A Iii\ Arkansas + • BlueAdvantage T. ~ BlueCross BlueShield • 9. Administrators of Arkansas
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July 2021
Arkansas Blue Cross and Blue Shield Standard with Step Drug List
The Arkansas Blue Cross and Blue Shield Standard with Step Drug List is a guide within select therapeutic categories for clients, plan members and health care providers. Generics should be considered the first line of prescribing. If there is no generic available, there may be more than one brand-name medicine to treat a condition. These preferred brand-name medicines are listed to help identify products that are clinically appropriate and cost-effective. Generics listed in therapeutic categories are for representational purposes only. This is not an all-inclusive list. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics.
PLAN MEMBER
Your benefit plan provides you with a prescription benefit program administered by Arkansas Blue Cross and Blue Shield. Ask your doctor to consider prescribing, when medically appropriate, a preferred medicine from this list. Take this list along when you or a
covered family member sees a doctor.
Please note:
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. Products recently approved by the U.S. Food and Drug Administration (FDA) may not be covered upon release to the market.
•
Your prescription benefit plan design may alter coverage of certain products or vary copay1 amounts based on the condition being treated.
•
You may be responsible for the full cost of non-formulary products that are removed from coverage.
•
For specific information regarding your prescription benefit coverage and copay information, please visit www.arkansasbluecross.com or contact an Arkansas Blue Cross and Blue Shield Customer Care representative at 1-800-863-5561.
•
Arkansas Blue Cross and Blue Shield may contact your doctor after receiving your prescription to request consideration of a drug list product or generic equivalent. This may result in your doctor prescribing, when medically appropriate, a different brand-name product or generic equivalent in place of your original prescription.
•
In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-preferred option upon release of the generic product to the market.
•
HEALTH CARE PROVIDER
Your patient is covered under a prescription benefit plan administered by Arkansas Blue Cross and Blue Shield. As a way to help manage health care costs, authorize generic substitution whenever possible. If you believe a brand-name product is
necessary, consider prescribing a brand name on this list.
Please note:
• Generics should be considered the first line of prescribing.
• The member's prescription benefit plan design may alter coverage of certain products or vary copay amounts based on the condition being treated.
• This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. The member's specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. Products recently approved by the FDA may not be covered upon release to the market.
• The member's prescription benefit plan may have a different copay for specific products on the list.
• Unless specifically indicated, drug list products will include all dosage forms.
• Log in to www.arkansasbluecross.com to check coverage and copay information for a specific medicine.
ANALGESICS naproxen (except naproxen CR or § NSAIDs, TOPICAL § OPIOID ANALGESICS § GOUT
naproxen suspension) diclofenac sodium gel 1% PA buprenorphine transdermal § NSAIDs allopurinol diclofenac sodium solution QL
§ NSAIDs, COMBINATIONS diclofenac sodium colchicine tablet codeine-acetaminophen QL ibuprofen diclofenac sodium- § COX-2 INHIBITORS probenecid fentanyl transdermal QL meloxicam misoprostol celecoxib
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit www.arkansasbluecross.com or contact an Arkansas Blue Cross and Blue Shield Customer Care representative at 1-800-863-5561.
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fentanyl transmucosal efavirenz-emtricitabine- nitrofurantoin (except NDC^ PROSTATE CANCER § ANTIARRHYTHMICS lozenge PA tenofovir disoproxil 70408023932) § LUTEINIZING HORMONE- disopyramide
hydrocodone ext-rel QL fumarate QL pyrimethamine PA RELEASING HORMONE sotalol hydrocodone-acetaminophen efavirenz-lamivudine- sulfamethoxazole- (LHRH) AGONISTS MULTAQ
QL tenofovir disoproxil trimethoprim ELIGARD SGM hydromorphone QL fumarate QL vancomycin capsule QL ANTILIPEMICS
hydromorphone ext-rel QL BIKTARVY QL EMVERM LUTEINIZING HORMONE- ACL INHIBITORS / methadone QL CIMDUO QL XIFAXAN 550 MG PA RELEASING HORMONE COMBINATIONS morphine QL COMPLERA QL
ANTINEOPLASTIC AGENTS
(LHRH) ANTAGONISTS NEXLETOL PA morphine ext-rel QL DESCOVY QL FIRMAGON † NEXLIZET PA morphine suppository QL DOVATO QL oxycodone QL EVOTAZ QL § MISCELLANEOUS § BILE ACID RESINS ANTIMETABOLITES oxycodone-acetaminophen GENVOYA QL ERIVEDGE SGM cholestyramine
LONSURF SGMQL ODEFSEY QL LYNPARZA SGM colesevelam tramadol (except NDC^ PREZCOBIX QL BIOSIMILARS ODOMZO SGM
§ CHOLESTEROL STRIBILD QL RUBRACA SGM52817019610) QL KANJINTI † ABSORPTION INHIBITORS SYMTUZA QL ZEJULA SGMtramadol ext-rel tablet QL RUXIENCE † TEMIXYS QL
CARDIOVASCULAR ezetimibe BELBUCA QL TRAZIMERA †
TRIUMEQ QLNUCYNTA QL ZIRABEV † § FIBRATES TRUVADA QLNUCYNTA ER QL § ACE INHIBITORS fenofibrate (except fenofibrate capsule SUBSYS PA HORMONAL INTEGRASE INHIBITORS fosinopril 50 mg, 130 mg; fenofibrate tablet 40 mg, XTAMPZA ER QL ANTINEOPLASTIC AGENTS
ISENTRESS QL lisinopril 120 mg)
ANTI INFECTIVES § ANTIANDROGENS
TIVICAY QL quinapril fenofibric acid delayed-rel abiraterone SGM ramipril
ANTIBACTERIALS § NUCLEOSIDE REVERSE bicalutamide § HMG-CoA REDUCTASE
TRANSCRIPTASE ERLEADA SGM § ACE INHIBITOR / INHIBITORS / § CEPHALOSPORINS INHIBITORS NUBEQA SGM DIURETIC COMBINATIONS COMBINATIONS
cefdinir abacavir tablet QL XTANDI SGM fosinopril-hydrochlorothiazide atorvastatin cefprozil lamivudine QL YONSA SGM lisinopril-hydrochlorothiazide ezetimibe-simvastatin cefuroxime axetil
quinapril-hydrochlorothiazide fluvastatin cephalexin § KINASE INHIBITORS § PROTEASE INHIBITORS lovastatin SUPRAX imatinib mesylate SGM § ANGIOTENSIN II atazanavir QL pravastatin § ERYTHROMYCINS / AFINITOR SGM RECEPTOR ANTAGONISTS / NORVIR QL rosuvastatin MACROLIDES DIURETIC COMBINATIONS ALECENSA SGMPREZISTA QL simvastatin azithromycin ALUNBRIG SGM candesartan / candesartan-clarithromycin ANTIVIRALS BOSULIF SGM hydrochlorothiazide § NIACINS clarithromycin ext-rel § CYTOMEGALOVIRUS CABOMETYX SGM irbesartan / irbesartan- niacin ext-rel erythromycins AGENTS COPIKTRA SGM hydrochlorothiazide § OMEGA-3 FATTY ACIDS DIFICID ST, QL IBRANCE SGM losartan / losartan-valganciclovir omega-3 acid ethyl esters PA
IRESSA SGM hydrochlorothiazide § FLUOROQUINOLONES VASCEPA PA
§ HEPATITIS B AGENTS KISQALI SGM olmesartan / olmesartan-ciprofloxacin
entecavir KISQALI FEMARA CO- hydrochlorothiazide PCSK9 INHIBITORS levofloxacin PACK SGM telmisartan / telmisartan-lamivudine PRALUENT PAmoxifloxacin
VEMLIDY RYDAPT SGM hydrochlorothiazide SPRYCEL SGM valsartan / valsartan- § BETA-BLOCKERS § PENICILLINS
§ HEPATITIS C AGENTS STIVARGA SGM hydrochlorothiazide atenolol amoxicillin
ribavirin SGM XOSPATA SGM carvedilol amoxicillin-clavulanate § ANGIOTENSIN II EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) carvedilol phosphate ext-rel dicloxacillin MONOCLONAL ANTIBODIES RECEPTOR ANTAGONIST / SGM metoprolol succinate ext-rel penicillin VK CALCIUM CHANNEL HARVONI (genotypes 1, 4, 5, 6) PERJETA † metoprolol tartrate
PHESGO SGM BLOCKER COMBINATIONS § TETRACYCLINES SGM nadolol VOSEVI 2 SGM amlodipine-olmesartan pindolol doxycycline hyclate 20 mg MULTIPLE MYELOMA amlodipine-telmisartan propranolol doxycycline hyclate capsule § HERPES AGENTS IMMUNOMODULATORS amlodipine-valsartan propranolol ext-rel minocycline acyclovir capsule, tablet POMALYST SGM BYSTOLIC tetracycline § ANGIOTENSIN II valacyclovir REVLIMID SGM
RECEPTOR ANTAGONIST / § CALCIUM CHANNEL § ANTIFUNGALS THALOMID SGM § INFLUENZA AGENTS CALCIUM CHANNEL BLOCKERS
fluconazole oseltamivir QL PROTEASOME INHIBITORS BLOCKER / DIURETIC amlodipine itraconazole PA COMBINATIONS RELENZA QL NINLARO SGM diltiazem ext-rel (except generics terbinafine tablet
VELCADE † amlodipine-valsartan- for CARDIZEM LA) § MISCELLANEOUS hydrochlorothiazide ANTIRETROVIRAL AGENTS nifedipine ext-rel clindamycin olmesartan-amlodipine-§ ANTIRETROVIRAL verapamil ext-rel ivermectin hydrochlorothiazide COMBINATIONS linezolid PA
abacavir-lamivudine QL metronidazole
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit www.arkansasbluecross.com or contact an Arkansas Blue Cross and Blue Shield Customer Care representative at 1-800-863-5561.
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§ CALCIUM CHANNEL BLOCKER / ANTILIPEMIC COMBINATIONS
amlodipine-atorvastatin
§ DIGITALIS GLYCOSIDES
digoxin
§ DIRECT RENIN INHIBITORS / DIURETIC COMBINATIONS
aliskiren TEKTURNA HCT ST
§ DIURETICS
amiloride furosemide hydrochlorothiazide metolazone spironolactone-
hydrochlorothiazide torsemide triamterene triamterene-
hydrochlorothiazide
HEART FAILURE
BIDIL CORLANOR ENTRESTO
§ NITRATES
isosorbide dinitrate (except isosorbide dinitrate 40 mg)
isosorbide mononitrate nitroglycerin lingual spray nitroglycerin sublingual
PULMONARY ARTERIAL HYPERTENSION
§ ENDOTHELIN RECEPTOR ANTAGONISTS
ambrisentan SGM bosentan SGM OPSUMIT SGM
§ PHOSPHODIESTERASE INHIBITORS
sildenafil SGM
PROSTACYCLIN RECEPTOR AGONISTS
UPTRAVI SGM
§ PROSTAGLANDIN VASODILATORS
treprostinil SGM ORENITRAM SGM
SOLUBLE GUANYLATE CYCLASE STIMULATORS
ADEMPAS SGM
§ MISCELLANEOUS
ranolazine ext-rel
CENTRAL NERVOUS SYSTEM
ANTIANXIETY
§ BENZODIAZEPINES
alprazolam clonazepam diazepam lorazepam oxazepam
§ ANTICONVULSANTS
carbamazepine carbamazepine ext-rel clobazam diazepam rectal gel divalproex sodium divalproex sodium ext-rel ethosuximide gabapentin lamotrigine lamotrigine ext-rel levetiracetam levetiracetam ext-rel oxcarbazepine phenobarbital phenytoin phenytoin sodium extended primidone rufinamide tiagabine topiramate valproic acid vigabatrin SGM zonisamide FYCOMPA NAYZILAM OXTELLAR XR VALTOCO VIMPAT XCOPRI
§ ANTIDEMENTIA
donepezil galantamine galantamine ext-rel memantine rivastigmine rivastigmine transdermal NAMZARIC
ANTIDEPRESSANTS
§ SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)
citalopram escitalopram fluoxetine (except fluoxetine tablet 60
mg, fluoxetine tablet [generics for
SARAFEM])
paroxetine HCl paroxetine HCl ext-rel sertraline TRINTELLIX ST
§ SEROTONIN NOREPINEPHRINE
REUPTAKE INHIBITORS (SNRIs)
desvenlafaxine ext-rel duloxetine venlafaxine venlafaxine ext-rel capsule
§ MISCELLANEOUS AGENTS
bupropion bupropion ext-rel (except
bupropion ext-rel tablet 450 mg)
mirtazapine trazodone
§ ANTIPARKINSONIAN AGENTS
amantadine carbidopa-levodopa carbidopa-levodopa ext-rel carbidopa-levodopa-
entacapone entacapone pramipexole pramipexole ext-rel rasagiline ropinirole ropinirole ext-rel selegiline INBRIJA SGM KYNMOBI SGM NEUPRO
ANTIPSYCHOTICS
§ ATYPICALS
aripiprazole clozapine olanzapine quetiapine quetiapine ext-rel risperidone ziprasidone ABILIFY MAINTENA LATUDA PERSERIS VRAYLAR ST
§ ATTENTION DEFICIT HYPERACTIVITY DISORDER
amphetamine-dextroamphetamine mixed salts QL
amphetamine-dextroamphetamine mixed salts ext-rel QL
atomoxetine QL dexmethylphenidate ext-rel
QL guanfacine ext-rel QL methylphenidate QL methylphenidate ext-rel QL MYDAYIS QL VYVANSE QL
FIBROMYALGIA
pregabalin ST, QL
HYPNOTICS
§ NONBENZODIAZEPINES
eszopiclone ramelteon zolpidem zolpidem ext-rel BELSOMRA ST
§ TRICYCLICS
doxepin
MIGRAINE
ACUTE MIGRAINE AGENTS
§ Triptans
eletriptan QL naratriptan QL rizatriptan QL sumatriptan QL zolmitriptan QL ONZETRA XSAIL ST ZEMBRACE SYMTOUCH ST ZOMIG NASAL SPRAY QL
Miscellaneous
NURTEC ODT ST REYVOW ST UBRELVY ST
PREVENTIVE MIGRAINE AGENTS
Monoclonal Antibodies
AIMOVIG ST AJOVY ST EMGALITY ST
§ MOVEMENT DISORDERS
tetrabenazine SGM AUSTEDO SGM INGREZZA SGM
§ MULTIPLE SCLEROSIS AGENTS
dimethyl fumarate delayed-rel SGM
glatiramer SGM AUBAGIO SGM BETASERON SGM COPAXONE SGM GILENYA SGM KESIMPTA SGM MAYZENT SGM OCREVUS † REBIF SGM TYSABRI †
VUMERITY SGM ZEPOSIA SGM
§ MUSCULOSKELETAL THERAPY AGENTS
cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg)
§ NARCOLEPSY
armodafinil PA modafinil PA SUNOSI PA
POSTHERPETIC NEURALGIA (PHN)
GRALISE ST
PSYCHOTHERAPEUTIC -MISCELLANEOUS
§ OPIOID ANTAGONISTS
naloxone injection NARCAN NASAL SPRAY
§ PARTIAL OPIOID AGONIST / OPIOID ANTAGONIST COMBINATIONS
buprenorphine-naloxone sublingual QL
ZUBSOLV QL
PSEUDOBULBAR AFFECT AGENTS
NUEDEXTA PA
ENDOCRINE AND METABOLIC
ACROMEGALY
SOMATULINE DEPOT SGM
§ ANDROGENS
testosterone gel (except authorized generics for TESTIM and VOGELXO)
PA testosterone solution PA ANDRODERM PA NATESTO PA
ANTIDIABETICS
AMYLIN ANALOGS
SYMLINPEN
§ BIGUANIDES
metformin metformin ext-rel (except generics
for FORTAMET and GLUMETZA)
§ BIGUANIDE / SULFONYLUREA COMBINATIONS
glipizide-metformin
DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS
JANUVIA
DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR / BIGUANIDE COMBINATIONS
JANUMET JANUMET XR
INCRETIN MIMETIC AGENTS
OZEMPIC RYBELSUS TRULICITY VICTOZA
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit www.arkansasbluecross.com or contact an Arkansas Blue Cross and Blue Shield Customer Care representative at 1-800-863-5561.
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GASTROINTESTINAL
INCRETIN MIMETIC AGENT / INSULIN COMBINATIONS
SOLIQUA XULTOPHY
glipizide glipizide ext-rel
SUPPLIES
§ EXTENDED CYCLE
ethinyl estradiol-levonorgestrel
PREMPRO
§ TRANSDERMAL
estradiol
promethazine scopolamine transdermal trimethobenzamide SANCUSO PA, QL
ACCU-CHEK AVIVA PLUS CLIMARA PRO INSULINS STRIPS AND KITS 3 OTC PROGESTIN INTRAUTERINE COMBIPATCH § ANTISPASMODICS
BASAGLAR ACCU-CHEK COMPACT DEVICES DIVIGEL dicyclomine
FIASP HUMULIN R U-500 LEVEMIR
PLUS STRIPS AND KITS 3
OTC ACCU-CHEK GUIDE
KYLEENA †
MIRENA †
SKYLA †
EVAMIST
§ VAGINAL § H2 RECEPTOR ANTAGONISTS
NOVOLIN 70/30 OTC NOVOLIN N OTC NOVOLIN R OTC NOVOLOG NOVOLOG MIX 70/30 TOUJEO TRESIBA
§ INSULIN SENSITIZERS
pioglitazone
§ INSULIN SENSITIZER / BIGUANIDE COMBINATIONS
pioglitazone-metformin
STRIPS AND KITS 3 OTC ACCU-CHEK SMARTVIEW
STRIPS AND KITS 3 OTC BD ULTRAFINE INSULIN
SYRINGES AND NEEDLES OTC
DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM PA
OMNIPOD DASH QL ONETOUCH ULTRA
STRIPS AND KITS 3 OTC ONETOUCH VERIO STRIPS
AND KITS 3 OTC
§ TRANSDERMAL
ethinyl estradiol-norelgestromin
§ VAGINAL
ethinyl estradiol-etonogestrel ANNOVERA
ENDOMETRIOSIS
ORILISSA PA
FERTILITY REGULATORS
GNRH / LHRH ANTAGONISTS
estradiol vaginal cream IMVEXXY
§ PHENYLKETONURIA TREATMENT AGENTS
sapropterin SGM
§ PHOSPHATE BINDER AGENTS
calcium acetate sevelamer carbonate PHOSLYRA VELPHORO ST
POLYNEUROPATHY
famotidine
INFLAMMATORY BOWEL DISEASE
§ ORAL AGENTS
balsalazide budesonide capsule budesonide ext-rel mesalamine delayed-rel
(except mesalamine delayed-rel tablet
800 mg)
mesalamine ext-rel sulfasalazine sulfasalazine delayed-rel PENTASA
§ INSULIN SENSITIZER / § CALCIUM RECEPTOR CETROTIDE TEGSEDI SGM
SULFONYLUREA COMBINATIONS
ANTAGONISTS
cinacalcet SGM OVULATION STIMULANTS, GONADOTROPINS
POTASSIUM-REMOVING AGENTS
§ RECTAL AGENTS
hydrocortisone enema pioglitazone-glimepiride
§ MEGLITINIDES CALCIUM REGULATORS
§ BISPHOSPHONATES
GONAL-F PA OVIDREL
LOKELMA VELTASSA
mesalamine suppository mesalamine suspension CORTIFOAM
nateglinide repaglinide
SODIUM-GLUCOSE
alendronate ibandronate risedronate
GAUCHER DISEASE
CERDELGA SGM CEREZYME †
PROGESTINS
§ ORAL
medroxyprogesterone
§ IRRITABLE BOWEL SYNDROME
alosetron CO-TRANSPORTER 2 (SGLT2) INHIBITORS
FARXIGA
§ CALCITONINS
calcitonin-salmon § GLUCOCORTICOIDS
dexamethasone
megestrol acetate progesterone, micronized
LINZESS VIBERZI
JARDIANCE PARATHYROID HORMONES fludrocortisone VAGINAL § LAXATIVES
SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITOR /
FORTEO SGM TYMLOS SGM
MISCELLANEOUS
hydrocortisone tablet methylprednisolone prednisolone solution prednisone
CRINONE PA ENDOMETRIN PA
§ SELECTIVE ESTROGEN
lactulose solution peg 3350-electrolytes CLENPIQ
BIGUANIDE COMBINATIONS
SYNJARDY SYNJARDY XR XIGDUO XR
PROLIA †
§ CARNITINE DEFICIENCY AGENTS
GLUCOSE ELEVATING AGENTS
BAQSIMI
RECEPTOR MODULATORS
raloxifene
§ THYROID SUPPLEMENTS
OPIOID-INDUCED CONSTIPATION
MOVANTIK SYMPROIC
levocarnitine GLUCAGEN HYPOKIT levothyroxine
SODIUM-GLUCOSE GLUCAGON EMERGENCY liothyronine PANCREATIC ENZYMES CO-TRANSPORTER 2 CENTRAL PRECOCIOUS KIT SYNTHROID CREON (SGLT2) INHIBITOR / DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR COMBINATIONS
PUBERTY
SUPPRELIN LA † TRIPTODUR †
GVOKE
HEREDITARY TYROSINEMIA TYPE 1 AGENTS
UTERINE FIBROIDS
ORIAHNN PA
VIOKACE ZENPEP
§ PROTON PUMP
GLYXAMBI CONTRACEPTIVES ORFADIN SGM INHIBITORS
SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITOR / DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR/BIGUANIDE COMBINATIONS
TRIJARDY XR
§ MONOPHASIC
ethinyl estradiol-drospirenone
ethinyl estradiol-drospirenone-levomefolate
ethinyl estradiol-norethindrone acetate
ethinyl estradiol-norethindrone acetate-iron
HUMAN GROWTH HORMONES
GENOTROPIN SGM NORDITROPIN SGM
MENOPAUSAL SYMPTOM AGENTS
§ ORAL
estradiol
§ ANTIDIARRHEALS
diphenoxylate-atropine loperamide
§ ANTIEMETICS
aprepitant QL dronabinol PA, QL granisetron QL meclizine
esomeprazole delayed-rel lansoprazole delayed-rel omeprazole delayed-rel pantoprazole delayed-rel
tablet DEXILANT ST
§ STEROIDS, RECTAL
PROCTOFOAM-HC
§ SULFONYLUREAS
glimepiride § TRIPHASIC
ethinyl estradiol-norgestimate
estradiol-norethindrone DUAVEE PREMPHASE
metoclopramide ondansetron QL prochlorperazine
§ MISCELLANEOUS
sucralfate tablet
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit www.arkansasbluecross.com or contact an Arkansas Blue Cross and Blue Shield Customer Care representative at 1-800-863-5561.
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GENITOURINARY BRILINTA RESPIRATORY § LEUKOTRIENE ONEXTON MODULATORS
§ BENIGN PROSTATIC THROMBOCYTOPENIA ALPHA-1 ANTITRYPSIN § ACTINIC KERATOSIS montelukast
HYPERPLASIA AGENTS DEFICIENCY AGENTS fluorouracil cream 5% zafirlukast alfuzosin ext-rel DOPTELET SGM PROLASTIN-C † fluorouracil solution
doxazosin MULPLETA SGM § NASAL ANTIHISTAMINES imiquimod § ANAPHYLAXIS
IMMUNOLOGIC AGENTS
PICATO dutasteride azelastine spray QLTREATMENT AGENTS TOLAK dutasteride-tamsulosin olopatadine spray QL
epinephrine auto-injector ZYCLARA
silodosin finasteride
EPIPEN § NASAL STEROIDS / ALLERGENIC EXTRACTS § ANTIBIOTICS EPIPEN JR COMBINATIONS tamsulosin
GRASTEK PA SYMJEPI gentamicin QLterazosin flunisolide QLORALAIR PA mupirocin ointment fluticasone QL
§ URINARY RAGWITEK PA § ANTICHOLINERGICS mometasone nasal spray QL § ANTIFUNGALS ANTISPASMODICS ipratropium inhalation DYMISTA ST, QL AUTOIMMUNE AGENTS
solution QL ciclopirox PAdarifenacin ext-rel (PHYSICIAN-SPIRIVA QL PHOSPHODIESTERASE-4 clotrimazole oxybutynin ADMINISTERED)
oxybutynin ext-rel YUPELRI QL INHIBITORS econazole QL REMICADE † ketoconazole cream 2% QL SIMPONI ARIA † ANTICHOLINERGIC / BETA
solifenacin DALIRESP nystatin QL
STELARA INTRAVENOUS † AGONIST COMBINATIONS PULMONARY FIBROSIS tolterodine
NAFTIN tolterodine ext-rel § SHORT ACTING AGENTS trospium AUTOIMMUNE AGENTS § ANTIPSORIATICS
trospium ext-rel ipratropium-albuterol ESBRIET SGM(SELF-ADMINISTERED) 4 acitretin PAMYRBETRIQ ST inhalation solution QL OFEV SGM COSENTYX SGM calcipotriene ointment, TOVIAZ ST ENBREL SGM LONG ACTING SEVERE ASTHMA AGENTS solution QL
HUMIRA SGMHEMATOLOGIC ANORO ELLIPTA QL DUPIXENT SGM methoxsalen
OTEZLA SGM STIOLTO RESPIMAT QL FASENRA AUTOINJECTOR § ANTICOAGULANTS RINVOQ SGM § ANTISEBORRHEICS SGM
warfarin SKYRIZI SGM ANTICHOLINERGIC / BETA NUCALA AUTOINJECTOR ketoconazole shampoo 2%
ELIQUIS STELARA AGONIST / STEROID SGM selenium sulfide lotion 2.5%
XARELTO SUBCUTANEOUS SGM INHALANT COMBINATIONS XOLAIR † ATOPIC DERMATITIS TREMFYA SGM BREZTRI AEROSPHERE
§ CHELATING AGENTS XELJANZ SGM STEROID / BETA AGONIST Injectable QL deferasirox SGM XELJANZ XR SGM COMBINATIONS TRELEGY ELLIPTA QL DUPIXENT SGM deferiprone SGM ADVAIR DISKUS QL
§ DISEASE-MODIFYING deferoxamine † § ANTIHISTAMINES, LOW § Topical ADVAIR HFA ‡, QLANTIRHEUMATIC DRUGS penicillamine capsule ST SEDATING BREO ELLIPTA ‡, QL pimecrolimus PA (DMARDs) trientine ST levocetirizine SYMBICORT QL tacrolimus PA
RASUVO SGM EUCRISA ST HEMATOPOIETIC GROWTH § ANTITUSSIVES § STEROID INHALANTS CORTICOSTEROIDS
§ HEREDITARY FACTORS benzonatate (except NDCs^ budesonide inhalation § Low Potency ANGIOEDEMA ARANESP SGM 69336012615, 69499032915) suspension QL desonide QLicatibant SGMNIVESTYM SGM ARNUITY ELLIPTA QL hydrocortisone QLBETA AGONISTS, RETACRIT SGM FLOVENT DISKUS QLIMMUNOMODULATORS
ZIEXTENZO SGM INHALANTS FLOVENT HFA QL § Medium Potency IMMUNE GLOBULINS
§ SHORT ACTING PULMICORT FLEXHALER hydrocortisone butyrate HEMOPHILIA A AGENTS CUTAQUIG SGM QLalbuterol inhalation solution cream, ointment, solution ADVATE † QVAR REDIHALER QLQLIMMUNOSUPPRESSANTS QLADYNOVATE †
albuterol sulfate CFC-free TOPICAL
mometasone QLAFSTYLA † § RAPAMYCIN DERIVATIVES
aerosol QL triamcinolone cream, lotion, ELOCTATE † everolimus SGM
levalbuterol tartrate CFC-free ointment (except triamcinolone DERMATOLOGY ESPEROCT †
NUTRITIONAL / SUPPLEMENTS
aerosol QL ointment 0.05%) QLACNEJIVI †
KOGENATE FS † LONG ACTING § Topical § High Potency KOVALTRY †
§ ELECTROLYTES Hand-held Active Inhalation adapalene PA desoximetasone QL NOVOEIGHT † benzoyl peroxide fluocinonide (except fluocinonide potassium chloride liquid SEREVENT QLNUWIQ † clindamycin gel (except NDC^ cream 0.1%) QLSTRIVERDI RESPIMAT QL
VITAMINS AND MINERALS 68682046275) BRYHALI PAHEMOPHILIA B AGENTS Nebulized Passive Inhalation clindamycin solution QL§ FOLIC ACID / REBINYN † § Very High Potency
COMBINATIONS PERFOROMIST QL clindamycin-benzoyl peroxide clobetasol cream, foam, gel, § PLATELET AGGREGATION folic acid § CYSTIC FIBROSIS erythromycin solution lotion, ointment, shampoo INHIBITORS
§ PRENATAL VITAMINS tobramycin inhalation erythromycin-benzoyl QLclopidogrel solution SGM peroxide
dipyridamole ext-rel-aspirin prenatal vitamins § LOCAL ANALGESICS BETHKIS SGM tretinoin PA, ** prasugrel CITRANATAL
EPIDUO lidocaine patch PA
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§ LOCAL ANESTHETICS sulfacetamide tobramycin
loteprednol prednisolone acetate 1%
CARBONIC ANHYDRASE INHIBITOR /
RHO KINASE INHIBITOR / PROSTAGLANDIN
lidocaine-prilocaine BESIVANCE DUREZOL SYMPATHOMIMETIC COMBINATIONS
§ ROSACEA
azelaic acid gel PA
§ ANTI-INFECTIVE / ANTI-INFLAMMATORY
§ ANTIVIRALS
trifluridine
COMBINATIONS
SIMBRINZA ROCKLATAN ST
§ SYMPATHOMIMETICS metronidazole FINACEA FOAM PA
COMBINATIONS
neomycin-polymyxin B- BETA-BLOCKERS DRY EYE DISEASE
RESTASIS brimonidine ALPHAGAN P
ORACEA PA bacitracin-hydrocortisone § Nonselective XIIDRA SOOLANTRA PA neomycin-polymyxin B- timolol maleate solution SYMPATHOMIMETIC / BETA-
OPHTHALMIC
§ ANTIALLERGICS
azelastine
dexamethasone tobramycin-dexamethasone TOBRADEX OINTMENT
Selective
BETOPTIC S
§ PROSTAGLANDINS
latanoprost travoprost LUMIGAN ST
BLOCKER COMBINATIONS
COMBIGAN
OTIC
cromolyn sodium olopatadine
ANTI-INFLAMMATORIES
§ Nonsteroidal
§ CARBONIC ANHYDRASE INHIBITORS
ZIOPTAN ST § ANTI-INFECTIVES
acetic acid
§ ANTI-INFECTIVES bromfenac diclofenac
dorzolamide AZOPT
RETINAL DISORDERS
EYLEA † ofloxacin otic
ciprofloxacin erythromycin gentamicin QL levofloxacin moxifloxacin
ketorolac QL ILEVRO PROLENSA
§ Steroidal
§ CARBONIC ANHYDRASE INHIBITOR / BETA-BLOCKER COMBINATIONS
dorzolamide-timolol
LUCENTIS †
RHO KINASE INHIBITORS
RHOPRESSA
§ ANTI-INFECTIVE / ANTI-INFLAMMATORY COMBINATIONS
ciprofloxacin-dexamethasone neomycin-polymyxin B-
ofloxacin dexamethasone hydrocortisone
QUICK REFERENCE DRUG LIST
A
abacavir tablet QL abacavir-lamivudine QL ABILIFY MAINTENA abiraterone SGM ACCU-CHEK AVIVA PLUS
STRIPS AND KITS 3 OTC ACCU-CHEK COMPACT
PLUS STRIPS AND KITS 3
OTC ACCU-CHEK GUIDE
STRIPS AND KITS 3 OTC ACCU-CHEK SMARTVIEW
STRIPS AND KITS 3 OTC acetic acid acitretin PA acyclovir capsule, tablet adapalene PA ADEMPAS SGM ADVAIR DISKUS QL ADVAIR HFA ‡, QL ADVATE †
ADYNOVATE †
AFINITOR SGM AFSTYLA †
AIMOVIG ST AJOVY ST albuterol inhalation solution
QL albuterol sulfate CFC-free
aerosol QL ALECENSA SGM alendronate alfuzosin ext-rel aliskiren allopurinol alosetron ALPHAGAN P
alprazolam ALUNBRIG SGM amantadine ambrisentan SGM amiloride amlodipine amlodipine-atorvastatin amlodipine-olmesartan amlodipine-telmisartan amlodipine-valsartan amlodipine-valsartan-
hydrochlorothiazide amoxicillin amoxicillin-clavulanate amphetamine-
dextroamphetamine mixed salts QL
amphetamine-dextroamphetamine mixed salts ext-rel QL
ANDRODERM PA ANNOVERA ANORO ELLIPTA QL aprepitant QL ARANESP SGM aripiprazole armodafinil PA ARNUITY ELLIPTA QL atazanavir QL atenolol atomoxetine QL atorvastatin AUBAGIO SGM AUSTEDO SGM azelaic acid gel PA azelastine azelastine spray QL azithromycin
AZOPT
B
balsalazide BAQSIMI BASAGLAR BD ULTRAFINE INSULIN
SYRINGES AND NEEDLES OTC
BELBUCA QL BELSOMRA ST
benzonatate (except NDCs^
69336012615, 69499032915)
benzoyl peroxide BESIVANCE BETASERON SGM BETHKIS SGM BETOPTIC S bicalutamide BIDIL BIKTARVY QL bosentan SGM BOSULIF SGM BREO ELLIPTA ‡, QL BREZTRI AEROSPHERE
QL BRILINTA brimonidine bromfenac BRYHALI PA budesonide capsule budesonide ext-rel budesonide inhalation
suspension QL buprenorphine transdermal
QL buprenorphine-naloxone
sublingual QL
bupropion bupropion ext-rel (except
bupropion ext-rel tablet 450 mg)
BYSTOLIC
C
CABOMETYX SGM calcipotriene ointment,
solution QL calcitonin-salmon calcium acetate candesartan candesartan-
hydrochlorothiazide carbamazepine carbamazepine ext-rel carbidopa-levodopa carbidopa-levodopa ext-rel carbidopa-levodopa-
entacapone carvedilol carvedilol phosphate ext-rel cefdinir cefprozil cefuroxime axetil celecoxib cephalexin CERDELGA SGM CEREZYME †
CETROTIDE cholestyramine ciclopirox PA CIMDUO QL cinacalcet SGM ciprofloxacin ciprofloxacin-dexamethasone citalopram CITRANATAL
clarithromycin clarithromycin ext-rel CLENPIQ CLIMARA PRO clindamycin clindamycin gel (except NDC^
68682046275)
clindamycin gel, solution QL clindamycin-benzoyl
peroxide clobazam clobetasol cream, foam, gel,
lotion, ointment, shampoo QL
clonazepam clopidogrel clotrimazole clozapine codeine-acetaminophen QL colchicine tablet colesevelam COMBIGAN COMBIPATCH COMPLERA QL COPAXONE SGM COPIKTRA SGM CORLANOR CORTIFOAM COSENTYX SGM CREON CRINONE PA cromolyn sodium CUTAQUIG SGM cyclobenzaprine (except
cyclobenzaprine tablet 7.5 mg)
D
DALIRESP
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darifenacin ext-rel ELIQUIS finasteride IBRANCE SGM liothyronine deferasirox SGM ELOCTATE † FIRMAGON † ibuprofen lisinopril deferiprone SGM EMGALITY ST FLOVENT DISKUS QL icatibant SGM lisinopril-hydrochlorothiazide deferoxamine † EMVERM FLOVENT HFA QL ILEVRO LOKELMA DESCOVY QL ENBREL SGM fluconazole imatinib mesylate SGM LONSURF SGM desonide QL ENDOMETRIN PA fludrocortisone imiquimod loperamide desoximetasone QL entacapone flunisolide QL IMVEXXY lorazepam desvenlafaxine ext-rel entecavir fluocinonide (except fluocinonide INBRIJA SGM losartan dexamethasone ENTRESTO cream 0.1%) QL INGREZZA SGM losartan-hydrochlorothiazide DEXCOM CONTINUOUS EPCLUSA SGM fluorouracil cream 5% ipratropium inhalation loteprednol
GLUCOSE MONITORING EPIDUO fluorouracil solution solution QL lovastatin SYSTEM PA epinephrine auto-injector fluoxetine (except fluoxetine tablet 60 ipratropium-albuterol LUCENTIS †
DEXILANT ST EPIPEN mg, fluoxetine tablet [generics for inhalation solution QL LUMIGAN ST dexmethylphenidate ext-rel EPIPEN JR SARAFEM]) irbesartan LYNPARZA SGM
QL ERIVEDGE SGM fluticasone QL irbesartan-diazepam ERLEADA SGM fluvastatin hydrochlorothiazide M
diazepam rectal gel erythromycin folic acid IRESSA SGM MAYZENT SGM diclofenac erythromycin solution FORTEO SGM ISENTRESS QL meclizine diclofenac sodium erythromycin-benzoyl fosinopril isosorbide dinitrate (except medroxyprogesterone diclofenac sodium gel 1% peroxide fosinopril-hydrochlorothiazide isosorbide dinitrate 40 mg) megestrol acetate
PA erythromycins furosemide isosorbide mononitrate meloxicam diclofenac sodium solution ESBRIET SGM FYCOMPA itraconazole PA memantine diclofenac sodium- escitalopram ivermectin mesalamine delayed-rel
misoprostol esomeprazole delayed-rel G (except mesalamine delayed-rel tablet dicloxacillin ESPEROCT † gabapentin J 800 mg) dicyclomine estradiol galantamine JANUMET mesalamine ext-rel DIFICID ST, QL estradiol vaginal cream galantamine ext-rel JANUMET XR mesalamine suppository digoxin estradiol-norethindrone GENOTROPIN SGM JANUVIA mesalamine suspension diltiazem ext-rel (except generics eszopiclone gentamicin QL JARDIANCE metformin
for CARDIZEM LA) ethinyl estradiol- GENVOYA QL JIVI † metformin ext-rel (except generics dimethyl fumarate delayed- drospirenone GILENYA SGM for FORTAMET and GLUMETZA)
rel SGM ethinyl estradiol- glatiramer SGM K methadone QL diphenoxylate-atropine drospirenone-levomefolate glimepiride KANJINTI † methoxsalen dipyridamole ext-rel-aspirin ethinyl estradiol-etonogestrel glipizide KESIMPTA SGM methylphenidate QL disopyramide ethinyl estradiol- glipizide ext-rel ketoconazole cream 2% QL methylphenidate ext-rel QL divalproex sodium levonorgestrel glipizide-metformin ketoconazole shampoo 2% methylprednisolone divalproex sodium ext-rel ethinyl estradiol- GLUCAGEN HYPOKIT ketorolac QL metoclopramide DIVIGEL norelgestromin GLUCAGON EMERGENCY KISQALI SGM metolazone donepezil ethinyl estradiol- KIT KISQALI FEMARA CO- metoprolol succinate ext-rel DOPTELET SGM norethindrone acetate GLYXAMBI PACK SGM metoprolol tartrate dorzolamide ethinyl estradiol- GONAL-F PA KOGENATE FS † metronidazole dorzolamide-timolol norethindrone acetate-iron GRALISE ST KOVALTRY † minocycline DOVATO QL ethinyl estradiol-norgestimate granisetron QL KYLEENA † MIRENA †
doxazosin ethosuximide GRASTEK PA KYNMOBI SGM mirtazapine doxepin EUCRISA ST guanfacine ext-rel QL modafinil PA doxycycline hyclate 20 mg EVAMIST GVOKE L mometasone QL doxycycline hyclate capsule everolimus SGM lactulose solution mometasone nasal spray QL dronabinol PA, QL DUAVEE duloxetine DUPIXENT SGM DUREZOL dutasteride
EVOTAZ QL EYLEA †
ezetimibe ezetimibe-simvastatin
F
H
HARVONI SGM HUMIRA SGM HUMULIN R U-500 hydrochlorothiazide hydrocodone ext-rel QL
lamivudine QL lamotrigine lamotrigine ext-rel lansoprazole delayed-rel latanoprost LATUDA
montelukast morphine QL morphine ext-rel QL morphine suppository QL MOVANTIK moxifloxacin
dutasteride-tamsulosin famotidine hydrocodone-acetaminophen levalbuterol tartrate CFC-free MULPLETA SGM DYMISTA ST, QL FARXIGA QL aerosol QL MULTAQ
E FASENRA AUTOINJECTOR
SGM hydrocortisone QL hydrocortisone butyrate
LEVEMIR levetiracetam
mupirocin ointment MYDAYIS QL
econazole QL fenofibrate (except fenofibrate capsule cream, ointment, solution levetiracetam ext-rel MYRBETRIQ ST efavirenz-emtricitabine- 50 mg, 130 mg; fenofibrate tablet 40 mg, QL levocarnitine
tenofovir disoproxil 120 mg) hydrocortisone enema levocetirizine N
fumarate QL fenofibric acid delayed-rel hydrocortisone tablet levofloxacin nadolol efavirenz-lamivudine- fentanyl transdermal QL hydromorphone QL levothyroxine NAFTIN
tenofovir disoproxil fentanyl transmucosal hydromorphone ext-rel QL lidocaine patch PA naloxone injection fumarate QL lozenge PA lidocaine-prilocaine NAMZARIC
eletriptan QL FIASP I linezolid PA naproxen (except naproxen CR or ELIGARD SGM FINACEA FOAM PA ibandronate LINZESS naproxen suspension)
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naratriptan QL OPSUMIT SGM PROLIA † solifenacin torsemide NARCAN NASAL SPRAY ORACEA PA promethazine SOLIQUA TOUJEO nateglinide ORALAIR PA propranolol SOMATULINE DEPOT SGM TOVIAZ ST NATESTO PA ORENITRAM SGM propranolol ext-rel SOOLANTRA PA tramadol (except NDC^ NAYZILAM ORFADIN SGM PULMICORT FLEXHALER sotalol 52817019610) QL neomycin-polymyxin B- ORIAHNN PA QL SPIRIVA QL tramadol ext-rel tablet QL
bacitracin-hydrocortisone ORILISSA PA pyrimethamine PA spironolactone- travoprost neomycin-polymyxin B- oseltamivir QL hydrochlorothiazide TRAZIMERA †
dexamethasone OTEZLA SGM Q SPRYCEL SGM trazodone neomycin-polymyxin B- OVIDREL quetiapine STELARA INTRAVENOUS † TRELEGY ELLIPTA QL
hydrocortisone oxazepam quetiapine ext-rel STELARA TREMFYA SGM NEUPRO oxcarbazepine quinapril SUBCUTANEOUS SGM treprostinil SGM NEXLETOL PA OXTELLAR XR quinapril-hydrochlorothiazide STIOLTO RESPIMAT QL TRESIBA NEXLIZET PA oxybutynin QVAR REDIHALER QL STIVARGA SGM tretinoin PA, ** niacin ext-rel oxybutynin ext-rel STRIBILD QL triamcinolone cream, lotion, nifedipine ext-rel oxycodone QL R STRIVERDI RESPIMAT QL ointment (except triamcinolone NINLARO SGM oxycodone-acetaminophen RAGWITEK PA SUBSYS PA ointment 0.05%) QL nitrofurantoin (except NDC^ QL raloxifene sucralfate tablet triamterene
70408023932) OZEMPIC ramelteon sulfacetamide triamterene-nitroglycerin lingual spray nitroglycerin sublingual P
ramipril ranolazine ext-rel
sulfamethoxazole-trimethoprim
hydrochlorothiazide trientine ST
NIVESTYM SGM pantoprazole delayed-rel rasagiline sulfasalazine trifluridine NORDITROPIN SGM tablet RASUVO SGM sulfasalazine delayed-rel TRIJARDY XR NORVIR QL paroxetine HCl REBIF SGM sumatriptan QL trimethobenzamide NOVOEIGHT † paroxetine HCl ext-rel REBINYN † SUNOSI PA TRINTELLIX ST NOVOLIN 70/30 OTC peg 3350-electrolytes RELENZA QL SUPPRELIN LA † TRIPTODUR † NOVOLIN N OTC penicillamine capsule ST REMICADE † SUPRAX TRIUMEQ QL NOVOLIN R OTC penicillin VK repaglinide SYMBICORT QL trospium NOVOLOG PENTASA RESTASIS SYMJEPI trospium ext-rel NOVOLOG MIX 70/30 PERFOROMIST QL RETACRIT SGM SYMLINPEN TRULICITY NUBEQA SGM PERJETA † REVLIMID SGM SYMPROIC TRUVADA QL NUCALA AUTOINJECTOR PERSERIS REYVOW ST SYMTUZA QL TYMLOS SGM
SGM phenobarbital RHOPRESSA SYNJARDY TYSABRI †
NUCYNTA QL phenytoin ribavirin SGM SYNJARDY XR NUCYNTA ER QL phenytoin sodium extended RINVOQ SGM SYNTHROID U NUEDEXTA PA NURTEC ODT ST
PHESGO SGM PHOSLYRA
risedronate risperidone T
UBRELVY ST UPTRAVI SGM
NUWIQ † PICATO rivastigmine tacrolimus PA nystatin QL pimecrolimus PA rivastigmine transdermal tamsulosin V
O
OCREVUS † ODEFSEY QL
pindolol pioglitazone pioglitazone-glimepiride pioglitazone-metformin
rizatriptan QL ROCKLATAN ST ropinirole ropinirole ext-rel
TEGSEDI SGM TEKTURNA HCT ST telmisartan telmisartan-
valacyclovir valganciclovir valproic acid valsartan
ODOMZO SGM OFEV SGM
POMALYST SGM potassium chloride liquid
rosuvastatin RUBRACA SGM
hydrochlorothiazide TEMIXYS QL
valsartan-hydrochlorothiazide VALTOCO
ofloxacin ofloxacin otic
PRALUENT PA pramipexole
rufinamide RUXIENCE †
terazosin terbinafine tablet
vancomycin capsule QL VASCEPA PA
olanzapine pramipexole ext-rel RYBELSUS testosterone gel (except authorized VELCADE † olmesartan prasugrel RYDAPT SGM generics for TESTIM and VOGELXO) VELPHORO ST olmesartan-amlodipine- pravastatin PA VELTASSA
hydrochlorothiazide prednisolone acetate 1% S testosterone solution PA VEMLIDY olmesartan- prednisolone solution SANCUSO PA, QL tetrabenazine SGM venlafaxine
hydrochlorothiazide olopatadine olopatadine spray QL
prednisone pregabalin ST, QL PREMPHASE
sapropterin SGM scopolamine transdermal selegiline
tetracycline THALOMID SGM tiagabine
venlafaxine ext-rel capsule verapamil ext-rel VIBERZI
omega-3 acid ethyl esters PREMPRO selenium sulfide lotion 2.5% timolol maleate solution VICTOZA PA
omeprazole delayed-rel prenatal vitamins PREZCOBIX QL
SEREVENT QL sertraline
TIVICAY QL TOBRADEX OINTMENT
vigabatrin SGM VIMPAT
OMNIPOD DASH QL PREZISTA QL sevelamer carbonate tobramycin VIOKACE ondansetron QL primidone sildenafil SGM tobramycin inhalation VOSEVI 2 SGM ONETOUCH ULTRA probenecid silodosin solution SGM VRAYLAR ST
STRIPS AND KITS 3 OTC prochlorperazine SIMBRINZA tobramycin-dexamethasone VUMERITY SGM ONETOUCH VERIO STRIPS
AND KITS 3 OTC PROCTOFOAM-HC progesterone, micronized
SIMPONI ARIA †
simvastatin
TOLAK tolterodine
VYVANSE QL
ONEXTON PROLASTIN-C † SKYLA † tolterodine ext-rel W ONZETRA XSAIL ST PROLENSA SKYRIZI SGM topiramate warfarin
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- -
X XIGDUO XR Y ZEMBRACE SYMTOUCH ZIRABEV † XIIDRA
YONSA SGM ST zolmitriptan QL
XOLAIR † XOSPATA SGM
YUPELRI QL ZENPEP ZEPOSIA SGM
zolpidem zolpidem ext-rel
XTAMPZA ER QL Z ZIEXTENZO SGM XTANDI SGM ZIOPTAN ST XULTOPHY
zafirlukast ZEJULA SGM
ziprasidone
XARELTO XCOPRI XELJANZ SGM XELJANZ XR SGM XIFAXAN 550 MG PA
ZOMIG NASAL SPRAY QL zonisamide ZUBSOLV QL ZYCLARA
PREFERRED OPTIONS LIST NON FORMULARY DRUG NAME(S) PREFERRED OPTION(S)* NON FORMULARY DRUG NAME(S) PREFERRED OPTION(S)*
ABILIFY aripiprazole, clozapine, olanzapine, quetiapine, AMITIZA quetiapine ext-rel, risperidone, ziprasidone, LATUDA, VRAYLAR ST AMRIX
ACANYA adapalene PA, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275) QL, clindamycin- ANDROGEL
benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin PA, **, EPIDUO, ONEXTON ANGELIQ
ACIPHEX, ACIPHEX SPRINKLE esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel, pantoprazole ANTARA delayed-rel tablet, DEXILANT ST
ACTEMRA ACTPEN, ACTEMRA ENBREL SGM, HUMIRA SGM, RINVOQ SGM, SUBCUTANEOUS XELJANZ SGM, XELJANZ XR SGM APEXICON E
ACTICLATE doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline
Activite folic acid APIDRA
ACTOS pioglitazone APOKYN
ACUVAIL bromfenac, diclofenac, ketorolac QL, ILEVRO, APTENSIO XR
PROLENSA
acyclovir cream acyclovir capsule, acyclovir tablet, valacyclovir
ADDERALL amphetamine-dextroamphetamine mixed salts APTIVUS QL, methylphenidate QL
ADZENYS ER, ADZENYS XR-ODT amphetamine-dextroamphetamine mixed salts ARALAST NP ext-rel QL, dexmethylphenidate ext-rel QL, methylphenidate ext-rel QL, MYDAYIS QL, ARMOUR THYROID
VYVANSE QL ARTHROTEC
ALCORTIN A desonide QL, hydrocortisone QL
ALEVICYN GEL, ALEVICYN SG, desonide QL, hydrocortisone QL ALEVICYN SOLUTION
ALIQOPA COPIKTRA SGM ASACOL HD
ALLISON MEDICAL INSULIN BD ULTRAFINE INSULIN SYRINGES OTC SYRINGES 5
ALORA estradiol, DIVIGEL, EVAMIST ASCENSIA STRIPS AND KITS 6
ALPROLIX Consult doctor
ALREX azelastine, cromolyn sodium, olopatadine
ALTOPREV atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin
ALVESCO ARNUITY ELLIPTA QL, FLOVENT DISKUS QL, FLOVENT HFA QL,
ASMANEX, ASMANEX HFA
PULMICORT FLEXHALER QL, QVAR REDIHALER QL
LINZESS, MOVANTIK, SYMPROIC
cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg)
testosterone gel (except authorized generics for TESTIM and VOGELXO) PA, testosterone solution PA, ANDRODERM PA, NATESTO PA
estradiol-norethindrone, PREMPHASE, PREMPRO
fenofibrate (except fenofibrate capsule 50 mg, 130 mg; fenofibrate tablet 40 mg, 120 mg), fenofibric acid delayed-rel
desoximetasone (except desoximetasone ointment 0.05%) QL, fluocinonide (except fluocinonide cream 0.1%) QL, BRYHALI PA
FIASP, NOVOLOG
INBRIJA SGM, KYNMOBI SGM
amphetamine-dextroamphetamine mixed salts ext-rel QL, dexmethylphenidate ext-rel QL, methylphenidate ext-rel QL, MYDAYIS QL, VYVANSE QL
Consult doctor
PROLASTIN-C †
levothyroxine, liothyronine, SYNTHROID
celecoxib; diclofenac sodium, ibuprofen, meloxicam or naproxen (except naproxen CR or naproxen suspension) WITH esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel, pantoprazole delayed-rel tablet or DEXILANT ST
balsalazide, mesalamine delayed-rel, mesalamine ext-rel, sulfasalazine, sulfasalazine delayed-rel, PENTASA
ACCU-CHEK AVIVA PLUS STRIPS AND KITS 3 OTC, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 3 OTC, ACCU-CHEK GUIDE STRIPS AND KITS 3 OTC, ACCU-CHEK SMARTVIEW STRIPS AND KITS 3 OTC, ONETOUCH ULTRA STRIPS AND KITS 3 OTC, ONETOUCH VERIO STRIPS AND KITS 3 OTC
ARNUITY ELLIPTA QL, FLOVENT DISKUS QL, FLOVENT HFA QL, PULMICORT FLEXHALER QL, QVAR REDIHALER QL
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit www.arkansasbluecross.com or contact an Arkansas Blue Cross and Blue Shield Customer Care representative at 1-800-863-5561.
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- -NON FORMULARY DRUG NAME(S) PREFERRED OPTION(S)* NON FORMULARY DRUG NAME(S) PREFERRED OPTION(S)*
ATACAND, ATACAND HCT candesartan, candesartan-hydrochlorothiazide, BERINERT icatibant SGM irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, BETAPACE, BETAPACE AF sotalol
olmesartan, olmesartan-hydrochlorothiazide, BETIMOL timolol maleate solution, BETOPTIC S telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide
BEVESPI AEROSPHERE ANORO ELLIPTA QL, STIOLTO RESPIMAT QL ATIVAN alprazolam, clonazepam, diazepam, lorazepam,
oxazepam BEYAZ ethinyl estradiol-drospirenone, ethinyl estradiol-
ATOPADERM desonide QL, hydrocortisone QL drospirenone-levomefolate, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-
ATROVENT HFA ipratropium inhalation solution QL, SPIRIVA QL, norethindrone acetate-iron
YUPELRI QL bimatoprost solution 0.03% latanoprost, travoprost, LUMIGAN, ZIOPTAN ST
AVASTIN ZIRABEV † BORTEZOMIB NINLARO SGM, VELCADE †
BREEZE 2 STRIPS AND KITS 6 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 3 AVENOVA Consult doctor OTC, ACCU-CHEK COMPACT PLUS STRIPS
AVONEX dimethyl fumarate delayed-rel SGM, glatiramer SGM, AUBAGIO SGM, BETASERON SGM, COPAXONE SGM, GILENYA SGM, KESIMPTA SGM, MAYZENT SGM, OCREVUS † , REBIF SGM, TYSABRI † , ZEPOSIA SGM
AND KITS 3 OTC, ACCU-CHEK GUIDE STRIPS AND KITS 3 OTC, ACCU-CHEK SMARTVIEW STRIPS AND KITS 3 OTC, ONETOUCH ULTRA STRIPS AND KITS 3 OTC, ONETOUCH VERIO STRIPS AND KITS 3 OTC
AZASITE ciprofloxacin, erythromycin, gentamicin QL, levofloxacin, moxifloxacin, ofloxacin, sulfacetamide, tobramycin, BESIVANCE
BROMSITE bromfenac, diclofenac, ketorolac QL, ILEVRO, PROLENSA
AZELEX adapalene PA, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275) QL,
Bupap diclofenac sodium, ibuprofen, naproxen (except naproxen CR or naproxen suspension)
clindamycin solution QL, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide,
bupropion ext-rel tablet 450 mg bupropion, bupropion ext-rel (except bupropion ext-rel tablet 450 mg)
tretinoin PA, **, EPIDUO, ONEXTON butalbital-acetaminophen tablet 50- diclofenac sodium, ibuprofen, naproxen (except
AZESCO 7 prenatal vitamins, CITRANATAL 300 mg, BUTALBITAL-ACETAMINOPHEN (NDC^
naproxen CR or naproxen suspension)
AZOR amlodipine-olmesartan, amlodipine-telmisartan, 69499034230 only)
amlodipine-valsartan butalbital-acetaminophen-caffeine diclofenac sodium, ibuprofen, naproxen (except
BANZEL SUSPENSION clobazam, lamotrigine, rufinamide, topiramate capsule naproxen CR or naproxen suspension)
BARACLUDE TABLET entecavir, lamivudine, VEMLIDY BUTRANS buprenorphine transdermal QL, BELBUCA QL
BEAU RX Consult doctor BYDUREON OZEMPIC, RYBELSUS, TRULICITY, VICTOZA
BECONASE AQ flunisolide QL, fluticasone QL, BYETTA OZEMPIC, RYBELSUS, TRULICITY, VICTOZA
mometasone nasal spray QL, DYMISTA ST, QL CAFERGOT eletriptan QL, rizatriptan QL, sumatriptan QL,
BENICAR, BENICAR HCT candesartan, candesartan-hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide,
zolmitriptan QL, NURTEC ODT ST, ONZETRA XSAIL ST, REYVOW ST, UBRELVY ST, ZEMBRACE SYMTOUCH ST, ZOMIG NASAL SPRAY QL
telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide
calcipotriene cream calcipotriene ointment QL, calcipotriene solution QL
BENSAL HP desonide QL, hydrocortisone QL calcipotriene-betamethasone calcipotriene ointment QL or calcipotriene
BENZAC AC adapalene PA, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275) QL, clindamycin solution QL, clindamycin-benzoyl peroxide, erythromycin solution,
solution QL WITH desoximetasone (except desoximetasone ointment 0.05%) QL, fluocinonide (except fluocinonide cream 0.1%) QLor BRYHALI PA
erythromycin-benzoyl peroxide, tretinoin PA, **, EPIDUO, ONEXTON
calcitriol ointment calcipotriene ointment QL, calcipotriene solution QL
BENZACLIN adapalene PA, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275) QL, clindamycin solution QL, clindamycin-
CAMBIA diclofenac sodium, ibuprofen, naproxen (except naproxen CR or naproxen suspension)
benzoyl peroxide, erythromycin solution, CARAC fluorouracil cream 5%, fluorouracil solution,
erythromycin-benzoyl peroxide, tretinoin PA, **, imiquimod, PICATO, TOLAK, ZYCLARA
EPIDUO, ONEXTON CARAFATE sucralfate tablet
benzonatate (NDCs^ 69336012615, 69499032915 only)
benzonatate (except NDCs^ 69336012615, 69499032915) CARBINOXAMINE TABLET 6 MG levocetirizine
BEPREVE azelastine, cromolyn sodium, olopatadine CARDIZEM, CARDIZEM CD, CARDIZEM LA
diltiazem ext-rel (except generics for CARDIZEM LA)
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit www.arkansasbluecross.com or contact an Arkansas Blue Cross and Blue Shield Customer Care representative at 1-800-863-5561.
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- -NON FORMULARY DRUG NAME(S) PREFERRED OPTION(S)* NON FORMULARY DRUG NAME(S) PREFERRED OPTION(S)*
CARNITOR, CARNITOR SF
carisoprodol 250 mg
CELEBREX
chlordiazepoxide-clidinium (NDCs^ 11534019701, 42494040901, 51293069601, 51293069610 only)
chlorzoxazone 375 mg, chlorzoxazone 500 mg (NDC^ 73007001303 only), chlorzoxazone 750 mg, CHLORZOXAZONE 250 MG
CICATRACE
CILOXAN
CIMZIA PREFILLED SYRINGE
CIPRO HC
CIPRODEX
CLINDAGEL
clindamycin gel (NDC^ 68682046275 only)
clobetasol spray
CLOBEX SPRAY
clocortolone cream
COLAZAL
colchicine capsule
COLCRYS
CONSENSI
CONTOUR NEXT STRIPS AND KITS 6
CONTOUR STRIPS AND KITS 6
levocarnitine
cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg)
celecoxib, diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)
dicyclomine
cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg)
Consult doctor
ciprofloxacin, erythromycin, gentamicin QL, levofloxacin, moxifloxacin, ofloxacin, sulfacetamide, tobramycin, BESIVANCE
COSENTYX SGM, ENBREL SGM, HUMIRA SGM, OTEZLA SGM, RINVOQ SGM, STELARA SUBCUTANEOUS SGM, TREMFYA SGM, XELJANZ SGM, XELJANZ XR SGM
ciprofloxacin-dexamethasone, ofloxacin otic
ciprofloxacin-dexamethasone, ofloxacin otic
erythromycin solution
adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin PA, **, EPIDUO, ONEXTON
clobetasol foam QL
clobetasol foam QL
hydrocortisone butyrate cream QL, hydrocortisone butyrate ointment QL, hydrocortisone butyrate solution QL, mometasone QL, triamcinolone cream QL, triamcinolone lotion QL, triamcinolone ointment (except triamcinolone ointment 0.05%) QL
balsalazide, mesalamine delayed-rel (except mesalamine delayed-rel tablet 800 mg), mesalamine ext-rel, sulfasalazine, sulfasalazine delayed-rel, PENTASA
colchicine tablet
colchicine tablet
amlodipine WITH celecoxib
ACCU-CHEK AVIVA PLUS STRIPS AND KITS 3 OTC, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 3 OTC, ACCU-CHEK GUIDE STRIPS AND KITS 3 OTC, ACCU-CHEK SMARTVIEW STRIPS AND KITS 3 OTC, ONETOUCH ULTRA STRIPS AND KITS 3 OTC, ONETOUCH VERIO STRIPS AND KITS 3 OTC
ACCU-CHEK AVIVA PLUS STRIPS AND KITS 3
OTC, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 3 OTC, ACCU-CHEK GUIDE STRIPS AND KITS 3 OTC, ACCU-CHEK SMARTVIEW STRIPS AND KITS 3 OTC, ONETOUCH ULTRA
CORDRAN OINTMENT
COREG CR
CoreMino
COZAAR
CRESEMBA
CRESTOR
CUPRIMINE
cyclobenzaprine ext-rel capsule, cyclobenzaprine tablet 7.5 mg
CYMBALTA
CYTOMEL
DARAPRIM
DAYTRANA
DELZICOL
DESFERAL
desoximetasone ointment 0.05%
DETROL LA
dexchlorpheniramine
Dexifol
Diclofex DC (NDC^ 51021037201 only)
Diclosaicin
STRIPS AND KITS 3 OTC, ONETOUCH VERIO STRIPS AND KITS 3 OTC
hydrocortisone butyrate cream QL, hydrocortisone butyrate ointment QL,hydrocortisone butyrate solution QL, mometasone QL, triamcinolone cream QL, triamcinolone lotion QL, triamcinolone ointment (except triamcinolone ointment 0.05%) QL
atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, pindolol, propranolol, propranolol ext-rel, BYSTOLIC
doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline
candesartan, irbesartan, losartan, olmesartan, telmisartan, valsartan
itraconazole PA
atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin
penicillamine capsule ST
cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg)
desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule
levothyroxine, liothyronine, SYNTHROID
pyrimethamine PA
amphetamine-dextroamphetamine mixed salts ext-rel QL, dexmethylphenidate ext-rel QL, methylphenidate ext-rel QL, MYDAYIS QL, VYVANSE QL
balsalazide, mesalamine delayed-rel (except mesalamine delayed-rel tablet 800 mg), mesalamine ext-rel, sulfasalazine, sulfasalazine delayed-rel, PENTASA
deferasirox SGM, deferiprone SGM, deferoxamine †
hydrocortisone butyrate cream QL, hydrocortisone butyrate ointment QL, hydrocortisone butyrate solution QL, mometasone QL, triamcinolone cream QL, triamcinolone lotion QL, triamcinolone ointment (except triamcinolone ointment 0.05%) QL
darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ ST, TOVIAZ ST
levocetirizine
folic acid
diclofenac sodium, diclofenac sodium gel 1% PA, diclofenac sodium solution, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)
diclofenac sodium, diclofenac sodium gel 1% PA, diclofenac sodium solution, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit www.arkansasbluecross.com or contact an Arkansas Blue Cross and Blue Shield Customer Care representative at 1-800-863-5561.
www.arkansasbluecross.com
- -NON FORMULARY DRUG NAME(S) PREFERRED OPTION(S)* NON FORMULARY DRUG NAME(S) PREFERRED OPTION(S)*
DIFFERIN LOTION adapalene PA, benzoyl peroxide, clindamycin gel EFFEXOR XR desvenlafaxine ext-rel, duloxetine, venlafaxine, (except NDC^ 68682046275) QL, venlafaxine ext-rel capsule clindamycin solution QL, clindamycin-benzoyl peroxide, erythromycin solution, ELELYSO CERDELGA SGM, CEREZYME
†
erythromycin-benzoyl peroxide, tretinoin PA, **, EPIDUO, ONEXTON
ELIDEL pimecrolimus PA, tacrolimus PA, EUCRISA ST
diflorasone cream, diflorasone desoximetasone (except desoximetasone ELMIRON Consult doctor
ointment
dihydroergotamine spray
ointment 0.05%) QL, fluocinonide (except fluocinonide cream 0.1%) QL, BRYHALI PA
eletriptan QL, naratriptan QL, rizatriptan QL, sumatriptan QL, zolmitriptan QL, NURTEC ODT ST, ONZETRA XSAIL ST, REYVOW ST,
ENABLEX
ENLITE CONTINUOUS GLUCOSE
darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ ST, TOVIAZ ST
DEXCOM CONTINUOUS GLUCOSE
UBRELVY ST, ZEMBRACE SYMTOUCH ST, MONITORING MONITORING SYSTEM PA
ZOMIG NASAL SPRAY QL ENTERAGAM alosetron, VIBERZI, XIFAXAN 550 MG PA
diltiazem ext-rel (generics for CARDIZEM LA only)
diltiazem ext-rel (except generics for CARDIZEM LA) ENTYVIO HUMIRA SGM,
STELARA SUBCUTANEOUS SGM,
DIOVAN, DIOVAN HCT candesartan, candesartan-hydrochlorothiazide, XELJANZ SGM
irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan- EPICERAM desonide QL, hydrocortisone QL
Diphen Elixir
hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide
levocetirizine
EPOGEN
ergotamine-caffeine
ARANESP SGM, RETACRIT SGM
eletriptan QL, naratriptan QL, rizatriptan QL, sumatriptan QL, zolmitriptan QL, NURTEC ODT ST, ONZETRA XSAIL ST, REYVOW ST, UBRELVY ST, ZEMBRACE SYMTOUCH ST, ZOMIG NASAL SPRAY QL
DORAL
DORYX, DORYX MPC
doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, BELSOMRA ST
doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline
ERYPED
estradiol vaginal tablet
ESTRING
erythromycins
estradiol vaginal cream, IMVEXXY
estradiol vaginal cream, IMVEXXY
doxepin cream
doxycycline hyclate delayed-rel tablet 50 mg, 200 mg
doxycycline hyclate tablet 50 mg (NDC^ 72143021160 only), doxycycline hyclate tablet 75
desonide QL, pimecrolimus PA, hydrocortisone QL, tacrolimus PA, EUCRISA ST
doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline
doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline
EVEKEO
EVERSENSE CONTINUOUS GLUCOSE MONITORING SYSTEM
EXFORGE
amphetamine-dextroamphetamine mixed salts QL, methylphenidate QL
DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM PA
amlodipine-olmesartan, amlodipine-telmisartan, amlodipine-valsartan
mg, doxycycline hyclate tablet 150 mg
EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide, olmesartan-amlodipine-hydrochlorothiazide
doxycycline monohydrate capsule 75 mg, doxycycline monohydrate capsul e 150 mg
doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline
EXJADE deferasirox SGM, deferiprone SGM, deferoxamine †
doxycycline monohydrate delayed-rel capsule
ORACEA PA EXTAVIA dimethyl fumarate delayed-rel SGM,
glatiramer SGM, AUBAGIO SGM, BETASERON SGM, COPAXONE SGM,
DULERA
DUTOPROL
DYRENIUM
ADVAIR DISKUS QL, ADVAIR HFA ‡ QL, BREO ELLIPTA ‡ QL, SYMBICORT QL
metoprolol succinate ext-rel WITH hydrochlorothiazide
amiloride, triamterene
FABIOR
GILENYA SGM, KESIMPTA SGM, MAYZENT SGM, OCREVUS † , REBIF SGM, TYSABRI † , ZEPOSIA SGM
adapalene PA, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275) QL, clindamycin solution QL, clindamycin-
EDARBI, EDARBYCLOR candesartan, candesartan-hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-
benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin PA, **, EPIDUO, ONEXTON
EDLUAR
E.E.S. GRANULES
hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide
doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, BELSOMRA ST
erythromycins
FANAPT
FEMRING
fenofibrate capsule 50 mg, 130 mg; fenofibrate tablet 40 mg, 120 mg
aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext-rel, risperidone, ziprasidone, LATUDA, VRAYLAR ST
estradiol vaginal cream, IMVEXXY
fenofibrate (except fenofibrate capsule 50 mg, 130 mg; fenofibrate tablet 40 mg, 120 mg), fenofibric acid delayed-rel
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit www.arkansasbluecross.com or contact an Arkansas Blue Cross and Blue Shield Customer Care representative at 1-800-863-5561.
www.arkansasbluecross.com
- -NON FORMULARY DRUG NAME(S) PREFERRED OPTION(S)* NON FORMULARY DRUG NAME(S) PREFERRED OPTION(S)*
FENOGLIDE TABLET 120 MG fenofibrate (except fenofibrate capsule 50 mg, FOSRENOL calcium acetate, sevelamer 130 mg; fenofibrate tablet 40 mg, 120 mg), carbonate, PHOSLYRA, VELPHORO ST fenofibric acid delayed-rel
FOSTEUM, FOSTEUM PLUS alendronate, ibandronate, risedronate fenoprofen, FENOPROFEN CAPSULE
diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)
FREESTYLE LIBRE CONTINUOUS GLUCOSE
DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM PA
FERIVA 21/7 folic acid FREESTYLE STRIPS AND KITS 6 ACCU-CHEK AVIVA PLUS STRIPS AND
KITS 3 OTC, ACCU-CHEK COMPACT PLUS FERRIPROX deferasirox SGM, deferiprone SGM, STRIPS AND KITS 3 OTC, ACCU-CHEK GUIDE
deferoxamine † STRIPS AND KITS 3 OTC, ACCU-CHEK
FETZIMA desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule
SMARTVIEW STRIPS AND KITS 3 OTC, ONETOUCH ULTRA STRIPS AND KITS 3 OTC, ONETOUCH VERIO STRIPS AND KITS 3 OTC
Fexmid cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg)
FROVA eletriptan QL, ergotamine-caffeine, naratriptan QL, rizatriptan QL, sumatriptan QL,
FINACEA GEL azelaic acid gel PA, metronidazole, FINACEA FOAM PA, SOOLANTRA PA
zolmitriptan QL, NURTEC ODT ST, ONZETRA XSAIL ST, REYVOW ST, UBRELVY ST, ZEMBRACE SYMTOUCH ST,
FIORICET CAPSULE diclofenac sodium, ibuprofen, naproxen (except ZOMIG NASAL SPRAY QL naproxen CR or naproxen suspension)
FULPHILA ZIEXTENZO SGM FLAREX dexamethasone, loteprednol,
prednisolone acetate 1%, DUREZOL Genicin Vita-S folic acid
flucytosine capsule 500 mg fluconazole GLASSIA PROLASTIN-C †
GLEEVEC imatinib mesylate SGM, BOSULIF SGM,
fluocinonide cream 0.1% clobetasol cream QL SPRYCEL SGM
fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil solution, GLUMETZA metformin, metformin ext-rel (except generics
imiquimod, PICATO, TOLAK, ZYCLARA for FORTAMET and GLUMETZA)
fluoxetine tablet (generics for SARAFEM only)
fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]),
GLYCOPYRROLATE TABLET 1.5 MG
dicyclomine
paroxetine HCl ext-rel, sertraline GOLYTELY peg 3350-electrolytes, CLENPIQ
fluoxetine tablet 60 mg citalopram, escitalopram, fluoxetine (except GRANIX NIVESTYM SGM fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, GUARDIAN CONNECT DEXCOM CONTINUOUS GLUCOSE paroxetine HCl ext-rel, sertraline, TRINTELLIX CONTINUOUS GLUCOSE MONITORING SYSTEM PA ST MONITORING SYSTEM
flurandrenolide cream, desonide QL, hydrocortisone QL GUARDIAN REAL-TIME DEXCOM CONTINUOUS GLUCOSE flurandrenolide lotion CONTINUOUS GLUCOSE MONITORING SYSTEM PA
MONITORING SYSTEM flurandrenolide ointment hydrocortisone butyrate cream QL,
hydrocortisone butyrate ointment QL, halcinonide cream desoximetasone (except desoximetasone hydrocortisone butyrate solution QL, ointment 0.05%) QL, fluocinonide (except mometasone QL, triamcinolone cream QL, fluocinonide cream 0.1%) QL, BRYHALI PA triamcinolone lotion QL, triamcinolone ointment (except triamcinolone ointment 0.05%) QL HORIZANT gabapentin, GRALISE ST
FML FORTE, FML LIQUIFILM, dexamethasone, loteprednol, prednisolone acetat HUMALOG FIASP, NOVOLOG
FML S.O.P. e 1%, DUREZOL HUMALOG MIX 50/50 NOVOLOG MIX 70/30
FOCALIN XR amphetamine-dextroamphetamine mixed salts ext-rel QL, dexmethylphenidate ext-rel QL,
HUMALOG MIX 75/25 NOVOLOG MIX 70/30
methylphenidate ext-rel QL, MYDAYIS QL, HUMATROPE GENOTROPIN SGM, NORDITROPIN SGM
VYVANSE QL HUMULIN 70/30 NOVOLIN 70/30 OTC
FOLIC-K folic acid HUMULIN N NOVOLIN N OTC
FOLLISTIM AQ GONAL-F PA HUMULIN R NOVOLIN R OTC
Folvite-D folic acid hydrocortisone butyrate lipophilic hydrocortisone butyrate cream QL,
FORTAMET metformin, metformin ext-rel (except generics cream 0.1% hydrocortisone butyrate ointment QL,
for FORTAMET and GLUMETZA) hydrocortisone butyrate solution QL, mometasone QL, triamcinolone
FORTESTA testosterone gel (except authorized generics for cream QL, triamcinolone lotion QL, triamcinolone TESTIM and VOGELXO) PA, testosterone solution PA, ANDRODERM PA, NATESTO PA
ointment (except triamcinolone ointment 0.05%) QL
FOSAMAX PLUS D alendronate, ibandronate, risedronate hydrocortisone butyrate lotion hydrocortisone butyrate cream QL, hydrocortisone butyrate ointment QL,
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit www.arkansasbluecross.com or contact an Arkansas Blue Cross and Blue Shield Customer Care representative at 1-800-863-5561.
www.arkansasbluecross.com
- -NON FORMULARY DRUG NAME(S) PREFERRED OPTION(S)* NON FORMULARY DRUG NAME(S) PREFERRED OPTION(S)*
hydrocortisone butyrate solution QL, KAMDOY desonide QL, hydrocortisone QL mometasone QL, triamcinolone cream QL, triamcinolone lotion QL, triamcinolone KAZANO JANUMET, JANUMET XR
ointment (except triamcinolone ointment 0.05%) QL
ketoconazole foam 2% ketoconazole shampoo 2%, selenium sulfide lotion 2.5%
HylaVite folic acid Ketodan ketoconazole shampoo 2%, selenium sulfide
hyoscyamine sulfate ext-rel dicyclomine lotion 2.5%
HYSINGLA ER fentanyl transdermal QL, hydrocodone ext-rel QL, hydromorphone ext-rel QL, methadone QL, morphine ext-rel QL,
ketoprofen capsule 25 mg diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)
NUCYNTA ER QL, XTAMPZA ER QL ketoprofen ext-rel capsule diclofenac sodium, ibuprofen, meloxicam,
HYZAAR candesartan-hydrochlorothiazide, irbesartan-hydrochlorothiazide, losartan-
naproxen (except naproxen CR or naproxen suspension)
hydrochlorothiazide, olmesartan- KINERET ENBREL SGM, HUMIRA SGM, RINVOQ SGM, hydrochlorothiazide, telmisartan- XELJANZ SGM, XELJANZ XR SGM hydrochlorothiazide, valsartan-hydrochlorothiazide KOMBIGLYZE XR JANUMET, JANUMET XR
INCRUSE ELLIPTA SPIRIVA QL, YUPELRI QL KUVAN sapropterin SGM
INDERAL LA, INDERAL XL atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol succinate ext-rel, metoprolol tartrate, KYPROLIS NINLARO SGM, VELCADE †
nadolol, pindolol, propranolol, propranolol ext-rel, BYSTOLIC LACRISERT RESTASIS, XIIDRA
INDOCIN diclofenac sodium, ibuprofen, meloxicam, Lactojen Consult doctor
naproxen (except naproxen CR or naproxen suspension) LACTULOSE PAK lactulose solution
indomethacin capsule 20 mg diclofenac sodium, ibuprofen, meloxicam, LANOXIN TABLET (125 MCG and digoxin naproxen (except naproxen CR or naproxen 250 MCG only) suspension)
lanthanum carbonate calcium acetate, sevelamer carbonate, Inflammacin diclofenac sodium, diclofenac sodium gel 1% PA, PHOSLYRA, VELPHORO ST
diclofenac sodium solution, ibuprofen, meloxicam, naproxen (except naproxen CR or LANTUS 8 BASAGLAR, LEVEMIR
naproxen suspension) LASTACAFT azelastine, cromolyn sodium, olopatadine
INNOPRAN XL atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, pindolol, propranolol, propranolol ext-rel,
LAZANDA fentanyl transmucosal lozenge PA, SUBSYS PA
BYSTOLIC LESCOL XL atorvastatin, ezetimibe-simvastatin, fluvastatin,
INTRAROSA estradiol vaginal cream, IMVEXXY lovastatin, pravastatin, rosuvastatin, simvastatin
INTUNIV amphetamine-dextroamphetamine mixed salts ext-rel QL, atomoxetine QL, dexmethylphenidate
LETAIRIS ambrisentan SGM, bosentan SGM, OPSUMIT SGM
ext-rel QL, guanfacine ext-rel QL, levorphanol fentanyl transdermal QL, hydrocodone ext-rel methylphenidate ext-rel QL, MYDAYIS QL, QL, hydromorphone ext-rel QL, methadone QL, VYVANSE QL morphine ext-rel QL,
INVELTYS dexamethasone, loteprednol, NUCYNTA ER QL, XTAMPZA ER QL
prednisolone acetate 1%, DUREZOL LEXAPRO citalopram, escitalopram, fluoxetine (except
INVIRASE atazanavir QL, EVOTAZ QL, PREZCOBIX QL, PREZISTA QL
fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel, sertraline,
INVOKAMET, INVOKAMET XR SYNJARDY, SYNJARDY XR, XIGDUO XR TRINTELLIX ST
INVOKANA FARXIGA, JARDIANCE LEXIVA atazanavir QL, EVOTAZ QL, PREZCOBIX QL, PREZISTA QL
isosorbide dinitrate 40 mg isosorbide dinitrate (except isosorbide dinitrate 40 mg), isosorbide mononitrate LIALDA balsalazide, mesalamine delayed-rel (except
mesalamine delayed-rel tablet 800 ISTALOL timolol maleate solution, BETOPTIC S mg), mesalamine ext-rel, sulfasalazine,
JADENU deferasirox SGM, deferiprone SGM, sulfasalazine delayed-rel, PENTASA
deferoxamine † LIBRAX dicyclomine
JALYN dutasteride-tamsulosin; dutasteride or finasteride WITH alfuzosin ext-rel, doxazosin, silodosin, LIDOCAINE-TETRACAINE CREAM lidocaine-prilocaine tamsulosin or terazosin (NDC^ 71800063115 only)
JENTADUETO, JENTADUETO XR JANUMET, JANUMET XR LIDOTREX lidocaine-prilocaine
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit www.arkansasbluecross.com or contact an Arkansas Blue Cross and Blue Shield Customer Care representative at 1-800-863-5561.
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- -NON FORMULARY DRUG NAME(S) PREFERRED OPTION(S)* NON FORMULARY DRUG NAME(S) PREFERRED OPTION(S)*
LIPITOR atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin
LITHOSTAT Consult doctor
LIVALO atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin
LOTEMAX, LOTEMAX SM dexamethasone, loteprednol, prednisolone acetate 1%, DUREZOL
Lorid folic acid
Lorzone cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg)
luliconazole ciclopirox PA, clotrimazole, econazole QL, ketoconazole cream 2% QL, NAFTIN
LUNESTA doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, BELSOMRA ST
LUPRON DEPOT ELIGARD SGM, FIRMAGON † , ORIAHNN PA, ORILISSA PA
LUPRON DEPOT-PED SUPPRELIN LA † , TRIPTODUR †
LYRICA duloxetine, pregabalin ST, QL
MACRODANTIN nitrofurantoin (except NDC^ 70408023932)
Matzim LA diltiazem ext-rel (except generics for CARDIZEM LA)
MAXIDEX dexamethasone, loteprednol, prednisolone acetate 1%, DUREZOL
MAVYRET EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) SGM, HARVONI (genotypes 1, 4, 5, 6) SGM, VOSEVI 2 SGM
MAXALT, MAXALT-MLT eletriptan QL, naratriptan QL, rizatriptan QL, sumatriptan QL, zolmitriptan QL, NURTEC ODT ST, ONZETRA XSAIL ST, REYVOW ST, UBRELVY ST, ZEMBRACE SYMTOUCH ST, ZOMIG NASAL SPRAY QL
mefenamic acid (NDC^ 69336012830 diclofenac sodium, ibuprofen, meloxicam, only) naproxen (except naproxen CR or naproxen
suspension)
MENEST estradiol
MENOSTAR estradiol
mesalamine delayed-rel tablet 800 balsalazide, mesalamine delayed-rel (except mg mesalamine delayed-rel tablet 800 mg),
mesalamine ext-rel, sulfasalazine, sulfasalazine delayed-rel, PENTASA
metaxalone 400 mg cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg)
metformin ext-rel metformin, metformin ext-rel (except generics (generics for FORTAMET and for FORTAMET and GLUMETZA) GLUMETZA only)
methocarbamol 500 mg (NDC^ cyclobenzaprine (except cyclobenzaprine tablet 69036091010 only), 7.5 mg) methocarbamol 750 mg (NDCs^ 69036093090, 70868090190 only)
MIACALCIN INJECTION alendronate, calcitonin-salmon, ibandronate, risedronate, FORTEO SGM, PROLIA † , TYMLOS SGM
MIACALCIN NASAL SPRAY calcitonin-salmon
MICARDIS, MICARDIS HCT candesartan, candesartan-hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide
Migergot eletriptan QL, naratriptan QL, rizatriptan QL, sumatriptan QL, zolmitriptan QL, NURTEC ODT ST, ONZETRA XSAIL ST, REYVOW ST, UBRELVY ST, ZEMBRACE SYMTOUCH ST, ZOMIG NASAL SPRAY QL
MINIVELLE estradiol, DIVIGEL, EVAMIST
MILLIPRED dexamethasone, hydrocortisone tablet, methylprednisolone, prednisolone solution, prednisone
MINASTRIN 24 FE ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron
MINOCIN doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline
minocycline ext-rel doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline
MIRVASO azelaic acid gel PA, metronidazole, FINACEA FOAM PA, SOOLANTRA PA
Mondoxyne NL capsule 75 mg doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline
MOVIPREP peg 3350-electrolytes, CLENPIQ
MultiPro Consult doctor
mupirocin cream gentamicin QL, mupirocin ointment
MYTESI diphenoxylate-atropine, loperamide
NAPRELAN diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)
naproxen-esomeprazole diclofenac sodium, ibuprofen, meloxicam or naproxen (except naproxen CR or naproxen suspension) WITH esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel, pantoprazole delayed-rel tablet or DEXILANT ST
naproxen CR diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)
naproxen suspension diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)
NATAZIA ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-levonorgestrel, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron, ethinyl estradiol-norgestimate
NATURE-THROID levothyroxine, liothyronine, SYNTHROID
NEO-SYNALAR desonide QL or hydrocortisone WITH gentamicin QL
NESINA JANUVIA
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit www.arkansasbluecross.com or contact an Arkansas Blue Cross and Blue Shield Customer Care representative at 1-800-863-5561.
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- -NON FORMULARY DRUG NAME(S) PREFERRED OPTION(S)* NON FORMULARY DRUG NAME(S) PREFERRED OPTION(S)*
NEULASTA, NEULASTA ONPRO ZIEXTENZO SGM ONFI clobazam, lamotrigine, rufinamide, topiramate
NEUPOGEN NIVESTYM SGM ONGLYZA JANUVIA
NEVANAC bromfenac, diclofenac, ketorolac QL, ILEVRO, ORENCIA CLICKJECT, COSENTYX SGM, ENBREL SGM, PROLENSA ORENCIA SUBCUTANEOUS HUMIRA SGM, OTEZLA SGM, RINVOQ SGM,
NEXIUM esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel, pantoprazole
STELARA SUBCUTANEOUS SGM, XELJANZ SGM, XELJANZ XR SGM
delayed-rel tablet, DEXILANT ST orphenadrine-aspirin-caffeine cyclobenzaprine (except cyclobenzaprine tablet
niacin tablet 500 mg niacin ext-rel 7.5 mg)
Niacor niacin ext-rel Orphengesic Forte cyclobenzaprine (except cyclobenzaprine tablet
7.5 mg)
NICADAN folic acid ORTHO D folic acid
NICAPRIN folic acid ORTHO DF folic acid
NICAZEL, NICAZEL FORTE folic acid Oscimin SR dicyclomine
NICOMIDE folic acid OSENI JANUMET, JANUMET XR; JANUVIA WITH
NILANDRON abiraterone SGM, pioglitazone
bicalutamide, XTANDI SGM, YONSA SGM, OSMOPREP peg 3350-electrolytes, CLENPIQ
nitrofurantoin (NDC^ 70408023932 nitrofurantoin (except NDC^ 70408023932) OSPHENA estradiol only)
OWEN MUMFORD NEEDLES 5 BD ULTRAFINE NEEDLES OTC NITROMIST nitroglycerin lingual spray,
nitroglycerin sublingual oxiconazole (NDCs^ 00168035830, ciclopirox PA, clotrimazole, econazole QL,
Nolix desonide QL, hydrocortisone QL 51672135902 only) ketoconazole cream 2% QL, NAFTIN
OXYCONTIN fentanyl transdermal QL, hydrocodone ext-rel
NORGESIC FORTE cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg)
QL, hydromorphone ext-rel QL, methadone QL, morphine ext-rel QL, NUCYNTA ER QL, XTAMPZA ER QL
NORITATE azelaic acid gel PA, metronidazole, FINACEA FOAM PA, SOOLANTRA PA
oxymorphone ext-rel fentanyl transdermal QL, hydrocodone ext-rel QL, hydromorphone ext-rel QL, methadone QL,
NORPACE disopyramide morphine ext-rel QL, NUCYNTA ER QL, XTAMPZA ER QL
NORVASC amlodipine OXYTROL darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel, trospium,
NOURIANZ amantadine, entacapone, pramipexole, trospium ext-rel, MYRBETRIQ ST, TOVIAZ ST pramipexole ext-rel, rasagiline, ropinirole, ropinirole ext-rel, selegiline, NEUPRO PANCREAZE CREON, VIOKACE, ZENPEP
NOVACORT desonide QL, hydrocortisone QL pantoprazole delayed-rel suspension esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel,
NOVO NORDISK NEEDLES 5 BD ULTRAFINE NEEDLES OTC pantoprazole delayed-rel tablet, DEXILANT ST
NOXAFIL fluconazole, itraconazole PA paroxetine mesylate capsule 7.5 mg paroxetine HCl
PAXIL, PAXIL CR citalopram, escitalopram, fluoxetine (except NuDiclo SoluPak, NuDiclo TabPak diclofenac sodium, diclofenac sodium gel 1% PA, fluoxetine tablet 60 mg, fluoxetine tablet
diclofenac sodium solution, ibuprofen, [generics for SARAFEM]), paroxetine HCl, meloxicam, naproxen (except naproxen CR or paroxetine HCl ext-rel, sertraline, TRINTELLIX naproxen suspension) ST
NUTROPIN AQ GENOTROPIN SGM, NORDITROPIN SGM PENNSAID diclofenac sodium, diclofenac sodium gel 1% PA,
NUVARING ethinyl estradiol-etonogestrel, ANNOVERA diclofenac sodium solution, ibuprofen, meloxicam , naproxen (except naproxen CR or naproxen
NUVIGIL armodafinil PA, modafinil PA, SUNOSI PA suspension)
OLEPTRO trazodone PERCOCET hydrocodone-acetaminophen QL, hydromorphone QL, morphine QL, oxycodone-
OLUX-E clobetasol foam QL acetaminophen QL, NUCYNTA QL
omeprazole-sodium bicarbonate esomeprazole delayed-rel, lansoprazole delayed- PERRIGO NEEDLES 5 BD ULTRAFINE NEEDLES OTC rel, omeprazole delayed-rel, pantoprazole delayed-rel tablet, DEXILANT ST PERTZYE CREON, VIOKACE, ZENPEP
OMNARIS flunisolide QL, fluticasone QL, PEXEVA citalopram, escitalopram, fluoxetine (except
mometasone nasal spray QL, DYMISTA ST, QL fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl,
OMNITROPE GENOTROPIN SGM, NORDITROPIN SGM paroxetine HCl ext-rel, sertraline, TRINTELLIX ST
OMNIVEX folic acid
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit www.arkansasbluecross.com or contact an Arkansas Blue Cross and Blue Shield Customer Care representative at 1-800-863-5561.
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- -NON FORMULARY DRUG NAME(S) PREFERRED OPTION(S)* NON FORMULARY DRUG NAME(S) PREFERRED OPTION(S)*
PLAVIX clopidogrel, prasugrel, BRILINTA QNASL flunisolide QL, fluticasone QL,
PLEGRIDY dimethyl fumarate delayed-rel SGM, mometasone nasal spray QL, DYMISTA ST, QL
glatiramer SGM, AUBAGIO SGM, BETASERON QTERN GLYXAMBI SGM, COPAXONE SGM, GILENYA SGM, KESIMPTA SGM, MAYZENT SGM, OCREVUS † , REBIF SGM, TYSABRI † , ZEPOSIA SGM
quazepam doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, BELSOMRA ST
POLYTOZA Consult doctor RAPAFLO alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin
posaconazole delayed-rel tablet fluconazole, itraconazole PA RAYOS dexamethasone,
PRADAXA warfarin, ELIQUIS, XARELTO hydrocortisone tablet, methylprednisolone, predni
PRECISION XTRA STRIPS AND ACCU-CHEK AVIVA PLUS STRIPS AND solone solution, prednisone
KITS 6 KITS 3 OTC, ACCU-CHEK COMPACT PLUS RECEDO Consult doctor STRIPS AND KITS 3 OTC, ACCU-CHEK GUIDE STRIPS AND KITS 3 OTC, ACCU-CHEK RELION INSULIN NOVOLIN INSULIN OTC
SMARTVIEW STRIPS AND KITS 3 OTC, ONETOUCH ULTRA STRIPS AND KITS 3 OTC,
REMODULIN treprostinil SGM
ONETOUCH VERIO STRIPS AND KITS 3 OTC REPATHA PRALUENT PA
PRED FORTE, PRED MILD dexamethasone, loteprednol, prednisolone acetat RHEUMATE folic acid
e 1%, DUREZOL RIABNI RUXIENCE †
PREFEST estradiol-norethindrone, PREMPHASE, PREMPRO
RIBOZEL folic acid
PREMARIN estradiol RIMSO-50 Consult doctor
PREMARIN CREAM estradiol vaginal cream, IMVEXXY RIOMET metformin, metformin ext-rel (except generics
PRENATAL PLUS 7 prenatal vitamins, CITRANATAL for FORTAMET and GLUMETZA)
PREVACID esomeprazole delayed-rel, lansoprazole RITUXAN RUXIENCE †
delayed-rel, omeprazole delayed-rel, pantoprazole delayed-rel tablet, DEXILANT ST
ROZEREM doxepin, eszopiclone, ramelteon, zolpidem,
PREVIDENT Consult doctor zolpidem ext-rel, BELSOMRA ST
PRILOSEC esomeprazole delayed-rel, lansoprazole RyClora levocetirizine
delayed-rel, omeprazole delayed-rel, pantoprazole delayed-rel tablet, DEXILANT ST RYTARI carbidopa-levodopa, carbidopa-levodopa ext-rel
PRISTIQ desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule SABRIL vigabatrin SGM
PROAIR HFA, PROAIR RESPICLICK albuterol sulfate CFC-free aerosol QL, SAIZEN GENOTROPIN SGM, NORDITROPIN SGM
levalbuterol tartrate CFC-free aerosol QL SANDOSTATIN LAR SOMATULINE DEPOT SGM
PROCRIT ARANESP SGM, RETACRIT SGM SCARSILK PAD Consult doctor
PRODIGEN Consult doctor SEASONIQUE ethinyl estradiol-drospirenone, ethinyl estradiol-
PROMETRIUM medroxyprogesterone; progesterone, micronized drospirenone-levomefolate, ethinyl estradiol-levonorgestrel, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-
PROTONIX esomeprazole delayed-rel, lansoprazole norethindrone acetate-iron
delayed-rel, omeprazole delayed-rel, pantoprazole delayed-rel tablet, DEXILANT ST SEROQUEL XR aripiprazole, clozapine, olanzapine,
quetiapine, quetiapine ext-rel, risperidone,
PROTOPIC pimecrolimus PA, tacrolimus PA, EUCRISA ST ziprasidone, LATUDA, VRAYLAR ST
PROVAD Consult doctor SIGNIFOR LAR SOMATULINE DEPOT SGM
PROVENTIL HFA albuterol sulfate CFC-free aerosol QL, SILENOR doxepin, eszopiclone, ramelteon, zolpidem,
levalbuterol tartrate CFC-free aerosol QL zolpidem ext-rel, BELSOMRA ST
PROVIGIL armodafinil PA, modafinil PA, SUNOSI PA SIL-K PAD Consult doctor
SILIVEX Consult doctor
PROZAC citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet SILTREX Consult doctor
[generics for SARAFEM]), paroxetine HCl, SIMPONI COSENTYX SGM, ENBREL SGM, paroxetine HCl ext-rel, sertraline, HUMIRA SGM, OTEZLA SGM, RINVOQ SGM, TRINTELLIX ST STELARA SUBCUTANEOUS SGM,
PSORCON desoximetasone (except desoximetasone XELJANZ SGM, XELJANZ XR SGM
ointment 0.05%) QL, fluocinonide (except SINGULAIR montelukast, zafirlukast fluocinonide cream 0.1%) QL, BRYHALI PA
SOMAVERT SOMATULINE DEPOT SGM
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit www.arkansasbluecross.com or contact an Arkansas Blue Cross and Blue Shield Customer Care representative at 1-800-863-5561.
www.arkansasbluecross.com
- -NON FORMULARY DRUG NAME(S) PREFERRED OPTION(S)* NON FORMULARY DRUG NAME(S) PREFERRED OPTION(S)*
SORILUX
SPRIX
SUBOXONE
sucralfate suspension
sumatriptan-naproxen
SUPREP
SURE-TEST STRIPS AND KITS 6
Symax-SR
SYNERDERM
SYPRINE
TALIVA
TALTZ
TARGADOX
TASIGNA
TAYTULLA
TAZORAC
TECFIDERA
TESTIM
testosterone gel 1% (authorized generics for TESTIM and VOGELXO only)
calcipotriene ointment QL, calcipotriene solution QL
diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)
buprenorphine-naloxone sublingual QL, ZUBSOLV QL
sucralfate tablet
diclofenac sodium, ibuprofen or naproxen (except naproxen CR or naproxen suspension) WITH eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT ST, ONZETRA XSAIL ST, REYVOW ST, UBRELVY ST, ZEMBRACE SYMTOUCH ST, ZOMIG NASAL SPRAY QL
peg 3350-electrolytes, CLENPIQ
ACCU-CHEK AVIVA PLUS STRIPS AND KITS 3 OTC, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 3 OTC, ACCU-CHEK GUIDE STRIPS AND KITS 3 OTC, ACCU-CHEK SMARTVIEW STRIPS AND KITS 3 OTC, ONETOUCH ULTRA STRIPS AND KITS 3 OTC, ONETOUCH VERIO STRIPS AND KITS 3 OTC
dicyclomine
desonide QL, hydrocortisone QL
trientine ST
folic acid
COSENTYX SGM, ENBREL SGM, HUMIRA SGM, OTEZLA SGM, SKYRIZI SGM, STELARA SUBCUTANEOUS SGM, TREMFYA SGM, XELJANZ SGM, XELJANZ XR SGM
doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline
imatinib mesylate SGM, BOSULIF SGM, SPRYCEL SGM
ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron
adapalene PA, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275) QL, clindamycin solution QL, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin PA, **, EPIDUO, ONEXTON; calcipotriene ointment QL, calcipotriene solution QL
dimethyl fumarate delayed-rel SGM, glatiramer SGM, AUBAGIO SGM, BETASERON SGM, COPAXONE SGM, GILENYA SGM, KESIMPTA SGM, MAYZENT SGM, OCREVUS † , REBIF SGM, TYSABRI † , ZEPOSIA SGM
testosterone gel (except authorized generics for TESTIM and VOGELXO) PA, testosterone solution PA, ANDRODERM PA, NATESTO PA
testosterone gel (except authorized generics for TESTIM and VOGELXO) PA, testosterone solution PA, ANDRODERM PA, NATESTO PA
THEO-24
THIOLA, THIOLA EC
TIMOPTIC OCUDOSE
TIROSINT
TOBI, TOBI PODHALER
TOBRADEX ST
topiramate ext-rel capsule (generics for QUDEXY XR only)
TOPROL-XL
TRACLEER
TRADJENTA
tramadol (NDC^ 52817019610 only), tramadol ext-rel capsule
TRANSDERM SCOP
TRAVATAN Z
TRELSTAR MIXJECT
triamcinolone aerosol