced or recurrent renal cell carcinoma or hepatocellular carcinoma, OR requires documentation of enrollment in a Phase II-IV investigative study approved by an appropriate IRB.Sprycel: Approved for treatment of chronic myelogenous leukemia in members who have experienced resistance or intolerance to Gleevec; treatment of Philadelphia chromosome-positive acute lymphoblastic leukemia in members who have experienced resistance or intolerance to Gleevec or cytotoxic chemotherapy; OR requires documentation of enrollment in a Phase II-IV investigative study approved by an appropriate IRB.Sutent: Approved for treatment of advanced renal cell carcinoma or gastrointestinal stromal tumor, OR requires documentation of enrollment in a Phase II-IV investigative study approved by an appropriate IRB. Evidence of disease progression or intolerance to Gleevec must be provided for members with gastrointestinal stromal tumor.

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ANTINEOPLASTICS & IMMUNOSUPPRESSANTS (Cont.)Kinase Inhibitors & Molecular Target Inhibitors (cont.)Formulary:Tarceva® (erlotinib), Tykerb® (lapatinib),VotrientTM (pazopanib)

Formulary agents:Tarceva: Approved for treatment of non-small cell lung cancer in members who have experienced treatment failure with at least one chemotherapy regimen or treatment of pancreatic cancer in members who will be receiving Tarceva in combination with gemcitabine, OR requires documentation of enrollment in a Phase II-IV investigative study approved by an appropriate IRB. Tykerb: Approved only for treatment of HER2 or HER2/neu positive advanced or metastatic breast cancer. Evidence of disease progression following treatment with an anthracycline, a taxane, and trastuzumab (Herceptin) must be provided. The member must be receiving Tykerb in combination with Xeloda, OR requires documentation of enrollment in phase II-IV investigative study approved by an appropriate IRB.Votrient: Approved for treatment of advanced renal cell carcinoma OR requires documentation of enrollment in phase II-IV investigative study approved by an appropriate IRB.

Miscellaneous Antineoplastic AgentsFormulary:Zolinza™ (vorinostat)

Approved for treatment of cutaneous manifestation of cutaneous T-cell lymphoma and requires documentation of persistent progressive or recurrent disease after trial with two systemic therapies, such as oral bexarotene (Targretin), α-interferon (Intron-A, Pegasys, PEG-Intron), denileukin diftitox (Ontak), photochemotherapy (Psoralen plus ultraviolet A (PUVA)), or systemic chemotherapy, OR requires documentation of enrollment in a Phase II-IV investigative study approved by an appropriate IRB.

CARDIOVASCULAR, HYPERTENSION, CHOLESTEROLAngiotensin Converting Enzyme Inhibitors (ACE-Inhibitor)Nonformulary:Altace® Tablets

Requires documentation that member has experienced failure of or intolerance to Altace(g) capsules.

Angiotensin II Receptor Blockers (ARBS)Formulary:Benicar® (olmesartan medoxomil), HCT

Nonformulary:Atacand®, HCT; Avapro®, Avalide®; Azor®, Diovan®, HCT; Exforge®, HCT; Micardis®, HCT; Teveten®, HCT; TribenzorTM, Twynsta®, Valturna®

Formulary agents:Benicar, HCT: Requires documentation that the member has experienced intolerance to an ACE inhibitor such as Prinivil/Zestril(g), Monopril(g), Lotensin(g), Vasotec(g), Accupril(g), etc.

Nonformulary agents:Atacand, HCT; Avapro, Avalide; Diovan, HCT; Micardis, HCT; Teveten, HCT: Requires documentation that the member has experienced intolerance to an ACE inhibitor and experienced treatment failure of or intolerance to a formulary ARB (Cozaar(g), Hyzaar(g); Benicar, HCT)Azor, Exforge, Tribenzor, Twynsta, Valturna: Requires successful treatment of at least three months of therapy with the individual agents contained in the requested medication at the prescribed dosage.Exforge HCT: Requires inadequate response with at least three months of therapy with Exforge.

Beta BlockersNonformulary:Bystolic®, Coreg CR™

Bystolic: Requires documentation that the member has experienced treatment failure of or intolerance to at least two unique formulary beta blockers, such as betaxolol, atenolol, acebutolol, metoprolol, or bisoprolol. Coreg CR: Requires documentation that the member experienced treatment failure of or intolerance to both carvedilol immediate-release (Coreg(g)) AND metoprolol succinate (Toprol XL(g)).

Cardiovascular TreatmentNonformulary:Ranexa®

Ranexa: Requires documentation that the member has experienced treatment failure of or intolerance to both a beta-blocker and a nitrate. The member must have no history of or high risk for cancer.

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CARDIOVASCULAR, HYPERTENSION, CHOLESTEROL (Cont.)Cholesterol-Lowering AgentsFormulary:Crestor® (rosuvastatin), Zetia® (ezetimibe)

Nonformulary:Advicor® , Altoprev®, Caduet®, Lescol®, XL; Lipitor®, Livalo®, Simcor®, TriLipix®, Vytorin®

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

Nonformulary agents:Altoprev, Caduet, Lescol, XL, Lipitor, Livalo, Vytorin: Requires documentation that member has experienced treatment failure of or intolerance to at least one high dose (>40mg) generic statin (Mevacor(g), Zocor(g), or Pravachol(g)) AND at least one formulary brand agent (Crestor or Zetia). Advicor, Simcor: Requires successful treatment of at least three months of therapy with the individual agents contained in the requested medication at the prescribed dosage.TriLipix: Requires documentation that the member has experienced treatment failure of or intolerance to ALL generic fibrates, such as Lofibra(g) and Lopid(g), AND supporting evidence for the use of this agent. Concomitant use of a statin does not satisfy criteria.

Miscellaneous AntihypertensivesNonformulary:TekamloTM; Tekturna®, HCT

Tekamlo: Requires successful treatment of at least three months of therapy with the individual agents contained in the requested medication at the prescribed dosage.Tekturna, HCT: Approved for the treatment of hypertension AND requires documentation that the member has experienced treatment failure of or intolerance to ALL of the following drug classes: diuretics, beta-blockers, ACE inhibitors, and angiotensin II receptor blockers (ARBS).

CENTRAL NERVOUS SYSTEMAnticonvulsantsNonformulary:Lyrica®

Requires documentation that the member has at least one of the following listed diagnoses: • Seizure disorder that is being treated concurrently with other anticonvulsants • Neuropathic pain associated with either diabetic peripheral neuropathy or post-herpetic

neuralgia AND the member has experienced treatment failure of or intolerance to:o Members ≥ 65 years of age: gabapentin 1200 mg per dayo Members ≤ 64 years: gabapentin 1200 mg per day AND a tricyclic antidepressant.• Fibromyalgia and documentation that the member has experienced intolerance to gabapentin

or inadequate relief from gabapentin 1200 mg per day AND treatment failure of or intolerance to at least three of the following: a tricyclic antidepressant, an SSRI, an SNRI, cyclobenzaprine, or tramadol.

Additional criteria:• Approvals are granted only at the specific strength requested.• Approved dosage is limited to < 300 mg per day for initial treatment and will not exceed 600 mg

per day if 300 mg/day is tolerated.• Any previous authorizations are discontinued when a new strength is approved.

AntidepressantsFormulary:Lexapro® (escitalopram)

Nonformulary:AplenzinTM

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Formulary agents: Requires documentation that member has experienced treatment failure of or intolerance to at least one generic antidepressant (Prozac(g), Celexa(g), Paxil(g), Effexor(g), Zoloft(g), or Wellbutrin SR, XL(g)).

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

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CENTRAL NERVOUS SYSTEM (Cont.)Antidepressants (cont.)Nonformulary:Cymbalta®, Luvox CR®, OleptroTM, Pexeva®, Pristiq®, Savella®

Nonformulary agents: Cymbalta: Depression and/or anxiety: Requires documentation that the member has experienced treatment failure of or intolerance to at least one generic antidepressant AND one brand name formulary antidepressant. Post-herpetic neuralgia or diabetic peripheral neuropathy: If older than 65 years, requires treatment failure of or intolerance to gabapentin 1200 mg per day. If under 65 years, requires treatment failure of or intolerance to gabapentin 1200 mg per day and a tricyclic antidepressant. Fibromyalgia: Documentation is required to show that the member has experienced intolerance to gabapentin OR inadequate relief from gabapentin 1200 mg per day AND treatment failure of or intolerance to at least three of the following: a tricyclic antidepressant, an SSRI, an SNRI, cyclobenzaprine, or tramadol.Luvox CR: Requires documentation that the member has experienced treatment failure of or intolerance to at least one generic antidepressant and one brand name formulary antidepressant AND documentation that continued use of Luvox(g) will adversely affect the member’s mental health.Oleptro: Approved for major depressive disorder in members who have experienced treatment failure of or intolerance to Desyrel®(g) AND documentation that continued use of Desyrel(g) will adversely affect the member’s mental health.Pexeva: Requires documentation that the member has experienced treatment failure of or intolerance to at least one generic antidepressant and one brand name formulary antidepressant AND documentation that continued use of Paxil(g) will adversely affect the member’s mental health.Pristiq: Requires documentation that the member has experienced treatment failure of or intolerance to at least one generic antidepressant and one brand name formulary antidepressant AND documentation that continued use of Effexor(g) or Effexor XR(g) will adversely affect the member’s mental health.Savella: Approved for treatment of fibromyalgia AND requires documentation that the member has experienced intolerance to gabapentin or inadequate relief from gabapentin 1200 mg per day and treatment failure of or intolerance to at least three of the following: a tricyclic antidepressant, an SSRI, an SNRI, cyclobenzaprine, or tramadol.

AntipsychoticsNonformulary:Invega®, Seroquel XR®

Requires documentation that the member has experienced treatment failure of or intolerance to all formulary atypical antipsychotic agents. Maximum dose of Invega is limited to 12 mg per day.

CNS StimulantsFormulary:Adderall XR® (amphet asp/amphet/d-amphet)(g), Provigil® (modafinil)

Nonformulary:Nuvigil®, Procentra™

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Formulary agents:Adderall XR(g): Requires documentation that member has experienced treatment failure of or intolerance to brand name Adderall XR.Provigil: Approved only for members with narcolepsy, obstructive sleep apnea, or an indication supported by peer-reviewed literature. Dosage limited to a maximum of 400mg per day. Shift-work sleep disorder is not covered since treatment is not medically necessary.

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

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CENTRAL NERVOUS SYSTEM (Cont.)CNS Stimulants (cont.)Nonformulary:Strattera™, Vyvanse™

Nonformulary agents:Strattera: Approvable when stimulants are contraindicated by medical history OR the following criteria by age:For BCN members age 5 to 20: Requires documentation that the member has experienced treatment failure of or intolerance to both a methylphenidate (such as Ritalin(g) or Concerta) AND an amphetamine (such as Adderall(g)).For BCN members age 21 and older: Requires documentation that the member has experienced treatment failure of or intolerance to either a methylphenidate OR an amphetamine.Note: The use of Strattera in members ≤ 4 years of age is not recommended or supported by literature.Vyvanse: Requires documentation that the member has experienced treatment failure of or intolerance to both a methylphenidate (such as Ritalin(g) or Concerta) AND an amphetamine (such as Adderall(g)).

Migraine TherapyFormulary:Amerge® (g) (naratriptan), Maxalt® , MLT® (rizatriptan)

Nonformulary:AlsumaTM, Axert® , Frova® , Relpax®, SumavelTM DoseProTM, Treximet®; Zomig® , ZMT® , nasal spray

Formulary agents:Amerge(g): Requires documentation that member has experienced failure of or intolerance to both sumatriptan (Imitrex(g)) and Maxalt.Maxalt, MLT: Requires documentation that member has experienced treatment failure of or intolerance to sumatriptan (Imitrex(g)).

Nonformulary agents:Alsuma, Axert, Frova, Relpax, Sumavel DosePro; Zomig, ZMT, nasal spray: Requires documentation that member has experienced failure of or intolerance to both sumatriptan (Imitrex(g)) and Maxalt.Treximet: Requires documentation that the member has experienced treatment failure of or intolerance to a combination of sumatriptan (Imitrex(g)) or Maxalt AND naproxen. Documentation as to why sumatriptan (Imitrex(g)) or Maxalt and naproxen as individual agents do not work for and/or may be harmful to the member must be provided.

Miscellaneous CNSNonformulary:Aricept® 23mg, IntunivTM

Aricept 23mg: Requires documentation for a progressive-type dementia AND requires successful treatment with Aricept 10mg for three months.Intuniv: Approved for treatment of ADHD and requires documentation that the member has experienced treatment failure of or intolerance to both a methylphenidate (such as Ritalin(g) or Concerta), an amphetamine (such as Adderall(g)), generic guanfacine immediate-release, and clonidine.

Narcotics Formulary:Actiq® (g) (fentanyl citrate), Opana® (g) (oxymorphone HCl)

Nonformulary:ButransTM, ExalgoTM

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Formulary agents:Actiq: Approved for the treatment of breakthrough cancer pain in members that are tolerant of high dose narcotics and is currently receiving a long-acting narcotic. The member must also have experienced treatment failure of or intolerance to the use of other oral immediate-release narcotics for the management of breakthrough pain. Opana(g): Requires documentation that the member has experienced treatment failure of or intolerance to morphine sulfate 20mg/mL (Roxanol(g)) or morphine sulfate immediate-release (MSIR(g)).

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

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CENTRAL NERVOUS SYSTEM (Cont.)Narcotics (cont.)Nonformulary:Fentora®, Onsolis®, Nucynta®; Opana® ER; Oxycontin®

Nonformulary agents:Fentora, Onsolis: Approved for the treatment of breakthrough cancer pain in members that are tolerant of high dose narcotics and is currently receiving a long-acting narcotic. The member must also have experienced treatment failure of or intolerance to the use of other oral immediate-release narcotics for the management of breakthrough pain. Also requires documentation that the member has experienced treatment failure of or intolerance to Actiq(g). Nucynta: Requires documentation that member has experienced treatment failure of or intolerance to a Ultram(g) or Ultracet(g) AND three formulary immediate-release narcotics. If use is to exceed 30 days, Nucynta must be used in combination with a long-acting narcotic, such as methadone, morphine sulfate extended-release (Oramorph(g), MS Contin(g)), and fentanyl transdermal patch (Duragesic(g)).Opana ER, Oxycontin: Requires documentation that the member has experienced treatment failure of or intolerance to ALL of the following long-acting formulary agents: methadone, morphine sulfate extended-release (Oramorph(g), MS Contin(g)), and fentanyl transdermal patch (Duragesic(g)).

Narcotic Mixed Agonist/AntagonistFormulary:Suboxone® SL tablets, Film (buprenorphine HCl/naloxone HCl),

Nonformulary:RybixTM ODT

Formulary agents:Suboxone SL tabs, Film: Approved only for the treatment of clinically diagnosed opioid dependence. Requires documentation of validated screening tools used to identify the opioid use problem.

Nonformulary agent:Rybix ODT: Requires documentation that member cannot swallow ANY oral tramadol tablets OR documentation that the member has had successful treatment with immediate release tramadol for a minimum of three months AND documentation as to why continued use of generic tramadol would harm the member.

Non-Steroidal Anti-Inflammatory DrugsNonformulary:Arthrotec®; Celebrex®, Flector® Patch, PennsaidTM, Prevacid NapraPACTM, VimovoTM, Voltaren® Gel

Arthrotec, Prevacid NapraPAC: Approved for members >60 years of age, receiving anticoagulant or antiplatelet therapy, receiving chronic treatment with oral corticosteroids (≥ 60 days duration), or a history of or current diagnosis of peptic ulcer disease, clinically significant gastrointestinal bleeding, and/or alcoholism. Celebrex: Approved for members >60 years of age whom are not at high risk for cardiovascular events, and do not have a previous history of stroke, MI, coronary heart disease, or blood clots. The member must not be receiving concomitant anticoagulant or an antiplatelet therapy. Approved for members ≤ 60 years of age whom are receiving chronic treatment with oral corticosteroids (≥ 60 days duration) or have a history of or current diagnosis of peptic ulcer disease, clinically significant gastrointestinal bleeding, and/or alcoholism. The member must not be receiving concomitant anticoagulant or antiplatelet therapy AND have no previous history or evidence of cardiovascular and thromboembolic disease. Note: Lodine®(g) is more selective than Celebrex for the COX-2 enzyme.Flector Patch: Approved only for the treatment of acute sprains AND requires treatment failure of or intolerance to Voltaren(g)/XR(g) tablets AND an OTC topical analgesic (Myoflex OR Aspercreme).Pennsaid, Voltaren Gel: Requires treatment failure of or intolerance to Voltaren(g)/XR(g) tablets AND an OTC topical analgesic (Myoflex OR Aspercreme).Vimovo: Requires documentation that member has had treatment failure of or intolerance to Prilosec(g), Protonix(g) and Prevacid(g) at a twice daily, high dose regimen AND meets any one of the following criteria:•Greater than 60 years of age•Receiving anticoagulant or antiplatelet therapy•Receiving chronic treatment with oral corticosteroids (>= 60 days duration)•A history or peptic ulcer disease, clinically significant gastrointestinal bleeding, and/or alcoholism.

Parkinson’s Disease and Related DisordersNonformulary: Mirapex ER®

Requires a diagnosis of Parkinson’s Disease. Must also try and fail Mirapex IR(g) AND documentation that the continued use of it will adversely afffect the member’s condition.

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CENTRAL NERVOUS SYSTEM (Cont.)Sedatives/HypnoticsFormulary:Ambien CR® (g)Nonformulary: EdluarTM, Lunesta®, Rozerem®, SilenorTM, ZolpiMistTM

Requires documentation that member has experienced treatment failure of or intolerance to an adequate trial of both zolpidem (Ambien®(g)) and zaleplon (Sonata®(g)).Silenor: Requires documentation that member has experienced treatment failure of or intolerance to Sinequan®(g), Ambien(g), Sonata(g) AND Desyrel®(g).

DERMATOLOGYAcne TreatmentNonformulary:Ziana™ gel

Requires documentation of medical necessity to identify why individual agents [Cleocin-T®(g) plus Retin-A®(g)] cannot be used.

Antipsoriatic/AntiseborrheicFormulary:Enbrel® (etanercept), Humira® (adalimumab)

Nonformulary:Taclonex, Scalp®

Formulary agents: Enbrel, Humira: Moderate to Severe Psoriasis: Requires 3 months of previous treatment with topical corticosteroids and 3 months treatment with PUVA.

Nonformulary agent:Taclonex: Requires documentation that the member has experienced treatment failure of or intolerance to at least 30 days of treatment with the combination of a very high potency corticosteroid [Diprolene ointment(g), Temovate(g), Psorcon(g)] PLUS Dovonex.

Miscellaneous DermatologicalsFormulary:Elidel® (pimecrolimus)

Nonformulary:Protopic®

Formulary agents: Elidel: Approved for members ≥2 years of age with a diagnosis of atopic dermatitis or eczema.

Nonformulary agent:Protopic: Approved for members ≥2 years of age with a diagnosis of atopic dermatitis or eczema and documentation that the member has experienced treatment failure of or intolerance to Elidel®. For members ages 2 to 15, only the 0.03% strength may be used.

Wound & Burn TherapyNonformulary:Regranex®

Requires documentation that the member has a diagnosis of diabetic skin ulcer or may be approved for wound therapy per policy criteria.

DIAGNOSTICS & OTHER MISCELLANEOUSDiagnostic & Other MiscellaneousFomulary:Carbaglu® (carglumic acid), Kuvan® (sapropterin dihydrochloride),Xenazine® (tetrabenazine)

Nonformulary:Campral®, Exjade®

Formulary agents:Carbaglu: Requires documentation that member has a diagnosis of hyperammonemia due to NAGS deficiency. Kuvan: Requires documentation that member has a diagnosis of phenylketonuria (PKU) and will be following a phenylalanine-restricted diet in conjunction with Kuvan.Xenazine: Requires documentation that member has a diagnosis of chorea associated with Huntingon’s disease.

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

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ENDOCRINOLOGYGrowth Hormone & Related ProductsFormulary:Genotropin® (somatropin),Nutropin®, AQ (somatropin)

Nonformulary:Humatrope®, Norditropin®, Omnitrope®, Saizen® , Serostim®, Tev-Tropin®, Valtropin®, Zorbtive™

Increlex™

Formulary agents:Children (<18 years of age): Requires a diagnosis of growth hormone deficiency, growth failure secondary to chronic renal failure/insufficiency in children who have not received a renal transplant, growth failure in children small for gestational age or with intrauterine growth retardation, Turner’s Syndrome, Noonan’s Syndrome, Prader-Willi Syndrome, SHOX deficiency, or for treatment of severe burns covering >40% of the total body surface area. The member’s current height and weight must be provided. The member must also have open epiphyses.Initial treatment: For growth hormone deficiency, two growth hormone stimulation tests OR one GH stimulation test along with a subnormal IGF-1 level and IGFBP-3 level must be provided. The member’s height must be below the 5th percentile.To continue: The member must achieve a growth velocity of > 4.5 cm/year while receivingtherapy over the past year. Treatment may continue until final height or epiphyseal closure hasbeen documented.Adults (≥18 years of age): Approved for treatment of growth hormone deficiency, AIDS wasting cachexia, Turner’s Syndrome, and Short Bowel Syndrome. The diagnosis must be made by an endocrinologist or a nephrologist. Initial diagnosis must be based on two growth hormonestimulation tests, 3 or more pituitary hormone deficiencies with an IGF-1 below 80ng/ml OR 1 growth hormone and at least 1 pituitary hormone deficiency Nonformulary agents: Also requires documentation that the member has experiencedtreatment failure of or intolerance to formulary agents.Increlex: Approved for treatment of severe IGF-1 deficiency, growth hormone gene deletion,and Laron’s syndrome in members <18 years of age, with open epiphyses, and height below the 3rd percentile. Member must have a normal or elevated growth hormone level with an IGF-1 level 3 or more standard deviations below normal. The prescriber must be a pediatric endocrinologist.Initial approval is granted for 1 year and renewal can be obtained if member has clinical response with therapy, as demonstrated by an annual growth velocity of ≥ 2.5cm

Non-Insulin Hypoglycemic Agents Formulary:Actos® (pioglitazone);Actoplus Met® (pioglitazone/metformin), Duetact® (pioglitazone/glimepiride)

Nonformulary: Actoplus Met® XR, Avandamet®, Avandaryl®, Avandia®, Byetta®, Januvia®, Janumet®, Onglyza™, Prandimet®, Symlin®, Victoza®

Formulary agents:Actos: Requires documentation that the member has experienced failure with metformin. If the member cannot tolerate metformin or if metformin is contraindicated, physicians are encouraged to prescribe a sulfonylurea, unless contraindicated, prior to treatment with a TZD.Actoplus Met, Duetact: Requires documentation that the member has experienced successful treatment with at least three months of therapy with the individual agents that are in the combination product.

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

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GASTROINTESTINAL AGENTSAntiemeticsNonformulary:Sancuso®, Zuplenz®

Sancuso: Requires documentation that the member has experienced treatment failure of or intolerance to both oral Kytril(g) AND Zofran(g), ODT(g).Zuplenz: Same as above AND documentation that the continued use of Zofran ODT(g) would adversely affect the member’s condition.

Miscellaneous Gastrointestinal AgentsFormulary:Relistor® (methylnaltrexone)

Nonformulary:Amitiza®, ChenodalTM, Cimzia®, Lotronex®, Xifaxan 550®

Formulary agent:Relistor: Approved for the treatment of opioid-induced constipation in members with advanced illness whom are receiving palliative care and requires documentation that the member has experienced inadequate response to at least 3 of the following laxatives: bulk laxatives (polycarbophil, psyllium, methylcellulose), saline laxatives (milk of magnesia/magnesium hydroxide), osmotic laxatives (Miralax(g)), or stimulant (Dulcolax(g), Senna(g)).

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

Proton Pump InhibitorsFormulary:Prevacid®(g) capsule (lansoprazole), Prevacid SolutabTM (g), Prilosec®(g) (omeprazole) 40mg, Protonix®(g) (pantoprazole), Zegerid® (g) capsule (omeprazole/sodium bicarbonate)

Nonformulary:Aciphex®, DexilantTM, Nexium®, Prilosec suspension, Protonix suspension,Zegerid® Packet, VimovoTM

Formulary agents:Prevacid(g), Solutab(g): Requires documentation that the member has experienced failure of or intolerance to Prilosec OTC(g) or Prilosec(g).Prilosec 40mg(g): Requires documentation that member has experienced treatment failure with Prilosec OTC(g) or Prilosec(g) (2 x 20mg).Protonix(g): Requires documentation that member has experienced failure of or intolerance to Prilosec OTC(g) or Prilosec(g) unless the member is currently receiving Plavix.Zegerid(g): Requires documentation that member has experienced failure of or intolerance to Prilosec OTC(g) or Prilosec(g) AND Prevacid(g) or Prevacid Solutab.

Nonformulary agents:Aciphex, Zegerid Packet: Requires documentation that the member has experienced treatment failure of or intolerance to Prilosec OTC or Prilosec(g) AND Prevacid(g) or Prevacid Solutab. Dexilant, Nexium: Requires documentation that the member has experienced treatment failure of or intolerance to both BCN formulary alternatives [either Prilosec OTC or Prilosec(g) AND Prevacid(g)], one of which is at a twice daily, high dose regimen.Prilosec suspension, Protonix suspension: Requires documentation that member has experienced treatment failure of or intolerance to Prevacid Solutab.Vimovo: Requires documentation that member has had treatment failure of or intolerance to Prilosec(g), Protonix(g) and Prevacid(g) AND meets any one of the following criteria:•Greater than 60 years of age•Receiving anticoagulant or antiplatelet therapy•Receiving chronic treatment with oral corticosteroids (>= 60 days duration)•A history or peptic ulcer disease, clinically significant GI bleeding, and/or alcoholism.

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IMMUNOLOGY & HEMATOLOGYHematopoietic AgentsFormulary:Procrit® (epoetin alfa)

Promacta® (eltrombopag)

Nonformulary: Aranesp®, Epogen®

Formulary agents:Procrit: Requires documentation that the member has one of the following conditions: anemia secondary to chronic renal failure, chronic renal insufficiency, HIV infection, HIV therapy, chemotherapy, myelodysplasia, or chronic hepatitis C therapy, OR prophylaxis prior to surgery to reduce need for allogenic blood transfusions. A Hgb level of less than 10 g/dL is required for initial therapy. For continued coverage dose adjustments are required to maintain Hgb between 10 to 12 g/dL. Duration of approval is dependent on the indication.Promacta: Approved for treatment of thrombocytopenia with chronic immune thrombocytopenic purpura, has a platelet count of <400 x 109/L if continuing therapy, and inadequate response to, intolerance to, or is not a candidate for standard first-line treatments, such as corticosteroids, immunoglobulins, or splenectomy.

Nonformulary agents: Also requires documentation that member has experienced failure of or intolerance to formulary epoetin alfa (Procrit) and applicable criteria for Procrit.

Hepatitis B & C TherapyFormulary:Infergen (interferon alfacon-1), Intron-A (interferon alfa-2B), Pegasys (peginterferon alfa 2-A), Peg-Intron (peginterferon alfa-2B), ribavirin

Infergen: Approved for the treatment of Hepatitis B. Intron-A: Approved for the treatment of Hepatitis B, condyloma acuminate, essential thrombocythemia, hairy cell leukemia, Kaposi’s sarcoma, malignant melanoma, multiple myeloma, non-Hodgkin’s lymphoma, Philadelphia chromosome (Ph) positive chronic phase myelogenous leukemia (CML), and renal cell carcinoma. Peg-Intron, Pegasys: Approved for the treatment of Hepatitis B and Hepatitis C. For hepatitis C, approval is for members naïve to pegylated interferon therapy only. Genotype,HIV status, previous therapy and duration must also be provided. The member must receive peglylated interferon in combination with ribavirin unless contraindicated. For genotypes 2, 3: Approval is for a total of 24 weeks duration. For non-genotypes 2, 3: Approval is for a total of 48 weeks duration. Members must achieve a ≥2 log decrease in viral load after 12 weeks of treatment. Ribavirin: Approved for the treatment of Hepatitis C. Genotype, HIV status, previous therapy and duration must also be provided.

Interferons and MS TherapyNonformulary:AmpyraTM

Betaseron®

Ampyra: Initial treatment: Requires a diagnosis of multiple sclerosis and documentation of difficulty walking resulting in significant limitations of instrumental activities of daily living. Also requires two timed 25-foot walk (T25FW) measurements that must be within 10% variability and demonstrates that the patient is able to walk 25 feet in 8-45 seconds. To continue: Requires documentation of improvement in walking speed by at least 10% as assessed by the T25FW AND that limitations of instrumental activities of daily living has improved as a result of increased walking speed within the first 2 months of therapy.Betaseron: Requires documentation that member has experienced failure of or intolerance to formulary agents (Avonex, Copaxone or Rebif) AND Extavia®.

LIFESTYLE MODIFICATION PRODUCTSImpotenceFormulary:Caverject® (alprostadil), Cialis® (tadalafil), Muse® (alprostadil), Viagra® (sildenafil citrate)

Nonformulary:Edex®, Levitra®, StaxynTM

For men over the age of 34: requires a diagnosis of erectile dysfunction (ED). For men 34 years and younger: requires a diagnosis of ED secondary to a medical cause such as multiple sclerosis, spinal cord injury, Parkinson’s disease, radiation for prostate or bladder cancer, and other indications deemed appropriate. The member must not be using nitrates concomitantly and avoid use of alpha blockers with oral ED agents. Maximum of 6 doses per 28 days.

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LIFESTYLE MODIFICATION PRODUCTS (Cont.)Weight Loss ProductsFormulary:phentermine and related products

Nonformulary:Xenical®

Requires verification that member’s Body Mass Index (BMI) is ≥30 kg/m2 or >27 kg/m2 with co-morbidities. and concurrent lifestyle modification plan. Initial coverage for all anorexiants and related drugs is limited to 3 months. Additional coverage requires documentation of weight loss of at least 2 pounds per month. Maximum benefit is 12 months of treatment per lifetime; 24 months for Xenical.

OBSTETRICS AND GYNECOLOGYInfertility treatmentFormulary:Bravelle® (urofollitropin), Cetrotide® (cetrorelix acetate), FertinexTM (urofollitropin), Ganirelix acetate® (ganirelix acetate), Gonal-F®, RFF (follitropin alfa, recomb), Ovidrel® (HCG alfa, recomb), Novarel®/Pregnyl®/Profasi® (gonadotropin, chorionic, human), Repronex® (menotropins)

Nonformulary:Follistim® AQ, Luveris®, Menopur®

Coverage is provided for most BCN female members with an infertility benefit and also in accordance with generally accepted medical practice. BCN does not provide coverage for infertility drugs to be used as part of assisted reproductive technology treatment, such as in-vitro fertilization (IVF), zygote in vitro fertilization transfer (ZIFT), gamete in vitro fertilization transfer (GIFT). Authorization will be provided for one year. Additional coverage will be based on documentation that the member is being treated according to accepted medical practice. Requests are not considered for men.

OTIC & NASAL PREPARATIONSIntranasal SteroidsFormulary:Nasacort AQ® (triamcinolone acetonide)

Nonformulary:Beconase AQ®, Nasonex®, Omnaris™,Rhinocort Aqua®, Veramyst™

Formulary agent:Nasacort AQ: Requires documentation that member has experienced treatment failure of or intolerance to fluticasone (Flonase(g)) or flunisolide (Nasalide(g)/Nasarel(g)).

Nonformulary agents: Requires documentation that member has experienced treatment failure of or intolerance to fluticasone (Flonase(g)) or flunisolide (Nasalide(g)/Nasarel(g)) AND Nasacort AQ.

RESPIRATORY COUGH & COLDAntihistamines and CombinationsFormulary:Allegra-D®(g) (p-ephed/fexofenadine), Xyzal® (g) (levocetirizine)

Nonformulary:Allegra® suspension, Allegra® ODT, Clarinex®, Clarinex-D®, Clarinex Reditabs®, Clarinex Syrup®, Semprex-D®, Xyzal® Oral Solution

Formulary agent:Allegra-D(g): Requires documentation that the member has experienced treatment failure of or intolerance to OTC loratadine D or OTC cetirizine DXyzal (g): Requires documentation that the member has experienced treatment failure of or intolerance to OTC loratadine or OTC cetirizine, AND generic fexofenadine (Allegra(g) or Allegra-D(g)) in appropriate dosage form for requested drug.

Nonformulary agents:Requires documentation that the member has experienced treatment failure of or intolerance to OTC loratadine or OTC cetirizine, AND generic fexofenadine (Allegra(g) or Allegra-D(g)) in appropriate dosage form for requested drug.

Inhaled Beta-AgonistsNonformulary:Brovana®, Perforomist™

Requires documentation that the member has experienced treatment failure of or intolerance to BOTH Serevent® AND Foradil®.

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RESPIRATORY COUGH & COLD (Cont.)Pulmonary Arterial HypertensionFormulary:Letairis™ (ambrisentan), Revatio® (sildenafil), Tracleer® (bosentan), TyvasoTM (treprostinil), Ventavis® (iloprost)

Nonformulary:Adcirca™

Formulary agents: Letairis, Revatio, Tracleer, Tyvaso, Ventavis: Approved for the treatment of pulmonary arterial hypertension (PAH) WHO Class III or IV symptoms.

Nonformulary agent:Adcirca: Approved for the treatment of pulmonary arterial hypertension (PAH) WHO Class III or IV symptoms AND requires documentation that member has experienced treatment failure of or intolerance to Revatio.

RHEUMATOLOGY & MUSCULOSKELETALGout TherapyNonformulary:Uloric®

Approved for the treatment of gout and hyperuricemia in members that have experienced treatment failure of, at appropriate dose, or intolerance to generic allopurinol. Uloric 80mg requires documentation that the member has had an inadequate response to the 40mg dose.

Miscellaneous Rheumatologic AgentsFormulary:Enbrel®(etanercept), Humira®

(adalimumab)

Nonformulary:Cimzia®, Kineret®, SimponiTM

Formulary agents: Enbrel, Humira: Requires four month trial with two concurrent disease modifying antirheumatic drugs (one must be methotrexate unless contraindicated). Examples of DMARDs include: methotrexate, sulfasalazine, azathioprine, hydroxychloroquine/chloroquine, cyclosporine, gold and penicillamine.

Nonformulary agent:Cimzia, Kineret, Simponi: Approved for the treatment of moderate to severe rheumatoid arthritis and requires documentation that the member has experienced treatment failure of or intolerance to Enbrel and Humira.

Osteoporosis/Bone Resorption Inhibitors Formulary:Actonel® (risedronate); Actonel® plus Calcium

Nonformulary:Boniva®, ForteoTM, Fosamax D™

Formulary agents: Actonel, Actonel plus Calcium: Requires documentation that member has experienced treatment failure of or intolerance to alendronate (Fosamax(g)).

Nonformulary agents: Boniva, Fosamax D: Requires documentation that member has experienced treatment failure of or intolerance to both alendronate (Fosamax(g)) and Actonel.Forteo: Approved for the treatment of osteoporosis (T-score <= -2.5) AND requires documentation that the member has a contraindication to or experienced treatment failure of or intolerance to a bisphosphonate.

UROLOGYBPH TreatmentNonformulary:JalynTM

Requires successful treatment of at least three months of therapy with the individual agents contained in the requested medication at the prescribed dosage.

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Blue Cross Blue Shield of MI

Prior Authorization and Step Therapy Program January 2011

BCBSM monitors the use of certain medications to ensure our members receive the most appropriate and cost-effective drug therapy. Prior authorization for these drugs means that certain clinical criteria must be met before coverage is provided. In the case of drugs requiring step therapy, for example, previous treatment with one or more formulary drugs may be required. Drugs that must meet clinical criteria are identified in the formulary list with (PA) or (ST). Your physician can contact our pharmacy help desk to request prior authorization for these drugs. The criteria for authorization are based on current medical information and the recommendations of the Blues’ Pharmacy and Therapeutics Committee, a group of physicians, pharmacists and other experts. You may be required to pay the full cost of the drug if your physician does not obtain prior authorization. When your doctor prescribes a brand-name drug that’s nonformulary, requires prior authorization or is not covered under your drug rider, it may not be a covered benefit. BCBSM reviews all physician and member requests to determine if the drug is medically necessary and that there aren’t equally effective alternative drugs on the formulary. Please call the Customer Service number on the back of your BCBSM ID card if you have questions about your drug coverage, a drug claim or filing a benefit exception.

Prior Authorization and Step Therapy Drug Categories

(CUSTOM FORMULARY)

MEDICATION/ DRUG CLASS CRITERIA

AdcircaTM (tadalafil) Nonformulary

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

Amitiza® (lubiprostone) Nonformulary

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

AmpyraTM (dalfampridine extended release) Nonformulary

Coverage may be provided in patients ≥ 18 years of age when the criteria below are met: A. Diagnosis of multiple sclerosis B. Prescribing physician is a neurologist C. Patient has documented difficulty walking resulting in significant limitations of instrumental activities of daily living D. Ambulatory function assessed with the timed 25-foot walk (T25FW) meeting the following criteria:

I. Clinical notes documenting two measurements with variability within 10% demonstrating the patient is able to walk 25 feet in 8-45 seconds. The faster time of the two measurements will serve as the baseline value.

II. Measurements were not taken within 60 days of an MS exacerbation III. Clinical notes documenting whether a walking assistive device was used E. Does not have a history of seizure F. Does not have moderate to severe renal impairment (CrCl ≤ 50 ml/min) G. Initial approval length is for 3 months Coverage may be renewed for 12 months when the following criteria are met:

I. Clinical notes documenting improvement in walking speed by at least 10% as assessed by the T25FW

II. Clinical documentation indicating that the limitations of instrumental activities of daily living has resolved as a result of increased speed of ambulation III. Clinical notes documenting consistency in whether a walking assistive device was used for all measurements (baseline and re-testing for renewal of therapy)

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MEDICATION/ DRUG CLASS CRITERIA

AmpyraTM (dalfampridine extended release) continued Nonformulary

Coverage may not be provided for any other uses including, but not limited to: A. To improve walking ability in any other condition aside from MS B. Improvement in symptoms related to multiple sclerosis (MS) other than slow ambulation, including but not limited to: difficulty with balance, fatigue, foot drop, poor stamina and weakness including, but not limited to upper extremity weakness such as impaired handwriting C. Guillain-Barre syndrome D. Lambert-Eaton Myasthenic Syndrome E. Spinal cord injury

Anabolic Steroids Oxandrin® [g] (oxandrolone) Nonformulary: Anadrol-50® (oxymetholone) Deca-Durabolin® (nandrolone decanoate)

Oxandrin® [g]: Approved when used as an adjunct therapy to promote weight gain in patients who have had extensive surgery, chronic infection, or severe trauma OR for therapy to offset protein catabolism associated with prolonged use of corticosteroids OR for bone pain associated with osteoporosis OR if prophylactic therapy is needed in patients with hereditary angioedema. Anadrol-50® (oxymetholone) and Deca-Durabolin® (nandrolone decanoate): Approved for the treatment of clinically diagnosed anemia (documentation must support the trial of standard supportive measures for treating anemia including: transfusion, correction of iron, folic acid, vitamin B12, or pyridoxine deficiency, antibacterial therapy, and the appropriate use of corticosteroids) OR for the treatment of HIV-associated wasting OR if prophylactic therapy is needed in patients with hereditary angioedema.

Angiotensin II Receptor Blockers (ARBs): Cozaar® (losartan)/Hyzaar® (g) Benicar® (olmesartan)/HCT Nonformulary: Atacand®(candesartan)/HCT Avapro® (irbesartan)/Avalide® Diovan® (valsartan)/HCT Micardis® (telmisartan)/HCT Teveten®(eprosartan)/HCT

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

Betaseron® (Interferon beta-1b) Nonformulary

Requires trial and failure or intolerance of Extavia®

Bisphosphonates: Fosamax® [g] (alendronate) Fosamax® [g] weekly Actonel® (risedronate) Actonel® with Calcium Nonformulary: Boniva® (ibandronate) Fosamax Plus D

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

Butrans TM (buprenorphine) transdermal system Nonformulary

Coverage will be provided for the management of moderate to severe chronic pain in patients requiring around the clock opioid analgesia for an extended period of time. Criteria also requires trial and failure, or intolerance to both extended-release morphine and the fentanyl patch.

Byetta® (exenatide) Nonformulary

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

Bystolic® (nebivolol) Nonformulary

Approval requires documentation that the patient has tried and failed/intolerant to at least 2 of the formulary cardioselective beta blockers: Kerlone® [g], Sectral ® [g], Tenormin ® [g], Zebeta ® [g], Lopressor® [g] OR Toprol XL® [g].

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MEDICATION/ DRUG CLASS CRITERIA

Carbaglu® (carglumic acid) Covered for the treatment of acute hyperammonemia due to the deficiency of the hepatic enzyme N-acetylglutamate synthase (NAGS).

Cayston® (aztreonam lysine) Nonformulary

Covered for the improvement of respiratory symptoms in cystic fibrosis patients with Pseudomonas aeruginosa.

ChenodalTM (chenodeoxycholic acid) Nonformulary

Coverage approved for patients with radiolucent stones in well-opacifying gallbladders, in whom selective surgery would be undertaken except for the presence of increased surgical risk because of systemic disease or age. Requires: 1. trial and failure or intolerance of ursodiol 2. patient is not a candidate for surgery 3. patient has no history of hepatocellular disease 4. if the patient is a woman, required that they are not pregnant and may not become pregnant. Coverage is limited to 24 months total of ursodiol plus ChenodalTM.

Cholesterol-lowering Agents Zocor® [g] (simvastatin) Mevacor® [g] (lovastatin) Pravachol® [g] (pravastatin) Crestor (rosuvastatin) Zetia (ezetimibe) Nonformulary: Altoprev (lovastatin ER) Lescol,Lescol XL (fluvastatin) Lipitor (atorvastatin) Livalo® (pitavastatin) Vytorin(simvastatin/ezetimibe) Advicor(lovastatin/niacin extended release) Simcor® (simvastatin/niacin extended release)

Crestor®: Requires documentation that member has experienced failure of or intolerance to at least one high dose (>40mg) generic statin (Mevacor® [g], Zocor® [g], and Pravachol® [g]). Zetia®: Patient has a documented trial and failure, intolerance, contraindication, or adverse reaction to Mevacor®[g], Pravachol®[g], or Zocor® [g].

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

COX-2 Preferential NSAIDs: Celebrex (celecoxib) Nonformulary

Requires age > 60 OR concomitant use of anticoagulants OR oral steroids OR risk of GI bleed (history of PUD, previous GI bleed, alcoholism).

Cymbalta® (duloxetine) Nonformulary

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

If patient less than 65 years of age: After a 30-day trial of gabapentin AND a tricyclic antidepressant, such as amitriptyline, desipramine, or imipramine. OR

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MEDICATION/ DRUG CLASS CRITERIA

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

Erythropoiesis Stimulating Agents (ESAs) Procrit® (epoetin alfa) Nonformulary Aranesp® (darbepoetin alfa) Epogen® (epoetin alfa)

Information may need to be submitted describing the use and setting of the drug to make the determination. Approved for use in the following conditions with a hemoglobin less than 12mg/dl: anemia of chronic renal disease (not yet on dialysis), anemia secondary to active chemotherapy of solid tumors, anemia secondary to active zidovudine (AZT) therapy, anemia in myelodysplastic disorders and prophylactic use during some major surgeries. Coverage is NOT provided in the following conditions: A. Anemia due to folate, vitamin B-12, and iron deficiencies, hemolysis, bleeding, or bone marrow fibrosis, B. Anemia associated with treatment of acute and chronic myelogenous leukemias (CML, AML), or erythroid cancers, C. Anemia due to cancer treatment in patients with uncontrolled hypertension, D. Anemia not associated with cancer treatment or renal disease under inclusion criteria, E. Anemia associated only with radiotherapy, F. Prophylactic use to prevent chemotherapy induced anemia, G. Prophylactic use to reduce tumor hypoxia, H. Patients with Erythropoietin type resistance due to neutralizing antibodies. Coverage duration = 3 months

ExalgoTM (hydromorphone extended-release) Nonformulary

Coverage will be provided for management of moderate to severe pain in opioid tolerant patients requiring continuous, around the clock opioid analgesia for an extended period of time. Criteria also requires trial and failure, or intolerance to equivalent doses of both extended-release morphine and the fentanyl patch. Coverage will not be provided for use as an “as needed” analgesic or for acute pain or postoperative pain

Flector® (diclofenac patch) Nonformulary

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

Forteo® (teriparatide) Nonformulary

Forteo® will be provided for the following guidelines: 1. For the treatment of postmenopausal women with osteoporosis who are at high risk of fracture or men with primary or hypogonadal osteoporosis who are at high risk for fracture and meet the following criteria (a, b and c): a. Have a bone mineral density (BMD) that is 2.5 standard deviations or more below the mean (T-score at or below -2.5). b. Patient has tried and failed a bisphosphonate (formulary agents include Fosamax® [g] and Actonel®) for a 24 month period except when:

1. contraindication to a bisphosphonate (such as a stricture or achalasia, inability to stand or sit upright for at least 30 minutes and increased risk of aspiration).

OR 2. documented intolerance to a bisphosphonate

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MEDICATION/ DRUG CLASS CRITERIA

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

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

Growth Hormone Genotropin (somatropin) Nutropin (somatropin) Nonformulary: Humatrope® Norditropin® Omnitrope® Saizen® Serostim® Tev-Tropin® Zorbtive™

Coverage will be provided for: Pediatric Growth Hormone Deficiency Children (M < 16 years old, F < 15 years old):

Initial Treatment: Req. > 6 months of initial height measurements, Ht < 5th percentile for age (based on initial evaluation), abnormal growth velocity based on > 6 mo. of measurement, < 50th percentile for age with growth hormone therapy, initial subnormal blood test for growth hormone. To continue treatment: must have a documented growth velocity of > 2.5 cm/year during the first 6 mo. of therapy & documented growth of > 4.5 cm/year for each succeeding 6 month review period. Treatment may continue until final height or epiphyseal closure has been documented or patient has reached age 16 years (M) or 15 years (F).

Adults: Diagnosis of growth hormone deficiency confirmed by laboratory testing (e.g. provocative stimulation), known indication for pituitary disease and multiple pituitary hormone deficiencies. Multiple stimulation tests may be required in certain clinical circumstances. May be approved for AIDS-wasting cachexia and Turner’s Syndrome. Growth hormone therapy is NOT covered for anti-aging, obesity or athletic enhancement.

HizentraTM (immune globulin subcutaneous) Nonformulary

Requires appropriate diagnosis for coverage and other criteria may apply depending on diagnosis.

H.P. Acthar Gel® (repository

corticotropin) Nonformulary

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

Increlex® (mecasermin) Nonformulary

Approval will require the following: 1. Medication to be prescribed by a pediatric endocrinologist AND 2. Diagnosis of one of the following:

Severe primary IGF-1 deficiency or growth hormone gene deletion or genetic mutation of growth hormone receptor (Laron Syndrome) AND 3. Current height measurement at less than 3rd percentile for age and sex AND 4. IGF-1 level greater than or equal to 3 standard deviations below normal AND 5. Normal or elevated growth hormone levels based on at least one growth hormone stimulation test AND 6. Open growth plates Authorizations shall be reviewed at least annually to confirm that current medical necessity criteria are met and that the medication is effective. Continued authorization in children may be given for up to 12 months until any one of the following conditions occurs: 1. Growth velocity is less than 2.5 cm/year OR 2. Bone age in males exceeds 16 0/12 years of age OR 3. Bone age in females exceeds 14 0/12 years of age Increlex® is considered investigational for all other indications, including, but not limited to:

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MEDICATION/ DRUG CLASS CRITERIA

a. Amyotrophic lateral sclerosis (ALS) b. Children less than two years of age c. Combination treatment with growth hormone d. Diabetes e. Individuals with closed growth plates f. Secondary forms of IGF-1 deficiency, such as growth hormone deficiency, malnutrition, hypothyroidism or chronic treatment with steroids g. Idiopathic short stature h. Growth failure due to other identifiable causes (including, but not limited to Prader-Willi syndrome, Russell-Silver syndrome, Turner syndrome, Noonan syndrome) i. Less severe forms of IGF-1 deficiency

Intranasal Steroids Flonase® [g] (fluticasone) Nasarel® [g] (flunisolide) Nasacort AQ® (triamcinolone) Nonformulary: Beconase® AQ (beclomethasone) Nasonex® (mometasone) Omnaris® (ciclesonide) Rhinocort AQ® (budesonide) Veramyst® (fluticasone)

Approval of Nasacort AQ® requires trial and failure/intolerance to Flonase® [g] OR Nasarel® [g]. Approval of nonformulary agents requires trial and failure/intolerance to generic fluticasone (Flonase®) OR generic flunisolide (Nasarel®) AND trial and failure/intolerance to Nasacort AQ®.

IntunivTM (guanfacine extended-release) Nonformulary

Requires diagnosis of ADHD AND therapeutic failure, intolerance or contraindication to BOTH an amphetamine-type product AND a methylphenidate product.

Lotronex® (alosetron hydrochloride) Nonformulary

Approved for treatment of women > 18 years old with severe, diarrhea-predominant Irritable Bowel Syndrome (IBS) who have failed to respond to conventional IBS therapy.

Lyrica® (pregabalin) Nonformulary

Coverage of Lyrica® will be provided for: Adjunctive treatment for adult patients with partial onset of seizures OR Treatment of diabetic neuropathic pain or post-herpetic neuralgia If patient equal to or greater than 65 years of age: After a 30-day trial of gabapentin.

If patient less than 65 years of age: After a 30-day trial of gabapentin AND a tricyclic antidepressant, such as amitriptyline, desipramine, or imipramine. OR Treatment of Fibromyalgia Fibromyalgia characterized by pain in all 4 body quadrants, for at least 3 months, with or without fatigue and sleep disturbance AND the patient has tried and experienced intolerance to gabapentin OR had inadequate pain relief at doses of 1200 mg or above AND has tried and experienced intolerance or inadequate pain relief to three of the following: tricyclic antidepressant, SSRI, SNRI, cyclobenzaprine, tramadol.

Mirapex® ERTM (pramipexole extended release) Nonformulary

Coverage approved for the treatment of Parkinson's. Requires trial and failure of Mirapex® (g).

Narcotics Actiq® [g] (fentanyl citrate) Nonformulary: Fentora™ (fentanyl citrate) OnsolisTM (fentanyl citrate)

Requires appropriate diagnosis for coverage and tolerance to high doses of narcotics.

Non-Sedating Antihistamines: Claritin/-D™ OTC (loratadine/pseudoephedrine) Zyrtec/-D™ OTC (cetirizine/pseudoephedrine) Allegra [g] (fexofenadine) Allegra-D 12hr [g] (fexofenadine/pseudoephedrine) Allegra-D 24hr (fexofenadine/pseudoephedrine) Nonformulary:

Clarinex/Clarinex-D and Xyzal

Requires failure of or intolerance to OTC loratadine/loratadine-D AND OTC cetirizine/cetirizine-D, AND fexofenadine/fexofenadine-D. Allegra® Suspension and Allegra® ODT Requires failure or intolerance to loratadine AND cetirizine

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MEDICATION/ DRUG CLASS CRITERIA

Allegra Suspension (fexofenadine) Allegra ODT (fexofenadine) Clarinex/-D®

(desloratadine/pseudoephedrine) Xyzal (levocetirizine) OleptroTM (trazodone extended release) Nonformulary

Coverage approved for the treament of major depressive disorder. Requires trial and failure of Desyrel (g) and documentation why the long acting would be more efficacious.

Pennsaid® topical solution (diclofenac sodium) Nonformulary

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

Promacta® (eltrombopag) Initial approval for coverage requires all of the following: 1, Age greater than 18 years old AND 2. Diagnosis of chronic immune thrombocytopenia (ITP) and persistent thrombocytopenia (platelet count < 150,000 mcL) for > 2 months AND 3. Prescribed by a hematologist or in consultation with a hematologist AND 4. Inadequate response or patient must not be a candidate for corticosteroids, immunoglobulins, or splenectomy AND 5. Current platelet count is < 50, 000 mcL AND 6. Dose is < 75mg/day Renewal approval for Promacta® requires recent platelet count of 30,000-150, 000 mcL AND dose is < 75mg/day.

Proton Pump Inhibitors (PPI’s): Prilosec OTC™ [g] (omeprazole) Prilosec®[g] (omeprazole) Protonix [g] (pantoprazole) Prevacid® [g] (lansoprazole) Prevacid® SoluTab™(g) (lansoprazole) Zegerid® (capsule (g) omeprazole/sodium bicarbinate Nonformulary: Aciphex (rabeprazole) DexilantTM (dexlansoprazole) Nexium (esomeprazole) Zegerid® powder for oral suspension(omeprazole/sodium bicarbonate

Approval of nonformulary medications requires failure of or intolerance to all formulary alternatives: Prilosec [g] OR Prilosec OTC™ [g] AND Protonix [g] AND Prevacid® [SoluTab™[g]

RelistorTM (methylnaltrexone bromide) injection

Coverage of RelistorTM will be provided for: 1. The treatment of opioid-induced constipation in patients with advanced illness who

are receiving palliative care, when response to laxative therapy has not been sufficient.

2. Patients shall be on stable doses of opioids for greater than 2 weeks. 3. Duration of methylnaltrexone therapy shall be limited to 3 months. 4. Previous history of treatment for constipation shall include fluids, stool softeners, bulk

laxatives, saline laxatives and osmotic laxatives. Laxatives trials shall be of at least 5 days duration.

5. Maximum initial regimen shall be 1 box (7 doses). Monthly doses shall not exceed 14.

6. Patients experiencing withdrawal symptoms while taking methylnaltrexone should consider using an alternate form of therapy.

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MEDICATION/ DRUG CLASS CRITERIA

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

Sancuso® (granisetron) Nonformulary

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

Sandostatin® (octreotide) [g] Sandostatin LAR®

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

SavellaTM (milnacipran) Nonformulary

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

Sedative/Hypnotics Ambien® [g] (zolpidem) Ambien CR® [g] (zolpidem) Sonata® [g] (zaleplon)

Nonformulary: Edluar™ (zolpidem sublingual) Lunesta™ (eszopiclone) Rozerem™ (ramelteon) Zolpimist® (zolpidem tartrate oral spray)

Ambien CR® [g], LunestaTM and RozeremTM require documentation that member has experienced failure of or intolerance to Ambien® [g] OR Sonata® [g]. Edluar™ and Zolpimist® require trial and failure, or intolerance, to Ambien® (zolpidem) AND Sonata® (zaleplon) AND documentation of medical necessity.

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MEDICATION/ DRUG CLASS CRITERIA

Selective Reuptake Inhibitor – antidepressants: Celexa [g] (citalopram) Effexor/XR®[g] capsule (venlafaxine) Luvox [g] (fluvoxamine) Paxil [g] (paroxetine) Paxil CR® [g] (paroxetine) Prozac [g] (fluoxetine) Prozac Weekly [g] (fluoxetine) Remeron [g] (mirtazapine) Venlafaxine ER [g] tablet Wellbutrin SR [g] (bupropion) Wellbutrin XL® [g] (bupropion) Zoloft [g] (sertraline) Lexapro (escitalopram)

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

Lexapro requires step therapy with at least one of the following generic formulary alternatives; Celexa [g], Effexor/XR®[g], Luvox [g], Paxil/CR [g], Prozac [g], Remeron [g], Wellbutrin/SR [g], Wellbutrin XL® [g], or Zoloft [g]. Aplenzin®; requires trial/failure of at least 2 formulary agents plus documentation that continued use of Wellbutrin® [g] will adversely affect the member’s mental health. Luvox CR; requires trial/failure of at least 2 formulary agents plus documentation that continued use of Luvox® [g] will adversely affect the member’s mental health. Pexeva; requires trial/failure of at least two of the above formulary agents PLUS documentation that continued use of Paxil® [g] will adversely affect the member’s health. Pristiq; requires trial/failure of at least 2 formulary agents.

SilenorTM (doxepin) Nonformulary

Requires trial and failure of Ambien (g) AND Sonata (g)

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

Strattera® (atomoxetine) Nonformulary

For members age 5-21: Requires documentation that member has experienced failure of or intolerance to BOTH a methylphenidate product (such as Ritalin® [g] or Concerta®) AND an amphetamine (such as Adderall® [g]). For members age >21: Requires documentation that the member has experienced failure of or intolerance to EITHER a methylphenidate product OR an amphetamine. Approvable when stimulants are contraindicated by medical history.

Tekturna® (aliskiren) Nonformulary

Requires documentation that the member has tried standard effective doses and not reached therapeutic goals or could not tolerate therapy with ALL of the following drug classes:

1. Diuretic 2. Beta-blocker 3. ACE-Inhibitor Angiotension II Receptor Blocker (ARB)

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MEDICATION/ DRUG CLASS CRITERIA

TNF-alpha agents and related products: Enbrel (etanercept) Humira (adalimumab) Nonformulary: Cimzia (certolizumab pegol injection) Kineret (anakinra) SimponiTM (golimumab)

Enbrel® and Humira®: Rheumatoid arthritis, juvenile RA, or psoriatic arthritis: Requires three-month trial with two concurrent DMARDs, (one must be methotrexate unless contraindicated). Examples of DMARDs include: methotrexate, sulfasalazine, azathioprine, hydroxychloroquine/chloroquine, cyclosporine, gold and penicillamine. Ankylosing spondylitis: requires therapy is being supervised by a Rheumatologist. Moderate to severe psoriasis: Requires 3 months of previous treatment with topical corticosteroids AND 3 months treatment with PUVA (unless PUVA is contraindicated) AND therapy must be supervised by a Dermatologist. Crohn’s Disease: Coverage for patients age 18 years and older, with a diagnosis of moderately to severely active Crohn’s disease with a history of inadequate response to conventional therapy. Applies to Humira® only. Cimzia®: The following criteria are used in reviewing medical exceptions for Cimzia®

A. OR B. A. Age 18 or older and for the treatment of acute exacerbation of moderate to severe Crohn’s disease when the following criteria are met (1 AND 2): 1) Treatment with an adequate course of systemic corticosteroids has been ineffective or is contraindicated or patient has been unable to taper or patient is experiencing breakthrough disease while stabilized on an immunomodulatory medication for at least 2 months. AND 2) Previous trial/failure/contraindication of Humira®. OR B. Age 18 or older and for the treatment of rheumatoid arthritis when the following criteria are met (1 AND 2) 1) Treatment failure with a three month trial with two concurrent DMARDs (one must be methotrexate unless contraindicated) AND

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

Kineret®: Rheumatoid arthritis in adults: Requires three-month trial with two concurrent DMARDs, (one must be methotrexate unless contraindicated) AND treatment failure or intolerance to Enbrel

and Humira. Examples of DMARDs include: methotrexate, sulfasalazine, azathioprine, hydroxychloroquine/chloroquine, cyclosporine, gold and penicillamine. SimponiTM: 18 years of age or older and A OR B A. Rheumatoid arthritis and psoriatic arthritis: Requires a 3-month trial on two concurrent

Disease Modifying Anti-Rheumatic Drugs (DMARDs), one of which must be methotrexate unless contraindicated AND treatment failure or contraindication to both Enbrel® AND Humira®.

OR B. Ankylosing spondylitis: Requires a treatment failure or contraindication to both Enbrel® AND Humira®.

TreximetTM (sumatriptan/naproxen sodium) Nonformulary

Requires prior use of Imitrex® [g] and Naprosyn® [g] in combination AND documentation indicating why use of the individual agents is harmful to the member AND documentation of trial and failure of formulary option Maxalt®.

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MEDICATION/ DRUG CLASS CRITERIA

TriLipixTM (fenofibric acid) Nonformulary

Requires trial and failure of gemfibrozil [g] AND fenofibrate [g].

Triptans: Amerge® (g) (naratriptan) Imitrex® [g] (sumatriptan) Maxalt® (rizatriptan) Nonformulary AlsumaTM (sumatriptan) Axert® (almotriptan) Frova® (frovatriptan) Relpax® (eletriptan) SumavelTM DoseProTM

(sumatriptan needle-free injection) Zomig® (zolmitriptan)

The formulary option Maxalt® will require trial and failure of the generic formulary alternative Imitrex® [g]. Approval of the nonformulary triptans, Axert®, Frova®, Relpax®, Zomig®, will require trial and failure of both the formulary options Imitrex® [g] AND Maxalt®. Approval of the nonformulary triptans AlsumaTM and SumavelTM DoseProTM will require trial and failure of both formulary options Imitrex (g) injection AND Maxalt MLT®

Uloric® (febuxostat)

Requires treatment failure, intolerance or contraindication with formulary alternative generic allopurinol.

Victoza® (liraglutide) Nonformulary

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

VimovoTM (naproxen/esomeprazole) Nonformulary

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

Voltaren Gel® (diclofenac gel) Nonformulary

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

Vyvanse™ (lisdexamfetamine) Nonformulary

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

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MEDICATION/ DRUG CLASS CRITERIA

Xenazine® (tetrabenazine)

Approval will require diagnosis of chorea associated with Huntington’s disease AND for doses above 50mg per day, documentation of the CYP2D6 genotype of the patient will be required. Tetrabenazine is considered investigational when used for all other conditions, including, but not limited to:

A. Chorea not associated with Huntington’s disease B. Tardive dyskinesia C. Dystonia, tics and other dyskinesias D. Hyperkinetic or involuntary movement disorders E. Tourette’s syndrome F. Athetoid cerebral palsy

Xyrem® (sodium oxybate) Nonformulary

Requires a diagnosis of narcolepsy and A OR B: A. Cataplexy demonstrated by supporting chart documentation or sleep studies

OR B. Excessive daytime sleepiness demonstrated by supporting chart documentation or

sleep studies when (1 AND 2): 1. Modafinil in doses up to 400mg daily has been ineffective, not tolerated, or

contraindicated. AND 2. At least one other formulary/preferred treatment, such as methylphenidate or dextroamphetamine, has been ineffective, not tolerated, or

contraindicated. Xyrem® will NOT be approved if:

1. Patient is being treated with sedative hypnotic agents, other CNS depressants, or using alcohol

2. Patient has a history of drug abuse 3. Patient has succinic semialdehyde dehydrogenase deficiency

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

1. Alcohol dependence and withdrawal 2. Fibromyalgia

Xyrem® is considered investigational for all other conditions or applications, including, but not limited to, the treatment of:

1. Opioid dependence and withdrawal 2. Parkinsonism 3. Night eating syndrome 4. Myoclonus and essential tremor

ZuplenzTM (ondansetron) oral soluble film Nonformulary

Requires documentation that the member has experienced treatment failure or intolerance to Zofran ODT (g) AND oral Kyrtril (g). Documentation must be provided as to why continued use of Zofran ODT will harm the patient.

[g] = generic available

Page 31

Possible brand alternatives

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

Possible brand alternatives Nonformulary Formulary alternative Epogen® Procrit® Follistim® Gonal-F® Humatrope®, Norditropin® , Omnitrope®, Saizen®, Serostim®, Tev-Tropin®, Zorbtive®

Genotropin®, Nutropin®

Ritalin LA® Metadate CD® Generic drug substitution Generic drug substitution is when a generic equivalent is dispensed rather than the brand-name product. Products designated in the formulary with “(g)” after the name are available as generics approved by the U.S. Food and Drug Administration. BCN members are required to use generic substitution. For BCN members, if a brand-name drug is requested when a generic version is available, members will pay their Tier 2 copayment plus the difference in cost between the brand and generic versions. Prescribers may request authorization for the brand-name version, based on medical necessity. A completed MedWatch form is required. BCBSM members are encouraged to receive the generic equivalent, if available, or they may be required to pay the difference in cost between the brand dispensed and the generic equivalent, in addition to the applicable copay. The maximum allowable cost list sets ceiling prices for reimbursement of certain generic prescription drugs. The drugs on the MAC list are commonly prescribed and dispensed, and have undergone the FDA’s review and approval process, which ensures:

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

o The FDA has given the generics an “A” rating and have determined they are the equivalent of their

brand-name counterparts. Or the BCBSM and BCN Pharmacy and Therapeutics Committee has reviewed the products and found them to be acceptable generic substitutes.

When the above two criteria are met, generics can be substituted with the full expectation that they will produce the same clinical effects and have the same safety profiles as the prescribed brand-name products. Possible therapeutic alternatives The BCBSM-BCN Formulary Alternatives – January 2011 list represents possible options to nonformulary drugs. These alternative medications can generally be prescribed without approval from BCBSM or BCN, and can be dispensed with lesser copayments for members. Therapeutic alternatives may represent a different drug class, contain different ingredients or may be available in different strengths or dosage forms than the prescribed branded products. Pharmacists must obtain authorization from a patient’s physician to dispense an alternative product. Listed below are examples of the therapeutic alternatives a patient’s physician should consider when determining appropriate treatment for the patient. The physician should consider individual drug product characteristics and patient factors such as coexisting disease states, contraindications, therapeutic history, concurrent medications and other relevant circumstances. This list is also available at bcbsm.com/provider/pharmacy_services/index.shtml.

Page 32

BCBSM/BCN Formulary Alternatives - January 2011NonFormulary Formulary Alternative NonFormulary Formulary Alternative

ACIPHEX Prilosec OTC**; Prevacid(g)*, Solutab(g)*; Prilosec 20mg(g), Protonix(g)*, Zegerid(g)*

ACTIVELLA 0.5-0.1MG

Activella(g); Estratest(g), H.S.(g)

ACTOPLUS MET XR

Glucophage(g) plus Actos*; ActoPlus Met*

ACUVAIL Acular, LS(g); Voltaren(g)

ACZONE Topical OTC benzoyl peroxide, clindamycin, erythromycin

ADCIRCA Revatio*

ADOXA, CK, TT Monodox(g), Vibramycin(g)

ADVICOR Mevacor(g), Pravachol(g), Zocor(g), Crestor*; plus Niaspan

AEROBID, M Alvesco, Asmanex, Azmacort, Flovent, Pulmicort, QVAR

AGGRENOX Persantine(g) plus ASA OTC, Plavix

AKNE-MYCIN Erythromycin topical solution & gel(g)

ALAMAST Zaditor OTC(g), Alomide, Patanol

ALLEGRA ODT, SUSP

Claritin Syr OTC(g)**, Zyrtec Syr OTC(g)**

ALREX Decadron ophth(g), Pred Forte(g), Pred Mild

ALTABAX Triple Antibiotic OTC, Bactroban(g)

ALTACE TABLETS Altace capsules(g)

ALTOPREV Mevacor(g), Pravachol(g), Zocor(g), Crestor*, Zetia*

AMITIZA OTC laxatives and stool softeners, Glycolax(g), Lactulose(g)

AMRIX Flexeril(g)

ANADROL-50 Androxy(g), Depo-testosterone(g), Androderm, Delatestryl

ANDROGEL Androderm

ANGELIQ FemHRT, Prempro/Premphase, or Estradiol plus Progestin

ANTARA Lofibra(g), Lopid(g), Tricor

ANZEMET Kytril(g); Zofran(g), ODT(g)

APHTHASOL Kenalog in Orabase(g)

APLENZIN Generic SSRI/SNRI (Celexa(g), Prozac(g), Zoloft (g), Effexor(g), Effexor XR(g); Wellbutrin, SR, XL(g), etc.)

APRISO Azulfidine(g), Azulfidine En-Tab(g), Asacol, HD; Pentasa

ARANESP Procrit*

ARICEPT 23MG Aricept 5, 10mg(g)

ARIXTRA Lovenox(g)

ARMOUR THYROID

Synthroid(g)

ARTHROTEC Lodine(g), Mobic(g), Motrin(g), Naprosyn(g), Voltaren(g), etc. plus Cytotec(g)

ATACAND, HCT Cozaar(g), Hyzaar(g), Benicar*, HCT*

AVALIDE, AVAPRO Cozaar(g), Hyzaar(g), Benicar*, HCT*

AVANDAMET ActoPlus Met*

AVANDARYL Duetact*

AVANDIA Glucophage(g); Insulin or a sulfonylurea (Glucotrol, XL(g); Micronase(g), Amaryl(g)), Actos*

AVC Diflucan(g) oral, Terazol(g) vaginal

AVINZA Methadone(g), MSIR(g), MS Contin(g), Oramorph SR(g)

AXERT Amerge(g)*, Imitrex(g); Maxalt*, MLT*

AZASITE Ciloxan(g), Vigamox

AZELEX Retin-A(g)

AZILECT Eldepryl(g)

AZOR Generic ACE (lisinopril, benazepril, etc.), Benicar*, or Cozaar(g) PLUS Norvasc(g)

BECONASE AQ Flonase(g), Nasalide(g), Nasarel(g), Nasacort AQ*

BENZACLIN Individual agents (BPO and clindamycin)

BENZASHAVE OTC benzoyl peroxide

BEPREVE Zaditor OTC(g), Patanol

BESIVANCE Ciloxan(g), Ocuflox(g), Vigamox

BETASERON Avonex, Copaxone, Rebif

BETIMOL Betagan(g), Betoptic(g), Timoptic(g)

BEYAZ Yasmin(g), Yaz(g) PLUS Folic Acid 1MG

BONIVA Fosamax(g), Actonel*

BROVANA Foradil, Serevent Diskus

BUTISOL SODIUM Ambien(g), Prosom(g), Restoril(g), Sonata(g)

BUTRANS Duragesic(g), Methadone(g), MS Contin(g), Oramorph(g)

BYETTA Insulin, Glucophage(g), Sulfonylurea's, TZD's

BYSTOLIC Blocadren(g), Lopressor(g), Tenormin(g), Toprol XL(g), etc.

CADUET Mevacor(g), Pravachol(g), Zocor(g), Crestor*; plus Norvasc(g), Zetia*

CAMPRAL Revia(g), Antabuse

CANTIL Bentyl(g), Donnatal(g), Robinul(g)

CARAC Efudex(g)

CARBATROL Tegretol(g), XR(g)

CARDENE SR Cardene(g), Norvasc(g), Procardia XL(g)

* Prior Authorization or Step Therapy may be required.

Most BCN members and some BCBSM members do not have coverage for nonformulary agents. Please use this list as a guide when selecting alternatives.

** Covered with a prescription for BCN members and certain BCBSM members.

Page 33

NonFormulary Formulary Alternative NonFormulary Formulary Alternative

CARDURA XL Cardura(g), Flomax(g), Hytrin(g), Avodart, Uroxatral

CARMOL HC Hydrocortisone plus Aquaphor OTC, Hydrocortisone plus Eucerin OTC

CAYSTON Tobi

CEDAX Ceclor(g), Ceftin(g), Duricef(g), Keflex(g), Omnicef(g)

CELEBREX Lodine(g), Mobic(g), Motrin(g), Naprosyn(g), Voltaren(g), etc.

CENESTIN Estrace(g), Ogen(g), Premarin

CESAMET Kytril(g); Zofran(g), ODT(g)

CHENODAL Actigall(g), Urso(g)

CIMZIA SYRINGE Enbrel*, Humira*

CLARIFOAM EF Plexion(g), Sulfacet-R(g)

CLARINEX (ALL) Claritin OTC(g)**, Zyrtec OTC(g)**, Allegra(g), Allegra-D 12 hour(g)*, Allegra-D 24 hour*, Astelin(g)

CLEOCIN VAGINAL OVULES

Cleocin Vaginal Cream(g)

CLIMARA PRO Climara(g), Vivelle-DOT, or Estraderm plus a progestin

CLINAC BPO Individual agents (Cleocin(g) topical and OTC BPO)

CLINDESSE Cleocin vaginal cream(g)

CLOBEX, SPRAY Diprolene(g), Psorcon(g), Temovate(g), Ultravate(g)

COGNEX Razadyne, ER(g); Aricept, ODT(g); Namenda

COLESTID FLAVORED

Colestid(g), Questran(g), Questran Light(g)

COLY-MYCIN S Cortisporin(g), Floxin(g) Otic, Cipro HC

COMBIPATCH Climara(g), Vivelle-DOT, Estraderm plus Progestin

COREG CR Coreg(g), Toprol XL(g)

CORTISPORIN-TC Cortisporin(g), Floxin(g) Otic, Cipro Otic HC

CYMBALTA Generic SSRI/SNRI (Celexa(g), Effexor(g), Effexor XR(g), Prozac(g), Zoloft(g), etc.)

DAYTRANA Adderall, XR(g)*; Ritalin, SR(g); Concerta, Metadate CD

DENAVIR Zovirax 5% cream/ointment

DEPEN Cuprimine

DERMA-SMOOTHE/FS

Elocon(g), Locoid(g), Synalar solution(g), Capex

DESONATE Elocon(g), Locoid(g), Synalar solution(g), Capex

DEXILANT Prilosec OTC**; Prevacid(g)*, Solutab(g)*; Prilosec 20mg(g), Protonix(g)*, Zegerid(g)*

DIOVAN, HCT Cozaar(g), Hyzaar(g), Benicar*, HCT*

DIPENTUM Azulfidine(g), Azulfidine En-Tab(g), Asacol, HD; Pentasa

DONNATAL EXTENTABS

Bentyl(g), Donnatal(g), Robinul(g)

DORAL Ambien(g), Halcion(g), Prosom(g), Restoril(g), Sonata(g)

DORYX Vibramycin(g)

DUAC CS Individual agents (Cleocin(g) topical and OTC BPO)

DUREZOL Decadron ophth(g); Inflamase, Forte(g); Pred Forte(g), etc.

DYNACIRC CR Cardene(g), Dynacirc(g), Norvasc(g), Procardia XL(g)

EDEX Caverject*, Cialis*, Muse*, Viagra*

EDLUAR Ambien(g), Sonata(g)

EFUDEX OCCLUSION

Efudex(g)

ELESTAT Zaditor OTC(g), Alomide, Patanol

ELESTRIN Climara(g), Estrace(g), Ogen(g), Vivelle-DOT, Estraderm

ELIGARD Lupron, Depot;Trelstar, Depot

ELLA Plan B(g)

EMADINE Zaditor OTC(g), Alomide, Patanol

EMBEDA Methadone(g), MSIR(g), MS Contin(g), Oramorph SR(g)

EMSAM Celexa(g), Effexor(g), Effexor XR(g), Paxil(g), Prozac(g), Wellbutrin, SR, XL(g); Venlafaxine ER(g), Lexapro*

ENABLEX Ditropan(g), XL(g), Detrol, LA

ENJUVIA Premarin

ENTOCORT EC Prednisone(g), Prednisolone(g), Hydrocortisone(g), etc.

EPIDUO Individual agents: Differin plus OTC BPO

EPOGEN Procrit*

EQUETRO Tegretol, XR(g)

ERTACZO Lamisil AT(g) OTC; Lotrimin(g), Ultra OTC; Monistat-Derm(g), Nizoral cream(g), Spectazole(g)

ESTRACE VAGINAL CREAM

Premarin Vaginal Cream

ESTRASORB Climara(g), Estrace(g), Ogen(g), Estraderm, Vivelle-DOT

ESTROGEL Climara(g), Estrace(g), Ogen(g), Estraderm, Vivelle-DOT

EVAMIST Climara(g), Estrace(g), Ogen(g), Estraderm, Vivelle-DOT

EVOXAC Bethanechol(g), Salagen(g)

EXALGO Duragesic(g), Methadone(g), MS Contin(g), Oramorph(g)

* Prior Authorization or Step Therapy may be required.

Most BCN members and some BCBSM members do not have coverage for nonformulary agents. Please use this list as a guide when selecting alternatives.

** Covered with a prescription for BCN members and certain BCBSM members.

Page 34

NonFormulary Formulary Alternative NonFormulary Formulary Alternative

EXFORGE Lotrel(g), Generic ACE Inhibitor (lisinopril, benazepril, etc.), Benicar*, or Cozaar(g) PLUS Norvasc(g)

EXFORGE HCT Lotrel(g) plus HCTZ(g)

EXJADE Desferal(g)

EXTAVIA Avonex, Betaseron, Copaxone, Rebif

EXTINA Nizoral(g)

FACTIVE Erythromycin(g), Vibramycin(g), Zithromax(g), Avelox

FANAPT Clozaril(g), Risperdal(g), Abilify, Geodon, Seroquel, Zyprexa

FAZACLO Clozaril(g), Risperdal(g), Abilify, Geodon, Seroquel, Zyprexa

FEMCON FE Loestrin Fe(g) [NOT 24], Estrostep Fe(g)

FEMRING Estring

FEMTRACE Estrace(g), Ogen(g), Premarin

FENOGLIDE Lofibra(g), Lopid(g), Tricor

FENTORA Actiq(g)*, MSIR(g), MS Contin(g), Oramorph SR(g), Roxanol(g)

FEXMID Flexeril(g)

FINACEA, PLUS Metrogel topical(g), Metrolotion(g), Retin-A(g)

FLECTOR PATCH Topical OTC analgesic balms, i.e. trolamine salicylate; Voltaren oral(g)

FLOXIN OTIC SINGLES

Floxin(g)

FOCALIN XR Adderall, XR(g)*, Focalin(g); Ritalin, SR; Concerta, Metadate CD

FOLLISTIM AQ Gonal-F, Gonal RFF

FORTAMET Glucophage(g)

FORTEO Fosamax(g), Miacalcin Nasal Spray(g), Actonel*

FOSAMAX PLUS D Fosamax(g) plus OTC Vitamin D

FOSRENOL Tums OTC, Phoslo(g), Renagel, Renvela

FRAGMIN Lovenox(g)

FROVA Amerge(g)*, Imitrex(g); Maxalt*, MLT*

GALZIN OTC zinc supplements

GELNIQUE Ditropan, XL(g); Detrol, LA

GILENYA Avonex, Copaxone, Rebif

GLUMETZA Glucophage(g)

GLYSET Precose(g)

GYNAZOLE-1 Lotrimin OTC, Monistat OTC, Diflucan 150mg(g), Terazol(g)

HALFLYTELY Colyte(g) plus bisacodyl OTC

HECTOROL Rocaltrol(g)

HUMATROPE Genotropin*; Nutropin*, AQ*

INNOPRAN XL Inderal(g), Inderal LA(g), Inderide(g)

INTUNIV Catapres(g), Tenex(g)

INVEGA Clozaril(g), Risperdal(g), Abilify, Geodon, Seroquel, Zyprexa

IOPIDINE Alphagan(g), Alphagan P

IQUIX Ciloxan(g), Ocuflox(g), Vigamox

JALYN Cardura(g), Flomax(g), Hytrin(g), Avodart, Uroxatral

JANUMET Glucophage(g); Insulin or a Sulfonylurea (Glucotrol, XL(g); Micronase(g), Amaryl(g)), Actos*

JANUVIA Glucophage(g); Insulin or a Sulfonylurea (Glucotrol, XL(g); Micronase(g), Amaryl(g)), Actos*

KADIAN Methadone(g), MSIR(g), MS Contin(g), Oramorph SR(g)

KAOCHLOR-EFF Potassium Chloride(g) liquid, capsules or tablets

KEFLEX 750MG Keflex(g)

KEPPRA XR Keppra(g)

KETEK Erythromycin(g), Zithromax(g)

KINERET Enbrel*, Humira*

LAMICTAL ODT, XR

Lamictal(g), Disper tabs(g), Tegretol(g)

LAMISIL GRANULES

Lamisil(g)

LESCOL, XL Mevacor(g), Pravachol(g), Zocor(g), Crestor*, Zetia*

LEVAQUIN Vibramycin(g), Avelox

LEVATOL Inderal(g), Inderal LA(g), Lopressor(g), Sectral(g), Tenormin(g), Toprol XL(g)

LEVITRA Cialis*, Viagra*

LIALDA Azulfidine(g); Asacol, HD; Pentasa

LIDODERM PATCH Topical lidocaine, EMLA(g)

LIPITOR Mevacor(g), Pravachol(g), Zocor(g), Crestor*, Zetia*

LIPOFEN Lofibra(g), Lopid(g), Tricor

LIVALO Mevacor(g), Pravachol(g), Zocor(g), Crestor*, Zetia*

LOCOID LIPOCREAM

Aristocort(g), Elocon(g), Locoid(g), Synalar(g), Topicort(g)

LOESTRIN 24 FE Loestrin(g), Loestrin Fe(g)

LOPROX SHAMPOO

Nizoral Shampoo 2%(g)

LOSEASONIQUE Generic biphasic contraceptives

LOTEMAX Decadron ophth(g), Pred Forte(g), Pred Mild

LOTRONEX OTC Anti-diarrheals; Levbid(g); Levsin, SL(g); Levsinex(g); Lomotil(g)

LOVAZA OTC Omega products, Lofibra(g), Lopid(g), Tricor

LUNESTA Ambien(g), Halcion(g), Prosom(g), Restoril(g), Sonata(g)

* Prior Authorization or Step Therapy may be required.

Most BCN members and some BCBSM members do not have coverage for nonformulary agents. Please use this list as a guide when selecting alternatives.

** Covered with a prescription for BCN members and certain BCBSM members.

Page 35

NonFormulary Formulary Alternative NonFormulary Formulary Alternative

LUVERIS Repronex

LUVOX CR Luvox(g) immediate release

LUXIQ Aristocort(g), Elocon(g), Locoid(g), Synalar(g), Topicort(g)

LYRICA Effexor(g), Effexor XR(g), Flexeril(g), Neurontin(g), SSRI's(g), TCA's(g), Ultram(g)

MAGNACET Percocet(g), Tylox(g)

MARPLAN Parnate(g), Nardil

MAXIDEX Decadron ophth(g)

MEGACE ES Megace(g)

MENEST Estradiol (various), Ogen(g)

MENOPUR Repronex

MENOSTAR Climara(g), Estrace(g), Ogen(g), Vivelle-DOT, Estraderm

MENTAX Lamisil AT(g), OTC; Lotrimin(g), Ultra OTC; Monistat-Derm(g), Nizoral cream(g), Spectazole(g)

METHITEST Androxy(g), Depo-Testosterone(g), Oxandrin(g), Androderm, Delatestryl

METHYLIN CHEW Adderall XR(g)*, Metadate CD (Both of which may be "sprinkled" on food)

METOZOLV ODT Reglan(g)

MICARDIS, HCT Cozaar(g), Hyzaar(g), Benicar*, HCT*

MIRAPEX ER Mirapex(g)

MONUROL Bactrim(g), DS(g); Macrobid(g), Cipro(g)

MOVIPREP Colyte(g), Nulytely(g)

MOXATAG Amoxil capsules(g)

MYFORTIC Cellcept(g)

MYTELASE Mestinon(g), Prostigmin

NAFTIN Lotrimin(g), Monistat(g), Nystatin(g)

NAMENDA XR Razadyne, ER(g); Aricept, ODT(g); Namenda

NAPRELAN Mobic(g); Motrin(g); Naprosyn, EC(g); etc*

NASCOBAL SPRAY Cyanocobalamin tabs OTC, Cyanocobalamin injection

NASONEX Flonase(g), Nasalide(g), Nasarel(g), Nasacort AQ*

NATAZIA Yasmin(g), Yaz(g)

NEULASTA Neupogen

NEVANAC Ocufen(g), Voltaren ophth(g)

NEXIUM Prilosec OTC**; Prevacid(g)*, Solutab(g)*; Prilosec 20mg(g), Protonix(g)*

NICOTROL, NS Nicotine gum(g), lozenge(g), patch(g)

NORDITROPIN, NORDIFLEX

Genotropin*; Nutropin*, AQ*

NORITATE MetroCream(g)

NOROXIN Bactrim DS/Septra DS(g); Cipro(g), XR(g)*

NUCYNTA Ultram(g); MSIR(g), oxycodone IR(g)

NUVARING Oral contraceptives, Ortho Evra

NUVIGIL Provigil*

OLEPTRO Desyrel(g)

OLUX-E Diprolene(g), Psorcon(g), Temovate(g), Ultravate(g)

OMNARIS Flonase(g), Nasalide(g), Nasarel(g), Nasacort AQ*

OMNITROPE Genotropin*, Nutropin*, AQ*

ONGLYZA Glucophage(g); Insulin or a Sulfonylurea (Glucotrol, XL(g); Micronase(g), Amaryl(g)), Actos*

ONSOLIS Actiq(g)*, MSIR(g), MS Contin(g), Oramorph SR(g), Roxanol(g)

OPANA, ER Methadone(g), Morphine(g), MS Contin(g), Oramorph SR(g)

ORACEA Monodox(g), Vibramycin(g)

ORAPRED ODT Orapred(g)

ORAXYL Vibramycin(g)

ORTHO-PREFEST Use FemHRT, Prempro/Premphase, or Estradiol plus progestin

OSMOPREP Fleet's Phospho Soda OTC, Colyte(g)

OVCON-50, FE Modicon(g), Ortho-Cyclen(g), Ortho-Novum(g), Ovcon-35(g)

OXISTAT Lamisil AT(g), OTC; Lotrimin(g), Ultra OTC; Monistat-Derm(g), Nizoral cream(g), Spectazole(g)

OXYCONTIN Duragesic(g), Methadone(g), MS Contin(g), Oramorph(g)

OXYTROL Ditropan, XL(g); Detrol, LA

PANCRECARB MS - 16

Pancrease MT - 16(g), Viokase

PANCRECARB MS - 4

Pancrease MT - 4(g), Pancrealipase EC

PANDEL Aristocort(g), Elocon(g), Locoid(g), Synalar(g), Topicort(g), Cloderm, Cordran

PANIXINE Keflex(g)

PAREMYD Atropine(g), Cyclogyl(g), Mydriacyl(g)

PATADAY Zaditor OTC(g), Alocril, Alomide, Patanol

PATANASE Flonase(g), Nasalide(g), Nasarel(g), Astelin(g), Nasacort AQ*

PCE Biaxin(g), Erythromycin(g), Zithromax(g)

PENNSAID Topical OTC analgesic balms, i.e. trolamine salicylate; Voltaren oral(g)

PERANEX HC Anusol HC(g), Proctocream HC(g)

PERFOROMIST Serevent Diskus, Foradil MDI

* Prior Authorization or Step Therapy may be required.

Most BCN members and some BCBSM members do not have coverage for nonformulary agents. Please use this list as a guide when selecting alternatives.

** Covered with a prescription for BCN members and certain BCBSM members.

Page 36

NonFormulary Formulary Alternative NonFormulary Formulary Alternative

PEXEVA Generic SSRI/SNRI (Celexa(g), Prozac(g), Paxil(g), Zoloft (g), etc.)

PLAN B ONE-STEP Plan B(g)

PRANDIMET Individual agents: Prandin and Glucophage(g)

PRED-G Garamycin(g), Pred Forte(g)

PREVACID NAPRAPAC

Prilosec OTC**; Prevacid(g)*, Solutab(g)*; Prilosec 20mg(g), PLUS Naprosyn(g)

PRILOSEC SUSPENSION

Prilosec OTC**; Prevacid(g)*, Solutab(g)*; Prilosec 20 mg(g), Protonix(g)*

PRISTIQ Generic SSRI/SNRI (Celexa(g), Prozac(g), Zoloft (g), Effexor(g), Effexor XR(g), etc.)

PROCENTRA Adderall XR(g)*, Metadate CD (Both of which may be "sprinkled" on food)

PROQUIN XR Bactrim DS/Septra DS(g), Cipro(g), XR(g) *

PROTONIX SUSP Prilosec OTC**; Prevacid(g)*, Solutab(g)*; Prilosec 20mg(g); Protonix(g)*

PROTOPIC Topical corticosteroids, Elidel*

PROVENTIL HFA Proair HFA, Ventolin HFA

PYLERA Use Tetracycline(g) plus Flagyl(g) plus Bismuth; or Helidac or PREVPAC

QUALAQUIN Aralen(g), Lariam(g), Plaquenil(g)

QUIXIN Ciloxan(g), Vigamox

RANEXA Long-acting nitrate, plus a beta-blocker or calcium channel blocker

RANICLOR Ceclor(g), Ceftin(g), Duricef(g), Keflex(g), Omnicef(g)

RAPAFLO Cardura(g), Flomax(g), Hytrin(g), Avodart, Uroxatral

REGRANEX Ethezyme(g), Granulex(g)

RELPAX Amerge(g)*, Imitrex(g); Maxalt*, MLT*

REQUIP XL Requip(g)

REVLIMID Thalomid

RHINOCORT AQUA

Flonase(g), Nasalide(g), Nasarel(g), Nasacort AQ*

RIOMET Glucophage(g)

RITALIN LA Adderall, XR(g)*; Ritalin(g), Concerta, Metadate CD

ROZEREM Ambien(g), Halcion(g), Prosom(g), Restoril(g), Sonata(g)

RYBIX ODT Ultram(g)

RYTHMOL SR Rythmol(g)

RYZOLT Ultram(g)

SAIZEN Genotropin*; Nutropin*, AQ*

SANCTURA XR Ditropan, XL(g); Sanctura(g); Detrol, LA

SANCUSO PATCH Kytril(g); Zofran, ODT(g)

SAPHRIS Clozaril(g), Risperdal(g), Abilify, Geodon, Seroquel, Zyprexa

SARAFEM TABLET Sarafem capsule(g)

SAVELLA Effexor(g), Effexor XR(g), Flexeril(g), Neurontin(g), SSRI(g), TCA's(g), Ultram(g)

SEASONIQUE Generic biphasic contraceptives

SEMPREX D Claritin OTC(g)**, Zyrtec OTC(g)**, Allegra(g), Allegra-D 12 hour(g)*, Allegra-D 24 hour*, Astelin(g)

SEROQUEL XR Clozaril(g), Risperdal(g), Abilify, Geodon, Zyprexa, Seroquel(IR)

SEROSTIM Genotropin*, Nutropin*, AQ*

SERZONE(g) Generic SSRI/SNRI (Celexa(g), Prozac(g), Paxil(g), Zoloft(g), etc.)

SILENOR Ambien(g), Desyrel(g), Sinequan(g), Sonata(g)

SIMCOR Individual agents (Zocor(g) PLUS Niaspan)

SIMPONI Enbrel*, Humira*

SOLARAZE Efudex(g)

SOLODYN Monodox(g), Vibramycin(g)

SOLTAMOX Nolvadex(g)

SOMA 250 Soma(g)

STAXYN Cialis*, Viagra*

STRATTERA Adderall, XR(g)*; Focalin(g), Ritalin(g), Concerta, Metadate CD

STRIANT Androxy(g), Depo-testosterone(g), Oxandrin(g), Androderm, Delatestryl

SUMAVEL DOSEPRO

Amerge(g)*, Imitrex(g); Maxalt*, MLT*

SUPRAX Ceclor(g), Ceftin(g), Duricef(g), Keflex(g), Omnicef(g)

SYMBYAX Use Zyprexa plus Prozac(g)

SYMLIN Insulin

TACLONEX, SCALP

Use Dovonex plus Diprosone/Diprolene(g)

TASMAR Comtan

TEKAMLO Lotrel(g), Generic ACE Inhibitor (lisinopril, benazepril, etc.), Benicar*, or Cozaar(g) PLUS Norvasc(g)

TEKTURNA, HCT Generic ACE Inhibitors (benazapril, enalapril, lisinopril, etc.)

TESTIM Androderm

TESTRED, ANDROID

Androxy(g), Depo-testosterone(g), Oxandrin(g), Androderm, Delatestryl

TEVETEN, HCT Cozaar(g), Hyzaar(g), Benicar*, HCT*

TEV-TROPIN Genotropin*; Nutropin*, AQ*

* Prior Authorization or Step Therapy may be required.

Most BCN members and some BCBSM members do not have coverage for nonformulary agents. Please use this list as a guide when selecting alternatives.

** Covered with a prescription for BCN members and certain BCBSM members.

Page 37

NonFormulary Formulary Alternative NonFormulary Formulary Alternative

TIROSINT Synthroid(g)

TOVIAZ Ditropan, XL(g); Detrol, LA

TRANXENE SD Ativan(g), Buspar(g), Serax(g), Tranxene(g), Valium(g), Xanax(g)

TREXIMET Individual agents (Imitrex(g) PLUS naproxen); Amerge(g)*; Maxalt, MLT*

TRIBENZOR Cozaar(g), HCTZ(g), Hyzaar(g), PLUS Norvasc(g)

TRIGLIDE Lofibra(g), Lopid(g), Tricor

TRILIPIX Lofibra(g), Lopid(g), Tricor

TWYNSTA Lotrel(g), Generic ACE Inhibitor (lisinopril, benazepril, etc.), Benicar*, or Cozaar(g) PLUS Norvasc(g)

TYZEKA Baraclude, Epivir HBV, Hepsera

ULORIC Zyloprim(g)

ULTRAM ER 300MG

Ultram(g)

VAGIFEM Climara(g), Ogen(g), Vivelle-DOT, Estraderm, Estring, Premarin Vaginal

VALTURNA Generic ACE Inhibitors (benazapril, enalapril, lisinopril, etc.)

VANOS 0.1% CR Diprolene(g), Psorcon(g), Temovate(g), Ultravate(g)

VECTICAL Dovonex

VERAMYST Flonase(g), Nasalide(g), Nasarel(g), Nasacort AQ*

VERDESO Elocon(g), Locoid(g), Synalar solution(g), Capex

VEREGEN Condylox Solution(g), Gel

VESICARE Ditropan, XL(g); Detrol, LA

VICTOZA Insulin, Glucophage(g), Sulfonylurea's, TZD's

VISICOL Fleet's Phospho Soda OTC, Colyte(g)

VOLTAREN GEL Topical OTC analgesic balms, i.e. trolamine salicylate; Voltaren oral(g)

VUSION OTC diaper rash products

VYTORIN Mevacor(g), Pravachol(g), Zocor(g), Crestor*; plus Zetia*

VYVANSE Adderall, XR(g)*; Ritalin, SR(g); Concerta, Metadate CD

XENICAL Alli OTC, Bontril(g)*, Didrex(g)*, Phentermine(g)*, Tenuate(g)*

XERESE Zovirax cream PLUS HC cream

XIBROM Ocufen(g), Voltaren (ophthalmic)(g)

XIFAXAN 220MG Bactrim DS(g), Vibramycin(g)

XIFAXAN 550MG Lactulose

XODOL Vicodin(g)

XOLEGEL Nizoral(g)

XOPENEX, HFA Albuterol(g); Maxair; Proair HFA, Ventolin HFA

XYREM Ambien(g), Halcion(g), Prosom(g), Restoril(g)

XYZAL SOLUTION Claritin OTC(g)**, Zyrtec OTC(g)**, Allegra(g)

ZANAFLEX(g) Dantrium(g), Flexeril(g), Lioresal(g)

ZANTAC EFFERDOSE

Zantac, OTC(g); Pepcid(g)

ZAVESCA Ceredase, Cerezyme (medical benefit)

ZEGERID PACKET Prilosec OTC**; Prevacid(g)*, Solutab(g)*; Prilosec 20mg(g), Protonix(g)*, Zegerid(g)*

ZELAPAR Eldepryl(g)

ZEMPLAR Rocaltrol(g)

ZIANA GEL Individual agents: Cleocin topical(g) and Retin-A(g)*

ZIPSOR Mobic(g), Motrin(g), Naprosyn, EC(g); Voltaren(g), etc*

ZMAX Zithromax(g)

ZOLPIMIST Ambien(g), Sonata(g)

ZOMIG, ZMT, NASAL SPRAY

Amerge(g)*, Imitrex(g); Maxalt*, MLT*

ZORBTIVE Genotropin*; Nutropin*, AQ*

ZUPLENZ Kytril(g); Zofran, ODT(g)

ZYCLARA Aldara(g)

ZYDONE Lortab(g), Tylenol with Codeine(g), Vicodin(g)

ZYFLO CR Accolate(g), Inhaled Steroids, Singulair

ZYLET Maxitrol(g), Tobradex(g), Vasocidin(g)

ZYMAR Ciloxan(g), Vigamox

ZYMAXID Ciloxan(g), Ocuflox(g)

* Prior Authorization or Step Therapy may be required.

Most BCN members and some BCBSM members do not have coverage for nonformulary agents. Please use this list as a guide when selecting alternatives.

** Covered with a prescription for BCN members and certain BCBSM members.

Page 38

Dose Optimization and Quantity Limits The Blue Cross Blue Shield of Michigan and Blue Care Network dose optimization programs encourage appropriate prescribing of medications intended for once-daily administration. Quantities of these medications are limited to single daily doses of appropriate strengths. Michigan Blues pharmacists work closely with physicians and community pharmacists to achieve this goal, which promotes patient compliance and more cost-effective therapy. Examples of some drugs include certain cholesterol-lowering, diabetes, antidepressant and antihypertensive medications. Quantity limits also apply to both BCBSM and BCN for other medications, based on manufacturer recommendations, available package size and other criteria. These drugs are identified with a Quantity Limit (#) indicator. A complete list of medications subject to quantity limits is available at: bcbsm.com/provider/pharmacy_services/index.shtml. Copayments A member’s benefit plan design determines applicable copayments for covered prescriptions. Symbols used throughout the document

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

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

Drug Information Services — Mail Code B773 Blue Cross Blue Shield of Michigan 600 E. Lafayette Boulevard Detroit, MI 48226-2998

or Pharmacy Services — Mail Code C303 Blue Care Network of Michigan 20500 Civic Center Drive Southfield, MI 48076-5043

Page 39

1. ANTI-INFECTIVES

1A. Penicillins

Formulary PreferredGeneric NameTrade Name Utilization Management

AMOXICILLIN TRIHYDRATEAMOXIL (g)AMPICILLIN TRIHYDRATEAMPICILLIN (g)

AMOX TR/POTASSIUM CLAVULANATEAUGMENTIN, ES, XR (g)DICLOXACILLIN SODIUMDICLOXACILLIN (g)

PENICILLIN V POTASSIUMPENICILLIN VK (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

NONE

NonformularyGeneric NameTrade Name Utilization Management

AMOXICILLIN TRIHYDRATEMOXATAG

1B. Cephalosporins

Formulary PreferredGeneric NameTrade Name Utilization Management

CEFACLORCECLOR (g)CEFACLORCECLOR ER (g)

CEFUROXIME AXETILCEFTIN (g)CEFPROZILCEFZIL (g)

CEFADROXIL HYDRATEDURICEF (g)CEPHALEXIN MONOHYDRATEKEFLEX (g)

CEFDINIROMNICEF (g)CEFDITOREN PIVOXILSPECTRACEF (g) [QL]

CEFPODOXIME PROXETILVANTIN (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

NONE

NonformularyGeneric NameTrade Name Utilization Management

CEFTIBUTEN DIHYDRATECEDAXCEPHALEXIN MONOHYDRATEKEFLEX 750MG

CEFACLORRANICLORCEFIXIMESUPRAX

(g) Use generic equivalent

[PA] Prior authorization may be required

Page 40

[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

1C. Tetracyclines

Formulary PreferredGeneric NameTrade Name Utilization Management

DOXYCYCLINE MONOHYDRATEADOXA (g) [PA]MINOCYCLINE HCLMINOCIN, DYNACIN (g)

DOXYCYCLINE MONOHYDRATEMONODOX (g)DOXYCYCLINE HYCLATEPERIOSTAT (g)

MINOCYCLINE HCLSOLODYN 45, 90, 135MG(g) [PA]TETRACYCLINE HCLTETRACYCLINE (g)

DOXYCYCLINE HYCLATEVIBRAMYCIN, VIBRATABS (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

NONE

NonformularyGeneric NameTrade Name Utilization Management

DOXYCYCLINE MONOHYDRATEADOXA 150MG CAPSULE [PA]DOXYCYCLINE MONOHY/SKIN CLNSR9ADOXA CK, TT [PA]

DOXYCYCLINE HYCLATEDORYX [PA]DOXYCYCLINE MONOHYDRATEORACEA [PA]

DOXYCYCLINE HYCLATEORAXYLMINOCYCLINE HCLSOLODYN 55, 65, 80, 105, 115MG [PA]

1D. Macrolides

Formulary PreferredGeneric NameTrade Name Utilization Management

CLARITHROMYCINBIAXIN, XL (g)ERYTHROMYCIN ETHYLSUCCINATEERYTHROMYCIN (g)

ERYTHROMYCIN BASEERYTHROMYCIN STEARATE, BASE (g)ERY E-SUCC/SULFISOXAZOLEPEDIAZOLE (g)

AZITHROMYCINZITHROMAX (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

NONE

NonformularyGeneric NameTrade Name Utilization Management

TELITHROMYCINKETEKERYTHROMYCIN BASEPCE

AZITHROMYCINZMAX

(g) Use generic equivalent

[PA] Prior authorization may be required

Page 41

[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

1E. Quinolones

Formulary PreferredGeneric NameTrade Name Utilization Management

CIPROFLOXACIN HCLCIPRO (g)CIPROFLOXACIN HCL-BETAINE COMBCIPRO XR (g) [PA] [QL]

OFLOXACINFLOXIN (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

MOXIFLOXACIN HCLAVELOX, ABC

NonformularyGeneric NameTrade Name Utilization Management

GEMIFLOXACIN MESYLATEFACTIVELEVOFLOXACINLEVAQUINNORFLOXACINNOROXIN

CIPROFLOXACIN HCLPROQUIN XR [PA] [QL]

1F. Sulfonamides and Combinations

Formulary PreferredGeneric NameTrade Name Utilization Management

SULFAMETHOXAZOLE/TRIMETHOPRIMBACTRIM, DS, SEPTRA, DS (g)ERY E-SUCC/SULFISOXAZOLEPEDIAZOLE (g)

SULFADIAZINESULFADIAZINE (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

NONE

NonformularyGeneric NameTrade Name Utilization Management

NONE

1G. Urinary Tract Agents

Formulary PreferredGeneric NameTrade Name Utilization Management

METHENAMINE HIPPURATEHIPREX/UREX (g)NITROFURANTOIN/NITROFURAN MACMACROBID (g)NITROFURANTOIN MACROCRYSTALMACRODANTIN (g)

METHENAMINE MANDELATEMANDELAMINE (g)PHENAZOPYRIDINE HCLPYRIDIUM (g)

TRIMETHOPRIMTRIMETHOPRIM (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

NONE

NonformularyGeneric NameTrade Name Utilization Management

FOSFOMYCIN TROMETHAMINEMONUROL

(g) Use generic equivalent

[PA] Prior authorization may be required

Page 42

[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

1H. Antifungals

Formulary PreferredGeneric NameTrade Name Utilization Management FLUCONAZOLEDIFLUCAN (g)

GRISEOFULVIN,MICROSIZEGRIFULVIN V SUSP (g)TERBINAFINE HCLLAMISIL TABLETS (g)

CLOTRIMAZOLEMYCELEX TROCHE (g)KETOCONAZOLENIZORAL (g)

NYSTATINNYSTATIN (g)ITRACONAZOLESPORANOX CAPS (g)

Formulary OptionsGeneric NameTrade Name Utilization Management FLUCYTOSINEANCOBON

GRISEOFULVIN,MICROSIZEGRIFULVIN V 500MGGRISEOFULVIN ULTRAMICROSIZEGRIS PEG

POSACONAZOLENOXAFILITRACONAZOLESPORANOX SOLNVORICONAZOLEVFEND

NonformularyGeneric NameTrade Name Utilization Management

TERBINAFINE HCLLAMISIL GRANULES [PA]MICONAZOLEORAVIG [QL]

1I. Antivirals

Formulary PreferredGeneric NameTrade Name Utilization Management

RIBAVIRINCOPEGUS (g) [PA] <s>GANCICLOVIRCYTOVENE (g)FAMCICLOVIRFAMVIR (g) [QL]

RIMANTADINE HCLFLUMADINE (g)RIBAVIRINREBETOL (g) [PA] <s>

AMANTADINE HCLSYMMETREL (g)VALACYCLOVIR HCLVALTREX (g) [QL]

ACYCLOVIRZOVIRAX (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

ENTECAVIRBARACLUDE <s>LAMIVUDINEEPIVIR HBV

ADEFOVIR DIPIVOXILHEPSERA <s>RIBAVIRINREBETOL SOLUTION [PA] <s>ZANAMIVIRRELENZA [QL]

OSELTAMIVIR PHOSPHATETAMIFLU CAP, SUSP [QL]VALGANCICLOVIR HYDROCHLORIDEVALCYTE

NonformularyGeneric NameTrade Name Utilization Management TELBIVUDINETYZEKA <s>

(g) Use generic equivalent

[PA] Prior authorization may be required

Page 43

[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

1J. Antiretrovirals

Formulary PreferredGeneric NameTrade Name Utilization Management

ZIDOVUDINERETROVIR (g)DIDANOSINEVIDEX EC (g)STAVUDINEZERIT (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

TIPRANAVIRAPTIVUS(MUST BE USED WITH NORVIR)EFAVIRENZ/EMTRICITAB/TENOFOVIRATRIPLA

LAMIVUDINE/ZIDOVUDINECOMBIVIRINDINAVIR SULFATECRIXIVAN

EMTRICITABINEEMTRIVALAMIVUDINEEPIVIR

ABACAVIR SULFATE/LAMIVUDINEEPZICOMENFUVIRTIDEFUZEON <s>ETRAVIRINEINTELENCE

SAQUINAVIR MESYLATEINVIRASERALTEGRAVIR POTASSIUMISENTRESS

RITONAVIR/LOPINAVIRKALETRAFOSAMPRENAVIR CALCIUMLEXIVA

RITONAVIRNORVIRDARUNAVIR ETHANOLATEPREZISTA(MUST BE USED WITH NORVIR)DELAVIRDINE MESYLATERESCRIPTOR

ATAZANAVIR SULFATEREYATAZMARAVIROCSELZENTRYEFAVIRENZSUSTIVA

ABACAVIR/LAMIVUDINE/ZIDOVUDINETRIZIVIREMTRICITABINE/TENOFOVIRTRUVADA

DIDANOSINEVIDEXNELFINAVIR MESYLATEVIRACEPT

NEVIRAPINEVIRAMUNETENOFOVIR DISOPROXIL FUMARATEVIREAD

ABACAVIR SULFATEZIAGEN

NonformularyGeneric NameTrade Name Utilization Management

NONE

(g) Use generic equivalent

[PA] Prior authorization may be required

Page 44

[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

1K. Antimalarials

Formulary PreferredGeneric NameTrade Name Utilization Management

CHLOROQUINE PHOSPHATEARALEN (g)MEFLOQUINE HCLLARIAM (g)

HYDROXYCHLOROQUINE SULFATEPLAQUENIL (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

ARTEMETHER/LUMEFANTRINECOARTEM [QL]PYRIMETHAMINEDARAPRIM

ATOVAQUONE/PROGUANIL HCLMALARONEPRIMAQUINE PHOSPHATEPRIMAQUINE

NonformularyGeneric NameTrade Name Utilization Management

QUININE SULFATEQUALAQUIN

1L. Antituberculars

Formulary PreferredGeneric NameTrade Name Utilization Management

ETHAMBUTOL HCLETHAMBUTOL (g)ISONIAZIDISONIAZID (g)

PYRAZINAMIDEPYRAZINAMIDE (g)RIFAMPINRIFADIN (g)

RIFAMPIN/ISONIAZIDRIFAMATE (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

DAPSONEDAPSONERIFABUTINMYCOBUTIN

CYCLOSERINESEROMYCIN

NonformularyGeneric NameTrade Name Utilization Management RIFAPENTINEPRIFTIN

RIFAMPIN/INH/PYRAZINAMIDERIFATERETHIONAMIDETRECATOR

(g) Use generic equivalent

[PA] Prior authorization may be required

Page 45

[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

1M. Antiparasitics/Anthelmintics

Formulary PreferredGeneric NameTrade Name Utilization Management

METRONIDAZOLEFLAGYL (g)PAROMOMYCIN SULFATEHUMATIN (g)

MEBENDAZOLEVERMOX (g) [QL]

Formulary OptionsGeneric NameTrade Name Utilization Management NITAZOXANIDEALINIAPRAZIQUANTELBILTRICIDE

METRONIDAZOLEFLAGYL ERATOVAQUONEMEPRON

PENTAMIDINE ISETHIONATENEBUPENT AEROSOLIVERMECTINSTROMECTROL - SINGLE DOSE [QL]TINIDAZOLETINDAMAX [QL]

NonformularyGeneric NameTrade Name Utilization Management ALBENDAZOLEALBENZA

1N. Miscellaneous Anti-infectives

Formulary PreferredGeneric NameTrade Name Utilization Management

CLINDAMYCIN HCLCLEOCIN (g)NEOMYCIN SULFATENEOMYCIN (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

TOBRAMYCIN/0.25 NORMAL SALINETOBI [QL] <s>VANCOMYCIN HCLVANCOCIN HCL

LINEZOLIDZYVOX

NonformularyGeneric NameTrade Name Utilization Management

AZTREONAM LYSINECAYSTON [PA] [QL] <s>RIFAXIMINXIFAXAN 200MG [QL]RIFAXIMINXIFAXAN 550MG [PA] [QL]

(g) Use generic equivalent

[PA] Prior authorization may be required

Page 46

[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

2. CARDIOVASCULAR, HYPERTENSION, CHOLESTEROL

2A. Lipid-lowering Agents

Formulary PreferredGeneric NameTrade Name Utilization Management

COLESTIPOL HCLCOLESTID (g)FENOFIBRIC ACIDFIBRICOR (g)

FENOFIBRATE,MICRONIZEDLOFIBRA (g) BEGEMFIBROZILLOPID (g) BELOVASTATINMEVACOR (g) [QL] BE

PRAVASTATIN SODIUMPRAVACHOL (g) [QL] BECHOLESTYRAMINEQUESTRAN, QUESTRAN LIGHT (g)

SIMVASTATINZOCOR (g) [QL] BE

Formulary OptionsGeneric NameTrade Name Utilization Management

ROSUVASTATIN CALCIUMCRESTOR [ST] [QL]NIACINNIASPAN BE

FENOFIBRATE NANOCRYSTALLIZEDTRICOR [QL]COLESEVELAM HCLWELCHOL

EZETIMIBEZETIA [ST] [QL]

NonformularyGeneric NameTrade Name Utilization Management

NIACIN/LOVASTATINADVICOR [PA] [QL]LOVASTATINALTOPREV [PA] [QL]

FENOFIBRATE,MICRONIZEDANTARAAMLODIPINE/ATORVAST CALCADUET [PA] [QL]

COLESTIPOL HCLCOLESTID FLAVOREDFENOFIBRATEFENOGLIDE

FLUVASTATIN SODIUMLESCOL, XL [PA] [QL]ATORVASTATIN CALCIUMLIPITOR [PA] [QL]

FENOFIBRATELIPOFEN [QL]PITAVASTATIN CALCIUMLIVALO [ST] [QL]

OMEGA-3 ACID ETHYL ESTERSLOVAZANIACIN/SIMVASTATINSIMCOR [ST]

FENOFIBRATE NANOCRYSTALLIZEDTRIGLIDEFENOFIBRIC ACIDTRILIPIX [PA] [QL]

EZETIMIBE/SIMVASTATINVYTORIN [PA] [QL]

(g) Use generic equivalent

[PA] Prior authorization may be required

Page 47

[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

2B. Beta Blockers and Combinations

Formulary PreferredGeneric NameTrade Name Utilization Management SOTALOL HCLBETAPACE, AF (g) BE

TIMOLOL MALEATEBLOCADREN (g) BECARVEDILOLCOREG (g) BE

NADOLOLCORGARD (g) BENADOLOL/BENDROFLUMETHIAZIDECORZIDE (g) BE

PROPRANOLOL HCLINDERAL (g) BEPROPRANOLOL HCLINDERAL LA (g) [QL] BE

PROPRANOLOL/HYDROCHLOROTHIAZIDEINDERIDE (g) BEBETAXOLOL HCLKERLONE (g) BE

METOPROLOL TARTRATELOPRESSOR (g) BEMETOPROLOL/HYDROCHLOROTHIAZIDELOPRESSOR HCT (g) BE

LABETALOL HCLNORMODYNE (g) BEPINDOLOLPINDOLOL (g) BE

ACEBUTOLOL HCLSECTRAL (g) BEATENOLOL/CHLORTHALIDONETENORETIC (g) BE

ATENOLOLTENORMIN (g) BEMETOPROLOL SUCCINATETOPROL XL (g) BEBISOPROLOL FUMARATEZEBETA (g) BE

BISOPROL/HYDROCHLOROTHIAZIDEZIAC (g) BE

Formulary OptionsGeneric NameTrade Name Utilization Management

NONE

NonformularyGeneric NameTrade Name Utilization Management NEBIVOLOL HCLBYSTOLIC [PA] [QL]

CARVEDILOL PHOSPHATECOREG CR [PA] [QL]PROPRANOLOL HCLINNOPRAN XL

PENBUTOLOL SULFATELEVATOL

(g) Use generic equivalent

[PA] Prior authorization may be required

Page 48

[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

2C. ACE-Inhibitors and Combinations

Formulary PreferredGeneric NameTrade Name Utilization Management QUINAPRIL HCLACCUPRIL (g) BE

QUINAPRIL/HYDROCHLOROTHIAZIDEACCURETIC (g) BEPERINDOPRIL ERBUMINEACEON (g)

RAMIPRILALTACE CAPSULE (g) BECAPTOPRILCAPOTEN (g) BE

CAPTOPRIL/HYDROCHLOROTHIAZIDECAPOZIDE (g) BEBENAZEPRIL HCLLOTENSIN (g) BE

BENAZEPRIL/HYDROCHLOROTHIAZIDELOTENSIN HCT (g) BEAMLODIPINE BESYLATE/BENAZEPRILLOTREL (g) BE

TRANDOLAPRILMAVIK (g) BEFOSINOPRIL SODIUMMONOPRIL (g) BE

FOSINOPRIL/HYDROCHLOROTHIAZIDEMONOPRIL HCT (g) BELISINOPRILPRINIVIL, ZESTRIL (g) BE

LISINOPRIL/HYDROCHLOROTHIAZIDEPRINZIDE, ZESTORETIC (g) BETRANDOLAPRIL/VERAPAMIL HCLTARKA (g) [QL]

MOEXIPRIL/HYDROCHLOROTHIAZIDEUNIRETIC (g) BEMOEXIPRIL HCLUNIVASC (g) BE

ENALAPRIL/HYDROCHLOROTHIAZIDEVASERETIC (g) BEENALAPRIL MALEATEVASOTEC (g) BE

Formulary OptionsGeneric NameTrade Name Utilization Management

AMLODIPINE BESYLATE/BENAZEPRILLOTREL 5/40, 10/40 [QL]

NonformularyGeneric NameTrade Name Utilization Management

RAMIPRILALTACE TABLET [PA] [QL]

(g) Use generic equivalent

[PA] Prior authorization may be required

Page 49

[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

2D. Angiotensin II Receptor Blockers and Combinations

Formulary PreferredGeneric NameTrade Name Utilization Management

LOSARTAN POTASSIUMCOZAAR (g) [QL] BELOSARTAN/HYDROCHLOROTHIAZIDEHYZAAR (g) [QL] BE

Formulary OptionsGeneric NameTrade Name Utilization Management

OLMESARTAN MEDOXOMILBENICAR [ST] [QL]OLMESARTAN/HYDROCHLOROTHIAZIDEBENICAR HCT [ST] [QL]

NonformularyGeneric NameTrade Name Utilization Management

CANDESARTAN CILEXETILATACAND [PA] [QL]CANDESARTAN/HYDROCHLOROTHIAZIDATACAND HCT [PA]IRBESARTAN/HYDROCHLOROTHIAZIDEAVALIDE [PA] [QL]

IRBESARTANAVAPRO [PA] [QL]AMLODIPINE BES/OLMESARTAN MEDAZOR [PA] [QL]

VALSARTANDIOVAN [PA]VALSARTAN/HYDROCHLOROTHIAZIDEDIOVAN HCT [PA] [QL]

AMLODIPINE/VALSARTANEXFORGE [PA]AMLODIPINE/VALSARTAN/HCTZEXFORGE HCT [PA] [QL]

TELMISARTANMICARDIS [PA] [QL]TELMISARTAN/HYDROCHLOROTHIAZIDMICARDIS HCT [PA] [QL]

EPROSARTAN MESYLATETEVETEN [PA]EPROSARTAN/HYDROCHLOROTHIAZIDETEVETEN HCT [PA]OLMESARTAN MED/AMLODIPINE/HCTZTRIBENZOR [ST] [QL]

TELMISARTAN/AMLODIPINETWYNSTA [PA] [QL]ALISKIREN/VALSARTANVALTURNA [PA] [QL]

(g) Use generic equivalent

[PA] Prior authorization may be required

Page 50

[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

2E. Calcium Channel Blockers and Combinations

Formulary PreferredGeneric NameTrade Name Utilization Management

VERAPAMIL HCLCALAN SR/ISOPTIN SR (g)NICARDIPINE HCLCARDENE (g)

DILTIAZEM HCLCARDIZEM LA (g)DILTIAZEM HCLCARDIZEM, SR, CD (g)

ISRADIPINEDYNACIRC (g)AMLODIPINE BESYLATE/BENAZEPRILLOTREL (g) BE

AMLODIPINE BESYLATENORVASC (g) BEFELODIPINEPLENDIL (g)NIFEDIPINEPROCARDIA, XL;ADALAT CC (g) [QL]

NISOLDIPINESULAR (g)TRANDOLAPRIL/VERAPAMIL HCLTARKA (g) [QL]

DILTIAZEM HCLTIAZAC (g)VERAPAMIL HCLVERELAN (g)VERAPAMIL HCLVERELAN PM (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

VERAPAMIL HCLCOVERA-HSAMLODIPINE BESYLATE/BENAZEPRILLOTREL 5/40, 10/40 [QL]

NonformularyGeneric NameTrade Name Utilization Management

AMLODIPINE BES/OLMESARTAN MEDAZOR [PA] [QL]AMLODIPINE/ATORVAST CALCADUET [PA] [QL]

NICARDIPINE HCLCARDENE SRDILTIAZEM HCLCARDIZEM LA

ISRADIPINEDYNACIRC CRAMLODIPINE/VALSARTANEXFORGE [PA]

AMLODIPINE/VALSARTAN/HCTZEXFORGE HCT [PA] [QL]NISOLDIPINESULAR 8.5, 17, 25.5, 34MG

ALISKIREN/AMLODIPINETEKAMLO [ST] [QL]OLMESARTAN MED/AMLODIPINE/HCTZTRIBENZOR [ST] [QL]

TELMISARTAN/AMLODIPINETWYNSTA [PA] [QL]

(g) Use generic equivalent

[PA] Prior authorization may be required

Page 51

[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

2F. Diuretics

Formulary PreferredGeneric NameTrade Name Utilization Management

SPIRONOLACT/HYDROCHLOROTHIAZIDALDACTAZIDE (g) BESPIRONOLACTONEALDACTONE (g) BE

BUMETANIDEBUMEX (g) BETORSEMIDEDEMADEX (g) BE

ACETAZOLAMIDEDIAMOX (g)ACETAZOLAMIDEDIAMOX SEQUELS (g)CHLOROTHIAZIDEDIURIL (g) BE

HYDROCHLOROTHIAZIDEHYDRODIURIL, MICROZIDE (g) BECHLORTHALIDONEHYGROTON, THALITONE (g) BE

EPLERENONEINSPRA (g) BEFUROSEMIDELASIX (g) BEINDAPAMIDELOZOL (g) BE

TRIAMTERENE/HYDROCHLOROTHIAZIDMAXZIDE, DYAZIDE (g) BEAMILORIDE HCLMIDAMOR (g) BE

AMILORIDE/HYDROCHLOROTHIAZIDEMODURETIC (g) BEMETOLAZONEZAROXOLYN (g) BE

Formulary OptionsGeneric NameTrade Name Utilization Management TRIAMTERENEDYRENIUM

ETHACRYNIC ACIDEDECRIN

NonformularyGeneric NameTrade Name Utilization Management

NONE

2G. Cardiovascular Treatment

Formulary PreferredGeneric NameTrade Name Utilization Management SOTALOL HCLBETAPACE, AF (g) BE

AMIODARONE HCLCORDARONE (g)DIGOXINDIGOXIN ELIXIR (g)DIGOXINDIGOXIN TABS (g)

MEXILETINE HCLMEXITIL (g)DISOPYRAMIDE PHOSPHATENORPACE (g)

MIDODRINE HCLPROAMATINE (g)PROCAINAMIDE HCLPRONESTYL, SR (g)QUINIDINE SULFATEQUINIDEX (g)

QUINIDINE GLUCONATEQUINIDINE GLUCONATE SA (g)PROPAFENONE HCLRYTHMOL (g)

FLECAINIDE ACETATETAMBOCOR (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

DRONEDARONE HYDROCHLORIDEMULTAQ [QL]DISOPYRAMIDE PHOSPHATENORPACE CR

DOFETILIDETIKOSYN

NonformularyGeneric NameTrade Name Utilization Management RANOLAZINERANEXA [PA]

PROPAFENONE HCLRYTHMOL SR

(g) Use generic equivalent

[PA] Prior authorization may be required

Page 52

[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

2H. Nitrates and Combinations

Formulary PreferredGeneric NameTrade Name Utilization Management

ISOSORBIDE MONONITRATEIMDUR (g)ISOSORBIDE MONONITRATEISMO, MONOKET (g)

ISOSORBIDE DINITRATEISORDIL (g)NITROGLYCERINNITROGLYCERIN PATCH (g)NITROGLYCERINNITROGLYCERIN SA CAP (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

ISOSORBIDE DINITRATEDILATRATE-SRNITROGLYCERINNITRO-BID OINTMENTNITROGLYCERINNITROLINGUAL SPRAYNITROGLYCERINNITROMISTNITROGLYCERINNITROSTAT

NonformularyGeneric NameTrade Name Utilization Management

NONE

2I. Anticoagulants and Hemostasis Agents

Formulary PreferredGeneric NameTrade Name Utilization Management

ANAGRELIDE HCLAGRYLIN (g)AMINOCAPROIC ACIDAMICAR (g)WARFARIN SODIUMCOUMADIN (g) BE

HEPARIN SODIUM,PORCINEHEPARIN (g) <s>ENOXAPARIN SODIUMLOVENOX (g) <s>

DIPYRIDAMOLEPERSANTINE (g)CILOSTAZOLPLETAL (g)

TICLOPIDINE HCLTICLID (g)PENTOXIFYLLINETRENTAL (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

PRASUGREL HYDROCHLORIDEEFFIENT [QL]PHYTONADIONEMEPHYTON

CLOPIDOGREL BISULFATEPLAVIX

NonformularyGeneric NameTrade Name Utilization Management

ASPIRIN/DIPYRIDAMOLEAGGRENOXFONDAPARINUX SODIUMARIXTRA <s>

DALTEPARIN SODIUM,PORCINEFRAGMIN <s>TINZAPARIN SODIUM,PORCINEINNOHEP <s>

(g) Use generic equivalent

[PA] Prior authorization may be required

Page 53

[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

2J. Alpha-adrenergic Agents

Formulary PreferredGeneric NameTrade Name Utilization Management METHYLDOPAALDOMET (g)

METHYLDOPA/HYDROCHLOROTHIAZIDEALDORIL (g)DOXAZOSIN MESYLATECARDURA (g)

CLONIDINE HCLCATAPRES (g)CLONIDINE HCLCATAPRES-TTS (g)TERAZOSIN HCLHYTRIN (g)PRAZOSIN HCLMINIPRESS (g)

RESERPINERESERPINE (g)GUANFACINE HCLTENEX (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

NONE

NonformularyGeneric NameTrade Name Utilization Management

NONE

2K. Miscellaneous Antihypertensives

Formulary PreferredGeneric NameTrade Name Utilization Management

HYDRALAZINE HCLAPRESOLINE (g)MINOXIDILLONITEN (g)

PAPAVERINE HCLPAPAVERINE CAPS (g)ISOXSUPRINE HCLVASODILAN (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

NONE

NonformularyGeneric NameTrade Name Utilization Management

ALISKIREN/AMLODIPINETEKAMLO [ST] [QL]ALISKIREN HEMIFUMARATETEKTURNA [PA]

ALISKIREN/HYDROCHLOROTHIAZIDETEKTURNA HCT [PA]ALISKIREN/VALSARTANVALTURNA [PA] [QL]

(g) Use generic equivalent

[PA] Prior authorization may be required

Page 54

[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

3. CENTRAL NERVOUS SYSTEM

3A. Antidepressants

Formulary PreferredGeneric NameTrade Name Utilization Management

AMOXAPINEAMOXAPINE (g)CLOMIPRAMINE HCLANAFRANIL (g) BE

CITALOPRAM HYDROBROMIDECELEXA (g) BETRAZODONE HCLDESYREL (g) BE

VENLAFAXINE HCLEFFEXOR (g) BEVENLAFAXINE HCLEFFEXOR XR (g) [QL] BE

AMITRIPTYLINE HCLELAVIL (g) BEAMITRIPTYLINE HCL/PERPHENAZINEETRAFON (g)

FLUVOXAMINE MALEATEFLUVOXAMINE MALEATE (g) BEAMITRIP HCL/CHLORDIAZEPOXIDELIMBITROL, DS (g)

MAPROTILINE HCLMAPROTILINE HCL (g) BEDESIPRAMINE HCLNORPRAMIN (g) BE

NORTRIPTYLINE HCLPAMELOR, AVENTYL (g) BETRANYLCYPROMINE SULFATEPARNATE (g)

PAROXETINE HCLPAXIL (g) BEPAROXETINE HCLPAXIL CR (g)FLUOXETINE HCLPROZAC WEEKLY (g) [QL]FLUOXETINE HCLPROZAC, SARAFEM (g) BE

MIRTAZAPINEREMERON (g) BEMIRTAZAPINEREMERON SOLTAB (g) BEDOXEPIN HCLSINEQUAN, ADAPIN (g) BE

TRIMIPRAMINE MALEATESURMONTIL (g)IMIPRAMINE HCLTOFRANIL (g) BE

IMIPRAMINE PAMOATETOFRANIL-PM (g)VENLAFAXINE HCLVENLAFAXINE HCL ER (g) [QL] BE

PROTRIPTYLINE HCLVIVACTIL (g)BUPROPION HCLWELLBUTRIN XL (g) [QL]BUPROPION HCLWELLBUTRIN, SR (g) BESERTRALINE HCLZOLOFT (g) BE

Formulary OptionsGeneric NameTrade Name Utilization Management

ESCITALOPRAM OXALATELEXAPRO [ST] [QL]PHENELZINE SULFATENARDIL

TRIMIPRAMINE MALEATESURMONTIL 100MG

NonformularyGeneric NameTrade Name Utilization Management

BUPROPRION HBRAPLENZIN [PA]DULOXETINE HCLCYMBALTA [PA] [QL]

SELEGILINEEMSAM [QL]FLUVOXAMINE MALEATELUVOX CR [ST] [QL]

ISOCARBOXAZIDMARPLANTRAZODONE HCLOLEPTRO ER [PA] [QL]

PAROXETINE MESYLATEPEXEVA [PA] [QL]DESVENLAFAXINE SUCCINATEPRISTIQ [ST] [QL]

FLUOXETINE HCLSARAFEM TABLETNEFAZODONE HCLSERZONE (g)

(g) Use generic equivalent

[PA] Prior authorization may be required

Page 55

[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

3B. Antipsychotics

Formulary PreferredGeneric NameTrade Name Utilization Management

CLOZAPINECLOZARIL (g) BEHALOPERIDOLHALDOL (g) BE

LOXAPINE SUCCINATELOXITANE (g)THIORIDAZINE HCLMELLARIL (g) BE

THIOTHIXENENAVANE (g)PERPHENAZINEPERPHENAZINE (g)

FLUPHENAZINE HCLPROLIXIN (g) BERISPERIDONERISPERDAL (g) (TIER 0-BCN ONLY) BERISPERIDONERISPERDAL M-TAB (g) BE

TRIFLUOPERAZINE HCLSTELAZINE (g) BECHLORPROMAZINE HCLTHORAZINE (g) BE

Formulary OptionsGeneric NameTrade Name Utilization Management ARIPIPRAZOLEABILIFY, DISCMELT, SOLUTION

ZIPRASIDONE HCLGEODONPIMOZIDEORAP

QUETIAPINE FUMARATESEROQUELOLANZAPINEZYPREXA, ZYDIS

NonformularyGeneric NameTrade Name Utilization Management ILOPERIDONEFANAPT

CLOZAPINEFAZACLOPALIPERIDONEINVEGA [PA] [QL]

ASENAPINESAPHRIS [QL]QUETIAPINE FUMARATESEROQUEL XR [PA] [QL]

OLANZAPINE/FLUOXETINE HCLSYMBYAX

3C. Anxiolytics

Formulary PreferredGeneric NameTrade Name Utilization Management

LORAZEPAMATIVAN (g)BUSPIRONE HCLBUSPAR (g)

CHLORDIAZEPOXIDE HCLLIBRIUM (g)MEPROBAMATEMILTOWN, EQUANIL (g)ALPRAZOLAMNIRAVAM (g)

OXAZEPAMSERAX (g)CLORAZEPATE DIPOTASSIUMTRANXENE (g)

DIAZEPAMVALIUM (g)ALPRAZOLAMXANAX, XR (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

NONE

NonformularyGeneric NameTrade Name Utilization Management

CLORAZEPATE DIPOTASSIUMTRANXENE SD

(g) Use generic equivalent

[PA] Prior authorization may be required

Page 56

[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

3D. Sedative/Hypnotics

Formulary PreferredGeneric NameTrade Name Utilization Management

ZOLPIDEM TARTRATEAMBIEN (g) [QL]ZOLPIDEM TARTRATEAMBIEN CR (g) [PA] [QL]CHLORAL HYDRATECHLORAL HYDRATE (g)FLURAZEPAM HCLDALMANE (g) [QL]

TRIAZOLAMHALCION (g) [QL]ESTAZOLAMPROSOM (g) [QL]TEMAZEPAMRESTORIL (g) [QL]ZALEPLONSONATA (g) [QL]

Formulary OptionsGeneric NameTrade Name Utilization Management

NONE

NonformularyGeneric NameTrade Name Utilization Management

BUTABARBITAL SODIUMBUTISOL SODIUMQUAZEPAMDORAL [QL]

ZOLPIDEM TARTRATEEDLUAR [PA] [QL]ESZOPICLONELUNESTA [PA] [QL]RAMELTEONROZEREM [PA] [QL]

DOXEPIN HCLSILENOR [PA] [QL]ZOLPIDEM TARTRATEZOLPIMIST [PA] [QL]

3E. CNS Stimulants

Formulary PreferredGeneric NameTrade Name Utilization Management

AMPHET ASP/AMPHET/D-AMPHETADDERALL (g) [QL]AMPHET ASP/AMPHET/D-AMPHETADDERALL XR (BRAND-BCN ONLY) [QL]AMPHET ASP/AMPHET/D-AMPHETADDERALL XR (g) (BCBSM ONLY) [QL]

METHAMPHETAMINE HCLDESOXYN (g) [QL]D-AMPHETAMINE SULFATEDEXEDRINE (g) [QL]

DEXMETHYLPHENIDATE HCLFOCALIN (g) [QL]METHYLPHENIDATE HCLMETHYLIN SOLN (g) [QL]METHYLPHENIDATE HCLRITALIN, SR; METHYLIN, ER (g) [QL]

Formulary OptionsGeneric NameTrade Name Utilization Management

METHYLPHENIDATE HCLCONCERTA [QL]METHYLPHENIDATE HCLMETADATE CD [QL]

MODAFINILPROVIGIL [PA] [QL]

NonformularyGeneric NameTrade Name Utilization Management

METHYLPHENIDATEDAYTRANA [QL]DEXMETHYLPHENIDATE HCLFOCALIN XR [QL]

METHYLPHENIDATE HCLMETHYLIN CHEW [QL]ARMODAFINILNUVIGIL [PA] [QL]

D-AMPHETAMINE SULFATEPROCENTRA [PA]METHYLPHENIDATE HCLRITALIN LA [QL]

ATOMOXETINE HCLSTRATTERA [PA] [QL]LISDEXAMFETAMINE DIMESYLATEVYVANSE [PA] [QL]

(g) Use generic equivalent

[PA] Prior authorization may be required

Page 57

[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

3F. Nonsteroidal Anti-inflammatory Drugs

Formulary PreferredGeneric NameTrade Name Utilization Management

NAPROXEN SODIUMANAPROX, DS (g)FLURBIPROFENANSAID (g)

DICLOFENAC POTASSIUMCATAFLAM (g)SULINDACCLINORIL (g)

OXAPROZINDAYPRO (g)NAPROXENEC-NAPROSYN (g)PIROXICAMFELDENE (g)

INDOMETHACININDOCIN, SR (g)KETOPROFENKETOPROFEN (g)

ETODOLACLODINE (g)ETODOLACLODINE XL (g)

MECLOFENAMATE SODIUMMECLOMEN (g)MELOXICAMMOBIC (g)IBUPROFENMOTRIN (g)NAPROXENNAPROSYN (g)

NABUMETONERELAFEN (g)TOLMETIN SODIUMTOLECTIN, DS (g)

KETOROLAC TROMETHAMINETORADOL (g) [QL]DICLOFENAC SODIUMVOLTAREN (g)DICLOFENAC SODIUMVOLTAREN-XR (g)

Formulary OptionsGeneric NameTrade Name Utilization Management INDOMETHACININDOCIN SUPPOSITORY

MEFENAMIC ACIDPONSTEL

NonformularyGeneric NameTrade Name Utilization Management

DICLOFENAC SODIUM/MISOPROSTOLARTHROTEC [PA]DICLOFENAC POTASSIUMCAMBIA [PA] [QL]

CELECOXIBCELEBREX [PA] [QL]DICLOFENAC EPOLAMINEFLECTOR PATCH [PA] [QL]

NAPROXEN SODIUMNAPRELANNAPROXEN SODIUMNAPRELAN CR DOSEPAK

DICLOFENAC SODIUMPENNSAID [PA] [QL]LANSOPRAZOLE/NAPROXENPREVACID NAPRAPAC [PA]

NAPROXEN/ESOMEPRAZOLE MAGVIMOVO [PA] [QL]DICLOFENAC SODIUMVOLTAREN GEL [PA] [QL]

DICLOFENAC POTASSIUMZIPSOR

(g) Use generic equivalent

[PA] Prior authorization may be required

Page 58

[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

3G. Salicylates

Formulary PreferredGeneric NameTrade Name Utilization Management

SALSALATEDISALCID, SALFLEX (g)DIFLUNISALDOLOBID (g)

CHOLINE MAGNESIUM TRISALICYLATETRILISATE (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

ASPIRINZORPRIN

NonformularyGeneric NameTrade Name Utilization Management

NONE

3H. Narcotics

Formulary PreferredGeneric NameTrade Name Utilization Management

FENTANYL CITRATEACTIQ (g) [PA] [QL]CODEINE SULFATE(g)CODEINE SULFATE (g)

MEPERIDINE HCLDEMEROL (g)HYDROMORPHONE HCLDILAUDID (g)

FENTANYLDURAGESIC (g) [QL]METHADONE HCLMETHADONE (g)

MORPHINE SULFATEMS CONTIN/ORAMORPH SR (g)MORPHINE SULFATEMSIR (g)OXYMORPHONE HCLOPANA (g) [PA] [QL]

OXYCODONE HCLOXYCODONE IMMEDIATE RELEASE (g)MORPHINE SULFATERMS SUPPOSITORY (g)MORPHINE SULFATEROXANOL (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

NONE

NonformularyGeneric NameTrade Name Utilization Management

MORPHINE SULFATEAVINZA [QL]MORPHINE SULFATE/NALTREXONEEMBEDA [QL]

HYDROMORPHONE HCLEXALGO [PA] [QL]FENTANYL CITRATEFENTORA [PA] [QL]MORPHINE SULFATEKADIAN

TAPENTADOL HYDROCHLORIDENUCYNTA [PA] [QL]FENTANYL CITRATEONSOLIS [PA] [QL]OXYMORPHONE HCLOPANA ER [PA] [QL]

OXYCODONE HCLOXYCONTIN [PA] [QL]

(g) Use generic equivalent

[PA] Prior authorization may be required

Page 59

[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

3I. Narcotic/Analgesic Combinations

Formulary PreferredGeneric NameTrade Name Utilization Management

CODEINE PHOS/ASPIRINASPIRIN W/CODEINE (g)CODEINE/BUTALBUT/ACETAMIN/CAFFFIORICET W/CODEINE (g)BUTALB/ACETAMINOPHEN/CAFFEINEFIORICET;ESGIC, PLUS (g)

BUTALBITAL/ASPIRIN/CAFFEINEFIORINAL (g)CODEINE/BUTALBITAL/ASA/CAFFEINFIORINAL W/CODEINE (g)OXYCODONE HCL/ACETAMINOPHENPERCOCET (g)

OXYCODONE HCL/ASPIRINPERCODAN (g)BUTALBITAL/ACETAMINOPHENPHRENILIN (g)

CODEINE PHOS/ACETAMINOPHENTYLENOL W/CODEINE (g)OXYCODONE HCL/ACETAMINOPHENTYLOX (g)

HYDROCODONE BIT/ACETAMINOPHENVICODIN, LORTAB (g)HYDROCODONE/IBUPROFENVICOPROFEN (g)

BUTALB/ACETAMINOPHEN/CAFFEINEZEBUTAL (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

BUTALBITAL/ACETAMINOPHENPHRENILIN FORTEDIHYDROCODEINE/ASPIRIN/CAFFEINSYNALGOS-DC

NonformularyGeneric NameTrade Name Utilization Management

OXYCODONE HCL/ACETAMINOPHENMAGNACETHYDROCODONE BIT/ACETAMINOPHENXODOLHYDROCODONE BIT/ACETAMINOPHENZYDONE

3J. Narcotic Mixed Agonist/Antagonist

Formulary PreferredGeneric NameTrade Name Utilization Management

BUTORPHANOL TARTRATESTADOL NS (g)PENTAZOCINE HCL/ACETAMINOPHENTALACEN (g)PENTAZOCINE HCL/NALOXONE HCLTALWIN NX (g)TRAMADOL HCL/ACETAMINOPHENULTRACET (g)

TRAMADOL HCLULTRAM (g)TRAMADOL HCLULTRAM ER 100MG, 200MG (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

BUPRENORPHINE HCL/NALOXONE HCLSUBOXONE FILM, TABS [PA]

NonformularyGeneric NameTrade Name Utilization Management

BUPRENORPHINEBUTRANS [PA] [QL]TRAMADOL HCLRYBIX ODT [PA] [QL]TRAMADOL HCLRYZOLT [QL]TRAMADOL HCLULTRAM ER 300MG

(g) Use generic equivalent

[PA] Prior authorization may be required

Page 60

[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

3K. Narcotic Antagonists

Formulary PreferredGeneric NameTrade Name Utilization Management

NALTREXONE HCLREVIA (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

METHYLNALTREXONERELISTOR [PA] [QL]

NonformularyGeneric NameTrade Name Utilization Management

NONE

3M. Migraine Therapy

Formulary PreferredGeneric NameTrade Name Utilization Management

NARATRIPTAN HCLAMERGE (g) [ST] [QL]BUTALBITAL/ACETAMINOPHENBUPAP (g)

ERGOTAMINE TARTRATE/CAFFEINECAFERGOT (g) [QL]DIHYDROERGOTAMINE MESYLATED.H.E.45 (g) [QL]

BUTALB/ACETAMINOPHEN/CAFFEINEFIORICET;ESGIC, PLUS (g)BUTALBITAL/ASPIRIN/CAFFEINEFIORINAL (g)

CODEINE/BUTALBITAL/ASA/CAFFEINFIORINAL W/CODEINE (g)SUMATRIPTAN SUCCINATEIMITREX INJECTION (g) [QL]

SUMATRIPTANIMITREX NASAL SPRAY (g) [QL]SUMATRIPTAN SUCCINATEIMITREX TABLETS (g) [QL]

ISOMETHEPTENE/APAP/DICHLPHENMIDRIN (g)BUTALBITAL/ACETAMINOPHENPHRENILIN (g)

BUTORPHANOL TARTRATESTADOL NS (g)BUTALB/ACETAMINOPHEN/CAFFEINEZEBUTAL (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

ERGOTAMINE TARTRATEERGOMAR [QL]RIZATRIPTAN BENZOATEMAXALT, MLT [ST] [QL]

DIHYDROERGOTAMINE MESYLATEMIGRANAL [QL]BUTALBITAL/ACETAMINOPHENPHRENILIN FORTE

NonformularyGeneric NameTrade Name Utilization Management

SUMATRIPTAN SUCCINATEALSUMA [ST] [QL]ALMOTRIPTAN MALATEAXERT [ST] [QL]

DICLOFENAC POTASSIUMCAMBIA [PA] [QL]FROVATRIPTAN SUCCINATEFROVA [ST] [QL]

ELETRIPTAN HYDROBROMIDERELPAX [ST] [QL]SUMATRIPTAN SUCCINATESUMAVEL DOSEPRO [ST] [QL]

SUMATRIPTAN SUCC/NAPROXEN SODTREXIMET [PA] [QL]ZOLMITRIPTANZOMIG NASAL SPRAY [ST] [QL]ZOLMITRIPTANZOMIG, ZMT [ST] [QL]

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

3O. Parkinsons Disease and Related Disorders

Formulary PreferredGeneric NameTrade Name Utilization Management

TRIHEXYPHENIDYL HCLARTANE (g)BENZTROPINE MESYLATECOGENTIN (g)

CABERGOLINEDOSTINEX (g)SELEGILINE HCLELDEPRYL(g)

PRAMIPEXOLE DI-HCLMIRAPEX (g)CARBIDOPA/LEVODOPAPARCOPA (g)

BROMOCRIPTINE MESYLATEPARLODEL (g)ROPINIROLE HCLREQUIP (g)

CARBIDOPA/LEVODOPASINEMET (g)CARBIDOPA/LEVODOPASINEMET CR (g)

AMANTADINE HCLSYMMETREL (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

APOMORPHINE HCLAPOKYN <s>ENTACAPONECOMTAN

CARBIDOPA/LEVODOPA/ENTACAPONESTALEVO

NonformularyGeneric NameTrade Name Utilization Management

RASAGILINE MESYLATEAZILECTPRAMIPEXOLE DI-HCLMIRAPEX ER [PA] [QL]

ROPINIROLE HCLREQUIP XL [QL]TOLCAPONETASMAR

SELEGILINE HCLZELAPAR [QL]

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

3P. Anticonvulsants

Formulary PreferredGeneric NameTrade Name Utilization Management

VALPROATE SODIUMDEPAKENE (g)DIVALPROEX SODIUMDEPAKOTE (g)DIVALPROEX SODIUMDEPAKOTE ER (g)DIVALPROEX SODIUMDEPAKOTE SPRINKLES (g)

ACETAZOLAMIDEDIAMOX (g)DIAZEPAMDIASTAT 2.5MG (g)

PHENYTOIN SODIUM EXTENDEDDILANTIN (g)LEVETIRACETAMKEPPRA (g)

CLONAZEPAMKLONOPIN, WAFER (g)LAMOTRIGINELAMICTAL DISPERTABS (g)LAMOTRIGINELAMICTAL TABS (g)

MEPHOBARBITALMEBARAL (g)PRIMIDONEMYSOLINE (g)

GABAPENTINNEURONTIN (g)PHENOBARBITALPHENOBARBITAL (g)CARBAMAZEPINETEGRETOL (g)CARBAMAZEPINETEGRETOL XR (g)

TOPIRAMATETOPAMAX (g)TOPIRAMATETOPAMAX SPRINKLE (g)

OXCARBAZEPINETRILEPTAL (g)OXCARBAZEPINETRILEPTAL SUSP (g)ETHOSUXIMIDEZARONTIN (g)

ZONISAMIDEZONEGRAN (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

RUFINAMIDEBANZELMETHSUXIMIDECELONTIN

DIAZEPAMDIASTATPHENYTOINDILANTIN CHEW TABSFELBAMATEFELBATOL

TIAGABINE HCLGABITRILGABAPENTINNEURONTIN SOLUTION

ETHOTOINPEGANONEVIGABATRINSABRIL <s>

CARBAMAZEPINETEGRETOL XR 100MGLACOSAMIDEVIMPAT

NonformularyGeneric NameTrade Name Utilization Management

CARBAMAZEPINECARBATROLCARBAMAZEPINEEQUETROLEVETIRACETAMKEPPRA XR

LAMOTRIGINELAMICTAL ODT [QL]LAMOTRIGINELAMICTAL XR [QL]PREGABALINLYRICA [PA] [QL]

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

3Q. Skeletal Muscle Relaxants

Formulary PreferredGeneric NameTrade Name Utilization Management

DANTROLENE SODIUMDANTRIUM (g)CYCLOBENZAPRINE HCLFLEXERIL (g)

BACLOFENLIORESAL (g)ORPHENADRINE CITRATENORFLEX (g)

ORPHENADRINE/ASPIRIN/CAFFEINENORGESIC, FORTE (g)CHLORZOXAZONEPARAFLEX, PARAFON FORTE DSC (g)METHOCARBAMOLROBAXIN (g)

METAXALONESKELAXIN (g)CARISOPRODOLSOMA (g)

CARISOPRODOL/ASPIRINSOMA COMPOUND (g)CODEINE PHOS/CARISOPRODOL/ASASOMA COMPOUND W/CODEINE (g)

DIAZEPAMVALIUM (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

NONE

NonformularyGeneric NameTrade Name Utilization Management

CYCLOBENZAPRINE HCLAMRIX [QL]CYCLOBENZAPRINE HCLFEXMID

TIZANIDINE HCLZANAFLEX CAPSTIZANIDINE HCLZANAFLEX TABS (g)

3R. Myesthenia Gravis

Formulary PreferredGeneric NameTrade Name Utilization Management

PYRIDOSTIGMINE BROMIDEMESTINON (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

PYRIDOSTIGMINE BROMIDEMESTINON TIMESPAN, SYRUPNEOSTIGMINE BROMIDEPROSTIGMIN

NonformularyGeneric NameTrade Name Utilization Management

AMBENONIUM CHLORIDEMYTELASE

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

3S. Miscellaneous CNS

Formulary PreferredGeneric NameTrade Name Utilization Management DONEPEZIL HCLARICEPT, ODT (g)

LITHIUM CARBONATEESKALITH (g)LITHIUM CARBONATEESKALITH CR (g)

RIVASTIGMINE TARTRATEEXELON (g) [QL]LITHIUM CITRATELITHIUM CITRATE (g)

LITHIUM CARBONATELITHOBID (g)NIMODIPINENIMOTOP (g)

GALANTAMINE HYDROBROMIDERAZADYNE SOLUTION (g)GALANTAMINE HYDROBROMIDERAZADYNE, ER (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

RIVASTIGMINE TARTRATEEXELON [QL]MEMANTINE HCLNAMENDA, SOLN

RILUZOLERILUTEK

NonformularyGeneric NameTrade Name Utilization Management DONEPEZIL HCLARICEPT 23MG [ST]

TACRINE HCLCOGNEXGUANFACINE HCLINTUNIV [PA] [QL]MILNACIPRAN HCLSAVELLA [PA] [QL]SODIUM OXYBATEXYREM [PA] [QL]

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

4. GASTROINTESTINAL AGENTS

4A. H2-Receptor Antagonists

Formulary PreferredGeneric NameTrade Name Utilization Management

NIZATIDINEAXID (RX ONLY) (g)FAMOTIDINEPEPCID (RX ONLY) (g)CIMETIDINETAGAMET (RX ONLY) (g)

RANITIDINE HCLZANTAC (RX ONLY) (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

NONE

NonformularyGeneric NameTrade Name Utilization Management RANITIDINE HCLZANTAC EFFERDOSE

4B. Proton Pump Inhibitors

Formulary PreferredGeneric NameTrade Name Utilization Management OMEPRAZOLEOMEPRAZOLE OTC (g)

LANSOPRAZOLEPREVACID (g) [ST]LANSOPRAZOLEPREVACID SOLUTAB (g) [PA]

OMEPRAZOLEPRILOSEC (g)OMEPRAZOLEPRILOSEC 40MG [PA]

OMEPRAZOLE MAGNESIUMPRILOSEC OTCPANTOPRAZOLE SODIUMPROTONIX (g) [PA]

OMEPRAZOLE/SODIUM BICARBONATEZEGERID CAP (Rx Only) (g) [PA] [QL]

Formulary OptionsGeneric NameTrade Name Utilization Management

NONE

NonformularyGeneric NameTrade Name Utilization Management

RABEPRAZOLE SODIUMACIPHEX [PA]DEXLANSOPRAZOLEDEXILANT [PA][ST] [QL]

ESOMEPRAZOLE MAG TRIHYDRATENEXIUM [PA][ST]OMEPRAZOLE MAGNESIUMPRILOSEC SUSPENSION [PA]PANTOPRAZOLE SODIUMPROTONIX SUSPENSION [ST]

NAPROXEN/ESOMEPRAZOLE MAGVIMOVO [PA] [QL]OMEPRAZOLE/SODIUM BICARBONATEZEGERID PACKET [PA] [QL]

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

4C. Other Ulcer Therapy

Formulary PreferredGeneric NameTrade Name Utilization Management SUCRALFATECARAFATE SUSP (g)SUCRALFATECARAFATE TABS (g)

MISOPROSTOLCYTOTEC (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

TETRACYC HCL/BIS SS/METRONIDHELIDACLANSOPRAZOLE/AMOX TR/CLARITHPREVPAC

NonformularyGeneric NameTrade Name Utilization Management

BISMUTH/METRONID/TETRACYCLINEPYLERA

4D. Antidiarrheals and Antispasmodics

Formulary PreferredGeneric NameTrade Name Utilization Management

ERGOTAMINE TART/BELLAD ALK/PBBELLAMINE/BELLASPAS (g)DICYCLOMINE HCLBENTYL (g)

BELLADONNA ALKALOIDS/PHENOBARBDONNATAL (g)HYOSCYAMINE SULFATELEVBID (g)HYOSCYAMINE SULFATELEVSIN, SL (g)HYOSCYAMINE SULFATELEVSINEX (g)

CLIDINIUM BR/CHLORDIAZEPOXIDELIBRAX (g)DIPHENOXYLATE HCL/ATROP SULFLOMOTIL (g)

PAREGORICPAREGORIC (g)PROPANTHELINE BROMIDEPRO-BANTHINE 15MG (g)

GLYCOPYRROLATEROBINUL, FORTE (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

NONE

NonformularyGeneric NameTrade Name Utilization Management

MEPENZOLATE BROMIDECANTILBELLADONNA ALKALOIDS/PHENOBARBDONNATAL EXTENTABS

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

4E. Antiemetics

Formulary PreferredGeneric NameTrade Name Utilization Management MECLIZINE HCLANTIVERT (g)

PROCHLORPERAZINE MALEATECOMPAZINE (g)GRANISETRON HCLKYTRIL (g) [QL]

DRONABINOLMARINOL (g) [QL]PROMETHAZINE HCLPHENERGAN (g)

TRIMETHOBENZAMIDE HCLTIGAN (g)ONDANSETRON HCLZOFRAN (g)

ONDANSETRONZOFRAN ODT (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

APREPITANTEMEND 80,125MG CAPSULES [QL]SCOPOLAMINE HYDROBROMIDETRANSDERM-SCOP

NonformularyGeneric NameTrade Name Utilization Management

DOLASETRON MESYLATEANZEMET [QL]NABILONECESAMET

GRANISETRONSANCUSO [ST] [QL]ONDANSETRONZUPLENZ [ST] [QL]

4F. Bile Acids

Formulary PreferredGeneric NameTrade Name Utilization Management

URSODIOLACTIGALL (g)URSODIOLURSO (g)URSODIOLURSO FORTE (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

NONE

NonformularyGeneric NameTrade Name Utilization Management

CHENODIOLCHENODAL [PA]

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

4G. Digestive Enzymes

Formulary PreferredGeneric NameTrade Name Utilization Management

AMYLASE/LIPASE/PROTEASEDYGASE (g)AMYLASE/LIPASE/PROTEASELAPASE (g)AMYLASE/LIPASE/PROTEASEPANCREASE MT 10, 16, 20 (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

AMYLASE/LIPASE/PROTEASECREONAMYLASE/LIPASE/PROTEASELIPRAM-UL20AMYLASE/LIPASE/PROTEASEPANCREASE MT 4AMYLASE/LIPASE/PROTEASEPANCRELIPASE ECAMYLASE/LIPASE/PROTEASEPANGESTYME UL 12AMYLASE/LIPASE/PROTEASEULTRASE MTAMYLASE/LIPASE/PROTEASEVIOKASE

NonformularyGeneric NameTrade Name Utilization Management

LIPASE/PROTEASE/AMYLASEPANCREAZEAMYLASE/LIPASE/PROTEASEPANCRECARB MSAMYLASE/LIPASE/PROTEASEZENPEP

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

4H. Miscellaneous Gastrointestinal Agents

Formulary PreferredGeneric NameTrade Name Utilization Management

HC ACETATE/PRAMOXINE HCLANALPRAM HC (g)LIDOCAINE HCL/HCANAMANTLE HC (g)HYDROCORTISONEANNUSOL HC, PROCTOCREAM HC (g)

SULFASALAZINEAZULFIDINE EN-TAB (g)SULFASALAZINEAZULFIDINE TAB (g)

BALSALAZIDE DISODIUMCOLAZAL (g)HYDROCORTISONE ACETATECORTENEMA (g)POLYETHYLENE GLYCOL 3350GLYCOLAX (g)

LACTULOSELACTULOSE (g)HC ACETATE/PRAMOXINE HCLPRAMOSONE (g)HYDROCORTISONE ACETATEPROCTOCORT SUPPOSITORY (g)

METOCLOPRAMIDE HCLREGLAN TAB, SOLUTION (g)MESALAMINEROWASA ENEMA (g)

Formulary OptionsGeneric NameTrade Name Utilization Management MESALAMINEASACOLMESALAMINEASACOL HDMESALAMINECANASA

HYDROCORTISONE ACETATECORTIFOAMMESALAMINEPENTASA

METHYLNALTREXONERELISTOR [PA] [QL]

NonformularyGeneric NameTrade Name Utilization Management LUBIPROSTONEAMITIZA [PA] [QL]

MESALAMINEAPRISOCERTOLIZUMABCIMZIA SYRINGE [PA] [QL] <s>

OLSALAZINE SODIUMDIPENTUMMESALAMINELIALDA [QL]

ALOSETRON HCLLOTRONEX [PA] [QL]METOCLOPRAMIDE HCLMETOZOLV ODT

HC ACETATE/LIDOCAINE HCLPERANEX HCHC ACETATE/PRAMOXINE HCLPRAMOSONE LOTION

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

5. OBSTETRICS AND GYNECOLOGY

5A. Contraceptives-Monophasic

Formulary PreferredGeneric NameTrade Name Utilization Management

LEVONORGESTREL-ETH ESTRAALESSE (g), LEVLITE (g)ETHYNODIOL D-ETHINYL ESTRADIOLDEMULEN (g)DESOGESTREL-ETHINYL ESTRADIOLDESOGEN (g), ORTHO-CEPT (g)NORGESTREL-ETHINYL ESTRADIOLLO/OVRAL (g)NORETH A-ET ESTRA/FE FUMARATELOESTRIN, FE (g)NORETHINDRONE-ETHINYL ESTRADMODICON (g)

LEVONORGESTREL-ETH ESTRANORDETTE, LEVLEN (g)NORETHINDRONE-MESTRANOLNORINYL 1/35 (g), ORTHO-NOVUM 1/35 (g)

NORETHINDRONE-ETHINYL ESTRADNORINYL 1/50 (g), ORTHO-NOVUM 1/50 (g)NORGESTIMATE-ETHINYL ESTRADIOLORTHO-CYCLEN (g)NORETHINDRONE-ETHINYL ESTRADOVCON 35 (g)NORGESTREL-ETHINYL ESTRADIOLOVRAL (g)

LEVONORGESTREL-ETH ESTRASEASONALE (g) [QL]ETHINYL ESTRADIOL/DROSPIRENONEYASMIN 28 (g)ETHINYL ESTRADIOL/DROSPIRENONEYAZ (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

LEVONORGESTREL-ETH ESTRALYBREL

NonformularyGeneric NameTrade Name Utilization Management

NORETH-ETHINYL ESTRADIOL/IRONFEMCON FENORETH A-ET ESTRA/FE FUMARATELOESTRIN 24 FENORETHINDRONE-ETHINYL ESTRADOVCON-50, FE

5B. Contraceptives-Biphasic

Formulary PreferredGeneric NameTrade Name Utilization Management

DESOG-ET ESTRA/ETHIN ESTRAMIRCETTE (g)NORETHINDRONE-ETHINYL ESTRADNECON 10/11 (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

NONE

NonformularyGeneric NameTrade Name Utilization Management

L-NORGEST-ETH ESTR/ETHIN ESTRALOSEASONIQUE [QL]L-NORGEST-ETH ESTR/ETHIN ESTRASEASONIQUE [QL]

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

5C. Contraceptives-Triphasic

Formulary PreferredGeneric NameTrade Name Utilization Management

DESOGESTREL-ETHINYL ESTRADIOLCYCLESSA (g)NORETH A-ET ESTRA/FE FUMARATEESTROSTEP FE (g)

NORGESTIMATE-ETHINYL ESTRADIOLORTHO TRI-CYCLEN (g)NORETHINDRONE-ETHINYL ESTRADORTHO-NOVUM 7/7/7 (g)NORETHINDRONE-ETHINYL ESTRADTRI-NORINYL (g)

LEVONORGESTREL-ETH ESTRATRIPHASIL, TRILEVLEN (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

NORGESTIMATE-ETHINYL ESTRADIOLORTHO TRI-CYCLEN LO

NonformularyGeneric NameTrade Name Utilization Management

NONE

5D. Contraceptives-Misc.

Formulary PreferredGeneric NameTrade Name Utilization Management

NORETHINDRONEORTHO MICRONOR (g), NOR-QD (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

ETHINYL ESTRADIOL/NORELGESTORTHO EVRA [QL]

NonformularyGeneric NameTrade Name Utilization Management

DROSPIR/ETH ESTRA/LEVOMEFOL CABEYAZESTRADIOL VALERATE/DIENOGESTNATAZIA

ETONOGESTREL/ETHINYL ESTRADIOLNUVARING [QL]

5E. Contraceptives-Postcoital

Formulary PreferredGeneric NameTrade Name Utilization Management

LEVONORGESTRELPLAN B (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

NONE

NonformularyGeneric NameTrade Name Utilization Management

ULIPRISTAL ACETATEELLA [QL]LEVONORGESTRELPLAN B ONE-STEP

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

5F. Progestins

Formulary PreferredGeneric NameTrade Name Utilization Management

NORETHINDRONE ACETATEAYGESTIN (g)MEDROXYPROGESTERONE ACETDEPO-PROVERA 150MG (g)

PROGESTERONEPROGESTERONE IN OIL (INJ) (g)MEDROXYPROGESTERONE ACETPROVERA (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

PROGESTERONE,MICRONIZEDCRINONEMEDROXYPROGESTERONE ACETDEPO-SUBQ PROVERA 104PROGESTERONE, MICRONIZEDENDOMETRINPROGESTERONE,MICRONIZEDPROCHIEVEPROGESTERONE,MICRONIZEDPROMETRIUM

NonformularyGeneric NameTrade Name Utilization Management

NONE

5G. Estrogens

Formulary PreferredGeneric NameTrade Name Utilization Management

ESTRADIOLCLIMARA (g) [QL]ESTRADIOLESTRACE (g)

ESTROPIPATEOGEN, ORTHO-EST (g)ESTRADIOLVIVELLE (g) [QL]

Formulary OptionsGeneric NameTrade Name Utilization Management

ESTRADIOLALORA [QL]ESTRADIOLESTRADERM [QL]ESTRADIOLESTRING [QL]

ESTROGENS,CONJUGATEDPREMARIN CREAMESTROGENS,CONJUGATEDPREMARIN, PREMARIN LOW DOSE

ESTRADIOLVIVELLE-DOT [QL]

NonformularyGeneric NameTrade Name Utilization Management

ESTROGENS,CONJ.,SYNTHETIC ACENESTINESTRADIOLDIVIGELESTRADIOLELESTRIN [QL]

ESTROGENS,CONJ.,SYNTHETIC BENJUVIA [QL]ESTRADIOLESTRACE VAGINAL CREAMESTRADIOLESTRASORB [QL]ESTRADIOLESTROGEL [QL]

ESTRADIOL TRANSDERMAL SPRAYEVAMIST [QL]ESTRADIOL ACETATEFEMRING [QL]ESTRADIOL ACETATEFEMTRACE

ESTROGENS,ESTERIFIEDMENESTESTRADIOLMENOSTAR [QL]ESTRADIOLVAGIFEM

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

5H. Estrogen/Progestin Combinations

Formulary PreferredGeneric NameTrade Name Utilization Management

ESTRADIOL/NORETH ACACTIVELLA (g)ESTROGEN,ESTER/ME-TESTOSTERONEESTRATEST, H.S. (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

ETHINYL ESTRADIOL/NORETH ACFEMHRTESTROGEN,CON/M-PROGEST ACETPREMPRO, LOW DOSE/PREMPHASE

NonformularyGeneric NameTrade Name Utilization Management

ESTRADIOL/NORETH ACACTIVELLA 0.5-0.1MGESTRADIOL/DROSPIRENONEANGELIQ

ESTRADIOL/LEVONORGESTRELCLIMARA PRO [QL]ESTRADIOL/NORETH ACCOMBIPATCH [QL]

ESTRADIOL/NORGESTIMATEORTHO-PREFEST

5J. Infertility Treatment

Formulary PreferredGeneric NameTrade Name Utilization Management

CLOMIPHENE CITRATECLOMID (g)LEUPROLIDE ACETATELUPRON (g) [PA] <s>

Formulary OptionsGeneric NameTrade Name Utilization Management

UROFOLLITROPIN (FSH)BRAVELLE [PA] <s>CETRORELIX ACETATECETROTIDE [PA] <s>UROFOLLITROPIN (FSH)FERTINEX [PA] <s>

GANIRELIX ACETATEGANIRELIX ACETATE [PA] <s>FOLLITROPIN ALPHA,RECOMBGONAL-F, RFF [PA] <s>

GONADOTROPIN,CHORIONIC,HUMANNOVAREL, PREGNYL, PROFASI [PA] <s>HCG ALPHA,RECOMBINANTOVIDREL [PA] <s>

GONADOTROPIN,CHORIONIC,HUMANPROFASI 5000UNITS [PA] <s>MENOTROPINSREPRONEX [PA] <s>

NonformularyGeneric NameTrade Name Utilization Management

FOLLITROPIN BETA,RECOMBFOLLISTIM AQ [PA] <s>LUTROPIN ALPHALUVERIS [PA] <s>

MENOTROPINSMENOPUR [PA] <s>

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

5K. Vaginal Anti-infective/Antifungal

Formulary PreferredGeneric NameTrade Name Utilization Management

CLINDAMYCIN PHOSPHATECLEOCIN VAG CREAM (g)FLUCONAZOLEDIFLUCAN (g)

METRONIDAZOLEMETROGEL-VAGINAL (g)NYSTATINNYSTATIN (g)

TERCONAZOLETERAZOL- 3, 7 (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

NONE

NonformularyGeneric NameTrade Name Utilization Management SULFANILAMIDEAVC

CLINDAMYCIN PHOSPHATECLEOCIN VAGINAL OVULESCLINDAMYCIN PHOSPHATECLINDESSEBUTOCONAZOLE NITRATEGYNAZOLE-1

5L. Miscellaneous OB-GYN

Formulary PreferredGeneric NameTrade Name Utilization Management

NONE

Formulary OptionsGeneric NameTrade Name Utilization Management

LEUPROLIDE ACETATELUPRON DEPOT <s>METHYLERGONOVINE MALEATEMETHERGINE

NAFARELIN ACETATESYNAREL

NonformularyGeneric NameTrade Name Utilization Management

TRANEXAMIC ACIDLYSTEDA [QL]

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

6. RHEUMATOLOGY AND MUSCULOSKELETAL

6A. Salicylates

Formulary PreferredGeneric NameTrade Name Utilization Management

SEE CHAPTERS 3F & 3GSALICYLATES AND NSAIDS

Formulary OptionsGeneric NameTrade Name Utilization Management

NONE

NonformularyGeneric NameTrade Name Utilization Management

NONE

6B. Gout Therapy

Formulary PreferredGeneric NameTrade Name Utilization Management

COLCHICINE/PROBENECIDCOLBENEMID (g)PROBENECIDPROBENECID (g)ALLOPURINOLZYLOPRIM (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

COLCHICINECOLCRYSFEBUXOSTATULORIC [PA] [QL]

NonformularyGeneric NameTrade Name Utilization Management

NONE

6C. Corticosteroids

Formulary PreferredGeneric NameTrade Name Utilization Management

SEE CHAPTER 7CCORTICOSTEROIDS

Formulary OptionsGeneric NameTrade Name Utilization Management

NONE

NonformularyGeneric NameTrade Name Utilization Management

NONE

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

6D. Miscellaneous Rheumatologic Agents

Formulary PreferredGeneric NameTrade Name Utilization Management LEFLUNOMIDEARAVA (g) [QL]

SULFASALAZINEAZULFIDINE EN-TAB (g)SULFASALAZINEAZULFIDINE TAB (g)AZATHIOPRINEIMURAN (g)

METHOTREXATE SODIUM/PFMETHOTREXATE (g)HYDROXYCHLOROQUINE SULFATEPLAQUENIL (g)

Formulary OptionsGeneric NameTrade Name Utilization Management PENICILLAMINECUPRIMINEETANERCEPTENBREL [PA] [QL] <s>ADALIMUMABHUMIRA [PA] [QL] <s>

METHOTREXATE SODIUMRHEUMATREX, TREXALLAURANOFINRIDAURA

NonformularyGeneric NameTrade Name Utilization Management CERTOLIZUMABCIMZIA SYRINGE [PA] [QL] <s>PENICILLAMINEDEPEN

ANAKINRAKINERET [PA] [QL] <s>GOLIMUMABSIMPONI [PA] [QL] <s>

6E. Osteoporosis/Hormonal Treatment

Formulary PreferredGeneric NameTrade Name Utilization Management

ESTRADIOLCLIMARA (g) [QL]ESTRADIOLESTRACE (g)

ESTROGEN,ESTER/ME-TESTOSTERONEESTRATEST, H.S. (g)ESTROPIPATEOGEN, ORTHO-EST (g)

ESTRADIOLVIVELLE (g) [QL]

Formulary OptionsGeneric NameTrade Name Utilization Management

ESTRADIOLALORA [QL]ESTRADIOLESTRADERM [QL]

ETHINYL ESTRADIOL/NORETH ACFEMHRTESTROGENS,CONJUGATEDPREMARIN CREAMESTROGENS,CONJUGATEDPREMARIN, PREMARIN LOW DOSE

ESTROGEN,CON/M-PROGEST ACETPREMPRO, LOW DOSE/PREMPHASEESTRADIOLVIVELLE-DOT [QL]

NonformularyGeneric NameTrade Name Utilization Management

ESTROGENS,CONJ.,SYNTHETIC ACENESTINESTROGENS,CONJ.,SYNTHETIC BENJUVIA [QL]

TERIPARATIDEFORTEO [PA] [QL] <s>ESTROGENS,ESTERIFIEDMENEST

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

6F. Osteoporosis/Bone Resorption

Formulary PreferredGeneric NameTrade Name Utilization Management

ETIDRONATE DISODIUMDIDRONEL (g) [QL]FIRST-LINE THERAPY WHEN APPROPRIATEESTROGENS

ALENDRONATE SODIUMFOSAMAX (g) BEALENDRONATE SODIUMFOSAMAX WEEKLY (g) [QL] BE

CALCITONIN,SALMON,SYNTHETICMIACALCIN NASAL SPRAY (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

RISEDRON SOD/CALCIUM CARBONATEACTONEL WITH CALCIUM [ST] [QL]RISEDRONATE SODIUMACTONEL, WEEKLY, 150MG [ST] [QL]

RALOXIFENE HCLEVISTACALCITONIN,SALMON,SYNTHETICMIACALCIN INJECTION

NonformularyGeneric NameTrade Name Utilization Management

IBANDRONATE SODIUMBONIVA [ST] [QL]ALENDRONATE SODIUM/VITAMIN D3FOSAMAX PLUS D [ST] [QL]

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

7. ENDOCRINOLOGY

7A. Antithyroid Agents

Formulary PreferredGeneric NameTrade Name Utilization Management

PROPYLTHIOURACILPROPYLTHIOURACIL (g)POTASSIUM IODIDESSKI (g)

METHIMAZOLETAPAZOLE (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

NONE

NonformularyGeneric NameTrade Name Utilization Management

NONE

7B. Thyroid Hormones

Formulary PreferredGeneric NameTrade Name Utilization Management

LIOTHYRONINE SODIUMCYTOMEL (g)LEVOTHYROXINE SODIUMLEVOTHYROXINE (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

LIOTRIXTHYROLAR

NonformularyGeneric NameTrade Name Utilization Management

THYROIDARMOUR THYROIDLEVOTHYROXINE SODIUMTIROSINT

7C. Corticosteroids

Formulary PreferredGeneric NameTrade Name Utilization Management

HYDROCORTISONECORTEF, HYDROCORTISONE (g)CORTISONE ACETATECORTISONE ACETATE (g)

DEXAMETHASONEDECADRON (g)FLUDROCORTISONE ACETATEFLORINEF (g)

METHYLPREDNISOLONEMEDROL, DOSEPAK (g)PREDNISOLONE SOD PHOSPHATEORAPRED (g)

PREDNISOLONEPREDNISOLONE, TABS, SYRUP (g)PREDNISONEPREDNISONE (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

NONE

NonformularyGeneric NameTrade Name Utilization Management BUDESONIDEENTOCORT EC

PREDNISOLONE SOD PHOSPHATEORAPRED ODT

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

7D. Androgens

Formulary PreferredGeneric NameTrade Name Utilization Management

FLUOXYMESTERONEANDROXY 10MG (g)DANAZOLDANOCRINE (g)

TESTOSTERONE CYPIONATEDEPO-TESTOSTERONE (g)OXANDROLONEOXANDRIN (g) [PA]

Formulary OptionsGeneric NameTrade Name Utilization Management

TESTOSTERONEANDRODERM [QL]TESTOSTERONE ENANTHATEDELATESTRYL

NonformularyGeneric NameTrade Name Utilization Management

OXYMETHOLONEANADROL-50 [PA]TESTOSTERONEANDROGEL [QL]

METHYLTESTOSTERONEMETHITEST [PA]TESTOSTERONESTRIANT [QL]TESTOSTERONETESTIM [QL]

METHYLTESTOSTERONETESTRED, ANDROID

7E. Miscellaneous Endocrine

Formulary PreferredGeneric NameTrade Name Utilization Management

ERGOCALCIFEROLCALCIFEROL (g)DESMOPRESSIN ACETATEDDAVP SPRAY (g)DESMOPRESSIN ACETATEDDAVP TABS (g)

CABERGOLINEDOSTINEX (g)CALCITONIN,SALMON,SYNTHETICMIACALCIN NASAL SPRAY (g)

FINASTERIDEPROSCAR (g)CALCITRIOLROCALTROL (g)

OCTREOTIDE ACETATESANDOSTATIN (g) [PA] <s>

Formulary OptionsGeneric NameTrade Name Utilization Management

DESMOPRESSIN ACETATEDDAVP SOLNGLUCAGON,HUMAN RECOMBINANTGLUCAGON EMERGENCY KIT

LEUPROLIDE ACETATELUPRON DEPOT-PED <s>CALCITONIN,SALMON,SYNTHETICMIACALCIN INJECTION

OCTREOTIDE ACETATESANDOSTATIN LAR [PA] <s>CINACALCET HCLSENSIPAR <s>

LANREOTIDE ACETATESOMATULINE DEPOT <s>PEGVISOMANTSOMAVERT [PA] <s>

DESMOPRESSIN ACETATESTIMATENAFARELIN ACETATESYNAREL

NonformularyGeneric NameTrade Name Utilization Management

DOXERCALCIFEROLHECTOROLPARICALCITOLZEMPLAR

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

7F. Insulins

Formulary PreferredGeneric NameTrade Name Utilization Management

NONE

Formulary OptionsGeneric NameTrade Name Utilization Management

INSULIN GLULISINEAPIDRA (PEN/CARTRIDGE)INSULIN GLULISINEAPIDRA (VIAL)

INSULIN LISPRO,HUMAN REC.ANLOGHUMALOG, MIX (PEN/CARTRIDGE)INSULIN NPL/INSULIN LISPROHUMALOG, MIX (VIAL) BE

HUMULINHUMULIN 70/30 (PEN/CARTRIDGE)HUMULINHUMULIN 70/30 (VIAL) BE

NPH, HUMAN INSULIN ISOPHANEHUMULIN N (PEN/CARTRIDGE)NPH, HUMAN INSULIN ISOPHANEHUMULIN N (VIAL) BEINSULIN REGULAR HUMAN RECHUMULIN R (VIAL) BE

INSULIN GLARGINE,HUM.REC.ANLOGLANTUS (PEN/CARTRIDGE)INSULIN GLARGINE,HUM.REC.ANLOGLANTUS (VIAL)

INSULIN DETEMIRLEVEMIR (PEN)INSULIN DETEMIRLEVEMIR (VIAL)

INSULIN REGULAR HUMAN RECNOVOLIN (PEN/CARTRIDGE)INSULIN REGULAR HUMAN RECNOVOLIN (VIAL) BE

INSULIN ASPARTNOVOLOG (PEN/CARTRIDGE)INSULIN ASPARTNOVOLOG (VIAL) BE

INSULN ASP PRT/INSULIN ASPARTNOVOLOG MIX (PEN/CARTRIDGE)

NonformularyGeneric NameTrade Name Utilization Management

NONE

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

7G. Non-insulin Hypoglycemic Agents

Formulary PreferredGeneric NameTrade Name Utilization Management GLIMEPIRIDEAMARYL (g) BEGLYBURIDEDIABETA, MICRONASE (g) BE

CHLORPROPAMIDEDIABINESE (g) BEMETFORMIN HCLGLUCOPHAGE (g) BEMETFORMIN HCLGLUCOPHAGE XR (g) BE

GLIPIZIDEGLUCOTROL (g) BEGLIPIZIDEGLUCOTROL XL (g) BE

GLYBURIDE/METFORMIN HCLGLUCOVANCE (g) BEGLYBURIDE,MICRONIZEDGLYNASE (g) BE

GLIPIZIDE/METFORMIN HCLMETAGLIP (g) BETOLBUTAMIDEORINASE (g)

ACARBOSEPRECOSE (g)NATEGLINIDESTARLIX (g)TOLAZAMIDETOLINASE (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

PIOGLITAZONE HCL/METFORMIN HCLACTOPLUS MET [ST] [QL]PIOGLITAZONE HCLACTOS [ST] [QL]

PIOGLITAZONE/GLIMEPIRIDEDUETACT [ST] [QL]REPAGLINIDEPRANDIN

NonformularyGeneric NameTrade Name Utilization Management

PIOGLITAZONE HCL/METFORMIN HCLACTOPLUS MET XR [ST] [QL]ROSIGLITAZONE/METFORMIN HCLAVANDAMET [ST] [QL]

ROSIGLITAZONE MALEATE/GLIMEPIRAVANDARYL [ST]ROSIGLITAZONE MALEATEAVANDIA [ST] [QL]

EXENATIDEBYETTA [PA] [QL]METFORMIN HCLFORTAMETMETFORMIN HCLGLUMETZA

MIGLITOLGLYSETSITAGLIPTIN PHOS/METFORMIN HCLJANUMET [PA]

SITAGLIPTIN PHOSPHATEJANUVIA [PA] [QL]SAXAGLIPTIN HYDROCHLORIDEONGLYZA [PA] [QL]REPAGLINIDE/METFORMIN HCLPRANDIMET [PA]

METFORMIN HCLRIOMETPRAMLINTIDE ACETATESYMLIN [ST] [QL]

LIRAGLUTIDEVICTOZA [PA] [QL]

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

7H. Growth Hormone and Related Products

Formulary PreferredGeneric NameTrade Name Utilization Management

NONE

Formulary OptionsGeneric NameTrade Name Utilization Management SOMATROPINGENOTROPIN [PA] <s>SOMATROPINNUTROPIN [PA] <s>SOMATROPINNUTROPIN AQ [PA] <s>SOMATROPINNUTROPIN AQ NUSPIN [PA] <s>

NonformularyGeneric NameTrade Name Utilization Management SOMATROPINHUMATROPE [PA] <s>MECASERMININCRELEX [PA] <s>SOMATROPINNORDITROPIN NORDIFLEX [PA] <s>SOMATROPINOMNITROPE [PA] <s>SOMATROPINSAIZEN [PA] <s>SOMATROPINSEROSTIM [PA] <s>SOMATROPINTEV-TROPIN [PA] <s>SOMATROPINZORBTIVE [PA] <s>

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

8. ANTINEOPLASTICS AND IMMUNOSUPPRESANTS

8A. Alkylating Agents

Formulary PreferredGeneric NameTrade Name Utilization Management

CYCLOPHOSPHAMIDECYTOXAN (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

MELPHALANALKERANLOMUSTINECEENU

CHLORAMBUCILLEUKERANBUSULFANMYLERAN

TEMOZOLOMIDETEMODAR <s>

NonformularyGeneric NameTrade Name Utilization Management

NONE

8B. Antimetabolites

Formulary PreferredGeneric NameTrade Name Utilization Management

METHOTREXATE SODIUM/PFMETHOTREXATE (g)MERCAPTOPURINEPURINETHOL (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

FLUDARABINE PHOSPHATEOFORTA [QL] <s>THIOGUANINETHIOGUANINECAPECITABINEXELODA <s>

NonformularyGeneric NameTrade Name Utilization Management

NONE

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

8C. Immunomodulators

Formulary PreferredGeneric NameTrade Name Utilization Management

MYCOPHENOLATE MOFETILCELLCEPT (g) <s>AZATHIOPRINEIMURAN (g)

CYCLOSPORINE, MODIFIEDNEORAL (g) <s>PREDNISONEPREDNISONE (g)

TACROLIMUS ANHYDROUSPROGRAF (g) <s>

Formulary OptionsGeneric NameTrade Name Utilization Management RILONACEPTARCALYST [PA] <s>

MYCOPHENOLATE MOFETILCELLCEPT SUSPENSION <s>SIROLIMUSRAPAMUNE TABS, SOLUTION <s>

CYCLOSPORINESANDIMMUNE <s>THALIDOMIDETHALOMID <s>

NonformularyGeneric NameTrade Name Utilization Management

MYCOPHENOLATE SODIUMMYFORTIC <s>LENALIDOMIDEREVLIMID [PA] [QL] <s>

8D. Hormonal Agents

Formulary PreferredGeneric NameTrade Name Utilization Management ANASTROZOLEARIMIDEX (g) [PA] <s>BICALUTAMIDECASODEX (g) <s>

FLUTAMIDEEULEXIN (g)LEUPROLIDE ACETATELUPRON (g) <s>MEGESTROL ACETATEMEGACE (g)TAMOXIFEN CITRATETAMOXIFEN CITRATE (g)

Formulary OptionsGeneric NameTrade Name Utilization Management EXEMESTANEAROMASIN [PA] <s>

MEDROXYPROGESTERONE ACETDEPO-PROVERA 400MGTOREMIFENE CITRATEFARESTON

FULVESTRANTFASLODEXLETROZOLEFEMARA [PA] <s>

LEUPROLIDE ACETATELUPRON DEPOT <s>NILUTAMIDENILANDRON

TRIPTORELIN PAMOATETRELSTAR DEPOT, LA <s>GOSERELIN ACETATEZOLADEX [QL] <s>

NonformularyGeneric NameTrade Name Utilization Management

LEUPROLIDE ACETATEELIGARD <s>MEGESTROL ACETATEMEGACE ES

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

8E. Miscellaneous Antineoplastic Agents

Formulary PreferredGeneric NameTrade Name Utilization Management HYDROXYUREAHYDREA (g)

OCTREOTIDE ACETATESANDOSTATIN (g) [PA] <s>ETOPOSIDEVEPESID (g)

Formulary OptionsGeneric NameTrade Name Utilization Management HYDROXYUREADROXIA

ESTRAMUSTINE PHOSPHATE SODIUMEMCYTALTRETAMINEHEXALEN

TOPOTECAN HCLHYCAMTIN [PA] <s>MITOTANELYSODREN

PROCARBAZINE HCLMATULANEOCTREOTIDE ACETATESANDOSTATIN LAR [PA] <s>

TRETINOINVESANOIDVORINOSTATZOLINZA [PA] <s>

NonformularyGeneric NameTrade Name Utilization Management BEXAROTENETARGRETIN ORAL <s>

8F. Adjuvant Therapy

Formulary PreferredGeneric NameTrade Name Utilization Management

LEUCOVORIN CALCIUMLEUCOVORIN (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

SARGRAMOSTIMLEUKINE <s>MESNAMESNEX

FILGRASTIMNEUPOGEN <s>EPOETIN ALFAPROCRIT [PA] <s>

NonformularyGeneric NameTrade Name Utilization Management

DARBEPOETIN ALFA IN ALBUMN SOLARANESP [PA] <s>EPOETIN ALFAEPOGEN [PA] <s>

PEGFILGRASTIMNEULASTA [QL] <s>

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

8G. Kinase Inhibitors and Molecular Target Inhibitors

Formulary PreferredGeneric NameTrade Name Utilization Management

NONE

Formulary OptionsGeneric NameTrade Name Utilization Management EVEROLIMUSAFINITOR [PA] [QL] <s>

IMATINIB MESYLATEGLEEVEC <s>GEFITINIBIRESSA [PA] <s>

SORAFENIB TOSYLATENEXAVAR [PA] [QL] <s>DASATINIBSPRYCEL [PA] <s>

SUNITINIB MALATESUTENT [PA] [QL] <s>ERLOTINIB HCLTARCEVA [PA] <s>

NILOTINIB HYDROCHLORIDETASIGNA <s>LAPATINIB DITOSYLATETYKERB [PA] <s>

PAZOPANIB HYDROCHLORIDEVOTRIENT [PA] <s>EVEROLIMUSZORTRESS [QL] <s>

NonformularyGeneric NameTrade Name Utilization Management

NONE

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

9. IMMUNOLOGY AND HEMATOLOGY

9B. Hematopoietic Agents

Formulary PreferredGeneric NameTrade Name Utilization Management

NONE

Formulary OptionsGeneric NameTrade Name Utilization Management

SARGRAMOSTIMLEUKINE <s>OPRELVEKINNEUMEGA <s>FILGRASTIMNEUPOGEN <s>

EPOETIN ALFAPROCRIT [PA] <s>ELTROMBOPAG OLAMINEPROMACTA [PA] [QL] <s>

NonformularyGeneric NameTrade Name Utilization Management

DARBEPOETIN ALFA IN ALBUMN SOLARANESP [PA] <s>EPOETIN ALFAEPOGEN [PA] <s>

PEGFILGRASTIMNEULASTA [QL] <s>

9C. Interferons and MS Therapy

Formulary PreferredGeneric NameTrade Name Utilization Management

NONE

Formulary OptionsGeneric NameTrade Name Utilization Management

INTERFERON GAMMA-1B,RECOMB.ACTIMMUNE <s>INTERFERON ALFA-N3ALFERON NINTERFERON BETA-1AAVONEX <s>GLATIRAMER ACETATECOPAXONE <s>

INTERFERON ALFACON-1INFERGEN [PA] <s>INTERFERON ALFA-2B,RECOMB.INTRON A [PA] <s>

PEGINTERFERON ALFA-2APEGASYS [PA] [QL] <s>PEGINTERFERON ALFA-2BPEG-INTRON, REDIPEN [PA] [QL] <s>

INTERFERON BETA-1A/ALBUMINREBIF <s>

NonformularyGeneric NameTrade Name Utilization Management

FAMPRIDINE (4-AMINOPYRIDINE)AMPYRA [PA] [QL] <s>INTERFERON BETA-1BBETASERON [PA] <s>INTERFERON BETA-1BEXTAVIA <s>

FINGOLIMOD HYDROCHLORIDEGILENYA [PA] [QL] <s>

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

10. DERMATOLOGY

10A. Very High Potency Corticosteriods

Formulary PreferredGeneric NameTrade Name Utilization Management

BETAMET DIPROP/PROP GLYDIPROLENE OINTMENT (g)CLOBETASOL PROPIONATEOLUX (g)DIFLORASONE DIACETATEPSORCON, FLORONE (g)CLOBETASOL PROPIONATETEMOVATE (g), CLOBEVATE (g)

HALOBETASOL PROPIONATEULTRAVATE (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

NONE

NonformularyGeneric NameTrade Name Utilization Management

CLOBETASOL PROPIONATECLOBEX, SPRAYCLOBETASOL PROPIONATE/EMOLLOLUX-E

HALOBETASOL PROP/AMMONIUM LACULTRAVATE PACFLUOCINONIDEVANOS 0.1% CR

10B. High Potency Corticosteroids

Formulary PreferredGeneric NameTrade Name Utilization Management

TRIAMCINOLONE ACETONIDEARISTOCORT, KENALOG 0.5% CR (g)AMCINONIDECYCLOCORT (g)

BETAMET DIPROP/PROP GLYDIPROLENE AF, GEL, CR, LOT (g)BETAMETHASONE DIPROPIONATEDIPROSONE (g), MAXIVATE (g)

FLUOCINONIDELIDEX, E (g)DIFLORASONE DIACETATEPSORCON, FLORONE (g)

DESOXIMETASONETOPICORT CR, GEL, OINT (g)BETAMETHASONE VALERATEVALISONE CR, LOTION, OINT (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

NONE

NonformularyGeneric NameTrade Name Utilization Management

DIFLORASONE DIACETATE/EMOLLAPEXICON EHALCINONIDEHALOG

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

10C. Medium Potency Corticosteroids

Formulary PreferredGeneric NameTrade Name Utilization Management

TRIAMCINOLONE ACETONIDEARISTOCORT, KENALOG (g)FLUTICASONE PROPIONATECUTIVATE (g)

PREDNICARBATEDERMATOP (g)MOMETASONE FUROATEELOCON (g)

HYDROCORTISONE BUTYRATELOCOID CM, OINT, SOLN (g)HYDROCORTISONE BUTYRATE/EMOLLLOCOID LIPOCREAM (g)

FLUOCINOLONE ACETONIDESYNALAR 0.025% CREAM, OINT (g)DESOXIMETASONETOPICORT LP (g)

BETAMETHASONE VALERATEVALISONE CR, LOTION, OINT (g)HYDROCORTISONE VALERATEWESTCORT (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

CLOCORTOLONE PIVALATECLODERMFLURANDRENOLIDECORDRAN, TAPE, SP

NonformularyGeneric NameTrade Name Utilization Management

FLUTICASONE PROPIONATECUTIVATE LOTIONHYDROCORTISONE BUTYRATELOCOID LOTIONBETAMETHASONE VALERATELUXIQ

HYDROCORTISONE PROBUTATEPANDEL

10D. Low Potency Corticosteroids

Formulary PreferredGeneric NameTrade Name Utilization Management

ALCLOMETASONE DIPROPIONATEACLOVATE (g)HYDROCORTISONEDERMACORT, HYTONE (Rx Only) (g)

DESONIDEDESOWEN, TRIDESILON (g)FLUOCINOLONE ACETONIDESYNALAR CREAM, SOLN (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

FLUOCINOLONE ACETONIDECAPEX SHAMPOO

NonformularyGeneric NameTrade Name Utilization Management

FLUOCINOLONE ACETONIDEDERMA-SMOOTHE/FSDESONIDEDESONATE [ST]DESONIDEVERDESO [ST]

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

10E. Topical Anesthetics

Formulary PreferredGeneric NameTrade Name Utilization Management

LIDOCAINE/PRILOCAINEEMLA (g)LIDOCAINE HCLXYLOCAINE (Rx Only) (g)LIDOCAINE HCLXYLOCAINE VISCOUS (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

NONE

NonformularyGeneric NameTrade Name Utilization Management

LIDOCAINELIDODERM PATCH

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

10F. Acne Treatment

Formulary PreferredGeneric NameTrade Name Utilization Management ISOTRETINOINACCUTANE (REQ DERM CONSULT) (g)

ERYTHROMYCIN BASE/BENZ PERBENZAMYCIN (g)BENZOYL PEROXIDEBENZOYL PEROXIDE-RX (g)BENZOYL PEROXIDEBREVOXYL GEL (g)

CLINDAMYCIN PHOSPHATECLEOCIN T (g)ADAPALENEDIFFERIN 0.1% CREAM, GEL (g)ADAPALENEDIFFERIN LOTION

ERYTHROMYCIN BASE/ETHANOLERYTHROMYCIN TOPICAL SOLN, GEL (g)CLINDAMYCIN PHOSPHATEEVOCLIN FOAM(g)

METRONIDAZOLEMETROCREAM, GEL, LOTION (g)BENZOYL PEROXIDE MICROSPHERESNEOBENZ MICRO

SULFACETAMIDE SODIUM/SULFURPLEXION, TS (g)TRETINOINRETIN-A, AVITA (g)

SULFACETAMIDE SOD/SULFUR/UREAROSULA CLEANSER (g)SULFACETAMIDE SODIUM/SULFURSULFACET-R (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

ADAPALENEDIFFERIN 0.3% GELMETRONIDAZOLEMETROGEL TOPICAL 1%

TRETINOIN MICROSPHERESRETIN-A MICROTAZAROTENETAZORAC

NonformularyGeneric NameTrade Name Utilization Management

DAPSONEACZONE [QL]ERYTHROMYCIN BASEAKNE-MYCIN

RETAPAMULINALTABAXAZELAIC ACIDAZELEX

CLINDAMYCIN PHOSPHATE/BENZ PERBENZACLINBENZOYL PEROXIDEBENZASHAVEBENZOYL PEROXIDECLINAC BPO

CLINDAMYCIN PHOSPHATE/BENZ PERDUAC, CSADAPALENE/BENZOYL PEROXIDEEPIDUO

AZELAIC ACIDFINACEAMETRONIDAZOLENORITATE

SULFACETAMIDE SODIUM/SULFURROSULA FOAMCLINDAMYCIN/TRETINOINZIANA GEL [PA]

10G. Topical Antibacterials

Formulary PreferredGeneric NameTrade Name Utilization Management

MUPIROCINBACTROBAN OINTMENT (g)GENTAMICIN SULFATEGENTAMICIN CR, OINT (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

MUPIROCIN CALCIUMBACTROBAN CREAM, NASAL

NonformularyGeneric NameTrade Name Utilization Management RETAPAMULINALTABAX

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

10H. Topical Antifungals

Formulary PreferredGeneric NameTrade Name Utilization Management

CICLOPIROX OLAMINELOPROX CR, LOTION, GEL (g)CICLOPIROXLOPROX SHAMPOO (g)

CLOTRIMAZOLELOTRIMIN (g)CLOTRIMAZOLE/BETAMET DIPROPLOTRISONE CR, LOTION (g)

MICONAZOLE NITRATEMONISTAT-DERM (g)NYSTATINMYCOSTATIN (g)

KETOCONAZOLENIZORAL CREAM (g)KETOCONAZOLENIZORAL SHAMPOO 2% (g)

NYSTATIN/TRIAMCINNYSTATIN W/TRIAMCINOLONE (g)CICLOPIROXPENLAC (g)

ECONAZOLE NITRATESPECTAZOLE (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

CICLOPIROX/NAIL LACQUER REMOVRCNL 8

NonformularyGeneric NameTrade Name Utilization Management

SERTACONAZOLE NITRATEERTACZOSULCONAZOLE NITRATEEXELDERM SOLN, CR

KETOCONAZOLEEXTINABUTENAFINE HCLMENTAX

NAFTIFINE HCLNAFTINOXICONAZOLE NITRATEOXISTAT

MICONAZOLE NITRATE/ZINC OXIDEVUSIONKETOCONAZOLEXOLEGEL

KETOCONAZOLE/HYDROCORTISONEXOLEGEL COREPAK

10I. Topical Antivirals

Formulary PreferredGeneric NameTrade Name Utilization Management

NONE

Formulary OptionsGeneric NameTrade Name Utilization Management

ACYCLOVIRZOVIRAX CREAM, OINT

NonformularyGeneric NameTrade Name Utilization Management PENCICLOVIRDENAVIR

ACYCLOVIR/HYDROCORTISONEXERESE

(g) Use generic equivalent

[PA] Prior authorization may be required

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[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

10J. Wound and Burn Therapy

Formulary PreferredGeneric NameTrade Name Utilization Management PAPAIN/UREAACCUZYME, ETHEZYME, GLADASE (g)

TRYPSIN/BALSAM PERU/CASTOR OILGRANULEX (g)SILVER SULFADIAZINESILVADENE (g)

Formulary OptionsGeneric NameTrade Name Utilization Management COLLAGENASESANTYL

NonformularyGeneric NameTrade Name Utilization Management BECAPLERMINREGRANEX [PA]

10K. Antipsoriatic/Antiseborrheic

Formulary PreferredGeneric NameTrade Name Utilization Management

CALCIPOTRIENEDOVONEX OINT(g)CALCIPOTRIENEDOVONEX SOLUTION (g)

ANTHRALINDRITHOCREME HP (g)SELENIUM SULFIDESELSUN RX (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

CALCIPOTRIENEDOVONEX CREAMANTHRALINDRITHO-SCALP

ETANERCEPTENBREL [PA] [QL] <s>ADALIMUMABHUMIRA [PA] [QL] <s>

METHOXSALEN, RAPIDOXSORALEN, ULTRAACITRETINSORIATANE [QL]

NonformularyGeneric NameTrade Name Utilization Management

BETAMET DIPROP/CALCIPOTRIENETACLONEX, SCALP [PA]CALCITRIOLVECTICAL

10L. Scabicides/Pediculicides

Formulary PreferredGeneric NameTrade Name Utilization Management PERMETHRINELIMITE (g)MALATHIONOVIDE (g)

Formulary OptionsGeneric NameTrade Name Utilization Management CROTAMITONEURAX

LINDANELINDANE

NonformularyGeneric NameTrade Name Utilization Management

NONE

(g) Use generic equivalent

[PA] Prior authorization may be required

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[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

10M. Miscellaneous Dermatologicals

Formulary PreferredGeneric NameTrade Name Utilization Management

IMIQUIMODALDARA (g) [QL]PODOFILOXCONDYLOX SOLN (g)

ALUMINUM CHLORIDEDRYSOL (g)FLUOROURACILEFUDEX (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

PODOFILOXCONDYLOX GELPIMECROLIMUSELIDEL [PA]ALITRETINOINPANRETINDOXEPIN HCLZONALON, PRUDOXIN

NonformularyGeneric NameTrade Name Utilization Management FLUOROURACILCARAC

HYDROCORTISONE ACETATE/UREACARMOL HCFLUOROURACIL/ADHESIVE BANDAGEEFUDEX OCCLUSION

TACROLIMUSPROTOPIC [ST]DICLOFENAC SODIUMSOLARAZE

BEXAROTENETARGRETIN GEL <s>SINECATECHINSVEREGEN

IMIQUIMODZYCLARA [QL]

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

11. OPHTHALMOLOGY

11A. Ophthalmic Beta Blockers

Formulary PreferredGeneric NameTrade Name Utilization Management

LEVOBUNOLOL HCLBETAGAN (g)BETAXOLOL HCLBETOPTIC SOLN (g)CARTEOLOL HCLOCUPRESS (g)METIPRANOLOLOPTIPRANOLOL (g)

TIMOLOL MALEATETIMOPTIC - XE (g)TIMOLOL MALEATETIMOPTIC (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

BETAXOLOL HCLBETOPTIC STIMOLOL MALEATEISTALOL

NonformularyGeneric NameTrade Name Utilization Management

TIMOLOLBETIMOL

11B. Other Glaucoma Agents

Formulary PreferredGeneric NameTrade Name Utilization Management

BRIMONIDINE TARTRATEALPHAGAN (g)BRIMONIDINE TARTRATEALPHAGAN P 0.15% (g)

TIMOLOL MALEATE/DORZOLAM HCLCOSOPT (g)APRACLONIDINE HCLIOPIDINE DROPS (g)

PILOCARPINE HCLPILOCAR, ISOPTO-CARPINE (g)DORZOLAMIDE HCLTRUSOPT (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

BRIMONIDINE TARTRATEALPHAGAN P 0.1%BRINZOLAMIDEAZOPT

CARBACHOLISOPTO CARBACHOLBIMATOPROSTLUMIGAN

ECHOTHIOPHATE IODIDEPHOSPHOLINE IODIDEPILOCARPINE HCLPILOPINE HSDIPIVEFRIN HCLPROPINETRAVOPROSTTRAVATAN, Z

LATANOPROSTXALATAN

NonformularyGeneric NameTrade Name Utilization Management

BRIMONIDINE TARTRATE/TIMOLOLCOMBIGANAPRACLONIDINE HCLIOPIDINE DROPERETTE

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

11C. Cycloplegic Mydriatics

Formulary PreferredGeneric NameTrade Name Utilization Management

CYCLOPENTOLATE HCLCYCLOGYL (g)ATROPINE SULFATEISOPTO ATROPINE (g)HOMATROPINE HBRISOPTO HOMATROPINE (g)

TROPICAMIDEMYDRIACYL (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

SCOPOLAMINE HYDROBROMIDEISOPTO HYOSCINE

NonformularyGeneric NameTrade Name Utilization Management

HYDROXYAMPHETAMINE/TROPICAMIDEPAREMYD

11D. Ophthalmic Anti-inflammatory Agents

Formulary PreferredGeneric NameTrade Name Utilization Management

KETOROLAC TROMETHAMINEACULAR, LS (g)FLURBIPROFEN SODIUMOCUFEN (g)

DICLOFENAC SODIUMVOLTAREN (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

NONE

NonformularyGeneric NameTrade Name Utilization Management

KETOROLAC TROMETHAMINEACUVAILNEPAFENACNEVANAC

BROMFENAC SODIUMXIBROM

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

11E. Ophthalmic Anti-infectives

Formulary PreferredGeneric NameTrade Name Utilization Management

BACITRACINBACITRACIN (g)SULFACETAMIDE SODIUMBLEPH-10, SODIUM SULAMYDE (g)

CIPROFLOXACIN HCLCILOXAN DROPS (g)GENTAMICIN SULFATEGARAMYCIN (g)ERYTHROMYCIN BASEILOTYCIN (g)

NEOMYCIN/GRAMICIDIN/POLYMYXN BNEOSPORIN OPHTH SOLN (g)NEOMY SULF/BACITRA/POLYMYXIN BNEOSPORIN OPTH OINT (g)

OFLOXACINOCUFLOX (g)BACITRACIN/POLYMYXIN B SULFATEPOLYSPORIN (g)

POLYMYXIN B SULFATE/TMPPOLYTRIM (g)TOBRAMYCIN SULFATETOBREX (g)

TRIFLURIDINEVIROPTIC (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

CIPROFLOXACIN HCLCILOXAN OINTNATAMYCINNATACYN

MOXIFLOXACIN HCLVIGAMOXGANCICLOVIRZIRGAN

NonformularyGeneric NameTrade Name Utilization Management AZITHROMYCINAZASITE

BESIFLOXACIN HYDROCHLORIDEBESIVANCEIQUIXIQUIX

LEVOFLOXACINQUIXINGATIFLOXACINZYMARGATIFLOXACINZYMAXID

11F. Ophthalmic Steroids

Formulary PreferredGeneric NameTrade Name Utilization Management

DEXAMETHASONE SOD PHOSPHATEDECADRON OPTH (g)FLUOROMETHOLONEFML (g)

PREDNISOLONE SOD PHOSPHATEINFLAMASE, FORTE (g)PREDNISOLONE ACETATEPRED FORTE (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

FLUOROMETHOLONEFML FORTE, S.O.P.PREDNISOLONE ACETATEPRED MILD

RIMEXOLONEVEXOL

NonformularyGeneric NameTrade Name Utilization Management

LOTEPREDNOL ETABONATEALREXDIFLUPREDNATEDUREZOL

LOTEPREDNOL ETABONATELOTEMAXDEXAMETHASONEMAXIDEX

(g) Use generic equivalent

[PA] Prior authorization may be required

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[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

11G. Ophthalmic Anti-infective/Steroid Combinations

Formulary PreferredGeneric NameTrade Name Utilization Management

NEOMY SULF/POLYMYX B SULF/HCCORTISPORIN (g)NEO/POLYMYX B SULF/DEXAMETHMAXITROL (g)TOBRAMYCIN SULFATE/DEXAMETHTOBRADEX (g)

NA SULFACETM/PREDNIS SPVASOCIDIN (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

NA SULFACETM/PREDNISOL ACBLEPHAMIDE DROPS, OINTNEOMY SULF/POLYMYX B SULF/PREDPOLY-PRED

TOBRAMYCIN SULFATE/DEXAMETHTOBRADEX OINT

NonformularyGeneric NameTrade Name Utilization Management

GENTAMICIN/PREDNISOL ACPRED-GTOBRAMYCIN/LOTEPRED ETABZYLET

11H. Miscellaneous Ophthalmic Agents

Formulary PreferredGeneric NameTrade Name Utilization Management

NAPHAZOLINE HCLALBALON (g)PHENYLEPHRINE HCLNEO-SYNEPHRINE (g)CROMOLYN SODIUMOPTICROM (g)

AZELASTINE HCLOPTIVAR (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

NEDOCROMIL SODIUMALOCRILLODOXAMIDE TROMETHAMINEALOMIDEHYDROXYPROPYL CELLULOSELACRISERT

OLOPATADINE HCLPATANOLCYCLOSPORINERESTASIS

NonformularyGeneric NameTrade Name Utilization Management

PEMIROLAST POTASSIUMALAMASTBEPOTASTINE BESILATEBEPREVE

EPINASTINE HCLELESTATEMEDASTINE DIFUMARATEEMADINE

OLOPATADINE HCLPATADAY

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

12. OTIC & NASAL PREPARATIONS

12A. Nasal Preparations

Formulary PreferredGeneric NameTrade Name Utilization Management

AZELASTINE HCLASTELIN NASAL SPRAY(g)IPRATROPIUM BROMIDEATROVENT NASAL SPRAY (g)

FLUTICASONE PROPIONATEFLONASE (g)FLUNISOLIDE 0.025% SPRAYNASALIDE (g)

FLUNISOLIDENASAREL (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

AZELASTINE HCLASTEPRO NASAL SPRAYTRIAMCINOLONE ACETONIDENASACORT AQ [ST]

NonformularyGeneric NameTrade Name Utilization Management

BECLOMETHASONE DIPROPIONATEBECONASE AQ [ST]MOMETASONE FUROATENASONEX [ST]

CICLESONIDEOMNARIS [ST]OLOPATADINE HCLPATANASE

BUDESONIDERHINOCORT AQUA [ST]FLUTICASONE FUROATEVERAMYST [ST]

12B. Otic Preparations

Formulary PreferredGeneric NameTrade Name Utilization Management

ACETIC ACID/HYDROCORTISONEACETASOL, HC/VOSOL, HC (g)AA/ANTPY/BCAINE/POLICO/AL ACETAURALGAN (g)NEOMY SULF/POLYMYX B SULF/HCCORTISPORIN (g)ACETIC ACID/ALUMINUM ACETATEDOMEBORO OTIC (g)

OFLOXACINFLOXIN OTIC (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

CIPROFLOXACIN HCL/HCCIPRO HCCIPROFLOXACIN HCL/DEXAMETHCIPRODEX

NonformularyGeneric NameTrade Name Utilization Management

NEOMYCIN SULFATE/COLIST SUL/HCCOLY-MYCIN SNEOMY SULF/COLIST SUL/HC/THONZCORTISPORIN-TC

OFLOXACINFLOXIN OTIC SINGLES

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

13. RESPIRATORY, COUGH & COLD

13A. Antihistamines

Formulary PreferredGeneric NameTrade Name Utilization Management

FEXOFENADINE HCLALLEGRA (g)AZELASTINE HCLASTELIN NASAL SPRAY(g)

HYDROXYZINEATARAX, VISTARIL (g)DIPHENHYDRAMINE HCLBENADRYL (g)

LORATADINECLARITIN, ALAVERT(OTC) (g)CYPROHEPTADINE HCLPERIACTIN (g)

PROMETHAZINE HCLPHENERGAN (g)DEXCHLORPHENIRAMINE MALEATEPOLARAMINE (g)

CLEMASTINE FUMARATETAVIST RX (2.68MG, SYRUP) (g)LEVOCETIRIZINE DIHYDROCHLORIDEXYZAL TABS (g) [ST] [QL]

CETIRIZINE HCLZYRTEC (OTC) (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

AZELASTINE HCLASTEPRO NASAL SPRAY

NonformularyGeneric NameTrade Name Utilization Management

FEXOFENADINE HCLALLEGRA ODT [ST]FEXOFENADINE HCLALLEGRA SUSP [ST]

DESLORATADINECLARINEX (ALL) [PA] [QL]OLOPATADINE HCLPATANASE

LEVOCETIRIZINE DIHYDROCHLORIDEXYZAL SOLUTION [PA] [QL]

13B. Antihistamine/Decongestant Combinations

Formulary PreferredGeneric NameTrade Name Utilization Management

P-EPHED HCL/FEXOFENADINE HCLALLEGRA-D 12 HOUR (g) [ST] [QL]P-EPHED HCL/BROMPHENIRAMINBROMFED, PD (g)

P-EPHED SUL/LORATADINECLARITIN-D 12HR, 24HR(OTC) (g)PSEUDOEPHEDRINE HCL/CHLOR-MALDECONAMINE SYRUP, SR (g)

PHENYLEPHRINE HCL/CHLOR-MALRONDEC (g)PHENYLEPHRINE/CHLOR-TANRYNATAN (g)PHENYLEPHRINE/CHLOR-TANRYNATAN PED SUSP (g)P-EPHED HCL/CETIRIZINE HCLZYRTEC-D(OTC) (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

P-EPHED HCL/FEXOFENADINE HCLALLEGRA-D 24 HOUR [ST] [QL]PSEUDOEPHEDRINE HCL/CHLOR-MALDECONAMINE SR

NonformularyGeneric NameTrade Name Utilization Management

P-EPHED SUL/DESLORATADINECLARINEX-D [PA] [QL]PSEUDOEPHEDRINE HCL/ACRIVASSEMPREX-D [ST]

(g) Use generic equivalent

[PA] Prior authorization may be required

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[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

13C. Antitussive combinations

Formulary PreferredGeneric NameTrade Name Utilization Management

D-METHORPHAN HB/P-EPD HCL/BPMBROMFED-DM (g)GUAIFENESIN/P-EPHED HCL/HCODDECONAMINE CX, SR (g)GUAIFENESIN/D-METHORPHAN HBHUMABID DM (g)D-METHORPHAN HB/PROMETH HCLPHENERGAN DM (g)

CODEINE/PROMETHAZINE HCLPHENERGAN W/CODEINE (g)D-METHORPHAN HB/PE/CHLORPHENIRRONDEC-DM (g)

BENZONATATETESSALON, PERLES (g)HYDROCODONE/CHLORPHEN POLISTUSSIONEX (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

HYDROCODONE/CHLORPHEN POLISTUSSICAPS

NonformularyGeneric NameTrade Name Utilization Management

NONE

13D. Expectorant combinations

Formulary PreferredGeneric NameTrade Name Utilization Management

GUAIFENESIN/P-EPHED HCLGUAIFED, ENTEX PSE (g)GUAIFENESIN/PHENYLEPHRINE HCLGUAIFED-PD (g)PHENYLEPHRINE HCL/PROMETH HCLPHENERGAN VC (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

NONE

NonformularyGeneric NameTrade Name Utilization Management

NONE

13F. Oral Beta-Agonists

Formulary PreferredGeneric NameTrade Name Utilization Management

METAPROTERENOL SULFATEALUPENT (g)TERBUTALINE SULFATEBRETHINE (g)ALBUTEROL SULFATEPROVENTIL SOLUTION (g)ALBUTEROL SULFATEVOSPIRE ER (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

NONE

NonformularyGeneric NameTrade Name Utilization Management

NONE

(g) Use generic equivalent

[PA] Prior authorization may be required

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[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

13G. Inhaled Beta-Agonists

Formulary PreferredGeneric NameTrade Name Utilization Management

ALBUTEROL SULFATEACCUNEB (g)ALBUTEROL SULFATEALBUTEROL NEBULIZER SOLN (g)

METAPROTERENOL SULFATEMETAPROTERENOL SOLN (g)LEVALBUTEROL HCLXOPENEX 1.25MG/0.5ML (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

FORMOTEROL FUMARATEFORADILPIRBUTEROL ACETATEMAXAIR AUTOHALER

ALBUTEROLPROAIR HFA, VENTOLIN HFASALMETEROL XINAFOATESEREVENT DISKUS

NonformularyGeneric NameTrade Name Utilization Management

ARFORMOTEROL TARTRATEBROVANA [PA] [QL]FORMOTEROL FUMARATEPERFOROMIST [PA] [QL]

ALBUTEROLPROVENTIL HFALEVALBUTEROL TARTRATEXOPENEX HFA

LEVALBUTEROL HCLXOPENEX SOLUTION

13H. Inhaled Steroids

Formulary PreferredGeneric NameTrade Name Utilization Management BUDESONIDEPULMICORT 0.25MG, 0.5MG/2ML (g) BE

Formulary OptionsGeneric NameTrade Name Utilization Management CICLESONIDEALVESCO (TIER 1-BCN ONLY) BE

MOMETASONE FUROATEASMANEX (TIER 1-BCN ONLY) BETRIAMCINOLONE ACETONIDEAZMACORT (TIER 1-BCN ONLY) BEFLUTICASONE PROPIONATEFLOVENT HFA, DISKUS (TIER 1-BCN ONLY) BE

BUDESONIDEPULMICORT 1MG/2ML (TIER 1-BCN ONLY)BUDESONIDEPULMICORT INH (TIER 1-BCN ONLY) BE

BECLOMETHASONE DIPROPIONATEQVAR (TIER 1-BCN ONLY) BE

NonformularyGeneric NameTrade Name Utilization Management

FLUNISOLIDE/MENTHOLAEROBID, M

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

13I. Intranasal Steroids

Formulary PreferredGeneric NameTrade Name Utilization Management

FLUTICASONE PROPIONATEFLONASE (g)FLUNISOLIDE 0.025% SPRAYNASALIDE (g)

FLUNISOLIDENASAREL (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

TRIAMCINOLONE ACETONIDENASACORT AQ [ST]

NonformularyGeneric NameTrade Name Utilization Management

BECLOMETHASONE DIPROPIONATEBECONASE AQ [ST]MOMETASONE FUROATENASONEX [ST]

CICLESONIDEOMNARIS [ST]BUDESONIDERHINOCORT AQUA [ST]

FLUTICASONE FUROATEVERAMYST [ST]

13J. Theophyllines

Formulary PreferredGeneric NameTrade Name Utilization Management

THEOPHYLLINE ANHYDROUSTHEOPHYLLINE ANHYDROUS (g)THEOPHYLLINE ANHYDROUSUNIPHYL (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

THEOPHYLLINE ANHYDROUSTHEO-24

NonformularyGeneric NameTrade Name Utilization Management

NONE

13K. Epinephrine

Formulary PreferredGeneric NameTrade Name Utilization Management

NONE

Formulary OptionsGeneric NameTrade Name Utilization Management EPINEPHRINEEPIPEN, JR

NonformularyGeneric NameTrade Name Utilization Management

NONE

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

13L. Miscellaneous Pulmonary Agents

Formulary PreferredGeneric NameTrade Name Utilization Management ZAFIRLUKASTACCOLATE(g) [QL]

IPRATROPIUM BROMIDEATROVENT NASAL SPRAY (g)IPRATROPIUM BROMIDEATROVENT SOLN (g)

IPRATROPIUM/ALBUTEROL SULFATEDUONEB (g)CROMOLYN SODIUMINTAL SOLUTION (g)

ACETYLCYSTEINEMUCOMYST (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

FLUTICASONE/SALMETEROLADVAIRIPRATROPIUM BROMIDEATROVENT INHALER

ALBUTEROL SULFATE/IPRATROPIUMCOMBIVENTMOMETASONE/FORMOTEROLDULERA [QL]

AMBRISENTANLETAIRIS [PA] [QL] <s>DORNASE ALFAPULMOZYME <s>

SILDENAFIL CITRATEREVATIO [PA] [QL] <s>MONTELUKAST SODIUMSINGULAIR [QL]TIOTROPIUM BROMIDESPIRIVA

BUDESONIDE/FORMOTEROL FUMARATESYMBICORTBOSENTANTRACLEER [PA] <s>

TREPROSTINILTYVASO [PA] [QL] <s>ILOPROSTVENTAVIS [PA] [QL] <s>

NonformularyGeneric NameTrade Name Utilization Management

TADALAFILADCIRCA [PA] [QL] <s>ZILEUTONZYFLO, CR [QL]

(g) Use generic equivalent

[PA] Prior authorization may be required

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[QL] Quantity limits may apply

[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

14. UROLOGY

14A. Urinary Antispasmodics

Formulary PreferredGeneric NameTrade Name Utilization Management

DICYCLOMINE HCLBENTYL (g)OXYBUTYNIN CHLORIDEDITROPAN (g)OXYBUTYNIN CHLORIDEDITROPAN XL (g)HYOSCYAMINE SULFATELEVBID (g)HYOSCYAMINE SULFATELEVSIN, SL (g)HYOSCYAMINE SULFATELEVSINEX (g)

PROPANTHELINE BROMIDEPRO-BANTHINE 15MG (g)TROSPIUM CHLORIDESANCTURA (g)

FLAVOXATE HCLURISPAS (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

TOLTERODINE TARTRATEDETROLTOLTERODINE TARTRATEDETROL LA

NonformularyGeneric NameTrade Name Utilization Management

DARIFENACIN HYDROBROMIDEENABLEXOXYBUTYNIN CHLORIDEGELNIQUE [QL]

OXYBUTYNINOXYTROL [QL]TROSPIUM CHLORIDESANCTURA XR [QL]

FESOTERODINE FUMARATETOVIAZ [QL]SOLIFENACIN SUCCINATEVESICARE

14B. Miscellaneous Urologicals

Formulary PreferredGeneric NameTrade Name Utilization Management

CITRIC ACID/POTASSIUM CITRATECYTRA-2, 3, K (g)PHOSPHORUS #1K-PHOS NEUTRAL (g)

SOD/POTASS/K CIT/SOD CIT/CAPOLYCITRA (g)PHENAZOPYRIDINE HCLPYRIDIUM (g)

BETHANECHOL CHLORIDEURECHOLINE (g)POTASSIUM CITRATEUROCIT-K (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

PENTOSAN POLYSULFATE SODIUMELMIRONMAG CARB/CITRIC ACID/G-LACTONERENACIDINMTH/ME BLUE/BA/SALICY/ATP/HYOSURETRON D-S

NonformularyGeneric NameTrade Name Utilization Management

NONE

(g) Use generic equivalent

[PA] Prior authorization may be required

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[ST] Step therapy may be required

<s> Specialty Drug

BE – Drugs offered at a zero dollar copayment for the “Blue Essentials” Rx benefit

14C. BPH Treatment

Formulary PreferredGeneric NameTrade Name Utilization Management

DOXAZOSIN MESYLATECARDURA (g)TAMSULOSIN HCLFLOMAX (g)TERAZOSIN HCLHYTRIN (g)

FINASTERIDEPROSCAR (g)

Formulary OptionsGeneric NameTrade Name Utilization Management DUTASTERIDEAVODART

ALFUZOSIN HCLUROXATRAL

NonformularyGeneric NameTrade Name Utilization Management

DOXAZOSIN MESYLATECARDURA XLDUTASTERIDE/TAMSULOSIN HCLJALYN [ST] [QL]

SILODOSINRAPAFLO [QL]

(g) Use generic equivalent

[PA] Prior authorization may be required

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15. VITAMINS AND SUPPLEMENTS

15A. Vitamins and Minerals

Formulary PreferredGeneric NameTrade Name Utilization Management

ERGOCALCIFEROLCALCIFEROL (g)CYANOCOBALAMINCYANOCOBALAMIN INJ (g)

FOLIC ACIDFOLVITE (g)SODIUM FLUORIDELURIDE (g)

FLUORIDE ION/MULTIVITAMINSPOLY-VI-FLOR (g)PRENATAL VIT/IRON,CARB/DOSS/FAPRENATAL VITS (g)

SODIUM FLUORIDEPREVIDENT (g)CALCITRIOLROCALTROL (g)

FLUORIDE ION/VIT A,C&DTRI-VI-FLOR (g)

Formulary OptionsGeneric NameTrade Name Utilization Management PHYTONADIONEMEPHYTON

NonformularyGeneric NameTrade Name Utilization Management ZINC ACETATEGALZIN

DOXERCALCIFEROLHECTOROLCYANOCOBALAMINNASCOBAL SPRAY

IRON ASPGLY&PS/C/B12/FA/CA/SUCNIFEREX GOLDLYSINE HCL/VIT B COMP/FA/ZINCSUPERVITE

PARICALCITOLZEMPLAR

15B. Potassium Replacement

Formulary PreferredGeneric NameTrade Name Utilization Management

POTASSIUM CHLORIDEKAYCIEL, KAON-CL, KAON LIQUID (g)POTASSIUM CHLORIDEK-LOR, KLOR-CON (g)

POTASSIUM BICARBONATE/CIT ACK-LYTE, KLOR-CON/EF (g)POTASSIUM CHLORIDEK-TAB, K-DUR, SLOW-K, KAON CL (g)POTASSIUM CHLORIDEMICRO-K(g)

Formulary OptionsGeneric NameTrade Name Utilization Management

NONE

NonformularyGeneric NameTrade Name Utilization Management

POTASSIUM CHLORIDE/POT BICARBKAOCHLOR-EFF

(g) Use generic equivalent

[PA] Prior authorization may be required

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16. DIAGNOSTIC AND OTHER MISCELLANEOUS

16A. Diagnostics and Other Miscellaneous

Formulary PreferredGeneric NameTrade Name Utilization Management

LEVOCARNITINECARNITOR (g)SOD SULF/SOD/NAHCO3/KCL/PEG'SCOLYTE (g)

DEFEROXAMINE MESYLATEDESFERAL (g)PEG 3350/NA SULF,BICARB,CL/KCLGOLYTELY (g)

SODIUM POLYSTYRENE SULFONATEKAYEXALATE (g)SOD SULF/SOD/NAHCO3/KCL/PEG'SNULYTELY (g)

CHLORHEXIDINE GLUCONATEPERIDEX (g)CALCIUM ACETATEPHOSLO (g)NALTREXONE HCLREVIA (g)PILOCARPINE HCLSALAGEN (g)

Formulary OptionsGeneric NameTrade Name Utilization Management

DISULFIRAMANTABUSECARGLUMIC ACIDCARBAGLU [PA] <s>PENICILLAMINECUPRIMINE

PEG 3350/NA SULF,BICARB,CL/KCLGOLYTELY PACKETSAPROPTERIN DIHYDROCHLORIDEKUVAN [PA] <s>

NITISINONEORFADIN <s>PRUSSIAN BLUERADIOGARDASE [QL]SEVELAMER HCLRENAGEL

SEVELAMER CARBONATERENVELA PACKET 2.4GSEVELAMER CARBONATERENVELA TABLET

TOLVAPTANSAMSCA <s>TRIENTINE HCLSYPRINE <s>

TETRABENAZINEXENAZINE [PA] [QL] <s>

NonformularyGeneric NameTrade Name Utilization Management

AMLEXANOXAPHTHASOLACAMPROSATE CALCIUMCAMPRAL [PA]

CEVIMELINE HCLEVOXACDEFERASIROXEXJADE [PA] <s>

LANTHANUM CARBONATEFOSRENOLBISAC/NACL/NAHCO3/KCL/PEG 3350HALFLYTELY [QL]PEG3350/SOD SUL/NACL/ASB/C/KCLMOVIPREP

NAPHOS M-B M-H/NA PHOS,DI-BAOSMOPREP, VISICOLSEVELAMER CARBONATERENVELA PACKET 0.8G

MIGLUSTATZAVESCA

(g) Use generic equivalent

[PA] Prior authorization may be required

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17. LIFESTYLE MODIFICATION

17A. Impotence

Formulary PreferredGeneric NameTrade Name Utilization Management YOHIMBINE HCLYOHIMBINE HCL (g)

Formulary OptionsGeneric NameTrade Name Utilization Management ALPROSTADILCAVERJECT [PA] [QL]

TADALAFILCIALIS [PA] [QL]ALPROSTADILMUSE [PA] [QL]

SILDENAFIL CITRATEVIAGRA [PA] [QL]

NonformularyGeneric NameTrade Name Utilization Management ALPROSTADILEDEX [PA] [QL]

VARDENAFIL HCLLEVITRA [PA] [QL]VARDENAFIL HCLSTAXYN [PA] [QL]

17B. Weight Loss Preparations

Formulary PreferredGeneric NameTrade Name Utilization Management

PHENTERMINE HCLADIPEX-P (g) [PA] [QL]PHENDIMETRAZINE TARTRATEBONTRIL (g) [PA] [QL]

BENZPHETAMINE HCLDIDREX (g) [PA] [QL]DIETHYLPROPION HCLTENUATE (g) [PA] [QL]

Formulary OptionsGeneric NameTrade Name Utilization Management

PHENTERMINE RESINIONAMIN [PA] [QL]

NonformularyGeneric NameTrade Name Utilization Management

ORLISTATXENICAL [PA] [QL]

17C. Smoking Cessation

Formulary PreferredGeneric NameTrade Name Utilization Management

NICOTINE POLACRILEXCOMMIT LOZENGE OTC (g) (BCN ONLY) [QL] BENICOTINE POLACRILEXNICOTINE GUM, NICORETTE (g) (BCN ONLY) [QL] BE

NICOTINENICOTINE PATCH (g) [QL] BEBUPROPION HCLZYBAN (g) BE

Formulary OptionsGeneric NameTrade Name Utilization Management

VARENICLINE TARTRATECHANTIX [QL]

NonformularyGeneric NameTrade Name Utilization Management

NICOTINENICOTROL, NS [QL]

(g) Use generic equivalent

[PA] Prior authorization may be required

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Index

Trade Name Page Trade Name PageABILIFY, DISCMELT, SOLUTION 56

ACCOLATE(g) 105

ACCUNEB (g) 103

ACCUPRIL (g) 49

ACCURETIC (g) 49

ACCUTANE (REQ DERM CONSULT) (g) 92

ACCUZYME, ETHEZYME, GLADASE (g) 94

ACEON (g) 49

ACETASOL, HC/VOSOL, HC (g) 100

ACIPHEX 66

ACLOVATE (g) 90

ACTIGALL (g) 68

ACTIMMUNE 88

ACTIQ (g) 59

ACTIVELLA (g) 74

ACTIVELLA 0.5-0.1MG 74

ACTONEL WITH CALCIUM 78

ACTONEL, WEEKLY, 150MG 78

ACTOPLUS MET 82

ACTOPLUS MET XR 82

ACTOS 82

ACULAR, LS (g) 97

ACUVAIL 97

ACZONE 92

ADCIRCA 105

ADDERALL (g) 57

ADDERALL XR (BRAND-BCN ONLY) 57

ADDERALL XR (g) (BCBSM ONLY) 57

ADIPEX-P (g) 110

ADOXA (g) 41

ADOXA 150MG CAPSULE 41

ADOXA CK, TT 41

ADVAIR 105

ADVICOR 47

AEROBID, M 103

AFINITOR 87

AGGRENOX 53

AGRYLIN (g) 53

AKNE-MYCIN 92

ALAMAST 99

ALBALON (g) 99

ALBENZA 46

ALBUTEROL NEBULIZER SOLN (g) 103

ALDACTAZIDE (g) 52

ALDACTONE (g) 52

ALDARA (g) 95

ALDOMET (g) 54

ALDORIL (g) 54

ALESSE (g), LEVLITE (g) 71

ALFERON N 88

ALINIA 46

ALKERAN 84

ALLEGRA (g) 101

ALLEGRA ODT 101

ALLEGRA SUSP 101

ALLEGRA-D 12 HOUR (g) 101

ALLEGRA-D 24 HOUR 101

ALOCRIL 99

ALOMIDE 99

ALORA 73

ALORA 77

ALPHAGAN (g) 96

ALPHAGAN P 0.1% 96

ALPHAGAN P 0.15% (g) 96

ALREX 98

ALSUMA 61

ALTABAX 92

ALTABAX 92

ALTACE CAPSULE (g) 49

ALTACE TABLET 49

ALTOPREV 47

ALUPENT (g) 102

ALVESCO (TIER 1-BCN ONLY) 103

AMARYL (g) 82

AMBIEN (g) 57

AMBIEN CR (g) 57

AMERGE (g) 61

AMICAR (g) 53

AMITIZA 70

AMOXAPINE (g) 55

AMOXIL (g) 40

AMPICILLIN (g) 40

AMPYRA 88

AMRIX 64

ANADROL-50 80

ANAFRANIL (g) 55

ANALPRAM HC (g) 70

ANAMANTLE HC (g) 70

ANAPROX, DS (g) 58

ANCOBON 43

ANDRODERM 80

ANDROGEL 80

ANDROXY 10MG (g) 80

ANGELIQ 74

ANNUSOL HC, PROCTOCREAM HC (g) 70

ANSAID (g) 58

ANTABUSE 109

ANTARA 47

ANTIVERT (g) 68

ANZEMET 68

APEXICON E 89

APHTHASOL 109

APIDRA (PEN/CARTRIDGE) 81

APIDRA (VIAL) 81

APLENZIN 55

APOKYN 62

Trade Name Page Trade Name PageAPRESOLINE (g) 54

APRISO 70

APTIVUS(MUST BE USED WITH NORVIR) 44

ARALEN (g) 45

ARANESP 88

ARANESP 86

ARAVA (g) 77

ARCALYST 85

ARICEPT 23MG 65

ARICEPT, ODT (g) 65

ARIMIDEX (g) 85

ARISTOCORT, KENALOG (g) 90

ARISTOCORT, KENALOG 0.5% CR (g) 89

ARIXTRA 53

ARMOUR THYROID 79

AROMASIN 85

ARTANE (g) 62

ARTHROTEC 58

ASACOL 70

ASACOL HD 70

ASMANEX (TIER 1-BCN ONLY) 103

ASPIRIN W/CODEINE (g) 60

ASTELIN NASAL SPRAY(g) 100

ASTELIN NASAL SPRAY(g) 101

ASTEPRO NASAL SPRAY 100

ASTEPRO NASAL SPRAY 101

ATACAND 50

ATACAND HCT 50

ATARAX, VISTARIL (g) 101

ATIVAN (g) 56

ATRIPLA 44

ATROVENT NASAL SPRAY (g) 105

ATROVENT NASAL SPRAY (g) 100

ATROVENT INHALER 105

ATROVENT SOLN (g) 105

AUGMENTIN, ES, XR (g) 40

AURALGAN (g) 100

AVALIDE 50

AVANDAMET 82

AVANDARYL 82

AVANDIA 82

AVAPRO 50

AVC 75

AVELOX, ABC 42

AVINZA 59

AVODART 107

AVONEX 88

AXERT 61

AXID (RX ONLY) (g) 66

AYGESTIN (g) 73

AZASITE 98

AZELEX 92

AZILECT 62

AZMACORT (TIER 1-BCN ONLY) 103

AZOPT 96

AZOR 51

AZOR 50

AZULFIDINE EN-TAB (g) 70

AZULFIDINE EN-TAB (g) 77

AZULFIDINE TAB (g) 77

AZULFIDINE TAB (g) 70

BACITRACIN (g) 98

BACTRIM, DS, SEPTRA, DS (g) 42

BACTROBAN CREAM, NASAL 92

BACTROBAN OINTMENT (g) 92

BANZEL 63

BARACLUDE 43

BECONASE AQ 100

BECONASE AQ 104

BELLAMINE/BELLASPAS (g) 67

BENADRYL (g) 101

BENICAR 50

BENICAR HCT 50

BENTYL (g) 106

BENTYL (g) 67

BENZACLIN 92

BENZAMYCIN (g) 92

BENZASHAVE 92

BENZOYL PEROXIDE-RX (g) 92

BEPREVE 99

BESIVANCE 98

BETAGAN (g) 96

BETAPACE, AF (g) 52

BETAPACE, AF (g) 48

BETASERON 88

BETIMOL 96

BETOPTIC S 96

BETOPTIC SOLN (g) 96

BEYAZ 72

BIAXIN, XL (g) 41

BILTRICIDE 46

BLEPH-10, SODIUM SULAMYDE (g) 98

BLEPHAMIDE DROPS, OINT 99

BLOCADREN (g) 48

BONIVA 78

BONTRIL (g) 110

BRAVELLE 74

BRETHINE (g) 102

BREVOXYL GEL (g) 92

BROMFED, PD (g) 101

BROMFED-DM (g) 102

BROVANA 103

BUMEX (g) 52

BUPAP (g) 61

BUSPAR (g) 56

BUTISOL SODIUM 57

BUTRANS 60

BYETTA 82

Trade Name Page Trade Name PageBYSTOLIC 48

CADUET 51

CADUET 47

CAFERGOT (g) 61

CALAN SR/ISOPTIN SR (g) 51

CALCIFEROL (g) 80

CALCIFEROL (g) 108

CAMBIA 58

CAMBIA 61

CAMPRAL 109

CANASA 70

CANTIL 67

CAPEX SHAMPOO 90

CAPOTEN (g) 49

CAPOZIDE (g) 49

CARAC 95

CARAFATE SUSP (g) 67

CARAFATE TABS (g) 67

CARBAGLU 109

CARBATROL 63

CARDENE (g) 51

CARDENE SR 51

CARDIZEM LA 51

CARDIZEM LA (g) 51

CARDIZEM, SR, CD (g) 51

CARDURA (g) 107

CARDURA (g) 54

CARDURA XL 107

CARMOL HC 95

CARNITOR (g) 109

CASODEX (g) 85

CATAFLAM (g) 58

CATAPRES (g) 54

CATAPRES-TTS (g) 54

CAVERJECT 110

CAYSTON 46

CECLOR (g) 40

CECLOR ER (g) 40

CEDAX 40

CEENU 84

CEFTIN (g) 40

CEFZIL (g) 40

CELEBREX 58

CELEXA (g) 55

CELLCEPT (g) 85

CELLCEPT SUSPENSION 85

CELONTIN 63

CENESTIN 73

CENESTIN 77

CESAMET 68

CETROTIDE 74

CHANTIX 110

CHENODAL 68

CHLORAL HYDRATE (g) 57

CIALIS 110

CILOXAN DROPS (g) 98

CILOXAN OINT 98

CIMZIA SYRINGE 77

CIMZIA SYRINGE 70

CIPRO (g) 42

CIPRO HC 100

CIPRO XR (g) 42

CIPRODEX 100

CLARINEX (ALL) 101

CLARINEX-D 101

CLARITIN, ALAVERT(OTC) (g) 101

CLARITIN-D 12HR, 24HR(OTC) (g) 101

CLEOCIN (g) 46

CLEOCIN T (g) 92

CLEOCIN VAG CREAM (g) 75

CLEOCIN VAGINAL OVULES 75

CLIMARA (g) 77

CLIMARA (g) 73

CLIMARA PRO 74

CLINAC BPO 92

CLINDESSE 75

CLINORIL (g) 58

CLOBEX, SPRAY 89

CLODERM 90

CLOMID (g) 74

CLOZARIL (g) 56

CNL 8 93

COARTEM 45

CODEINE SULFATE (g) 59

COGENTIN (g) 62

COGNEX 65

COLAZAL (g) 70

COLBENEMID (g) 76

COLCRYS 76

COLESTID (g) 47

COLESTID FLAVORED 47

COLY-MYCIN S 100

COLYTE (g) 109

COMBIGAN 96

COMBIPATCH 74

COMBIVENT 105

COMBIVIR 44

COMMIT LOZENGE OTC (g) (BCN ONLY) 110

COMPAZINE (g) 68

COMTAN 62

CONCERTA 57

CONDYLOX GEL 95

CONDYLOX SOLN (g) 95

COPAXONE 88

COPEGUS (g) 43

CORDARONE (g) 52

CORDRAN, TAPE, SP 90

COREG (g) 48

Trade Name Page Trade Name PageCOREG CR 48

CORGARD (g) 48

CORTEF, HYDROCORTISONE (g) 79

CORTENEMA (g) 70

CORTICOSTEROIDS 76

CORTIFOAM 70

CORTISONE ACETATE (g) 79

CORTISPORIN (g) 99

CORTISPORIN (g) 100

CORTISPORIN-TC 100

CORZIDE (g) 48

COSOPT (g) 96

COUMADIN (g) 53

COVERA-HS 51

COZAAR (g) 50

CREON 69

CRESTOR 47

CRINONE 73

CRIXIVAN 44

CUPRIMINE 77

CUPRIMINE 109

CUTIVATE (g) 90

CUTIVATE LOTION 90

CYANOCOBALAMIN INJ (g) 108

CYCLESSA (g) 72

CYCLOCORT (g) 89

CYCLOGYL (g) 97

CYMBALTA 55

CYTOMEL (g) 79

CYTOTEC (g) 67

CYTOVENE (g) 43

CYTOXAN (g) 84

CYTRA-2, 3, K (g) 106

D.H.E.45 (g) 61

DALMANE (g) 57

DANOCRINE (g) 80

DANTRIUM (g) 64

DAPSONE 45

DARAPRIM 45

DAYPRO (g) 58

DAYTRANA 57

DDAVP SOLN 80

DDAVP SPRAY (g) 80

DDAVP TABS (g) 80

DECADRON (g) 79

DECADRON OPTH (g) 98

DECONAMINE CX, SR (g) 102

DECONAMINE SR 101

DECONAMINE SYRUP, SR (g) 101

DELATESTRYL 80

DEMADEX (g) 52

DEMEROL (g) 59

DEMULEN (g) 71

DENAVIR 93

DEPAKENE (g) 63

DEPAKOTE (g) 63

DEPAKOTE ER (g) 63

DEPAKOTE SPRINKLES (g) 63

DEPEN 77

DEPO-PROVERA 150MG (g) 73

DEPO-PROVERA 400MG 85

DEPO-SUBQ PROVERA 104 73

DEPO-TESTOSTERONE (g) 80

DERMACORT, HYTONE (Rx Only) (g) 90

DERMA-SMOOTHE/FS 90

DERMATOP (g) 90

DESFERAL (g) 109

DESOGEN (g), ORTHO-CEPT (g) 71

DESONATE 90

DESOWEN, TRIDESILON (g) 90

DESOXYN (g) 57

DESYREL (g) 55

DETROL 106

DETROL LA 106

DEXEDRINE (g) 57

DEXILANT 66

DIABETA, MICRONASE (g) 82

DIABINESE (g) 82

DIAMOX (g) 63

DIAMOX (g) 52

DIAMOX SEQUELS (g) 52

DIASTAT 63

DIASTAT 2.5MG (g) 63

DICLOXACILLIN (g) 40

DIDREX (g) 110

DIDRONEL (g) 78

DIFFERIN 0.1% CREAM, GEL (g) 92

DIFFERIN 0.3% GEL 92

DIFFERIN LOTION 92

DIFLUCAN (g) 75

DIFLUCAN (g) 43

DIGOXIN ELIXIR (g) 52

DIGOXIN TABS (g) 52

DILANTIN (g) 63

DILANTIN CHEW TABS 63

DILATRATE-SR 53

DILAUDID (g) 59

DIOVAN 50

DIOVAN HCT 50

DIPENTUM 70

DIPROLENE AF, GEL, CR, LOT (g) 89

DIPROLENE OINTMENT (g) 89

DIPROSONE (g), MAXIVATE (g) 89

DISALCID, SALFLEX (g) 59

DITROPAN (g) 106

DITROPAN XL (g) 106

DIURIL (g) 52

DIVIGEL 73

Trade Name Page Trade Name PageDOLOBID (g) 59

DOMEBORO OTIC (g) 100

DONNATAL (g) 67

DONNATAL EXTENTABS 67

DORAL 57

DORYX 41

DOSTINEX (g) 62

DOSTINEX (g) 80

DOVONEX CREAM 94

DOVONEX OINT(g) 94

DOVONEX SOLUTION (g) 94

DRITHOCREME HP (g) 94

DRITHO-SCALP 94

DROXIA 86

DRYSOL (g) 95

DUAC, CS 92

DUETACT 82

DULERA 105

DUONEB (g) 105

DURAGESIC (g) 59

DUREZOL 98

DURICEF (g) 40

DYGASE (g) 69

DYNACIRC (g) 51

DYNACIRC CR 51

DYRENIUM 52

EC-NAPROSYN (g) 58

EDECRIN 52

EDEX 110

EDLUAR 57

EFFEXOR (g) 55

EFFEXOR XR (g) 55

EFFIENT 53

EFUDEX (g) 95

EFUDEX OCCLUSION 95

ELAVIL (g) 55

ELDEPRYL(g) 62

ELESTAT 99

ELESTRIN 73

ELIDEL 95

ELIGARD 85

ELIMITE (g) 94

ELLA 72

ELMIRON 106

ELOCON (g) 90

EMADINE 99

EMBEDA 59

EMCYT 86

EMEND 80,125MG CAPSULES 68

EMLA (g) 91

EMSAM 55

EMTRIVA 44

ENABLEX 106

ENBREL 94

ENBREL 77

ENDOMETRIN 73

ENJUVIA 77

ENJUVIA 73

ENTOCORT EC 79

EPIDUO 92

EPIPEN, JR 104

EPIVIR 44

EPIVIR HBV 43

EPOGEN 88

EPOGEN 86

EPZICOM 44

EQUETRO 63

ERGOMAR 61

ERTACZO 93

ERYTHROMYCIN (g) 41

ERYTHROMYCIN STEARATE, BASE (g) 41

ERYTHROMYCIN TOPICAL SOLN, GEL (g) 92

ESKALITH (g) 65

ESKALITH CR (g) 65

ESTRACE (g) 77

ESTRACE (g) 73

ESTRACE VAGINAL CREAM 73

ESTRADERM 73

ESTRADERM 77

ESTRASORB 73

ESTRATEST, H.S. (g) 77

ESTRATEST, H.S. (g) 74

ESTRING 73

ESTROGEL 73

ESTROGENS 78

ESTROSTEP FE (g) 72

ETHAMBUTOL (g) 45

ETRAFON (g) 55

EULEXIN (g) 85

EURAX 94

EVAMIST 73

EVISTA 78

EVOCLIN FOAM(g) 92

EVOXAC 109

EXALGO 59

EXELDERM SOLN, CR 93

EXELON 65

EXELON (g) 65

EXFORGE 51

EXFORGE 50

EXFORGE HCT 51

EXFORGE HCT 50

EXJADE 109

EXTAVIA 88

EXTINA 93

FACTIVE 42

FAMVIR (g) 43

FANAPT 56

Trade Name Page Trade Name PageFARESTON 85

FASLODEX 85

FAZACLO 56

FELBATOL 63

FELDENE (g) 58

FEMARA 85

FEMCON FE 71

FEMHRT 74

FEMHRT 77

FEMRING 73

FEMTRACE 73

FENOGLIDE 47

FENTORA 59

FERTINEX 74

FEXMID 64

FIBRICOR (g) 47

FINACEA 92

FIORICET W/CODEINE (g) 60

FIORICET;ESGIC, PLUS (g) 60

FIORICET;ESGIC, PLUS (g) 61

FIORINAL (g) 60

FIORINAL (g) 61

FIORINAL W/CODEINE (g) 61

FIORINAL W/CODEINE (g) 60

FLAGYL (g) 46

FLAGYL ER 46

FLECTOR PATCH 58

FLEXERIL (g) 64

FLOMAX (g) 107

FLONASE (g) 100

FLONASE (g) 104

FLORINEF (g) 79

FLOVENT HFA, DISKUS (TIER 1-BCN ONLY) 103

FLOXIN (g) 42

FLOXIN OTIC (g) 100

FLOXIN OTIC SINGLES 100

FLUMADINE (g) 43

FLUVOXAMINE MALEATE (g) 55

FML (g) 98

FML FORTE, S.O.P. 98

FOCALIN (g) 57

FOCALIN XR 57

FOLLISTIM AQ 74

FOLVITE (g) 108

FORADIL 103

FORTAMET 82

FORTEO 77

FOSAMAX (g) 78

FOSAMAX PLUS D 78

FOSAMAX WEEKLY (g) 78

FOSRENOL 109

FRAGMIN 53

FROVA 61

FUZEON 44

GABITRIL 63

GALZIN 108

GANIRELIX ACETATE 74

GARAMYCIN (g) 98

GELNIQUE 106

GENOTROPIN 83

GENTAMICIN CR, OINT (g) 92

GEODON 56

GILENYA 88

GLEEVEC 87

GLUCAGON EMERGENCY KIT 80

GLUCOPHAGE (g) 82

GLUCOPHAGE XR (g) 82

GLUCOTROL (g) 82

GLUCOTROL XL (g) 82

GLUCOVANCE (g) 82

GLUMETZA 82

GLYCOLAX (g) 70

GLYNASE (g) 82

GLYSET 82

GOLYTELY (g) 109

GOLYTELY PACKET 109

GONAL-F, RFF 74

GRANULEX (g) 94

GRIFULVIN V 500MG 43

GRIFULVIN V SUSP (g) 43

GRIS PEG 43

GUAIFED, ENTEX PSE (g) 102

GUAIFED-PD (g) 102

GYNAZOLE-1 75

HALCION (g) 57

HALDOL (g) 56

HALFLYTELY 109

HALOG 89

HECTOROL 80

HECTOROL 108

HELIDAC 67

HEPARIN (g) 53

HEPSERA 43

HEXALEN 86

HIPREX/UREX (g) 42

HUMABID DM (g) 102

HUMALOG, MIX (PEN/CARTRIDGE) 81

HUMALOG, MIX (VIAL) 81

HUMATIN (g) 46

HUMATROPE 83

HUMIRA 94

HUMIRA 77

HUMULIN 70/30 (PEN/CARTRIDGE) 81

HUMULIN 70/30 (VIAL) 81

HUMULIN N (PEN/CARTRIDGE) 81

HUMULIN N (VIAL) 81

HUMULIN R (VIAL) 81

HYCAMTIN 86

Trade Name Page Trade Name PageHYDREA (g) 86

HYDRODIURIL, MICROZIDE (g) 52

HYGROTON, THALITONE (g) 52

HYTRIN (g) 107

HYTRIN (g) 54

HYZAAR (g) 50

ILOTYCIN (g) 98

IMDUR (g) 53

IMITREX INJECTION (g) 61

IMITREX NASAL SPRAY (g) 61

IMITREX TABLETS (g) 61

IMURAN (g) 77

IMURAN (g) 85

INCRELEX 83

INDERAL (g) 48

INDERAL LA (g) 48

INDERIDE (g) 48

INDOCIN SUPPOSITORY 58

INDOCIN, SR (g) 58

INFERGEN 88

INFLAMASE, FORTE (g) 98

INNOHEP 53

INNOPRAN XL 48

INSPRA (g) 52

INTAL SOLUTION (g) 105

INTELENCE 44

INTRON A 88

INTUNIV 65

INVEGA 56

INVIRASE 44

IONAMIN 110

IOPIDINE DROPERETTE 96

IOPIDINE DROPS (g) 96

IQUIX 98

IRESSA 87

ISENTRESS 44

ISMO, MONOKET (g) 53

ISONIAZID (g) 45

ISOPTO ATROPINE (g) 97

ISOPTO CARBACHOL 96

ISOPTO HOMATROPINE (g) 97

ISOPTO HYOSCINE 97

ISORDIL (g) 53

ISTALOL 96

JALYN 107

JANUMET 82

JANUVIA 82

KADIAN 59

KALETRA 44

KAOCHLOR-EFF 108

KAYCIEL, KAON-CL, KAON LIQUID (g) 108

KAYEXALATE (g) 109

KEFLEX (g) 40

KEFLEX 750MG 40

KEPPRA (g) 63

KEPPRA XR 63

KERLONE (g) 48

KETEK 41

KETOPROFEN (g) 58

KINERET 77

KLONOPIN, WAFER (g) 63

K-LOR, KLOR-CON (g) 108

K-LYTE, KLOR-CON/EF (g) 108

K-PHOS NEUTRAL (g) 106

K-TAB, K-DUR, SLOW-K, KAON CL (g) 108

KUVAN 109

KYTRIL (g) 68

LACRISERT 99

LACTULOSE (g) 70

LAMICTAL DISPERTABS (g) 63

LAMICTAL ODT 63

LAMICTAL TABS (g) 63

LAMICTAL XR 63

LAMISIL GRANULES 43

LAMISIL TABLETS (g) 43

LANTUS (PEN/CARTRIDGE) 81

LANTUS (VIAL) 81

LAPASE (g) 69

LARIAM (g) 45

LASIX (g) 52

LESCOL, XL 47

LETAIRIS 105

LEUCOVORIN (g) 86

LEUKERAN 84

LEUKINE 88

LEUKINE 86

LEVAQUIN 42

LEVATOL 48

LEVBID (g) 67

LEVBID (g) 106

LEVEMIR (PEN) 81

LEVEMIR (VIAL) 81

LEVITRA 110

LEVOTHYROXINE (g) 79

LEVSIN, SL (g) 106

LEVSIN, SL (g) 67

LEVSINEX (g) 106

LEVSINEX (g) 67

LEXAPRO 55

LEXIVA 44

LIALDA 70

LIBRAX (g) 67

LIBRIUM (g) 56

LIDEX, E (g) 89

LIDODERM PATCH 91

LIMBITROL, DS (g) 55

LINDANE 94

LIORESAL (g) 64

Trade Name Page Trade Name PageLIPITOR 47

LIPOFEN 47

LIPRAM-UL20 69

LITHIUM CITRATE (g) 65

LITHOBID (g) 65

LIVALO 47

LO/OVRAL (g) 71

LOCOID CM, OINT, SOLN (g) 90

LOCOID LIPOCREAM (g) 90

LOCOID LOTION 90

LODINE (g) 58

LODINE XL (g) 58

LOESTRIN 24 FE 71

LOESTRIN, FE (g) 71

LOFIBRA (g) 47

LOMOTIL (g) 67

LONITEN (g) 54

LOPID (g) 47

LOPRESSOR (g) 48

LOPRESSOR HCT (g) 48

LOPROX CR, LOTION, GEL (g) 93

LOPROX SHAMPOO (g) 93

LOSEASONIQUE 71

LOTEMAX 98

LOTENSIN (g) 49

LOTENSIN HCT (g) 49

LOTREL (g) 49

LOTREL (g) 51

LOTREL 5/40, 10/40 49

LOTREL 5/40, 10/40 51

LOTRIMIN (g) 93

LOTRISONE CR, LOTION (g) 93

LOTRONEX 70

LOVAZA 47

LOVENOX (g) 53

LOXITANE (g) 56

LOZOL (g) 52

LUMIGAN 96

LUNESTA 57

LUPRON (g) 74

LUPRON (g) 85

LUPRON DEPOT 75

LUPRON DEPOT 85

LUPRON DEPOT-PED 80

LURIDE (g) 108

LUVERIS 74

LUVOX CR 55

LUXIQ 90

LYBREL 71

LYRICA 63

LYSODREN 86

LYSTEDA 75

MACROBID (g) 42

MACRODANTIN (g) 42

MAGNACET 60

MALARONE 45

MANDELAMINE (g) 42

MAPROTILINE HCL (g) 55

MARINOL (g) 68

MARPLAN 55

MATULANE 86

MAVIK (g) 49

MAXAIR AUTOHALER 103

MAXALT, MLT 61

MAXIDEX 98

MAXITROL (g) 99

MAXZIDE, DYAZIDE (g) 52

MEBARAL (g) 63

MECLOMEN (g) 58

MEDROL, DOSEPAK (g) 79

MEGACE (g) 85

MEGACE ES 85

MELLARIL (g) 56

MENEST 77

MENEST 73

MENOPUR 74

MENOSTAR 73

MENTAX 93

MEPHYTON 53

MEPHYTON 108

MEPRON 46

MESNEX 86

MESTINON (g) 64

MESTINON TIMESPAN, SYRUP 64

METADATE CD 57

METAGLIP (g) 82

METAPROTERENOL SOLN (g) 103

METHADONE (g) 59

METHERGINE 75

METHITEST 80

METHOTREXATE (g) 77

METHOTREXATE (g) 84

METHYLIN CHEW 57

METHYLIN SOLN (g) 57

METOZOLV ODT 70

METROCREAM, GEL, LOTION (g) 92

METROGEL TOPICAL 1% 92

METROGEL-VAGINAL (g) 75

MEVACOR (g) 47

MEXITIL (g) 52

MIACALCIN INJECTION 80

MIACALCIN INJECTION 78

MIACALCIN NASAL SPRAY (g) 80

MIACALCIN NASAL SPRAY (g) 78

MICARDIS 50

MICARDIS HCT 50

MICRO-K(g) 108

MIDAMOR (g) 52

Trade Name Page Trade Name PageMIDRIN (g) 61

MIGRANAL 61

MILTOWN, EQUANIL (g) 56

MINIPRESS (g) 54

MINOCIN, DYNACIN (g) 41

MIRAPEX (g) 62

MIRAPEX ER 62

MIRCETTE (g) 71

MOBIC (g) 58

MODICON (g) 71

MODURETIC (g) 52

MONISTAT-DERM (g) 93

MONODOX (g) 41

MONOPRIL (g) 49

MONOPRIL HCT (g) 49

MONUROL 42

MOTRIN (g) 58

MOVIPREP 109

MOXATAG 40

MS CONTIN/ORAMORPH SR (g) 59

MSIR (g) 59

MUCOMYST (g) 105

MULTAQ 52

MUSE 110

MYCELEX TROCHE (g) 43

MYCOBUTIN 45

MYCOSTATIN (g) 93

MYDRIACYL (g) 97

MYFORTIC 85

MYLERAN 84

MYSOLINE (g) 63

MYTELASE 64

NAFTIN 93

NAMENDA, SOLN 65

NAPRELAN 58

NAPRELAN CR DOSEPAK 58

NAPROSYN (g) 58

NARDIL 55

NASACORT AQ 100

NASACORT AQ 104

NASALIDE (g) 100

NASALIDE (g) 104

NASAREL (g) 104

NASAREL (g) 100

NASCOBAL SPRAY 108

NASONEX 100

NASONEX 104

NATACYN 98

NATAZIA 72

NAVANE (g) 56

NEBUPENT AEROSOL 46

NECON 10/11 (g) 71

NEOBENZ MICRO 92

NEOMYCIN (g) 46

NEORAL (g) 85

NEOSPORIN OPHTH SOLN (g) 98

NEOSPORIN OPTH OINT (g) 98

NEO-SYNEPHRINE (g) 99

NEULASTA 88

NEULASTA 86

NEUMEGA 88

NEUPOGEN 86

NEUPOGEN 88

NEURONTIN (g) 63

NEURONTIN SOLUTION 63

NEVANAC 97

NEXAVAR 87

NEXIUM 66

NIASPAN 47

NICOTINE GUM, NICORETTE (g) (BCN ONLY 110

NICOTINE PATCH (g) 110

NICOTROL, NS 110

NIFEREX GOLD 108

NILANDRON 85

NIMOTOP (g) 65

NIRAVAM (g) 56

NITRO-BID OINTMENT 53

NITROGLYCERIN PATCH (g) 53

NITROGLYCERIN SA CAP (g) 53

NITROLINGUAL SPRAY 53

NITROMIST 53

NITROSTAT 53

NIZORAL (g) 43

NIZORAL CREAM (g) 93

NIZORAL SHAMPOO 2% (g) 93

NORDETTE, LEVLEN (g) 71

NORDITROPIN NORDIFLEX 83

NORFLEX (g) 64

NORGESIC, FORTE (g) 64

NORINYL 1/35 (g), ORTHO-NOVUM 1/35 (g) 71

NORINYL 1/50 (g), ORTHO-NOVUM 1/50 (g) 71

NORITATE 92

NORMODYNE (g) 48

NOROXIN 42

NORPACE (g) 52

NORPACE CR 52

NORPRAMIN (g) 55

NORVASC (g) 51

NORVIR 44

NOVAREL, PREGNYL, PROFASI 74

NOVOLIN (PEN/CARTRIDGE) 81

NOVOLIN (VIAL) 81

NOVOLOG (PEN/CARTRIDGE) 81

NOVOLOG (VIAL) 81

NOVOLOG MIX (PEN/CARTRIDGE) 81

NOXAFIL 43

NUCYNTA 59

NULYTELY (g) 109

Trade Name Page Trade Name PageNUTROPIN 83

NUTROPIN AQ 83

NUTROPIN AQ NUSPIN 83

NUVARING 72

NUVIGIL 57

NYSTATIN (g) 43

NYSTATIN (g) 75

NYSTATIN W/TRIAMCINOLONE (g) 93

OCUFEN (g) 97

OCUFLOX (g) 98

OCUPRESS (g) 96

OFORTA 84

OGEN, ORTHO-EST (g) 77

OGEN, ORTHO-EST (g) 73

OLEPTRO ER 55

OLUX (g) 89

OLUX-E 89

OMEPRAZOLE OTC (g) 66

OMNARIS 104

OMNARIS 100

OMNICEF (g) 40

OMNITROPE 83

ONGLYZA 82

ONSOLIS 59

OPANA (g) 59

OPANA ER 59

OPTICROM (g) 99

OPTIPRANOLOL (g) 96

OPTIVAR (g) 99

ORACEA 41

ORAP 56

ORAPRED (g) 79

ORAPRED ODT 79

ORAVIG 43

ORAXYL 41

ORFADIN 109

ORINASE (g) 82

ORTHO EVRA 72

ORTHO MICRONOR (g), NOR-QD (g) 72

ORTHO TRI-CYCLEN (g) 72

ORTHO TRI-CYCLEN LO 72

ORTHO-CYCLEN (g) 71

ORTHO-NOVUM 7/7/7 (g) 72

ORTHO-PREFEST 74

OSMOPREP, VISICOL 109

OVCON 35 (g) 71

OVCON-50, FE 71

OVIDE (g) 94

OVIDREL 74

OVRAL (g) 71

OXANDRIN (g) 80

OXISTAT 93

OXSORALEN, ULTRA 94

OXYCODONE IMMEDIATE RELEASE (g) 59

OXYCONTIN 59

OXYTROL 106

PAMELOR, AVENTYL (g) 55

PANCREASE MT 10, 16, 20 (g) 69

PANCREASE MT 4 69

PANCREAZE 69

PANCRECARB MS 69

PANCRELIPASE EC 69

PANDEL 90

PANGESTYME UL 12 69

PANRETIN 95

PAPAVERINE CAPS (g) 54

PARAFLEX, PARAFON FORTE DSC (g) 64

PARCOPA (g) 62

PAREGORIC (g) 67

PAREMYD 97

PARLODEL (g) 62

PARNATE (g) 55

PATADAY 99

PATANASE 101

PATANASE 100

PATANOL 99

PAXIL (g) 55

PAXIL CR (g) 55

PCE 41

PEDIAZOLE (g) 41

PEDIAZOLE (g) 42

PEGANONE 63

PEGASYS 88

PEG-INTRON, REDIPEN 88

PENICILLIN VK (g) 40

PENLAC (g) 93

PENNSAID 58

PENTASA 70

PEPCID (RX ONLY) (g) 66

PERANEX HC 70

PERCOCET (g) 60

PERCODAN (g) 60

PERFOROMIST 103

PERIACTIN (g) 101

PERIDEX (g) 109

PERIOSTAT (g) 41

PERPHENAZINE (g) 56

PERSANTINE (g) 53

PEXEVA 55

PHENERGAN (g) 68

PHENERGAN (g) 101

PHENERGAN DM (g) 102

PHENERGAN VC (g) 102

PHENERGAN W/CODEINE (g) 102

PHENOBARBITAL (g) 63

PHOSLO (g) 109

PHOSPHOLINE IODIDE 96

PHRENILIN (g) 61

Trade Name Page Trade Name PagePHRENILIN (g) 60

PHRENILIN FORTE 60

PHRENILIN FORTE 61

PILOCAR, ISOPTO-CARPINE (g) 96

PILOPINE HS 96

PINDOLOL (g) 48

PLAN B (g) 72

PLAN B ONE-STEP 72

PLAQUENIL (g) 45

PLAQUENIL (g) 77

PLAVIX 53

PLENDIL (g) 51

PLETAL (g) 53

PLEXION, TS (g) 92

POLARAMINE (g) 101

POLYCITRA (g) 106

POLY-PRED 99

POLYSPORIN (g) 98

POLYTRIM (g) 98

POLY-VI-FLOR (g) 108

PONSTEL 58

PRAMOSONE (g) 70

PRAMOSONE LOTION 70

PRANDIMET 82

PRANDIN 82

PRAVACHOL (g) 47

PRECOSE (g) 82

PRED FORTE (g) 98

PRED MILD 98

PRED-G 99

PREDNISOLONE, TABS, SYRUP (g) 79

PREDNISONE (g) 85

PREDNISONE (g) 79

PREMARIN CREAM 73

PREMARIN CREAM 77

PREMARIN, PREMARIN LOW DOSE 73

PREMARIN, PREMARIN LOW DOSE 77

PREMPRO, LOW DOSE/PREMPHASE 77

PREMPRO, LOW DOSE/PREMPHASE 74

PRENATAL VITS (g) 108

PREVACID (g) 66

PREVACID NAPRAPAC 58

PREVACID SOLUTAB (g) 66

PREVIDENT (g) 108

PREVPAC 67

PREZISTA(MUST BE USED WITH NORVIR) 44

PRIFTIN 45

PRILOSEC (g) 66

PRILOSEC 40MG 66

PRILOSEC OTC 66

PRILOSEC SUSPENSION 66

PRIMAQUINE 45

PRINIVIL, ZESTRIL (g) 49

PRINZIDE, ZESTORETIC (g) 49

PRISTIQ 55

PROAIR HFA, VENTOLIN HFA 103

PROAMATINE (g) 52

PRO-BANTHINE 15MG (g) 106

PRO-BANTHINE 15MG (g) 67

PROBENECID (g) 76

PROCARDIA, XL;ADALAT CC (g) 51

PROCENTRA 57

PROCHIEVE 73

PROCRIT 88

PROCRIT 86

PROCTOCORT SUPPOSITORY (g) 70

PROFASI 5000UNITS 74

PROGESTERONE IN OIL (INJ) (g) 73

PROGRAF (g) 85

PROLIXIN (g) 56

PROMACTA 88

PROMETRIUM 73

PRONESTYL, SR (g) 52

PROPINE 96

PROPYLTHIOURACIL (g) 79

PROQUIN XR 42

PROSCAR (g) 107

PROSCAR (g) 80

PROSOM (g) 57

PROSTIGMIN 64

PROTONIX (g) 66

PROTONIX SUSPENSION 66

PROTOPIC 95

PROVENTIL HFA 103

PROVENTIL SOLUTION (g) 102

PROVERA (g) 73

PROVIGIL 57

PROZAC WEEKLY (g) 55

PROZAC, SARAFEM (g) 55

PSORCON, FLORONE (g) 89

PSORCON, FLORONE (g) 89

PULMICORT 0.25MG, 0.5MG/2ML (g) 103

PULMICORT 1MG/2ML (TIER 1-BCN ONLY) 103

PULMICORT INH (TIER 1-BCN ONLY) 103

PULMOZYME 105

PURINETHOL (g) 84

PYLERA 67

PYRAZINAMIDE (g) 45

PYRIDIUM (g) 42

PYRIDIUM (g) 106

QUALAQUIN 45

QUESTRAN, QUESTRAN LIGHT (g) 47

QUINIDEX (g) 52

QUINIDINE GLUCONATE SA (g) 52

QUIXIN 98

QVAR (TIER 1-BCN ONLY) 103

RADIOGARDASE 109

RANEXA 52

Trade Name Page Trade Name PageRANICLOR 40

RAPAFLO 107

RAPAMUNE TABS, SOLUTION 85

RAZADYNE SOLUTION (g) 65

RAZADYNE, ER (g) 65

REBETOL (g) 43

REBETOL SOLUTION 43

REBIF 88

REGLAN TAB, SOLUTION (g) 70

REGRANEX 94

RELAFEN (g) 58

RELENZA 43

RELISTOR 61

RELISTOR 70

RELPAX 61

REMERON (g) 55

REMERON SOLTAB (g) 55

RENACIDIN 106

RENAGEL 109

RENVELA PACKET 0.8G 109

RENVELA PACKET 2.4G 109

RENVELA TABLET 109

REPRONEX 74

REQUIP (g) 62

REQUIP XL 62

RESCRIPTOR 44

RESERPINE (g) 54

RESTASIS 99

RESTORIL (g) 57

RETIN-A MICRO 92

RETIN-A, AVITA (g) 92

RETROVIR (g) 44

REVATIO 105

REVIA (g) 109

REVIA (g) 61

REVLIMID 85

REYATAZ 44

RHEUMATREX, TREXALL 77

RHINOCORT AQUA 100

RHINOCORT AQUA 104

RIDAURA 77

RIFADIN (g) 45

RIFAMATE (g) 45

RIFATER 45

RILUTEK 65

RIOMET 82

RISPERDAL (g) (TIER 0-BCN ONLY) 56

RISPERDAL M-TAB (g) 56

RITALIN LA 57

RITALIN, SR; METHYLIN, ER (g) 57

RMS SUPPOSITORY (g) 59

ROBAXIN (g) 64

ROBINUL, FORTE (g) 67

ROCALTROL (g) 80

ROCALTROL (g) 108

RONDEC (g) 101

RONDEC-DM (g) 102

ROSULA CLEANSER (g) 92

ROSULA FOAM 92

ROWASA ENEMA (g) 70

ROXANOL (g) 59

ROZEREM 57

RYBIX ODT 60

RYNATAN (g) 101

RYNATAN PED SUSP (g) 101

RYTHMOL (g) 52

RYTHMOL SR 52

RYZOLT 60

SABRIL 63

SAIZEN 83

SALAGEN (g) 109

SALICYLATES AND NSAIDS 76

SAMSCA 109

SANCTURA (g) 106

SANCTURA XR 106

SANCUSO 68

SANDIMMUNE 85

SANDOSTATIN (g) 86

SANDOSTATIN (g) 80

SANDOSTATIN LAR 86

SANDOSTATIN LAR 80

SANTYL 94

SAPHRIS 56

SARAFEM TABLET 55

SAVELLA 65

SEASONALE (g) 71

SEASONIQUE 71

SECTRAL (g) 48

SELSUN RX (g) 94

SELZENTRY 44

SEMPREX-D 101

SENSIPAR 80

SERAX (g) 56

SEREVENT DISKUS 103

SEROMYCIN 45

SEROQUEL 56

SEROQUEL XR 56

SEROSTIM 83

SERZONE (g) 55

SILENOR 57

SILVADENE (g) 94

SIMCOR 47

SIMPONI 77

SINEMET (g) 62

SINEMET CR (g) 62

SINEQUAN, ADAPIN (g) 55

SINGULAIR 105

SKELAXIN (g) 64

Trade Name Page Trade Name PageSOLARAZE 95

SOLODYN 45, 90, 135MG(g) 41

SOLODYN 55, 65, 80, 105, 115MG 41

SOMA (g) 64

SOMA COMPOUND (g) 64

SOMA COMPOUND W/CODEINE (g) 64

SOMATULINE DEPOT 80

SOMAVERT 80

SONATA (g) 57

SORIATANE 94

SPECTAZOLE (g) 93

SPECTRACEF (g) 40

SPIRIVA 105

SPORANOX CAPS (g) 43

SPORANOX SOLN 43

SPRYCEL 87

SSKI (g) 79

STADOL NS (g) 61

STADOL NS (g) 60

STALEVO 62

STARLIX (g) 82

STAXYN 110

STELAZINE (g) 56

STIMATE 80

STRATTERA 57

STRIANT 80

STROMECTROL - SINGLE DOSE 46

SUBOXONE FILM, TABS 60

SULAR (g) 51

SULAR 8.5, 17, 25.5, 34MG 51

SULFACET-R (g) 92

SULFADIAZINE (g) 42

SUMAVEL DOSEPRO 61

SUPERVITE 108

SUPRAX 40

SUPRINE 109

SURMONTIL (g) 55

SURMONTIL 100MG 55

SUSTIVA 44

SUTENT 87

SYMBICORT 105

SYMBYAX 56

SYMLIN 82

SYMMETREL (g) 43

SYMMETREL (g) 62

SYNALAR 0.025% CREAM, OINT (g) 90

SYNALAR CREAM, SOLN (g) 90

SYNALGOS-DC 60

SYNAREL 80

SYNAREL 75

TACLONEX, SCALP 94

TAGAMET (RX ONLY) (g) 66

TALACEN (g) 60

TALWIN NX (g) 60

TAMBOCOR (g) 52

TAMIFLU CAP, SUSP 43

TAMOXIFEN CITRATE (g) 85

TAPAZOLE (g) 79

TARCEVA 87

TARGRETIN GEL 95

TARGRETIN ORAL 86

TARKA (g) 49

TARKA (g) 51

TASIGNA 87

TASMAR 62

TAVIST RX (2.68MG, SYRUP) (g) 101

TAZORAC 92

TEGRETOL (g) 63

TEGRETOL XR (g) 63

TEGRETOL XR 100MG 63

TEKAMLO 51

TEKAMLO 54

TEKTURNA 54

TEKTURNA HCT 54

TEMODAR 84

TEMOVATE (g), CLOBEVATE (g) 89

TENEX (g) 54

TENORETIC (g) 48

TENORMIN (g) 48

TENUATE (g) 110

TERAZOL- 3, 7 (g) 75

TESSALON, PERLES (g) 102

TESTIM 80

TESTRED, ANDROID 80

TETRACYCLINE (g) 41

TEVETEN 50

TEVETEN HCT 50

TEV-TROPIN 83

THALOMID 85

THEO-24 104

THEOPHYLLINE ANHYDROUS (g) 104

THIOGUANINE 84

THORAZINE (g) 56

THYROLAR 79

TIAZAC (g) 51

TICLID (g) 53

TIGAN (g) 68

TIKOSYN 52

TIMOPTIC - XE (g) 96

TIMOPTIC (g) 96

TINDAMAX 46

TIROSINT 79

TOBI 46

TOBRADEX (g) 99

TOBRADEX OINT 99

TOBREX (g) 98

TOFRANIL (g) 55

TOFRANIL-PM (g) 55

Trade Name Page Trade Name PageTOLECTIN, DS (g) 58

TOLINASE (g) 82

TOPAMAX (g) 63

TOPAMAX SPRINKLE (g) 63

TOPICORT CR, GEL, OINT (g) 89

TOPICORT LP (g) 90

TOPROL XL (g) 48

TORADOL (g) 58

TOVIAZ 106

TRACLEER 105

TRANSDERM-SCOP 68

TRANXENE (g) 56

TRANXENE SD 56

TRAVATAN, Z 96

TRECATOR 45

TRELSTAR DEPOT, LA 85

TRENTAL (g) 53

TREXIMET 61

TRIBENZOR 50

TRIBENZOR 51

TRICOR 47

TRIGLIDE 47

TRILEPTAL (g) 63

TRILEPTAL SUSP (g) 63

TRILIPIX 47

TRILISATE (g) 59

TRIMETHOPRIM (g) 42

TRI-NORINYL (g) 72

TRIPHASIL, TRILEVLEN (g) 72

TRI-VI-FLOR (g) 108

TRIZIVIR 44

TRUSOPT (g) 96

TRUVADA 44

TUSSICAPS 102

TUSSIONEX (g) 102

TWYNSTA 50

TWYNSTA 51

TYKERB 87

TYLENOL W/CODEINE (g) 60

TYLOX (g) 60

TYVASO 105

TYZEKA 43

ULORIC 76

ULTRACET (g) 60

ULTRAM (g) 60

ULTRAM ER 100MG, 200MG (g) 60

ULTRAM ER 300MG 60

ULTRASE MT 69

ULTRAVATE (g) 89

ULTRAVATE PAC 89

UNIPHYL (g) 104

UNIRETIC (g) 49

UNIVASC (g) 49

URECHOLINE (g) 106

URETRON D-S 106

URISPAS (g) 106

UROCIT-K (g) 106

UROXATRAL 107

URSO (g) 68

URSO FORTE (g) 68

VAGIFEM 73

VALCYTE 43

VALISONE CR, LOTION, OINT (g) 89

VALISONE CR, LOTION, OINT (g) 90

VALIUM (g) 56

VALIUM (g) 64

VALTREX (g) 43

VALTURNA 50

VALTURNA 54

VANCOCIN HCL 46

VANOS 0.1% CR 89

VANTIN (g) 40

VASERETIC (g) 49

VASOCIDIN (g) 99

VASODILAN (g) 54

VASOTEC (g) 49

VECTICAL 94

VENLAFAXINE HCL ER (g) 55

VENTAVIS 105

VEPESID (g) 86

VERAMYST 104

VERAMYST 100

VERDESO 90

VEREGEN 95

VERELAN (g) 51

VERELAN PM (g) 51

VERMOX (g) 46

VESANOID 86

VESICARE 106

VEXOL 98

VFEND 43

VIAGRA 110

VIBRAMYCIN, VIBRATABS (g) 41

VICODIN, LORTAB (g) 60

VICOPROFEN (g) 60

VICTOZA 82

VIDEX 44

VIDEX EC (g) 44

VIGAMOX 98

VIMOVO 66

VIMOVO 58

VIMPAT 63

VIOKASE 69

VIRACEPT 44

VIRAMUNE 44

VIREAD 44

VIROPTIC (g) 98

VIVACTIL (g) 55

Trade Name Page Trade Name PageVIVELLE (g) 77

VIVELLE (g) 73

VIVELLE-DOT 73

VIVELLE-DOT 77

VOLTAREN (g) 97

VOLTAREN (g) 58

VOLTAREN GEL 58

VOLTAREN-XR (g) 58

VOSPIRE ER (g) 102

VOTRIENT 87

VUSION 93

VYTORIN 47

VYVANSE 57

WELCHOL 47

WELLBUTRIN XL (g) 55

WELLBUTRIN, SR (g) 55

WESTCORT (g) 90

XALATAN 96

XANAX, XR (g) 56

XELODA 84

XENAZINE 109

XENICAL 110

XERESE 93

XIBROM 97

XIFAXAN 200MG 46

XIFAXAN 550MG 46

XODOL 60

XOLEGEL 93

XOLEGEL COREPAK 93

XOPENEX 1.25MG/0.5ML (g) 103

XOPENEX HFA 103

XOPENEX SOLUTION 103

XYLOCAINE (Rx Only) (g) 91

XYLOCAINE VISCOUS (g) 91

XYREM 65

XYZAL SOLUTION 101

XYZAL TABS (g) 101

YASMIN 28 (g) 71

YAZ (g) 71

YOHIMBINE HCL (g) 110

ZANAFLEX CAPS 64

ZANAFLEX TABS (g) 64

ZANTAC (RX ONLY) (g) 66

ZANTAC EFFERDOSE 66

ZARONTIN (g) 63

ZAROXOLYN (g) 52

ZAVESCA 109

ZEBETA (g) 48

ZEBUTAL (g) 61

ZEBUTAL (g) 60

ZEGERID CAP (Rx Only) (g) 66

ZEGERID PACKET 66

ZELAPAR 62

ZEMPLAR 108

ZEMPLAR 80

ZENPEP 69

ZERIT (g) 44

ZETIA 47

ZIAC (g) 48

ZIAGEN 44

ZIANA GEL 92

ZIPSOR 58

ZIRGAN 98

ZITHROMAX (g) 41

ZMAX 41

ZOCOR (g) 47

ZOFRAN (g) 68

ZOFRAN ODT (g) 68

ZOLADEX 85

ZOLINZA 86

ZOLOFT (g) 55

ZOLPIMIST 57

ZOMIG NASAL SPRAY 61

ZOMIG, ZMT 61

ZONALON, PRUDOXIN 95

ZONEGRAN (g) 63

ZORBTIVE 83

ZORPRIN 59

ZORTRESS 87

ZOVIRAX (g) 43

ZOVIRAX CREAM, OINT 93

ZUPLENZ 68

ZYBAN (g) 110

ZYCLARA 95

ZYDONE 60

ZYFLO, CR 105

ZYLET 99

ZYLOPRIM (g) 76

ZYMAR 98

ZYMAXID 98

ZYPREXA, ZYDIS 56

ZYRTEC (OTC) (g) 101

ZYRTEC-D(OTC) (g) 101

ZYVOX 46

104277BCNMCB 2870 NOV 10