Blue Cross Blue Shield of Wyoming Standard Drug List October 2014 < Contents
< October 2014 Blue Cross Blue Shield of Wyoming Standard Drug List Click to search for a drug name in this document Contents Therapeutic Class Drug List Introduction .................................................................... I Anti-Infective Agents ....................................................... 1 Member prescription benefit ............................................ I Cancer Drugs .................................................................. 7 Prior Authorization ........................................................... I Hormones, Diabetes and Related Drugs ...................... 10 How to use this list .......................................................... II Heart and Circulatory Drugs ......................................... 17 Specialty Products ........................................................ III Respiratory Agents ....................................................... 26 Generic substitution ...................................................... III Gastrointestinal Drugs .................................................. 28 Abbreviation Key............................................................ III Genitourinary Drugs ...................................................... 30 Central Nervous System Drugs .................................... 32 Pain Relief Drugs .......................................................... 39 Neuromuscular Drugs ................................................... 44 Supplements ................................................................. 47 Blood Modifying Drugs .................................................. 49 Topical Products ........................................................... 50 Miscellaneous Categories (includes Supplies and Devices) ............................................................. 56 Index............................................................................. 93 To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click on Search. Blue Cross Blue Shield of Wyoming is an independent licensee of the Blue Cross and Blue Shield Association 2278 WY © Prime Therapeutics LLC 10/14 Introduction This Blue Cross Blue Shield of Wyoming (BCBSWY) Standard Drug List, also called a patient medication guide, includes Brand drugs and Generic drugs. This guide, current at time of printing and subject to change, is updated quarterly. Members and physicians can review the most up-to-date version of the Standard Drug List at www.wyomingblue.com/pharmacy. The Standard Drug List includes a list of prescription drugs, insulin, and diabetic supplies that reflect the current recommendations of BCBSWY. The Standard Drug List is developed in conjunction with Prime Therapeutics’ National Pharmacy & Therapeutics Committee, which includes practicing physicians and pharmacists dedicated to providing patients with high-quality, cost-effective drug therapy. The Committee includes physicians and pharmacists from throughout the country. Prime Therapeutics does not have voting privileges. Drugs are reviewed in terms of safety, efficacy, and clinical uniqueness. Member prescription benefit Medications and supplies on this list are Preferred products. Drugs or supplies not listed are Non-Preferred (NP). Coverage of Preferred and Non-Preferred drugs will vary depending on your individual prescription benefit. Some drugs may be excluded from coverage. For example, drugs indicated for cosmetic purposes, e.g., Propecia, for hair growth, are not covered. Prescription drugs may be excluded from coverage if there are over-the-counter (OTC) versions marketed. OTC drugs are not covered with the exception of insulin and selected diabetic supplies. Prior Authorization Drugs are selected for prior authorization (PA) because of actual or potential misuse or overuse that may be of clinical and/or economic concern. Drugs selected for PA require that specific clinical criteria are met before the drugs will be covered under a member’s prescription benefit. Not all drugs selected for PA are on the Standard Drug List. Coverage of Preferred and Non-Preferred drugs will vary depending on your individual prescription benefit. Drugs selected for PA are subject to change. For information about benefit coverage on specific drugs, please call 800.442.2376. I Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 How to use this list This list is organized into broad therapeutic categories (e.g. Hormones, Diabetes and Related Drugs).Within most categories, drugs are sub-grouped based upon drug class (e.g Corticosteroids). All drugs listed, whether generic or brand, are Preferred drugs. The first column of the chart lists the drug name. Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand drug in (parentheses). Some generic products have no reference brand. Brand prescription drugs are shown in capital letters followed by the generic name. The second column indicates if the drug is a specialty drug. Note: Additional information about specialty drugs can be found in this document under the header for Specialty Products. The columns indicate the Utilization Management (UM) program(s) that apply to the prescription drug (e.g., Prior Authorization and Quantity Limits). If an indicator is present in the column(s), then the UM program noted is possibly applied to your benefit. Some plans may have UM on additional medications beyond those noted in this document. Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 II Specialty Products Specialty drugs are used in the treatment of medical conditions such as hepatitis, multiple sclerosis and rheumatoid arthritis. Specialty drugs may be oral or injectable medications that can either be self-administered or administered by a health care professional. These high cost medications also have one or more of the following characteristics: Unique storage or shipment requirements Additional education and support required from a health care professional Usually not stocked at retail pharmacies Generic substitution BCBSWY encourages generic utilization as a way to provide high-quality drugs at a reduced cost. Generic drugs are as safe and effective as their brand-name counterparts, but are usually less expensive. Generic drugs are manufactured under the same strict standards of FDA’s Good Manufacturing Practice regulations that are required for brand products including batch requirements for identity, strength, purity, and quality. An FDA-approved generic drug may be substituted for the brand counterpart because it: Contains the same active ingredient(s) as the brand drug Is identical in strength, dosage form, and route of administration Is therapeutically equivalent and can be expected to have the same clinical effect and safety profile To encourage the use of generic drugs, Preferred brand drugs usually become Non-Preferred after the generic equivalent version is added to the drug guide. If the brand drug you are looking for does not appear on this list, it may be present under the generic name. You can ask your pharmacist for assistance. Abbreviation/acronym key caps .................................................................... capsules chew .................................................................. chewable odt ......................................... orally disintegrating tablets oint ..................................................................... ointment conc .............................................................. concentrate cr .......................................................... controlled release ophth ............................................................... ophthalmic osm .......................................................... osmotic release dr ............................................................. delayed release ec ................................................................enteric coated powd ..................................................................... powder sa ............................................................ sustained action effe................................................................. effervescent equiv ................................................................ equivalent sl ...................................................................... sublingual soln ....................................................................... solution er ...........................................................extended release inhal................................................................... inhalation sr .......................................................... sustained release suppos ........................................................ suppositories inj ......................................................................... injection liq .............................................................................. liquid susp ................................................................ suspension tab ...........................................................................tablets lotn ........................................................................... lotion nebu ................................................................... nebulizer td ................................................................... transdermal III Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 ANTI-INFECTIVE AGENTS PENICILLINS AMPICILLIN – ampicillin for susp 125 mg/5ml AMOXICILLIN – amoxicillin (trihydrate) chew tab 125 mg AMPICILLIN – ampicillin for susp 250 mg/5ml AMOXICILLIN – amoxicillin (trihydrate) chew tab 250 mg ampicillin cap 250 mg amoxicillin (trihydrate) cap 250 mg AUGMENTIN – amoxicillin & k clavulanate for susp 125-31.25 mg/5ml amoxicillin (trihydrate) cap 500 mg dicloxacillin sodium cap 250 mg amoxicillin (trihydrate) for susp 200 mg/5ml penicillin v potassium for soln 125 mg/5ml amoxicillin (trihydrate) for susp 250 mg/5ml penicillin v potassium for soln 250 mg/5ml amoxicillin (trihydrate) for susp 400 mg/5ml penicillin v potassium tab 250 mg amoxicillin (trihydrate) tab 500 mg CEPHALOSPORINS amoxicillin (trihydrate) tab 875 mg cefaclor cap 250 mg amoxicillin & k clavulanate chew tab 200-28.5 mg cefaclor cap 500 mg amoxicillin & k clavulanate chew tab 400-57 mg cefadroxil for susp 250 mg/5ml dicloxacillin sodium cap 500 mg penicillin v potassium tab 500 mg cefadroxil cap 500 mg amoxicillin & k clavulanate for susp 200-28.5 mg/5ml cefadroxil for susp 500 mg/5ml amoxicillin & k clavulanate for susp 250-62.5 mg/5ml (Augmentin) cefdinir cap 300 mg amoxicillin & k clavulanate for susp 400-57 mg/5ml cefdinir for susp 250 mg/5ml amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg (Augmentin xr) amoxicillin & k clavulanate tab 250-125 mg Quantity Limits ampicillin cap 500 mg amoxicillin (trihydrate) for susp 125 mg/5ml amoxicillin & k clavulanate for susp 600-42.9 mg/5ml (Augmentin es-600) Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 cefadroxil tab 1 gm cefdinir for susp 125 mg/5ml cefpodoxime proxetil for susp 100 mg/5ml cefpodoxime proxetil for susp 50 mg/5ml cefpodoxime proxetil tab 100 mg cefpodoxime proxetil tab 200 mg amoxicillin & k clavulanate tab 500-125 mg (Augmentin) cefprozil for susp 125 mg/5ml amoxicillin & k clavulanate tab 875-125 mg (Augmentin) cefprozil tab 250 mg cefprozil for susp 250 mg/5ml cefprozil tab 500 mg Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 1 cefuroxime axetil for susp 125 mg/5ml (Ceftin) ERY-TAB – erythromycin tab delayed release 333 mg cefuroxime axetil tab 250 mg (Ceftin) ERY-TAB – erythromycin tab delayed release 500 mg cefuroxime axetil tab 500 mg (Ceftin) cephalexin cap 250 mg (Keflex) cephalexin cap 500 mg (Keflex) cephalexin for susp 125 mg/5ml cephalexin for susp 250 mg/5ml SUPRAX – cefixime cap 400 mg SUPRAX – cefixime tab 400 mg SUPRAX – cefixime chew tab 100 mg SUPRAX – cefixime chew tab 200 mg SUPRAX – cefixime for susp 100 mg/5ml SUPRAX – cefixime for susp 200 mg/5ml SUPRAX – cefixime for susp 500 mg/5ml MACROLIDES AZITHROMYCIN – azithromycin powd pack for susp 1 gm azithromycin for susp 100 mg/5ml (Zithromax) azithromycin for susp 200 mg/5ml (Zithromax) azithromycin tab 250 mg (Zithromax) ERYTHROMYCIN BASE – erythromycin tab 250 mg ERYTHROMYCIN BASE – erythromycin tab 500 mg ERYTHROMYCIN ETHYLSUCCINA – erythromycin ethylsuccinate tab 400 mg erythromycin w/ delayed release particles cap 250 mg TETRACYCLINES demeclocycline hcl tab 150 mg demeclocycline hcl tab 300 mg doxycycline hyclate cap 100 mg (Vibramycin) doxycycline hyclate cap 50 mg doxycycline hyclate tab delayed release 100 mg doxycycline hyclate tab delayed release 150 mg (Doryx) doxycycline hyclate tab delayed release 75 mg azithromycin tab 600 mg (Zithromax) doxycycline hyclate tab 100 mg clarithromycin for susp 125 mg/5ml doxycycline hyclate tab 20 mg clarithromycin for susp 250 mg/5ml (Biaxin) doxycycline monohydrate cap 100 mg (Monodox) clarithromycin tab sr 24hr 500 mg (Biaxin xl pac) doxycycline monohydrate cap 150 mg (Adoxa) clarithromycin tab 250 mg (Biaxin) doxycycline monohydrate cap 50 mg clarithromycin tab 500 mg (Biaxin) doxycycline monohydrate cap 75 mg (Monodox) ERY-TAB – erythromycin tab delayed release 250 mg 2 Quantity Limits ERYTHROCIN STEARATE – erythromycin stearate tab 250 mg azithromycin tab 500 mg (Zithromax) E.E.S. 400 – erythromycin ethylsuccinate tab 400 mg Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 doxycycline monohydrate tab 100 mg (Adoxa pak 1/100) doxycycline monohydrate tab 150 mg (Adoxa pak 1/150) Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 Quantity Limits Quantity Limits OFLOXACIN – ofloxacin tab 400 mg ofloxacin tab 200 mg ofloxacin tab 300 mg minocycline hcl cap 75 mg (Minocin) ofloxacin tab 400 mg minocycline hcl tab sr 24hr 135 mg AMINOGLYCOSIDES minocycline hcl tab sr 24hr 45 mg neomycin sulfate tab 500 mg minocycline hcl tab sr 24hr 90 mg paromomycin sulfate cap 250 mg minocycline hcl tab 100 mg minocycline hcl tab 50 mg tobramycin nebu soln 300 mg/5ml (Tobi) minocycline hcl tab 75 mg TUBERCULOSIS TETRACYCLINE HCL – tetracycline hcl cap 250 mg ethambutol hcl tab 100 mg (Myambutol) TETRACYCLINE HCL – tetracycline hcl cap 500 mg ISONIAZID – isoniazid syrup 50 mg/5ml ethambutol hcl tab 400 mg (Myambutol) isoniazid & rifampin cap 150-300 mg isoniazid tab 100 mg isoniazid tab 300 mg ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) (Cipro) PRIFTIN – rifapentine tab 150 mg ciprofloxacin hcl tab 100 mg (base equiv) rifabutin cap 150 mg (Mycobutin) ciprofloxacin hcl tab 250 mg (base equiv) (Cipro) • moxifloxacin hcl tab 400 mg (base equiv) (Avelox) minocycline hcl cap 50 mg (Minocin) ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) (Cipro) • levofloxacin tab 750 mg (Levaquin) minocycline hcl cap 100 mg (Minocin) FLUOROQUINOLONES Prior Authorization doxycycline monohydrate tab 75 mg (Adoxa) Drug Name Specialty doxycycline monohydrate tab 50 mg (Adoxa) Prior Authorization Drug Name Specialty 2014 pyrazinamide tab 500 mg RIFAMATE – isoniazid & rifampin cap 150-300 mg rifampin cap 150 mg (Rifadin) ciprofloxacin hcl tab 500 mg (base equiv) (Cipro) rifampin cap 300 mg (Rifadin) ciprofloxacin hcl tab 750 mg (base equiv) nystatin oral powder FUNGAL INFECTIONS ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq) (Cipro xr) fluconazole for susp 10 mg/ml (Diflucan) ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq) (Cipro xr) fluconazole for susp 40 mg/ml (Diflucan) levofloxacin oral soln 25 mg/ml (Levaquin) fluconazole tab 100 mg (Diflucan) levofloxacin tab 250 mg (Levaquin) fluconazole tab 200 mg (Diflucan) levofloxacin tab 500 mg (Levaquin) fluconazole tab 50 mg (Diflucan) fluconazole tab 150 mg (Diflucan) Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 3 Prior Authorization PEGASYS – peginterferon alfa-2a inj 180 mcg/ml • • griseofulvin microsize tab 500 mg (Grifulvin v) PEGASYS – peginterferon alfa-2a inj 180 mcg/0.5ml • • griseofulvin ultramicrosize tab 125 mg (Gris-peg) PEGASYS – peginterferon alfa-2a inj kit 180 mcg/0.5ml • • griseofulvin ultramicrosize tab 250 mg (Gris-peg) PEGASYS PROCLICK – peginterferon alfa-2a inj 135 mcg/0.5ml • • itraconazole cap 100 mg (Sporanox) PEGASYS PROCLICK – peginterferon alfa-2a inj 180 mcg/0.5ml • • ribavirin cap 200 mg (Rebetol) • • • • • • LAMISIL – terbinafine hcl oral granules packet 125 mg ribavirin tab 200 mg (Copegus) LAMISIL – terbinafine hcl oral granules packet 187.5 mg NOXAFIL – posaconazole susp 40 mg/ml Drug Name SOVALDI – sofosbuvir tab 400 mg • Herpes nystatin tab 500000 unit acyclovir cap 200 mg (Zovirax) SPORANOX – itraconazole oral soln 10 mg/ml acyclovir susp 200 mg/5ml (Zovirax) acyclovir tab 400 mg (Zovirax) terbinafine hcl tab 250 mg (Lamisil) voriconazole for susp 40 mg/ml (Vfend) voriconazole tab 200 mg (Vfend) voriconazole tab 50 mg (Vfend) • • • acyclovir tab 800 mg (Zovirax) famciclovir tab 125 mg (Famvir) famciclovir tab 250 mg (Famvir) famciclovir tab 500 mg (Famvir) VIRAL INFECTIONS valacyclovir hcl tab 1 gm (Valtrex) Cytomegalovirus valacyclovir hcl tab 500 mg (Valtrex) VALCYTE – valganciclovir hcl tab 450 mg HIV/AIDS VALCYTE – valganciclovir hcl for soln 50 mg/ml (base equiv) abacavir sulfate tab 300 mg (base equiv) (Ziagen) Hepatitis adefovir dipivoxil tab 10 mg (Hepsera) BARACLUDE – entecavir tab 0.5 mg BARACLUDE – entecavir tab 1 mg BARACLUDE – entecavir oral soln 0.05 mg/ml EPIVIR HBV – lamivudine oral soln 5 mg/ ml lamivudine tab 100 mg (Epivir hbv) Quantity Limits Specialty griseofulvin microsize susp 125 mg/5ml flucytosine cap 250 mg (Ancobon) Quantity Limits • Specialty • flucytosine cap 500 mg (Ancobon) OLYSIO – simeprevir sodium cap 150 mg (base equivalent) Drug Name Prior Authorization 2014 • • • • abacavir sulfate-lamivudinezidovudine tab 300-150-300 mg (Trizivir) APTIVUS – tipranavir cap 250 mg APTIVUS – tipranavir oral soln 100 mg/ml ATRIPLA – efavirenz-emtricitabinetenofovir df tab 600-200-300 mg COMPLERA – emtricitabine-rilpivirinetenofovir df tab 200-25-300 mg CRIXIVAN – indinavir sulfate cap 200 mg 4 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 CRIXIVAN – indinavir sulfate cap 400 mg lamivudine tab 300 mg (Epivir) didanosine delayed release capsule 125 mg (Videx ec) lamivudine-zidovudine tab 150-300 mg (Combivir) didanosine delayed release capsule 200 mg (Videx ec) LEXIVA – fosamprenavir calcium tab 700 mg (base equiv) didanosine delayed release capsule 250 mg (Videx ec) LEXIVA – fosamprenavir calcium susp 50 mg/ml (base equiv) didanosine delayed release capsule 400 mg (Videx ec) nevirapine tab sr 24hr 400 mg (Viramune xr) EDURANT – rilpivirine hcl tab 25 mg (base equivalent) nevirapine tab 200 mg (Viramune) EMTRIVA – emtricitabine caps 200 mg NORVIR – ritonavir tab 100 mg EMTRIVA – emtricitabine soln 10 mg/ml NORVIR – ritonavir oral soln 80 mg/ml EPIVIR – lamivudine oral soln 10 mg/ml PREZISTA – darunavir ethanolate tab 75 mg (base equiv) INTELENCE – etravirine tab 25 mg INTELENCE – etravirine tab 100 mg INTELENCE – etravirine tab 200 mg INVIRASE – saquinavir mesylate cap 200 mg INVIRASE – saquinavir mesylate tab 500 mg ISENTRESS – raltegravir potassium tab 400 mg (base equiv) ISENTRESS – raltegravir potassium chew tab 25 mg (base equiv) ISENTRESS – raltegravir potassium chew tab 100 mg (base equiv) ISENTRESS – raltegravir potassium packet for susp 100 mg (base equiv) KALETRA – lopinavir-ritonavir tab 100-25 mg KALETRA – lopinavir-ritonavir tab 200-50 mg KALETRA – lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) lamivudine tab 150 mg (Epivir) Quantity Limits NORVIR – ritonavir cap 100 mg EPZICOM – abacavir sulfate-lamivudine tab 600-300 mg FUZEON – enfuvirtide for inj 90 mg Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 • • PREZISTA – darunavir ethanolate tab 150 mg (base equiv) PREZISTA – darunavir ethanolate tab 400 mg (base equiv) PREZISTA – darunavir ethanolate tab 600 mg (base equiv) PREZISTA – darunavir ethanolate tab 800 mg (base equiv) PREZISTA – darunavir ethanolate susp 100 mg/ml (base equiv) RESCRIPTOR – delavirdine mesylate tab 100 mg RESCRIPTOR – delavirdine mesylate tab 200 mg REYATAZ – atazanavir sulfate cap 100 mg (base equiv) REYATAZ – atazanavir sulfate cap 150 mg (base equiv) REYATAZ – atazanavir sulfate cap 200 mg (base equiv) REYATAZ – atazanavir sulfate cap 300 mg (base equiv) SELZENTRY – maraviroc tab 150 mg SELZENTRY – maraviroc tab 300 mg Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 5 stavudine cap 15 mg (Zerit) Influenza stavudine cap 20 mg (Zerit) RELENZA DISKHALER – zanamivir aero powder breath activated 5 mg/blister stavudine cap 30 mg (Zerit) stavudine cap 40 mg (Zerit) stavudine for oral soln 1 mg/ml (Zerit) STRIBILD – elvitegrav-cobicis-emtricitabtenofov tab 150-150-200-300 mg SUSTIVA – efavirenz cap 50 mg SUSTIVA – efavirenz cap 200 mg SUSTIVA – efavirenz tab 600 mg TIVICAY – dolutegravir sodium tab 50 mg (base equiv) TRUVADA – emtricitabine-tenofovir disoproxil fumarate tab 200-300 mg Quantity Limits TAMIFLU – oseltamivir phosphate cap 30 mg (base equiv) TAMIFLU – oseltamivir phosphate cap 45 mg (base equiv) TAMIFLU – oseltamivir phosphate cap 75 mg (base equiv) TAMIFLU – oseltamivir phosphate for susp 6 mg/ml (base equiv) MALARIA atovaquone-proguanil hcl tab 250-100 mg (Malarone) VIDEX – didanosine for soln 2 gm atovaquone-proguanil hcl tab 62.5-25 mg (Malarone) VIDEX – didanosine for soln 4 gm chloroquine phosphate tab 250 mg VIRACEPT – nelfinavir mesylate tab 250 mg chloroquine phosphate tab 500 mg (Aralen) VIRACEPT – nelfinavir mesylate tab 625 mg COARTEM – artemether-lumefantrine tab 20-120 mg VIRAMUNE – nevirapine susp 50 mg/5ml DARAPRIM – pyrimethamine tab 25 mg VIRAMUNE XR – nevirapine tab sr 24hr 100 mg hydroxychloroquine sulfate tab 200 mg (Plaquenil) VIREAD – tenofovir disoproxil fumarate tab 150 mg mefloquine hcl tab 250 mg VIREAD – tenofovir disoproxil fumarate tab 200 mg Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 PRIMAQUINE PHOSPHATE – primaquine phosphate tab 26.3 mg quinine sulfate cap 324 mg (Qualaquin) VIREAD – tenofovir disoproxil fumarate tab 250 mg WORM INFECTIONS VIREAD – tenofovir disoproxil fumarate tab 300 mg BILTRICIDE – praziquantel tab 600 mg ALBENZA – albendazole tab 200 mg VIREAD – tenofovir disoproxil fumarate oral powder 40 mg/gm STROMECTOL – ivermectin tab 3 mg ZIAGEN – abacavir sulfate soln 20 mg/ml (base equiv) atovaquone susp 750 mg/5ml (Mepron) zidovudine cap 100 mg (Retrovir) clindamycin hcl cap 300 mg (Cleocin) zidovudine syrup 10 mg/ml (Retrovir) clindamycin hcl cap 75 mg (Cleocin) OTHER ANTI-INFECTIVES clindamycin hcl cap 150 mg (Cleocin) zidovudine tab 300 mg 6 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 DAPSONE – dapsone tab 25 mg DAPSONE – dapsone tab 100 mg erythromycin-sulfisoxazole for susp 200-600 mg/5ml AFINITOR DISPERZ – everolimus tab for oral susp 2 mg • • AFINITOR DISPERZ – everolimus tab for oral susp 3 mg • • AFINITOR DISPERZ – everolimus tab for oral susp 5 mg • • • • • • • • • • • • • • COMETRIQ – cabozantinib s-malate cap 3 x 20 mg (60 mg dose) kit • • COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 1 x 20 mg (100 dose) kit • • COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 3 x 20 mg (140 dose) kit • • ELIGARD – leuprolide acetate for subcutaneous inj kit 7.5 mg • • ELIGARD – leuprolide acetate (3 month) for subcutaneous inj kit 22.5mg • • ELIGARD – leuprolide acetate (4 month) for subcutaneous inj kit 30 mg • • Drug Name ALKERAN – melphalan tab 2 mg metronidazole tab 250 mg (Flagyl) anastrozole tab 1 mg (Arimidex) metronidazole tab 500 mg (Flagyl) bicalutamide tab 50 mg (Casodex) NEBUPENT – pentamidine isethionate for nebulization soln 300 mg BOSULIF – bosutinib tab 100 mg sulfamethoxazole-trimethoprim susp 200-40 mg/5ml capecitabine tab 150 mg (Xeloda) sulfamethoxazole-trimethoprim tab 400-80 mg (Bactrim) CAPRELSA – vandetanib tab 100 mg BOSULIF – bosutinib tab 500 mg capecitabine tab 500 mg (Xeloda) sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrim ds) CAPRELSA – vandetanib tab 300 mg trimethoprim tab 100 mg CEENU – lomustine cap 40 mg vancomycin hcl cap 125 mg (Vancocin hcl) CEENU – lomustine cap 100 mg CEENU – lomustine cap 10 mg vancomycin hcl cap 250 mg (Vancocin hcl) XIFAXAN – rifaximin tab 550 mg ZYVOX – linezolid tab 600 mg ZYVOX – linezolid for susp 100 mg/5ml CANCER DRUGS The list of drugs below includes selected oral and injectable cancer drugs on the Preferred Drug List. However, all generic cancer drugs are Preferred. All brand drugs are on the Preferred Drug List until a generic version is available and has been added to the Preferred Drug List. Typically, after the generic has been added, the corresponding brand becomes NonPreferred. AFINITOR – everolimus tab 2.5 mg AFINITOR – everolimus tab 5 mg AFINITOR – everolimus tab 7.5 mg AFINITOR – everolimus tab 10 mg Quantity Limits Prior Authorization clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) (Cleocin pediatric gr) Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 • • • • • • • • CYCLOPHOSPHAMIDE – cyclophosphamide cap 25 mg CYCLOPHOSPHAMIDE – cyclophosphamide cap 50 mg CYCLOPHOSPHAMIDE – cyclophosphamide tab 25 mg CYCLOPHOSPHAMIDE – cyclophosphamide tab 50 mg Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 7 EMCYT – estramustine phosphate sodium cap 140 mg ERIVEDGE – vismodegib cap 150 mg • • ETOPOSIDE – etoposide cap 50 mg exemestane tab 25 mg (Aromasin) FARESTON – toremifene citrate tab 60 mg (base equivalent) JAKAFI – ruxolitinib phosphate tab 10 mg (base equivalent) • • JAKAFI – ruxolitinib phosphate tab 15 mg (base equivalent) • • JAKAFI – ruxolitinib phosphate tab 20 mg (base equivalent) • • JAKAFI – ruxolitinib phosphate tab 25 mg (base equivalent) • • • • • • MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg (base equivalent) • • MEKINIST – trametinib dimethyl sulfoxide tab 2 mg (base equivalent) • • • • Drug Name letrozole tab 2.5 mg (Femara) FIRMAGON – degarelix acetate for inj 80 mg (base equiv) • • LEUCOVORIN CALCIUM – leucovorin calcium tab 10 mg FIRMAGON – degarelix acetate for inj 120 mg (base equiv) • • LEUCOVORIN CALCIUM – leucovorin calcium tab 15 mg leucovorin calcium tab 25 mg flutamide cap 125 mg GILOTRIF – afatinib dimaleate tab 20 mg (base equivalent) • GILOTRIF – afatinib dimaleate tab 30 mg (base equivalent) • • GILOTRIF – afatinib dimaleate tab 40 mg (base equivalent) • • GLEEVEC – imatinib mesylate tab 100 mg (base equivalent) • • GLEEVEC – imatinib mesylate tab 400 mg (base equivalent) • • HEXALEN – altretamine cap 50 mg • • • • • • HYCAMTIN – topotecan hcl cap 0.25 mg (base equiv) HYCAMTIN – topotecan hcl cap 1 mg (base equiv) • ICLUSIG – ponatinib hcl tab 15 mg (base equiv) • • ICLUSIG – ponatinib hcl tab 45 mg (base equiv) • • IMBRUVICA – ibrutinib cap 140 mg • • • • INLYTA – axitinib tab 5 mg JAKAFI – ruxolitinib phosphate tab 5 mg (base equivalent) 8 leucovorin calcium tab 5 mg LEUKERAN – chlorambucil tab 2 mg hydroxyurea cap 500 mg (Hydrea) INLYTA – axitinib tab 1 mg Quantity Limits Prior Authorization • Quantity Limits • Specialty ELIGARD – leuprolide acetate (6 month) for subcutaneous inj kit 45 mg Prior Authorization Drug Name Specialty 2014 LOMUSTINE – lomustine cap 10 mg LOMUSTINE – lomustine cap 40 mg LOMUSTINE – lomustine cap 100 mg LYSODREN – mitotane tab 500 mg MATULANE – procarbazine hcl cap 50 mg megestrol acetate susp 40 mg/ml (Megace oral) megestrol acetate tab 20 mg megestrol acetate tab 40 mg mercaptopurine tab 50 mg (Purinethol) MESNEX – mesna tab 400 mg methotrexate sodium for inj 1 gm • • • • methotrexate sodium tab 2.5 mg (base equiv) MYLERAN – busulfan tab 2 mg NEXAVAR – sorafenib tosylate tab 200 mg (base equivalent) Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 POMALYST – pomalidomide cap 2 mg POMALYST – pomalidomide cap 3 mg POMALYST – pomalidomide cap 4 mg PURIXAN – mercaptopurine susp 2000 mg/100ml (20 mg/ml) • • • • • • • • • • SOLTAMOX – tamoxifen citrate oral soln 10 mg/5ml (base equivalent) TAFINLAR – dabrafenib mesylate cap 50 mg (base equivalent) • • TAFINLAR – dabrafenib mesylate cap 75 mg (base equivalent) • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Drug Name tamoxifen citrate tab 10 mg (base equivalent) tamoxifen citrate tab 20 mg (base equivalent) TARCEVA – erlotinib tab 25 mg • • • • • • • • • • • • • • • • TARCEVA – erlotinib tab 100 mg SUTENT – sunitinib malate cap 25 mg (base equivalent) • • temozolomide cap 250 mg (Temodar) SUTENT – sunitinib malate cap 37.5 mg (base equivalent) • • tretinoin cap 10 mg SUTENT – sunitinib malate cap 50 mg (base equivalent) • • TYKERB – lapatinib ditosylate tab 250 mg (base equiv) SYLATRON – peginterferon alfa-2b for inj kit 296 mcg • • SYLATRON – peginterferon alfa-2b for inj kit 444 mcg • • VANTAS – histrelin acetate implant kit 50 mg SYLATRON – peginterferon alfa-2b for inj kit 888 mcg • • VOTRIENT – pazopanib hcl tab 200 mg (base equiv) • • SYLATRON – peginterferon alfa-2b for inj kit 4 x 296 mcg • • XALKORI – crizotinib cap 200 mg SYLATRON – peginterferon alfa-2b for inj kit 4 x 444 mcg • • XTANDI – enzalutamide cap 40 mg • • • • SYLATRON – peginterferon alfa-2b for inj kit 4 x 888 mcg • • ZELBORAF – vemurafenib tab 240 mg (base equivalent) • • • • • • SPRYCEL – dasatinib tab 20 mg SPRYCEL – dasatinib tab 50 mg SPRYCEL – dasatinib tab 70 mg SPRYCEL – dasatinib tab 80 mg SPRYCEL – dasatinib tab 100 mg SPRYCEL – dasatinib tab 140 mg STIVARGA – regorafenib tab 40 mg SUTENT – sunitinib malate cap 12.5 mg (base equivalent) TABLOID – thioguanine tab 40 mg Quantity Limits Prior Authorization POMALYST – pomalidomide cap 1 mg Specialty NILANDRON – nilutamide tab 150 mg Quantity Limits Prior Authorization Drug Name Specialty 2014 TARCEVA – erlotinib tab 150 mg TARGRETIN – bexarotene cap 75 mg TASIGNA – nilotinib cap 150 mg TASIGNA – nilotinib cap 200 mg temozolomide cap 100 mg (Temodar) temozolomide cap 140 mg (Temodar) temozolomide cap 180 mg (Temodar) temozolomide cap 20 mg (Temodar) temozolomide cap 5 mg (Temodar) VANDETANIB – vandetanib tab 100 mg VANDETANIB – vandetanib tab 300 mg XALKORI – crizotinib cap 250 mg ZOLINZA – vorinostat cap 100 mg ZYDELIG – idelalisib tab 100 mg ZYDELIG – idelalisib tab 150 mg Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 9 ZYKADIA – ceritinib cap 150 mg ZYTIGA – abiraterone acetate tab 250 mg PREDNISONE – prednisone tab 50 mg CORTICOSTEROIDS PREDNISONE – prednisone oral soln 5 mg/5ml CORTISONE ACETATE – cortisone acetate tab 25 mg DEXAMETHASONE – dexamethasone tab 1 mg PREDNISONE – prednisone tab 5 mg dose pack PREDNISONE – prednisone tab 10 mg dose pack prednisone tab 1 mg DEXAMETHASONE – dexamethasone tab 2 mg prednisone tab 10 mg DEXAMETHASONE – dexamethasone soln 0.5 mg/5ml prednisone tab 2.5 mg dexamethasone elixir 0.5 mg/5ml prednisone tab 5 mg DEXAMETHASONE INTENSOL – dexamethasone conc 1 mg/ml prednisone tab 5 mg dose pack dexamethasone tab 0.5 mg dexamethasone tab 0.75 mg dexamethasone tab 1.5 mg dexamethasone tab 4 mg dexamethasone tab 6 mg fludrocortisone acetate tab 0.1 mg hydrocortisone tab 10 mg (Cortef) hydrocortisone tab 20 mg (Cortef) hydrocortisone tab 5 mg (Cortef) methylprednisolone tab 16 mg (Medrol) methylprednisolone tab 32 mg (Medrol) methylprednisolone tab 4 mg (Medrol) methylprednisolone tab 4 mg dose pack (Medrol dosepak) methylprednisolone tab 8 mg (Medrol) prednisone tab 10 mg dose pack prednisone tab 20 mg MALE HORMONES ANDRODERM – testosterone td patch 24hr 2 mg/24hr ANDRODERM – testosterone td patch 24hr 4 mg/24hr ANDROGEL – testosterone td gel 25 mg/2.5gm (1%) ANDROGEL – testosterone td gel 50 mg/5gm (1%) ANDROGEL – testosterone td gel 20.25 mg/1.25gm (1.62%) ANDROGEL – testosterone td gel 40.5 mg/2.5gm (1.62%) ANDROGEL PUMP – testosterone td gel 12.5 mg/act (1%) ANDROGEL PUMP – testosterone td gel 20.25 mg/act (1.62%) prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) (Pediapred) ANDROXY – fluoxymesterone tab 10 mg prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) danazol cap 50 mg 10 Quantity Limits prednisolone syrup 15 mg/5ml (usp solution equivalent) (Prelone) HORMONES, DIABETES AND RELATED DRUGS budesonide cap sr 24hr 3 mg (Entocort ec) Prior Authorization • • Drug Name Specialty • • Quantity Limits Prior Authorization Drug Name Specialty 2014 danazol cap 100 mg danazol cap 200 mg oxandrolone tab 10 mg (Oxandrin) Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 oxandrolone tab 2.5 mg (Oxandrin) testosterone cypionate im in oil 100 mg/ml (Depo-testosterone) FEMHRT LOW DOSE – norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg testosterone cypionate im in oil 200 mg/ml (Depo-testosterone) JINTELI – norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg testosterone enanthate im in oil 200 mg/ml norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg ESTROGENS PREMARIN – estrogens, conjugated tab 0.3 mg CLIMARA PRO – estradiol-levonorgestrel td patch weekly 0.045-0.015 mg/day DIVIGEL – estradiol td gel 0.25 mg/0.25gm (0.1%) DIVIGEL – estradiol td gel 0.5 mg/0.5gm (0.1%) DIVIGEL – estradiol td gel 1 mg/gm (0.1%) estradiol & norethindrone acetate tab 0.5-0.1 mg (Activella) estradiol & norethindrone acetate tab 1-0.5 mg (Activella) estradiol tab 0.5 mg (Estrace) estradiol tab 1 mg (Estrace) estradiol tab 2 mg (Estrace) estradiol td patch weekly 0.025 mg/24hr (Climara) estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) (Climara) Quantity Limits Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 PREMARIN – estrogens, conjugated tab 0.45 mg PREMARIN – estrogens, conjugated tab 0.625 mg PREMARIN – estrogens, conjugated tab 0.9 mg PREMARIN – estrogens, conjugated tab 1.25 mg PREMPHASE – conj est 0.625(14)/conj est-medroxypro ac tab 0.625-5mg(14) PREMPRO – conjugated estrogenmedroxyprogest acetate tab 0.3-1.5 mg PREMPRO – conjugated estrogenmedroxyprogest acetate tab 0.45-1.5 mg PREMPRO – conjugated estrogenmedroxyprogest acetate tab 0.625-2.5 mg PREMPRO – conjugated estrogenmedroxyprogest acetate tab 0.625-5 mg estradiol td patch weekly 0.05 mg/24hr (Climara) VIVELLE-DOT – estradiol td patch biweekly 0.025 mg/24hr estradiol td patch weekly 0.06 mg/24hr (Climara) VIVELLE-DOT – estradiol td patch biweekly 0.0375 mg/24hr estradiol td patch weekly 0.075 mg/24hr (Climara) VIVELLE-DOT – estradiol td patch biweekly 0.05 mg/24hr estradiol td patch weekly 0.1 mg/24hr (Climara) VIVELLE-DOT – estradiol td patch biweekly 0.075 mg/24hr ESTROPIPATE – estropipate tab 3 mg estropipate tab 0.75 mg VIVELLE-DOT – estradiol td patch biweekly 0.1 mg/24hr estropipate tab 1.5 mg PROGESTINS Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 11 medroxyprogesterone acetate tab 10 mg (Provera) levonorgestrel tab 1.5 mg (Plan b onestep) medroxyprogesterone acetate tab 2.5 mg (Provera) levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg medroxyprogesterone acetate tab 5 mg (Provera) NECON 1/50-28 – norethindrone & mestranol tab 1 mg-50 mcg norethindrone acetate tab 5 mg (Aygestin) NECON 10/11-28 – norethindrone-eth estradiol tab 0.5-35/1-35 mg-mcg (10/11) progesterone micronized cap 100 mg (Prometrium) progesterone micronized cap 200 mg (Prometrium) BIRTH CONTROL AMETHYST – levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg (Brevicon-28) desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5) (Mircette) norethindrone & ethinyl estradiol tab 1 mg-35 mcg (Norinyl 1+35) desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mgmg (Cyclessa) norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg (Femcon fe) drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz) drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin 28) ELLA – ulipristal acetate tab 30 mg ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) (Loseasonique) levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) (Seasonique) levonorgestrel & ethinyl estradiol (91day) tab 0.15-0.03 mg levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg Quantity Limits norelgestromin-ethinyl estradiol td ptwk 150-35 mcg/24hr (Ortho evra) norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg (Ovcon-35) desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg (Desogen) Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg (Estrostep fe) norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg (Loestrin 1/20-21) norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg (Loestrin 1.5/30-21) norethindrone ace & ethinyl estradiolfe tab 1 mg-20 mcg (Loestrin fe 1/20) norethindrone ace & ethinyl estradiolfe tab 1.5 mg-30 mcg (Loestrin fe 1.5/30) norethindrone tab 0.35 mg (Nor-qd) norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg (Orthonovum 7/7/7) norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg (Tri-norinyl 28) norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg (Ortho-cyclen) levonorgestrel tab 0.75 mg (Plan b) 12 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 NUVARING – etonogestrel-ethinyl estradiol va ring 0.120-0.015 mg/24hr OGESTREL – norgestrel & ethinyl estradiol tab 0.5 mg-50 mcg ORTHO TRI-CYCLEN LO – norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg GONAL-F RFF PEN – follitropin alfa inj 900 unit/1.5ml • • GONAL-F RFF REDIJECT – follitropin alfa inj 300 unit/0.5ml • • GONAL-F RFF REDIJECT – follitropin alfa inj 450 unit/0.75ml • • GONAL-F RFF REDIJECT – follitropin alfa inj 900 unit/1.5ml • • OVIDREL – choriogonadotropin alfa inj 250 mcg/0.5ml • • REPRONEX – menotropins for inj 75 unit • • Drug Name SYNAREL – nafarelin acetate nasal soln 2 mg/ml ZOVIA 1/50E – ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg DIABETES INFERTILITY CETROTIDE – cetrorelix acetate for inj kit 0.25 mg • • acarbose tab 100 mg (Precose) CETROTIDE – cetrorelix acetate for inj kit 3 mg • • acarbose tab 50 mg (Precose) chorionic gonadotropin for inj 10000 unit • • BYDUREON – exenatide extended release for susp pen-injector 2 mg acarbose tab 25 mg (Precose) BYDUREON – exenatide extended release for inj susp 2 mg clomiphene citrate tab 50 mg (Clomid) FOLLISTIM AQ – follitropin beta inj 75 unit/0.5ml • • BYETTA – exenatide soln pen-injector 5 mcg/0.02ml FOLLISTIM AQ – follitropin beta inj 150 unit/0.5ml • • BYETTA – exenatide soln pen-injector 10 mcg/0.04ml FOLLISTIM AQ – follitropin beta inj 300 unit/0.36ml • • glimepiride tab 1 mg (Amaryl) FOLLISTIM AQ – follitropin beta inj 600 unit/0.72ml • • FOLLISTIM AQ – follitropin beta inj 900 unit/1.08ml • • GONAL-F – follitropin alfa for inj 450 unit • • • • • • GONAL-F RFF PEN – follitropin alfa inj 300 unit/0.5ml • • glipizide-metformin hcl tab 2.5-250 mg GONAL-F RFF PEN – follitropin alfa inj 450 unit/0.75ml • • glipizide-metformin hcl tab 5-500 mg GONAL-F – follitropin alfa for inj 1050 unit GONAL-F RFF – follitropin alfa for inj 75 unit Quantity Limits Prior Authorization norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg Specialty norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg (Ortho tri-cyclen) Quantity Limits Prior Authorization Drug Name Specialty 2014 glimepiride tab 2 mg (Amaryl) glimepiride tab 4 mg (Amaryl) glipizide tab sr 24hr 10 mg (Glucotrol xl) glipizide tab sr 24hr 2.5 mg (Glucotrol xl) glipizide tab sr 24hr 5 mg (Glucotrol xl) glipizide tab 10 mg (Glucotrol) glipizide tab 5 mg (Glucotrol) glipizide-metformin hcl tab 2.5-500 mg Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 13 GLUCAGON EMERGENCY KIT – glucagon (rdna) for inj kit 1 mg JUVISYNC – sitagliptin-simvastatin tab 50-10 mg GLYBURIDE – glyburide tab 1.25 mg JUVISYNC – sitagliptin-simvastatin tab 50-20 mg GLYBURIDE – glyburide tab 2.5 mg glyburide micronized tab 1.5 mg (Glynase) JUVISYNC – sitagliptin-simvastatin tab 100-10 mg glyburide micronized tab 3 mg (Glynase) JUVISYNC – sitagliptin-simvastatin tab 100-20 mg glyburide micronized tab 6 mg (Glynase) JUVISYNC – sitagliptin-simvastatin tab 100-40 mg glyburide tab 1.25 mg KOMBIGLYZE XR – saxagliptinmetformin hcl tab sr 24hr 2.5-1000 mg glyburide tab 2.5 mg glyburide tab 5 mg KOMBIGLYZE XR – saxagliptinmetformin hcl tab sr 24hr 5-500 mg glyburide-metformin tab 1.25-250 mg (Glucovance) KOMBIGLYZE XR – saxagliptinmetformin hcl tab sr 24hr 5-1000 mg glyburide-metformin tab 2.5-500 mg (Glucovance) metformin hcl tab sr 24hr osmotic 1000 mg (Fortamet) glyburide-metformin tab 5-500 mg (Glucovance) INVOKANA – canagliflozin tab 300 mg JANUMET – sitagliptin-metformin hcl tab 50-500 mg JANUMET – sitagliptin-metformin hcl tab 50-1000 mg JANUMET XR – sitagliptin-metformin hcl tab sr 24hr 50-500 mg • • metformin hcl tab sr 24hr osmotic 500 mg (Fortamet) metformin hcl tab sr 24hr 500 mg (Glucophage xr) metformin hcl tab sr 24hr 750 mg (Glucophage xr) metformin hcl tab 1000 mg (Glucophage) metformin hcl tab 500 mg (Glucophage) JANUMET XR – sitagliptin-metformin hcl tab sr 24hr 50-1000 mg metformin hcl tab 850 mg (Glucophage) JANUMET XR – sitagliptin-metformin hcl tab sr 24hr 100-1000 mg nateglinide tab 60 mg (Starlix) JANUVIA – sitagliptin phosphate tab 25 mg (base equiv) JANUVIA – sitagliptin phosphate tab 50 mg (base equiv) JANUVIA – sitagliptin phosphate tab 100 mg (base equiv) 14 Quantity Limits JUVISYNC – sitagliptin-simvastatin tab 50-40 mg GLYBURIDE – glyburide tab 5 mg INVOKANA – canagliflozin tab 100 mg Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 nateglinide tab 120 mg (Starlix) ONGLYZA – saxagliptin hcl tab 2.5 mg (base equiv) ONGLYZA – saxagliptin hcl tab 5 mg (base equiv) pioglitazone hcl tab 15 mg (base equiv) (Actos) pioglitazone hcl tab 30 mg (base equiv) (Actos) Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 pioglitazone hcl tab 45 mg (base equiv) (Actos) pioglitazone hcl-metformin hcl tab 15-500 mg (Actoplus met) pioglitazone hcl-metformin hcl tab 15-850 mg (Actoplus met) repaglinide tab 0.5 mg (Prandin) repaglinide tab 1 mg (Prandin) repaglinide tab 2 mg (Prandin) tolazamide tab 250 mg VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/ml) DIABETES - INSULINS Rapid-Acting Insulins HUMALOG – insulin lispro (human) soln cartridge 100 unit/ml HUMALOG – insulin lispro (human) inj 100 unit/ml HUMALOG KWIKPEN – insulin lispro (human) soln pen-injector 100 unit/ml NOVOLOG – insulin aspart inj 100 unit/ml NOVOLOG FLEXPEN – insulin aspart soln pen-injector 100 unit/ml NOVOLOG PENFILL – insulin aspart soln cartridge 100 unit/ml HUMALOG MIX 75/25 – insulin lispro prot & lispro (human) inj 100 unit/ml (75-25) HUMALOG MIX 75/25 KWIKPEN – insulin lispro prot & lispro sus pen-inj 100 unit/ml (75-25) HUMULIN N – insulin isophane (human) inj 100 unit/ml HUMULIN N KWIKPEN – insulin isophane (human) susp pen-injector 100 unit/ml HUMULIN N U-100 PEN – insulin isophane (human) susp pen-injector 100 unit/ml HUMULIN 70/30 – insulin isophane & regular (human) inj 100 unit/ml (70-30) HUMULIN 70/30 KWIKPEN – insulin isophane & regular susp pen-inj 100 unit/ml (70-30) HUMULIN 70/30 PEN – insulin isophane & regular susp pen-inj 100 unit/ml (70-30) NOVOLIN N – insulin isophane (human) inj 100 unit/ml NOVOLIN N RELION – insulin isophane (human) inj 100 unit/ml HUMULIN R – insulin regular (human) inj 100 unit/ml NOVOLIN 70/30 – insulin isophane & regular (human) inj 100 unit/ml (70-30) HUMULIN R U-500 (CONCENTR – insulin regular (human) inj 500 unit/ml NOVOLIN 70/30 RELION – insulin isophane & regular (human) inj 100 unit/ml (70-30) NOVOLIN R RELION – insulin regular (human) inj 100 unit/ml Intermediate-Acting Insulins HUMALOG MIX 50/50 – insulin lispro prot & lispro (human) inj 100 unit/ml (50-50) Quantity Limits HUMALOG MIX 50/50 KWIKPEN – insulin lispro prot & lispro sus pen-inj 100 unit/ml (50-50) Short-Acting Insulins NOVOLIN R – insulin regular (human) inj 100 unit/ml Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 NOVOLOG MIX 70/30 – insulin aspart prot & aspart (human) inj 100 unit/ml (70-30) NOVOLOG MIX 70/30 PREFILL – insulin aspart prot & aspart sus pen-inj 100 unit/ml (70-30) Basal Insulins LANTUS – insulin glargine inj 100 unit/ml Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 15 Prior Authorization INCRELEX – mecasermin inj 40 mg/4ml (10 mg/ml) • • OMNITROPE – somatropin inj 5 mg/1.5ml • • • • • • LEVEMIR FLEXPEN – insulin detemir soln pen-injector 100 unit/ml Drug Name GROWTH HORMONE LEVEMIR FLEXTOUCH – insulin detemir soln pen-injector 100 unit/ml OMNITROPE – somatropin inj 10 mg/1.5ml THYROID REGULATION OMNITROPE – somatropin for inj 5.8 mg levothyroxine sodium tab 100 mcg (Synthroid) OTHER HORMONES AND RELATED DRUGS levothyroxine sodium tab 112 mcg (Synthroid) levothyroxine sodium tab 125 mcg (Synthroid) levothyroxine sodium tab 137 mcg (Synthroid) levothyroxine sodium tab 150 mcg (Synthroid) levothyroxine sodium tab 175 mcg (Synthroid) ACTONEL – risedronate sodium tab 5 mg ACTONEL – risedronate sodium tab 30 mg ACTONEL – risedronate sodium tab 35 mg ACTONEL – risedronate sodium tab 150 mg ALENDRONATE SODIUM – alendronate sodium tab 40 mg alendronate sodium tab 10 mg levothyroxine sodium tab 200 mcg (Synthroid) alendronate sodium tab 35 mg levothyroxine sodium tab 25 mcg (Synthroid) alendronate sodium tab 70 mg (Fosamax) levothyroxine sodium tab 300 mcg (Synthroid) cabergoline tab 0.5 mg levothyroxine sodium tab 50 mcg (Synthroid) levothyroxine sodium tab 75 mcg (Synthroid) levothyroxine sodium tab 88 mcg (Synthroid) liothyronine sodium tab 25 mcg (Cytomel) liothyronine sodium tab 5 mcg (Cytomel) liothyronine sodium tab 50 mcg (Cytomel) methimazole tab 10 mg (Tapazole) Quantity Limits Specialty LEVEMIR – insulin detemir inj 100 unit/ml Quantity Limits propylthiouracil tab 50 mg Specialty LANTUS SOLOSTAR – insulin glargine soln pen-injector 100 unit/ml Drug Name Prior Authorization 2014 alendronate sodium tab 5 mg calcitonin (salmon) nasal soln 200 unit/ act (Miacalcin) calcitriol cap 0.25 mcg (Rocaltrol) calcitriol cap 0.5 mcg (Rocaltrol) calcitriol oral soln 1 mcg/ml (Rocaltrol) desmopressin acetate nasal soln 0.01% (refrigerated) (Ddavp) desmopressin acetate nasal spray soln 0.01% (Ddavp) desmopressin acetate nasal spray soln 0.01% (refrigerated) desmopressin acetate tab 0.1 mg (Ddavp) methimazole tab 5 mg (Tapazole) 16 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 desmopressin acetate tab 0.2 mg (Ddavp) benazepril & hydrochlorothiazide tab 10-12.5 mg (Lotensin hct) doxercalciferol cap 0.5 mcg (Hectorol) benazepril & hydrochlorothiazide tab 20-12.5 mg (Lotensin hct) doxercalciferol cap 1 mcg (Hectorol) ETIDRONATE DISODIUM – etidronate disodium tab 200 mg benazepril & hydrochlorothiazide tab 5-6.25 mg ETIDRONATE DISODIUM – etidronate disodium tab 400 mg benazepril hcl tab 10 mg (Lotensin) • • benazepril hcl tab 20 mg (Lotensin) benazepril hcl tab 40 mg (Lotensin) ibandronate sodium tab 150 mg (base equivalent) (Boniva) benazepril hcl tab 5 mg levocarnitine oral soln 1 gm/10ml (10%) (Carnitor) captopril tab 12.5 mg captopril tab 100 mg captopril tab 25 mg levocarnitine tab 330 mg (Carnitor) captopril tab 50 mg methylergonovine maleate tab 0.2 mg ORFADIN – nitisinone cap 2 mg ORFADIN – nitisinone cap 5 mg ORFADIN – nitisinone cap 10 mg Quantity Limits benazepril & hydrochlorothiazide tab 20-25 mg (Lotensin hct) doxercalciferol cap 2.5 mcg (Hectorol) FORTEO – teriparatide (recombinant) inj 600 mcg/2.4ml Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 • • • paricalcitol cap 1 mcg (Zemplar) paricalcitol cap 2 mcg (Zemplar) paricalcitol cap 4 mcg (Zemplar) raloxifene hcl tab 60 mg (Evista) risedronate sodium tab 150 mg (Actonel) SENSIPAR – cinacalcet hcl tab 30 mg (base equiv) • • • CAPTOPRIL/HYDROCHLOROTHIA – captopril & hydrochlorothiazide tab 25-15 mg CAPTOPRIL/HYDROCHLOROTHIA – captopril & hydrochlorothiazide tab 25-25 mg CAPTOPRIL/HYDROCHLOROTHIA – captopril & hydrochlorothiazide tab 50-15 mg CAPTOPRIL/HYDROCHLOROTHIA – captopril & hydrochlorothiazide tab 50-25 mg SENSIPAR – cinacalcet hcl tab 60 mg (base equiv) enalapril maleate & hydrochlorothiazide tab 10-25 mg (Vaseretic) SENSIPAR – cinacalcet hcl tab 90 mg (base equiv) enalapril maleate & hydrochlorothiazide tab 5-12.5 mg STIMATE – desmopressin acetate nasal soln 1.5 mg/ml enalapril maleate tab 10 mg (Vasotec) HEART AND CIRCULATORY DRUGS enalapril maleate tab 20 mg (Vasotec) ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS AND COMBINATI enalapril maleate tab 5 mg (Vasotec) enalapril maleate tab 2.5 mg (Vasotec) fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 17 fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg quinapril-hydrochlorothiazide tab 20-25 mg (Accuretic) fosinopril sodium tab 10 mg ramipril cap 1.25 mg (Altace) fosinopril sodium tab 20 mg ramipril cap 10 mg (Altace) fosinopril sodium tab 40 mg ramipril cap 2.5 mg (Altace) lisinopril & hydrochlorothiazide tab 10-12.5 mg (Zestoretic) ramipril cap 5 mg (Altace) lisinopril & hydrochlorothiazide tab 20-12.5 mg (Zestoretic) trandolapril tab 2 mg (Mavik) lisinopril & hydrochlorothiazide tab 20-25 mg (Zestoretic) lisinopril tab 10 mg (Prinivil) lisinopril tab 2.5 mg (Zestril) lisinopril tab 20 mg (Prinivil) lisinopril tab 30 mg (Zestril) lisinopril tab 40 mg (Zestril) lisinopril tab 5 mg (Prinivil) moexipril hcl tab 15 mg (Univasc) moexipril hcl tab 7.5 mg (Univasc) moexipril-hydrochlorothiazide tab 15-12.5 mg (Uniretic) moexipril-hydrochlorothiazide tab 15-25 mg moexipril-hydrochlorothiazide tab 7.5-12.5 mg perindopril erbumine tab 2 mg perindopril erbumine tab 4 mg (Aceon) perindopril erbumine tab 8 mg (Aceon) quinapril hcl tab 10 mg (Accupril) quinapril hcl tab 20 mg (Accupril) quinapril hcl tab 40 mg (Accupril) Quantity Limits Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 trandolapril tab 1 mg (Mavik) trandolapril tab 4 mg (Mavik) ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS) AND COMBINATIONS candesartan cilexetil tab 16 mg (Atacand) candesartan cilexetil tab 32 mg (Atacand) candesartan cilexetil tab 4 mg (Atacand) candesartan cilexetil tab 8 mg (Atacand) candesartan cilexetilhydrochlorothiazide tab 16-12.5 mg (Atacand hct) candesartan cilexetilhydrochlorothiazide tab 32-12.5 mg (Atacand hct) candesartan cilexetilhydrochlorothiazide tab 32-25 mg (Atacand hct) eprosartan mesylate tab 600 mg (Teveten) EXFORGE HCT – amlodipine-valsartanhydrochlorothiazide tab 5-160-12.5 mg quinapril hcl tab 5 mg (Accupril) EXFORGE HCT – amlodipine-valsartanhydrochlorothiazide tab 5-160-25 mg quinapril-hydrochlorothiazide tab 10-12.5 mg (Accuretic) EXFORGE HCT – amlodipine-valsartanhydrochlorothiazide tab 10-160-12.5 mg quinapril-hydrochlorothiazide tab 20-12.5 mg (Accuretic) EXFORGE HCT – amlodipine-valsartanhydrochlorothiazide tab 10-160-25 mg EXFORGE HCT – amlodipine-valsartanhydrochlorothiazide tab 10-320-25 mg 18 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 irbesartan tab 150 mg (Avapro) irbesartan tab 300 mg (Avapro) irbesartan tab 75 mg (Avapro) irbesartan-hydrochlorothiazide tab 150-12.5 mg (Avalide) valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan hct) BETA BLOCKERS AND COMBINATIONS acebutolol hcl cap 200 mg (Sectral) losartan potassium & hydrochlorothiazide tab 100-12.5 mg (Hyzaar) atenolol & chlorthalidone tab 100-25 mg (Tenoretic 100) losartan potassium & hydrochlorothiazide tab 50-12.5 mg (Hyzaar) losartan potassium tab 100 mg (Cozaar) losartan potassium tab 25 mg (Cozaar) losartan potassium tab 50 mg (Cozaar) telmisartan tab 20 mg (Micardis) telmisartan tab 40 mg (Micardis) telmisartan tab 80 mg (Micardis) telmisartan-hydrochlorothiazide tab 40-12.5 mg (Micardis hct) acebutolol hcl cap 400 mg (Sectral) atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50) atenolol tab 100 mg (Tenormin) atenolol tab 25 mg (Tenormin) atenolol tab 50 mg (Tenormin) bisoprolol & hydrochlorothiazide tab 10-6.25 mg (Ziac) bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg (Ziac) bisoprolol & hydrochlorothiazide tab 5-6.25 mg (Ziac) bisoprolol fumarate tab 10 mg (Zebeta) bisoprolol fumarate tab 5 mg (Zebeta) carvedilol tab 12.5 mg (Coreg) carvedilol tab 25 mg (Coreg) telmisartan-hydrochlorothiazide tab 80-12.5 mg (Micardis hct) carvedilol tab 3.125 mg (Coreg) telmisartan-hydrochlorothiazide tab 80-25 mg (Micardis hct) DUTOPROL – metoprolol & hydrochlorothiazide tab sr 24hr 25-12.5 mg valsartan tab 160 mg (Diovan) valsartan tab 320 mg (Diovan) valsartan tab 40 mg (Diovan) valsartan tab 80 mg (Diovan) valsartan-hydrochlorothiazide tab 160-12.5 mg (Diovan hct) Quantity Limits valsartan-hydrochlorothiazide tab 320-25 mg (Diovan hct) irbesartan-hydrochlorothiazide tab 300-12.5 mg (Avalide) losartan potassium & hydrochlorothiazide tab 100-25 mg (Hyzaar) Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 carvedilol tab 6.25 mg (Coreg) DUTOPROL – metoprolol & hydrochlorothiazide tab sr 24hr 50-12.5 mg DUTOPROL – metoprolol & hydrochlorothiazide tab sr 24hr 100-12.5 mg valsartan-hydrochlorothiazide tab 160-25 mg (Diovan hct) labetalol hcl tab 100 mg (Trandate) valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovan hct) labetalol hcl tab 300 mg (Trandate) labetalol hcl tab 200 mg (Trandate) Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 19 metoprolol & hydrochlorothiazide tab 100-25 mg (Lopressor hct) propranolol hcl tab 60 mg metoprolol & hydrochlorothiazide tab 100-50 mg PROPRANOLOL/HYDROCHLOROTH – propranolol & hydrochlorothiazide tab 40-25 mg metoprolol & hydrochlorothiazide tab 50-25 mg (Lopressor hct) PROPRANOLOL/HYDROCHLOROTH – propranolol & hydrochlorothiazide tab 80-25 mg metoprolol succinate tab sr 24hr 200 mg (Toprol xl) TIMOLOL MALEATE – timolol maleate tab 5 mg metoprolol succinate tab sr 24hr 25 mg (Toprol xl) TIMOLOL MALEATE – timolol maleate tab 10 mg metoprolol succinate tab sr 24hr 50 mg (Toprol xl) TIMOLOL MALEATE – timolol maleate tab 20 mg metoprolol tartrate tab 100 mg (Lopressor) CALCIUM CHANNEL BLOCKERS AND COMBINATIONS metoprolol tartrate tab 25 mg amlodipine besylate tab 10 mg (Norvasc) nadolol tab 20 mg (Corgard) amlodipine besylate tab 2.5 mg (Norvasc) nadolol tab 40 mg (Corgard) amlodipine besylate tab 5 mg (Norvasc) nadolol tab 80 mg (Corgard) amlodipine besylate-atorvastatin calcium tab 10-10 mg (Caduet) pindolol tab 10 mg pindolol tab 5 mg amlodipine besylate-atorvastatin calcium tab 10-20 mg (Caduet) PROPRANOLOL HCL – propranolol hcl oral soln 20 mg/5ml amlodipine besylate-atorvastatin calcium tab 10-40 mg (Caduet) PROPRANOLOL HCL – propranolol hcl oral soln 40 mg/5ml amlodipine besylate-atorvastatin calcium tab 10-80 mg (Caduet) propranolol hcl cap sr 24hr 120 mg (Inderal la) amlodipine besylate-atorvastatin calcium tab 2.5-10 mg (Caduet) propranolol hcl cap sr 24hr 160 mg (Inderal la) amlodipine besylate-atorvastatin calcium tab 2.5-20 mg (Caduet) propranolol hcl cap sr 24hr 60 mg (Inderal la) amlodipine besylate-atorvastatin calcium tab 2.5-40 mg (Caduet) propranolol hcl cap sr 24hr 80 mg (Inderal la) amlodipine besylate-atorvastatin calcium tab 5-10 mg (Caduet) propranolol hcl tab 10 mg amlodipine besylate-atorvastatin calcium tab 5-20 mg (Caduet) propranolol hcl tab 20 mg Quantity Limits propranolol hcl tab 80 mg metoprolol succinate tab sr 24hr 100 mg (Toprol xl) metoprolol tartrate tab 50 mg (Lopressor) Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 propranolol hcl tab 40 mg 20 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 amlodipine besylate-atorvastatin calcium tab 5-40 mg (Caduet) diltiazem hcl coated beads tab sr 24hr 360 mg (Cardizem la) amlodipine besylate-atorvastatin calcium tab 5-80 mg (Caduet) diltiazem hcl coated beads tab sr 24hr 420 mg (Cardizem la) amlodipine besylate-benazepril hcl cap 10-20 mg (Lotrel) diltiazem hcl extended release beads cap sr 24hr 120 mg (Tiazac) amlodipine besylate-benazepril hcl cap 10-40 mg (Lotrel) diltiazem hcl extended release beads cap sr 24hr 180 mg (Tiazac) amlodipine besylate-benazepril hcl cap 2.5-10 mg (Lotrel) diltiazem hcl extended release beads cap sr 24hr 240 mg (Tiazac) amlodipine besylate-benazepril hcl cap 5-10 mg (Lotrel) diltiazem hcl extended release beads cap sr 24hr 300 mg (Tiazac) amlodipine besylate-benazepril hcl cap 5-20 mg (Lotrel) diltiazem hcl extended release beads cap sr 24hr 360 mg (Tiazac) amlodipine besylate-benazepril hcl cap 5-40 mg (Lotrel) diltiazem hcl extended release beads cap sr 24hr 420 mg (Tiazac) diltiazem hcl cap sr 12hr 120 mg diltiazem hcl tab 120 mg (Cardizem) diltiazem hcl cap sr 12hr 60 mg diltiazem hcl tab 30 mg (Cardizem) diltiazem hcl cap sr 12hr 90 mg diltiazem hcl tab 60 mg (Cardizem) diltiazem hcl cap sr 24hr 120 mg diltiazem hcl tab 90 mg diltiazem hcl cap sr 24hr 180 mg diltiazem hcl cap sr 24hr 240 mg EXFORGE – amlodipine besylatevalsartan tab 5-160 mg diltiazem hcl coated beads cap sr 24hr 120 mg (Cardizem cd) EXFORGE – amlodipine besylatevalsartan tab 5-320 mg diltiazem hcl coated beads cap sr 24hr 180 mg (Cardizem cd) EXFORGE – amlodipine besylatevalsartan tab 10-160 mg diltiazem hcl coated beads cap sr 24hr 240 mg (Cardizem cd) EXFORGE – amlodipine besylatevalsartan tab 10-320 mg diltiazem hcl coated beads cap sr 24hr 300 mg (Cardizem cd) felodipine tab sr 24hr 10 mg diltiazem hcl coated beads cap sr 24hr 360 mg (Cardizem cd) felodipine tab sr 24hr 5 mg diltiazem hcl coated beads tab sr 24hr 180 mg (Cardizem la) nicardipine hcl cap 30 mg diltiazem hcl coated beads tab sr 24hr 240 mg (Cardizem la) nifedipine cap 20 mg diltiazem hcl coated beads tab sr 24hr 300 mg (Cardizem la) Quantity Limits Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 felodipine tab sr 24hr 2.5 mg nicardipine hcl cap 20 mg nifedipine cap 10 mg (Procardia) nifedipine tab sr 24hr osmotic 30 mg (Procardia xl) Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 21 nifedipine tab sr 24hr osmotic 60 mg (Procardia xl) ISOSORBIDE DINITRATE – isosorbide dinitrate tab 30 mg nifedipine tab sr 24hr osmotic 90 mg (Procardia xl) isosorbide dinitrate tab cr 40 mg nifedipine tab sr 24hr 30 mg (Adalat cc) isosorbide dinitrate tab 20 mg nifedipine tab sr 24hr 60 mg (Adalat cc) isosorbide dinitrate tab 30 mg nifedipine tab sr 24hr 90 mg (Adalat cc) nimodipine cap 30 mg isosorbide dinitrate tab 5 mg (Isordil titradose) telmisartan-amlodipine tab 40-10 mg (Twynsta) isosorbide mononitrate tab sr 24hr 120 mg (Imdur) telmisartan-amlodipine tab 40-5 mg (Twynsta) isosorbide mononitrate tab sr 24hr 30 mg (Imdur) telmisartan-amlodipine tab 80-10 mg (Twynsta) isosorbide mononitrate tab sr 24hr 60 mg (Imdur) telmisartan-amlodipine tab 80-5 mg (Twynsta) isosorbide mononitrate tab 10 mg VERAPAMIL HCL – verapamil hcl tab 40 mg NITRO-BID – nitroglycerin oint 2% verapamil hcl cap sr 24hr 100 mg (Verelan pm) nitroglycerin cap cr 6.5 mg verapamil hcl cap sr 24hr 120 mg (Verelan) verapamil hcl cap sr 24hr 180 mg (Verelan) verapamil hcl cap sr 24hr 200 mg (Verelan pm) verapamil hcl cap sr 24hr 240 mg (Verelan) verapamil hcl cap sr 24hr 300 mg (Verelan pm) isosorbide mononitrate tab 20 mg nitroglycerin cap cr 2.5 mg nitroglycerin cap cr 9 mg nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur) nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur) nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur) nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur) NITROSTAT – nitroglycerin sl tab 0.3 mg NITROSTAT – nitroglycerin sl tab 0.4 mg verapamil hcl tab cr 120 mg (Calan sr) CHOLESTEROL LOWERING verapamil hcl tab cr 180 mg (Calan sr) atorvastatin calcium tab 10 mg (base equivalent) (Lipitor) verapamil hcl tab 120 mg (Calan) verapamil hcl tab 80 mg (Calan) CHEST PAIN 22 Quantity Limits isosorbide dinitrate tab 10 mg verapamil hcl cap sr 24hr 360 mg (Verelan) verapamil hcl tab cr 240 mg (Calan sr) Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 NITROSTAT – nitroglycerin sl tab 0.6 mg atorvastatin calcium tab 20 mg (base equivalent) (Lipitor) atorvastatin calcium tab 40 mg (base equivalent) (Lipitor) Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 atorvastatin calcium tab 80 mg (base equivalent) (Lipitor) fenofibrate tab 54 mg (Lofibra) cholestyramine light powder packets 4 gm fluvastatin sodium cap 40 mg (Lescol) cholestyramine light powder 4 gm/ dose (Questran light) lovastatin tab 10 mg gemfibrozil tab 600 mg (Lopid) lovastatin tab 20 mg (Mevacor) cholestyramine powder 4 gm/dose (Questran) niacin tab cr 1000 mg (antihyperlipidemic) (Niaspan) choline fenofibrate cap dr 135 mg (fenofibric acid equiv) (Trilipix) niacin tab cr 500 mg (antihyperlipidemic) (Niaspan) choline fenofibrate cap dr 45 mg (fenofibric acid equiv) (Trilipix) niacin tab cr 750 mg (antihyperlipidemic) (Niaspan) colestipol hcl granule packets 5 gm (Colestid flavored) pravastatin sodium tab 10 mg lovastatin tab 40 mg (Mevacor) pravastatin sodium tab 20 mg (Pravachol) colestipol hcl tab 1 gm (Colestid) pravastatin sodium tab 40 mg (Pravachol) CRESTOR – rosuvastatin calcium tab 5 mg pravastatin sodium tab 80 mg (Pravachol) CRESTOR – rosuvastatin calcium tab 10 mg simvastatin tab 10 mg (Zocor) CRESTOR – rosuvastatin calcium tab 20 mg simvastatin tab 40 mg (Zocor) CRESTOR – rosuvastatin calcium tab 40 mg simvastatin tab 80 mg (Zocor) fenofibrate micronized cap 130 mg (Antara) fenofibrate micronized cap 134 mg (Lofibra) Quantity Limits fluvastatin sodium cap 20 mg (Lescol) cholestyramine powder packets 4 gm (Questran) colestipol hcl granules 5 gm (Colestid flavored) Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 simvastatin tab 20 mg (Zocor) simvastatin tab 5 mg (Zocor) WELCHOL – colesevelam hcl tab 625 mg WELCHOL – colesevelam hcl packet for susp 3.75 gm FLUID RETENTION fenofibrate micronized cap 200 mg (Lofibra) ACETAZOLAMIDE – acetazolamide tab 125 mg fenofibrate micronized cap 43 mg (Antara) acetazolamide cap sr 12hr 500 mg (Diamox) fenofibrate micronized cap 67 mg (Lofibra) acetazolamide tab 250 mg fenofibrate tab 145 mg (Tricor) amiloride & hydrochlorothiazide tab 5-50 mg fenofibrate tab 160 mg (Lofibra) amiloride hcl tab 5 mg fenofibrate tab 48 mg (Tricor) Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 23 bumetanide tab 0.5 mg bumetanide tab 1 mg bumetanide tab 2 mg CHLOROTHIAZIDE – chlorothiazide tab 250 mg chlorothiazide tab 250 mg chlorothiazide tab 500 mg CHLORTHALIDONE – chlorthalidone tab 25 mg CHLORTHALIDONE – chlorthalidone tab 50 mg furosemide oral soln 10 mg/ml furosemide tab 20 mg (Lasix) furosemide tab 40 mg (Lasix) furosemide tab 80 mg (Lasix) hydrochlorothiazide cap 12.5 mg (Microzide) triamterene & hydrochlorothiazide tab 37.5-25 mg (Maxzide-25) triamterene & hydrochlorothiazide tab 75-50 mg (Maxzide) TRIAMTERENE/HYDROCHLOROTH – triamterene & hydrochlorothiazide cap 50-25 mg HEART RHYTHM amiodarone hcl tab 100 mg amiodarone hcl tab 200 mg (Cordarone) amiodarone hcl tab 400 mg disopyramide phosphate cap 100 mg (Norpace) disopyramide phosphate cap 150 mg (Norpace) flecainide acetate tab 100 mg flecainide acetate tab 150 mg hydrochlorothiazide tab 25 mg flecainide acetate tab 50 mg hydrochlorothiazide tab 50 mg mexiletine hcl cap 150 mg indapamide tab 1.25 mg mexiletine hcl cap 200 mg indapamide tab 2.5 mg mexiletine hcl cap 250 mg methazolamide tab 25 mg (Neptazane) propafenone hcl cap sr 12hr 225 mg (Rythmol sr) metolazone tab 10 mg metolazone tab 2.5 mg (Zaroxolyn) metolazone tab 5 mg (Zaroxolyn) spironolactone & hydrochlorothiazide tab 25-25 mg (Aldactazide) propafenone hcl cap sr 12hr 325 mg (Rythmol sr) propafenone hcl cap sr 12hr 425 mg (Rythmol sr) propafenone hcl tab 150 mg (Rythmol) spironolactone tab 100 mg (Aldactone) propafenone hcl tab 225 mg (Rythmol) spironolactone tab 25 mg (Aldactone) propafenone hcl tab 300 mg spironolactone tab 50 mg (Aldactone) quinidine gluconate tab cr 324 mg torsemide tab 10 mg (Demadex) QUINIDINE SULFATE – quinidine sulfate tab 200 mg torsemide tab 100 mg (Demadex) torsemide tab 20 mg (Demadex) QUINIDINE SULFATE ER – quinidine sulfate tab cr 300 mg torsemide tab 5 mg (Demadex) quinidine sulfate tab 200 mg 24 Quantity Limits triamterene & hydrochlorothiazide cap 37.5-25 mg (Dyazide) hydrochlorothiazide tab 12.5 mg methazolamide tab 50 mg (Neptazane) Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 quinidine sulfate tab 300 mg hydralazine hcl tab 10 mg sotalol hcl (afib/afl) tab 120 mg (Betapace af) hydralazine hcl tab 100 mg sotalol hcl (afib/afl) tab 160 mg (Betapace af) hydralazine hcl tab 50 mg • • • • • • • • • • Quantity Limits • • hydralazine hcl tab 25 mg LANOXIN – digoxin tab 62.5 mcg (0.0625 mg) sotalol hcl (afib/afl) tab 80 mg (Betapace af) LANOXIN – digoxin tab 125 mcg (0.125 mg) sotalol hcl tab 120 mg (Betapace) sotalol hcl tab 160 mg (Betapace) LANOXIN – digoxin tab 187.5 mcg (0.1875 mg) sotalol hcl tab 240 mg sotalol hcl tab 80 mg (Betapace) LANOXIN – digoxin tab 250 mcg (0.25 mg) OTHER HEART RELATED DRUGS ADCIRCA – tadalafil tab 20 mg (pah) Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 • • LETAIRIS – ambrisentan tab 5 mg clonidine hcl tab 0.1 mg (Catapres) LETAIRIS – ambrisentan tab 10 mg clonidine hcl tab 0.2 mg (Catapres) methyldopa tab 250 mg clonidine hcl tab 0.3 mg (Catapres) methyldopa tab 500 mg clonidine hcl td patch weekly 0.1 mg/24hr (Catapres-tts-1) midodrine hcl tab 10 mg clonidine hcl td patch weekly 0.2 mg/24hr (Catapres-tts-2) midodrine hcl tab 5 mg clonidine hcl td patch weekly 0.3 mg/24hr (Catapres-tts-3) minoxidil tab 2.5 mg DIBENZYLINE – phenoxybenzamine hcl cap 10 mg prazosin hcl cap 1 mg (Minipress) midodrine hcl tab 2.5 mg minoxidil tab 10 mg OPSUMIT – macitentan tab 10 mg DIGOXIN – digoxin oral soln 0.05 mg/ml prazosin hcl cap 2 mg (Minipress) digoxin tab 125 mcg (0.125 mg) (Lanoxin) prazosin hcl cap 5 mg (Minipress) digoxin tab 250 mcg (0.25 mg) (Lanoxin) terazosin hcl cap 1 mg doxazosin mesylate tab 1 mg (Cardura) terazosin hcl cap 2 mg doxazosin mesylate tab 2 mg (Cardura) terazosin hcl cap 5 mg doxazosin mesylate tab 4 mg (Cardura) TRACLEER – bosentan tab 62.5 mg doxazosin mesylate tab 8 mg (Cardura) TRACLEER – bosentan tab 125 mg eplerenone tab 25 mg (Inspra) ERECTILE DYSFUNCTION eplerenone tab 50 mg (Inspra) VIAGRA – sildenafil citrate tab 25 mg guanfacine hcl tab 1 mg (Tenex) VIAGRA – sildenafil citrate tab 50 mg guanfacine hcl tab 2 mg (Tenex) VIAGRA – sildenafil citrate tab 100 mg sildenafil citrate tab 20 mg (Revatio) terazosin hcl cap 10 mg Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 • • • 25 BEE STING KITS acetylcysteine inhal soln 10% EPIPEN 2-PAK – epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) acetylcysteine inhal soln 20% EPIPEN-JR 2-PAK – epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000) ASTHMA/COPD RESPIRATORY AGENTS ANTIHISTAMINES cyproheptadine hcl syrup 2 mg/5ml cyproheptadine hcl tab 4 mg promethazine hcl suppos 12.5 mg promethazine hcl suppos 25 mg promethazine hcl suppos 50 mg promethazine hcl syrup 6.25 mg/5ml promethazine hcl tab 12.5 mg promethazine hcl tab 25 mg ADVAIR DISKUS – fluticasone-salmeterol aer powder ba 100-50 mcg/dose ADVAIR DISKUS – fluticasone-salmeterol aer powder ba 250-50 mcg/dose ADVAIR DISKUS – fluticasone-salmeterol aer powder ba 500-50 mcg/dose ADVAIR HFA – fluticasone-salmeterol inhal aerosol 45-21 mcg/act ADVAIR HFA – fluticasone-salmeterol inhal aerosol 115-21 mcg/act ADVAIR HFA – fluticasone-salmeterol inhal aerosol 230-21 mcg/act NASAL PRODUCTS ASTEPRO – azelastine hcl nasal spray 0.15% (205.5 mcg/spray) albuterol sulfate soln nebu 0.5% (5 mg/ ml) azelastine hcl nasal spray 0.15% (205.5 mcg/spray) (Astepro) albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) azelastine hcl nasal spray 137 mcg/ spray (1 mg/ml) albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) BACTROBAN NASAL – mupirocin calcium nasal oint 2% albuterol sulfate syrup 2 mg/5ml FLUNISOLIDE – flunisolide nasal soln 29 mcg/act (0.025%) flunisolide nasal soln 0.025% (Flunisolide) fluticasone propionate nasal susp 50 mcg/act (Flonase) ipratropium bromide nasal soln 0.03% (21 mcg/spray) (Atrovent) ipratropium bromide nasal soln 0.06% (42 mcg/spray) (Atrovent) triamcinolone acetonide nasal inhal 55 mcg/act (Nasacort aq) COUGH/COLD/ALLERGY 26 Quantity Limits SSKI – potassium iodide soln 1 gm/ml albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) promethazine hcl tab 50 mg Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 albuterol sulfate tab sr 12hr 4 mg (Vospire er) albuterol sulfate tab sr 12hr 8 mg (Vospire er) albuterol sulfate tab 2 mg albuterol sulfate tab 4 mg ANORO ELLIPTA – umeclidiniumvilanterol aero powd ba 62.5-25 mcg/ inh ASMANEX TWISTHALER 120 ME – mometasone furoate inhal powd 220 mcg/inh (breath activated) ASMANEX TWISTHALER 14 MET – mometasone furoate inhal powd 220 mcg/inh (breath activated) Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 ASMANEX TWISTHALER 30 ME – mometasone furoate inhal powd 220 mcg/inh (breath activated) ASMANEX TWISTHALER 30 MET – mometasone furoate inhal powd 110 mcg/inh (breath activated) ASMANEX TWISTHALER 60 MET – mometasone furoate inhal powd 220 mcg/inh (breath activated) ATROVENT HFA – ipratropium bromide hfa inhal aerosol 17 mcg/act BREO ELLIPTA – fluticasone furoatevilanterol aero powd ba 100-25 mcg/inh budesonide inhalation susp 0.25 mg/2ml (Pulmicort) budesonide inhalation susp 0.5 mg/2ml (Pulmicort) COMBIVENT – ipratropium-albuterol aerosol 18-103 mcg/act (20-120mcg/ act) COMBIVENT RESPIMAT – ipratropiumalbuterol inhal aerosol soln 20-100 mcg/ act cromolyn sodium soln nebu 20 mg/2ml DULERA – mometasone furoateformoterol fumarate aerosol 100-5 mcg/ act DULERA – mometasone furoateformoterol fumarate aerosol 200-5 mcg/ act FLOVENT DISKUS – fluticasone propionate aer pow ba 50 mcg/blister FLOVENT DISKUS – fluticasone propionate aer pow ba 100 mcg/blister FLOVENT DISKUS – fluticasone propionate aer pow ba 250 mcg/blister FLOVENT HFA – fluticasone propionate hfa inhal aero 44 mcg/act (50/valve) FLOVENT HFA – fluticasone propionate hfa inhal aer 110 mcg/act (125/valve) Quantity Limits Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 FLOVENT HFA – fluticasone propionate hfa inhal aer 220 mcg/act (250/valve) FORADIL AEROLIZER – formoterol fumarate inhal cap 12 mcg ipratropium bromide inhal soln 0.02% ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml (Duoneb) levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) (Xopenex concentrate) levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv) (Xopenex) levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv) (Xopenex) levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) (Xopenex) montelukast sodium chew tab 4 mg (base equiv) (Singulair) montelukast sodium chew tab 5 mg (base equiv) (Singulair) montelukast sodium oral granules packet 4 mg (base equiv) (Singulair) montelukast sodium tab 10 mg (base equiv) (Singulair) PROAIR HFA – albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv) PULMICORT – budesonide inhalation susp 1 mg/2ml QVAR – beclomethasone dipropionate inhal aero soln 40 mcg/act QVAR – beclomethasone dipropionate inhal aero soln 80 mcg/act SEREVENT DISKUS – salmeterol xinafoate aer pow ba 50 mcg/dose (base equiv) SPIRIVA HANDIHALER – tiotropium bromide monohydrate inhal cap 18 mcg (base equiv) SYMBICORT – budesonide-formoterol fumarate dihyd aerosol 80-4.5 mcg/act Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 27 SYMBICORT – budesonide-formoterol fumarate dihyd aerosol 160-4.5 mcg/act ULCER/GERD terbutaline sulfate tab 2.5 mg cimetidine hcl soln 300 mg/5ml terbutaline sulfate tab 5 mg cimetidine tab 200 mg theophylline soln 80 mg/15ml cimetidine tab 300 mg theophylline tab sr 12hr 100 mg cimetidine tab 400 mg theophylline tab sr 12hr 200 mg cimetidine tab 800 mg theophylline tab sr 12hr 300 mg theophylline tab sr 12hr 450 mg DICYCLOMINE HCL – dicyclomine hcl oral soln 10 mg/5ml theophylline tab sr 24hr 400 mg dicyclomine hcl cap 10 mg (Bentyl) theophylline tab sr 24hr 600 mg dicyclomine hcl tab 20 mg (Bentyl) VENTOLIN HFA – albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv) famotidine for susp 40 mg/5ml (Pepcid) zafirlukast tab 10 mg (Accolate) famotidine tab 40 mg (Pepcid) zafirlukast tab 20 mg (Accolate) GASTRINEX NF – hyoscyaminephenyltoloxamine cap 0.0625-15 mg PULMOZYME – dornase alfa inhal soln 1 mg/ml famotidine tab 20 mg (Pepcid) • • • • glycopyrrolate tab 1 mg (Robinul) glycopyrrolate tab 2 mg (Robinul forte) GASTROINTESTINAL DRUGS hyoscyamine sulfate elixir 0.125 mg/5ml LAXATIVES hyoscyamine sulfate soln 0.125 mg/ml lactulose solution 10 gm/15ml hyoscyamine sulfate tab disp 0.125 mg (Anaspaz) peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm (Golytely) peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm (Colyte-flavor packs) peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/flavor pack) polyethylene glycol 3350 oral packet polyethylene glycol 3350 oral powder ANTIDIARRHEALS diphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil) DIPHENOXYLATE/ATROPINE – diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml loperamide hcl cap 2 mg 28 Quantity Limits CARAFATE – sucralfate susp 1 gm/10ml OTHER RESPIRATORY DRUGS KALYDECO – ivacaftor tab 150 mg Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl) hyoscyamine sulfate tab sr 12hr 0.375 mg (Levbid) hyoscyamine sulfate tab 0.125 mg (Levsin) lansoprazole cap delayed release 15 mg (Prevacid) lansoprazole cap delayed release 30 mg (Prevacid) methscopolamine bromide tab 2.5 mg (Pamine) methscopolamine bromide tab 5 mg (Pamine forte) misoprostol tab 100 mcg (Cytotec) Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 misoprostol tab 200 mcg (Cytotec) NEXIUM – esomeprazole magnesium for delayed release susp pack 2.5 mg ranitidine hcl tab 150 mg (Zantac) ranitidine hcl tab 300 mg (Zantac) NEXIUM – esomeprazole magnesium for delayed release susp packet 10 mg NAUSEA AND VOMITING NEXIUM – esomeprazole magnesium for delayed release susp packet 20 mg dronabinol cap 2.5 mg (Marinol) sucralfate tab 1 gm (Carafate) dronabinol cap 10 mg (Marinol) NEXIUM – esomeprazole magnesium for delayed release susp packet 40 mg dronabinol cap 5 mg (Marinol) NEXIUM – esomeprazole magnesium cap delayed release 20 mg EMEND – aprepitant capsule 80 mg NEXIUM – esomeprazole magnesium cap delayed release 40 mg EMEND – aprepitant capsule therapy pack 80 & 125 mg nizatidine cap 150 mg granisetron hcl tab 1 mg nizatidine cap 300 mg (Axid) meclizine hcl tab 12.5 mg nizatidine oral soln 15 mg/ml (Axid) meclizine hcl tab 25 mg omeprazole cap delayed release 10 mg (Prilosec) meclizine hcl tab 32 mg omeprazole cap delayed release 40 mg (Prilosec) omeprazole-sodium bicarbonate cap 40-1100 mg (Zegerid) pantoprazole sodium ec tab 20 mg (base equiv) (Protonix) pantoprazole sodium ec tab 40 mg (base equiv) (Protonix) PROPANTHELINE BROMIDE – propantheline bromide tab 15 mg PYLERA – bismuth subcit-metronidazoletetracycline cap 140-125-125 mg EMEND – aprepitant capsule 40 mg EMEND – aprepitant capsule 125 mg ondansetron hcl oral soln 4 mg/5ml (Zofran) ondansetron hcl tab 24 mg ondansetron hcl tab 4 mg (Zofran) ondansetron hcl tab 8 mg (Zofran) ondansetron orally disintegrating tab 4 mg (Zofran odt) ondansetron orally disintegrating tab 8 mg (Zofran odt) TRANSDERM-SCOP – scopolamine td patch 72hr 1.5 mg trimethobenzamide hcl cap 300 mg (Tigan) DIGESTIVE ENZYMES rabeprazole sodium ec tab 20 mg (Aciphex) CREON – pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000 unit ranitidine hcl cap 150 mg CREON – pancrelipase (lip-prot-amyl) dr cap 6000-19000-30000 unit ranitidine hcl cap 300 mg Quantity Limits ranitidine hcl syrup 15 mg/ml (75 mg/5ml) NEXIUM – esomeprazole magnesium for delayed release susp packet 5 mg omeprazole cap delayed release 20 mg (Prilosec) Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 29 CREON – pancrelipase (lip-prot-amyl) dr cap 12000-38000-60000 unit metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) CREON – pancrelipase (lip-prot-amyl) dr cap 24000-76000-120000 unit metoclopramide hcl tab 10 mg (Reglan) CREON – pancrelipase (lip-prot-amyl) dr cap 36000-114000-180000 unit PENTASA – mesalamine cap cr 250 mg PENTASA – mesalamine cap cr 500 mg RENVELA – sevelamer carbonate tab 800 mg ZENPEP – pancrelipase (lip-prot-amyl) dr cap 5000-17000-27000 unit RENVELA – sevelamer carbonate packet 0.8 gm ZENPEP – pancrelipase (lip-prot-amyl) dr cap 10000-34000-55000 unit RENVELA – sevelamer carbonate packet 2.4 gm ZENPEP – pancrelipase (lip-prot-amyl) dr cap 15000-51000-82000 unit sulfasalazine tab delayed release 500 mg (Azulfidine en-tabs) ZENPEP – pancrelipase (lip-prot-amyl) dr cap 20000-68000-109000 unit sulfasalazine tab 500 mg (Azulfidine) ZENPEP – pancrelipase (lip-prot-amyl) dr cap 25000-85000-136000 unit ursodiol cap 300 mg (Actigall) OTHER GASTROINTESTINAL DRUGS ursodiol tab 500 mg (Urso forte) ASACOL – mesalamine tab delayed release 400 mg GENITOURINARY DRUGS ASACOL HD – mesalamine tab delayed release 800 mg methenamine-hyos-meth blue-sod phos-phen sal tab 81.6 mg balsalazide disodium cap 750 mg (Colazal) methenamine-hyosamine-meth bluesod phos tab 81.6 mg (Urogesic-blue) calcium acetate (phosphate binder) cap 667 mg (169 mg ca) (Phoslo) methenamine-hyosc-meth blue-sod phos-phen sal cap 120 mg calcium acetate (phosphate binder) tab 667 mg (Eliphos) MACRODANTIN – nitrofurantoin macrocrystalline cap 25 mg ursodiol tab 250 mg (Urso 250) URINARY TRACT INFECTIONS CANASA – mesalamine suppos 1000 mg cromolyn sodium oral conc 100 mg/5ml (Gastrocrom) DELZICOL – mesalamine cap dr 400 mg lactulose (encephalopathy) solution 10 gm/15ml LIALDA – mesalamine tab delayed release 1.2 gm mesalamine enema 4 gm 30 Quantity Limits metoclopramide hcl tab 5 mg (Reglan) ZENPEP – pancrelipase (lip-prot-amyl) dr cap 3000-10000-16000 unit CHENODAL – chenodiol tab 250 mg Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 • • methenamine hippurate tab 1 gm (Hiprex) methenamine mandelate tab 1 gm methenamine-hyosc-meth blue-benz acid-phenyl sal tab 81.6mg (Prosed/ ds) nitrofurantoin macrocrystalline cap 100 mg (Macrodantin) nitrofurantoin macrocrystalline cap 50 mg (Macrodantin) Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 CYSTAGON – cysteamine bitartrate cap 50 mg • • CYSTAGON – cysteamine bitartrate cap 150 mg • • Drug Name CLEOCIN – clindamycin phosphate vaginal suppos 100 mg clindamycin phosphate vaginal cream 2% (Cleocin) URINARY TRACT SPASMS metronidazole vaginal gel 0.75% (Metrogel-vaginal) bethanechol chloride tab 10 mg (Urecholine) PREMARIN – estrogens, conjugated vaginal cream 0.625 mg/gm bethanechol chloride tab 25 mg (Urecholine) terconazole vaginal cream 0.4% (Terazol 7) bethanechol chloride tab 5 mg (Urecholine) terconazole vaginal cream 0.8% (Terazol 3) bethanechol chloride tab 50 mg (Urecholine) terconazole vaginal suppos 80 mg MYRBETRIQ – mirabegron tab sr 24 hr 25 mg OTHER GENITOURINARY DRUGS MYRBETRIQ – mirabegron tab sr 24 hr 50 mg oxybutynin chloride syrup 5 mg/5ml oxybutynin chloride tab sr 24hr 10 mg (Ditropan xl) oxybutynin chloride tab sr 24hr 15 mg (Ditropan xl) oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl) VAGIFEM – estradiol vaginal tab 10 mcg alfuzosin hcl tab sr 24hr 10 mg (Uroxatral) AVODART – dutasteride cap 0.5 mg CYTRA-K – potassium citrate & citric acid soln 1100-334 mg/5ml oxybutynin chloride tab 5 mg CYTRA-3 – pot & sod citrates w/ cit ac syrup 550-500-334 mg/5ml tolterodine tartrate cap sr 24hr 2 mg (Detrol la) ELMIRON – pentosan polysulfate sodium caps 100 mg tolterodine tartrate cap sr 24hr 4 mg (Detrol la) finasteride tab 5 mg (Proscar) tolterodine tartrate tab 1 mg (Detrol) tolterodine tartrate tab 2 mg (Detrol) trospium chloride cap sr 24hr 60 mg trospium chloride tab 20 mg (Sanctura) VESICARE – solifenacin succinate tab 5 mg VESICARE – solifenacin succinate tab 10 mg VAGINAL PRODUCTS Quantity Limits Quantity Limits Prior Authorization nitrofurantoin susp 25 mg/5ml (Furadantin) Specialty nitrofurantoin monohydrate macrocrystalline cap 100 mg (Macrobid) Prior Authorization Drug Name Specialty 2014 K-PHOS NO 2 – potassium & sodium acid phosphates tab 305-700 mg potassium citrate & citric acid powder pack 3300-1002 mg potassium citrate tab cr 10 meq (1080 mg) (Urocit-k 10) potassium citrate tab cr 5 meq (540 mg) (Urocit-k 5) sodium citrate & citric acid soln 500-334 mg/5ml (Shohls solution modi) Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 31 tamsulosin hcl cap 0.4 mg (Flomax) diazepam tab 10 mg (Valium) TRICITRATES – pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml diazepam tab 2 mg (Valium) CENTRAL NERVOUS SYSTEM DRUGS hydroxyzine hcl syrup 10 mg/5ml ANXIETY hydroxyzine hcl tab 10 mg alprazolam orally disintegrating tab 0.25 mg (Niravam) hydroxyzine hcl tab 25 mg alprazolam orally disintegrating tab 0.5 mg alprazolam orally disintegrating tab 1 mg alprazolam orally disintegrating tab 2 mg alprazolam tab sr 24hr 0.5 mg (Xanax xr) alprazolam tab sr 24hr 1 mg (Xanax xr) alprazolam tab sr 24hr 2 mg (Xanax xr) alprazolam tab sr 24hr 3 mg (Xanax xr) alprazolam tab 0.25 mg (Xanax) alprazolam tab 0.5 mg (Xanax) alprazolam tab 1 mg (Xanax) alprazolam tab 2 mg (Xanax) buspirone hcl tab 10 mg buspirone hcl tab 15 mg buspirone hcl tab 30 mg buspirone hcl tab 5 mg buspirone hcl tab 7.5 mg chlordiazepoxide hcl cap 10 mg chlordiazepoxide hcl cap 25 mg Quantity Limits Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 diazepam tab 5 mg (Valium) hydroxyzine hcl tab 50 mg HYDROXYZINE PAMOATE – hydroxyzine pamoate cap 100 mg hydroxyzine pamoate cap 25 mg (Vistaril) hydroxyzine pamoate cap 50 mg (Vistaril) lorazepam conc 2 mg/ml (Lorazepam intensol) lorazepam tab 0.5 mg (Ativan) lorazepam tab 1 mg (Ativan) lorazepam tab 2 mg (Ativan) oxazepam cap 10 mg oxazepam cap 15 mg oxazepam cap 30 mg DEPRESSION amitriptyline hcl tab 10 mg amitriptyline hcl tab 100 mg amitriptyline hcl tab 150 mg amitriptyline hcl tab 25 mg amitriptyline hcl tab 50 mg amitriptyline hcl tab 75 mg chlordiazepoxide hcl cap 5 mg bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr) clorazepate dipotassium tab 15 mg (Tranxene t) bupropion hcl tab sr 12hr 150 mg (Wellbutrin sr) clorazepate dipotassium tab 3.75 mg (Tranxene t) bupropion hcl tab sr 12hr 200 mg (Wellbutrin sr) clorazepate dipotassium tab 7.5 mg (Tranxene t) bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl) DIAZEPAM – diazepam soln 1 mg/ml 32 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl) escitalopram oxalate tab 10 mg (base equiv) (Lexapro) bupropion hcl tab 100 mg (Wellbutrin) bupropion hcl tab 75 mg (Wellbutrin) escitalopram oxalate tab 20 mg (base equiv) (Lexapro) citalopram hydrobromide oral soln 10 mg/5ml escitalopram oxalate tab 5 mg (base equiv) (Lexapro) citalopram hydrobromide tab 10 mg (base equiv) (Celexa) fluoxetine hcl cap delayed release 90 mg (Prozac weekly) citalopram hydrobromide tab 20 mg (base equiv) (Celexa) fluoxetine hcl cap 10 mg (Prozac) citalopram hydrobromide tab 40 mg (base equiv) (Celexa) fluoxetine hcl cap 40 mg (Prozac) clomipramine hcl cap 25 mg (Anafranil) fluoxetine hcl tab 10 mg clomipramine hcl cap 50 mg (Anafranil) fluoxetine hcl tab 20 mg clomipramine hcl cap 75 mg (Anafranil) desipramine hcl tab 10 mg (Norpramin) fluvoxamine maleate cap sr 24hr 100 mg (Luvox cr) desipramine hcl tab 100 mg (Norpramin) fluvoxamine maleate cap sr 24hr 150 mg (Luvox cr) desipramine hcl tab 150 mg (Norpramin) fluvoxamine maleate tab 100 mg desipramine hcl tab 25 mg (Norpramin) fluvoxamine maleate tab 50 mg desipramine hcl tab 50 mg (Norpramin) imipramine hcl tab 10 mg (Tofranil) desipramine hcl tab 75 mg (Norpramin) imipramine hcl tab 25 mg (Tofranil) DOXEPIN HCL – doxepin hcl cap 75 mg imipramine hcl tab 50 mg (Tofranil) doxepin hcl cap 10 mg imipramine pamoate cap 100 mg (Tofranil-pm) doxepin hcl cap 100 mg doxepin hcl cap 150 mg doxepin hcl cap 25 mg doxepin hcl cap 50 mg doxepin hcl conc 10 mg/ml duloxetine hcl enteric coated pellets cap 20 mg (Cymbalta) duloxetine hcl enteric coated pellets cap 30 mg (Cymbalta) duloxetine hcl enteric coated pellets cap 60 mg (Cymbalta) escitalopram oxalate soln 5 mg/5ml (base equiv) (Lexapro) Quantity Limits Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 fluoxetine hcl cap 20 mg (Prozac) fluoxetine hcl solution 20 mg/5ml fluvoxamine maleate tab 25 mg imipramine pamoate cap 125 mg (Tofranil-pm) imipramine pamoate cap 150 mg (Tofranil-pm) imipramine pamoate cap 75 mg (Tofranil-pm) mirtazapine orally disintegrating tab 15 mg (Remeron soltab) mirtazapine orally disintegrating tab 30 mg (Remeron soltab) mirtazapine orally disintegrating tab 45 mg (Remeron soltab) Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 33 mirtazapine tab 15 mg (Remeron) mirtazapine tab 30 mg (Remeron) mirtazapine tab 45 mg (Remeron) mirtazapine tab 7.5 mg NORTRIPTYLINE HCL – nortriptyline hcl soln 10 mg/5ml nortriptyline hcl cap 10 mg (Pamelor) nortriptyline hcl cap 25 mg (Pamelor) venlafaxine hcl cap sr 24hr 75 mg (base equivalent) (Effexor xr) venlafaxine hcl tab sr 24hr 150 mg (base equivalent) (Venlafaxine hcl er) venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent) (Venlafaxine hcl er) nortriptyline hcl cap 50 mg (Pamelor) nortriptyline hcl cap 75 mg (Pamelor) venlafaxine hcl tab 100 mg paroxetine hcl tab sr 24hr 12.5 mg (Paxil cr) venlafaxine hcl tab 25 mg paroxetine hcl tab sr 24hr 25 mg (Paxil cr) venlafaxine hcl tab 50 mg paroxetine hcl tab sr 24hr 37.5 mg (Paxil cr) PSYCHOTIC AND BIPOLAR DISORDERS venlafaxine hcl tab 37.5 mg venlafaxine hcl tab 75 mg paroxetine hcl tab 10 mg (Paxil) chlorpromazine hcl tab 10 mg paroxetine hcl tab 20 mg (Paxil) chlorpromazine hcl tab 100 mg paroxetine hcl tab 30 mg (Paxil) chlorpromazine hcl tab 200 mg paroxetine hcl tab 40 mg (Paxil) chlorpromazine hcl tab 25 mg phenelzine sulfate tab 15 mg (Nardil) chlorpromazine hcl tab 50 mg protriptyline hcl tab 10 mg (Vivactil) clozapine tab 100 mg (Clozaril) protriptyline hcl tab 5 mg (Vivactil) clozapine tab 200 mg sertraline hcl oral conc 20 mg/ml (Zoloft) clozapine tab 25 mg (Clozaril) sertraline hcl tab 100 mg (Zoloft) FLUPHENAZINE HCL – fluphenazine hcl elixir 2.5 mg/5ml sertraline hcl tab 50 mg (Zoloft) tranylcypromine sulfate tab 10 mg (Parnate) Quantity Limits venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) (Effexor xr) venlafaxine hcl tab sr 24hr 75 mg (base equivalent) (Venlafaxine hcl er) sertraline hcl tab 25 mg (Zoloft) Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 clozapine tab 50 mg FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/ml fluphenazine hcl tab 1 mg trazodone hcl tab 100 mg fluphenazine hcl tab 10 mg trazodone hcl tab 150 mg fluphenazine hcl tab 2.5 mg trazodone hcl tab 300 mg fluphenazine hcl tab 5 mg trazodone hcl tab 50 mg haloperidol lactate oral conc 2 mg/ml venlafaxine hcl cap sr 24hr 150 mg (base equivalent) (Effexor xr) haloperidol tab 0.5 mg haloperidol tab 1 mg haloperidol tab 10 mg 34 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 haloperidol tab 2 mg perphenazine tab 8 mg haloperidol tab 20 mg haloperidol tab 5 mg prochlorperazine maleate tab 10 mg (Compazine) LITHIUM CARBONATE – lithium carbonate cap 150 mg prochlorperazine maleate tab 5 mg (Compazine) lithium carbonate cap 150 mg (Lithium carbonate) prochlorperazine suppos 25 mg lithium carbonate cap 300 mg quetiapine fumarate tab 100 mg (Seroquel) lithium carbonate cap 600 mg (Lithium carbonate) quetiapine fumarate tab 200 mg (Seroquel) lithium carbonate tab cr 300 mg (Lithobid) quetiapine fumarate tab 25 mg (Seroquel) lithium carbonate tab cr 450 mg quetiapine fumarate tab 300 mg (Seroquel) lithium carbonate tab 300 mg LITHIUM CITRATE – lithium citrate oral soln 8 meq/5ml loxapine succinate cap 10 mg loxapine succinate cap 25 mg loxapine succinate cap 5 mg (Loxitane) loxapine succinate cap 50 mg olanzapine orally disintegrating tab 10 mg (Zyprexa zydis) olanzapine orally disintegrating tab 15 mg (Zyprexa zydis) olanzapine orally disintegrating tab 20 mg (Zyprexa zydis) olanzapine orally disintegrating tab 5 mg (Zyprexa zydis) Quantity Limits Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 quetiapine fumarate tab 400 mg (Seroquel) quetiapine fumarate tab 50 mg (Seroquel) risperidone orally disintegrating tab 0.25 mg risperidone orally disintegrating tab 0.5 mg (Risperdal m-tab) risperidone orally disintegrating tab 1 mg (Risperdal m-tab) risperidone orally disintegrating tab 2 mg (Risperdal m-tab) risperidone orally disintegrating tab 3 mg (Risperdal m-tab) olanzapine tab 10 mg (Zyprexa) risperidone orally disintegrating tab 4 mg (Risperdal m-tab) olanzapine tab 15 mg (Zyprexa) risperidone soln 1 mg/ml (Risperdal) olanzapine tab 2.5 mg (Zyprexa) risperidone tab 0.25 mg (Risperdal) olanzapine tab 20 mg (Zyprexa) risperidone tab 0.5 mg (Risperdal) olanzapine tab 5 mg (Zyprexa) risperidone tab 1 mg (Risperdal) olanzapine tab 7.5 mg (Zyprexa) risperidone tab 2 mg (Risperdal) perphenazine tab 16 mg risperidone tab 3 mg (Risperdal) perphenazine tab 2 mg risperidone tab 4 mg (Risperdal) perphenazine tab 4 mg SEROQUEL XR – quetiapine fumarate tab sr 24hr 50 mg Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 35 SEROQUEL XR – quetiapine fumarate tab sr 24hr 150 mg phenobarbital tab 32.4 mg SEROQUEL XR – quetiapine fumarate tab sr 24hr 200 mg temazepam cap 22.5 mg (Restoril) SEROQUEL XR – quetiapine fumarate tab sr 24hr 300 mg temazepam cap 7.5 mg (Restoril) temazepam cap 30 mg (Restoril) zaleplon cap 10 mg (Sonata) thiothixene cap 1 mg zolpidem tartrate tab cr 12.5 mg (Ambien cr) thiothixene cap 2 mg thiothixene cap 5 mg trifluoperazine hcl tab 1 mg trifluoperazine hcl tab 10 mg trifluoperazine hcl tab 2 mg trifluoperazine hcl tab 5 mg ziprasidone hcl cap 20 mg (Geodon) ziprasidone hcl cap 40 mg (Geodon) ziprasidone hcl cap 60 mg (Geodon) ziprasidone hcl cap 80 mg (Geodon) SLEEP AIDS estazolam tab 1 mg estazolam tab 2 mg flurazepam hcl cap 15 mg zaleplon cap 5 mg (Sonata) zolpidem tartrate tab cr 6.25 mg (Ambien cr) zolpidem tartrate tab 10 mg (Ambien) zolpidem tartrate tab 5 mg (Ambien) HYPERACTIVITY/NARCOLEPSY amphetamine-dextroamphetamine cap sr 24hr 10 mg (Adderall xr) amphetamine-dextroamphetamine cap sr 24hr 15 mg (Adderall xr) amphetamine-dextroamphetamine cap sr 24hr 20 mg (Adderall xr) amphetamine-dextroamphetamine cap sr 24hr 25 mg (Adderall xr) amphetamine-dextroamphetamine cap sr 24hr 30 mg (Adderall xr) flurazepam hcl cap 30 mg amphetamine-dextroamphetamine cap sr 24hr 5 mg (Adderall xr) midazolam hcl syrup 2 mg/ml (base equivalent) amphetamine-dextroamphetamine tab 10 mg (Adderall) PHENOBARBITAL – phenobarbital tab 15 mg amphetamine-dextroamphetamine tab 12.5 mg (Adderall) PHENOBARBITAL – phenobarbital tab 30 mg amphetamine-dextroamphetamine tab 15 mg (Adderall) PHENOBARBITAL – phenobarbital tab 60 mg amphetamine-dextroamphetamine tab 20 mg (Adderall) PHENOBARBITAL – phenobarbital tab 100 mg amphetamine-dextroamphetamine tab 30 mg (Adderall) phenobarbital elixir 20 mg/5ml amphetamine-dextroamphetamine tab 5 mg (Adderall) phenobarbital tab 16.2 mg 36 Quantity Limits temazepam cap 15 mg (Restoril) SEROQUEL XR – quetiapine fumarate tab sr 24hr 400 mg thiothixene cap 10 mg Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 Prior Authorization BETASERON – interferon beta-1b for inj kit 0.3 mg • • COPAXONE – glatiramer acetate soln prefilled syringe 40 mg/ml • • COPAXONE – glatiramer acetate inj kit 20 mg/ml • • REBIF – interferon beta-1a inj 22 mcg/0.5ml (12mu/ml) (44 mcg/ml) • • REBIF – interferon beta-1a inj 44 mcg/0.5ml (24mu/ml) (88 mcg/ml) • • REBIF REBIDOSE – interferon beta-1a inj 22 mcg/0.5ml (12mu/ml) (44 mcg/ml) • • REBIF REBIDOSE – interferon beta-1a inj 44 mcg/0.5ml (24mu/ml) (88 mcg/ml) • • REBIF REBIDOSE TITRATION – interferon beta-1a inj 6 x 8.8 mcg/0.2ml & 6 x 22 mcg/0.5ml • • Drug Name amphetamine-dextroamphetamine tab 7.5 mg (Adderall) STRATTERA – atomoxetine hcl cap 25 mg (base equiv) caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv) (Cafcit) STRATTERA – atomoxetine hcl cap 40 mg (base equiv) clonidine hcl tab sr 12hr 0.1 mg (Kapvay) STRATTERA – atomoxetine hcl cap 60 mg (base equiv) dexmethylphenidate hcl cap sr 24 hr 15 mg (Focalin xr) STRATTERA – atomoxetine hcl cap 80 mg (base equiv) dexmethylphenidate hcl cap sr 24 hr 30 mg (Focalin xr) STRATTERA – atomoxetine hcl cap 100 mg (base equiv) dexmethylphenidate hcl cap sr 24 hr 40 mg (Focalin xr) VYVANSE – lisdexamfetamine dimesylate cap 20 mg dexmethylphenidate hcl tab 10 mg (Focalin) VYVANSE – lisdexamfetamine dimesylate cap 30 mg dexmethylphenidate hcl tab 2.5 mg (Focalin) VYVANSE – lisdexamfetamine dimesylate cap 40 mg dexmethylphenidate hcl tab 5 mg (Focalin) VYVANSE – lisdexamfetamine dimesylate cap 50 mg dextroamphetamine sulfate cap sr 24hr 10 mg (Dexedrine) VYVANSE – lisdexamfetamine dimesylate cap 60 mg dextroamphetamine sulfate cap sr 24hr 15 mg (Dexedrine) VYVANSE – lisdexamfetamine dimesylate cap 70 mg dextroamphetamine sulfate cap sr 24hr 5 mg (Dexedrine) MULTIPLE SCLEROSIS dextroamphetamine sulfate tab 10 mg dextroamphetamine sulfate tab 5 mg METHYLPHENIDATE HCL ER – methylphenidate hcl tab cr 10 mg methylphenidate hcl tab cr 20 mg (Ritalin sr) methylphenidate hcl tab 10 mg (Ritalin) methylphenidate hcl tab 20 mg (Ritalin) methylphenidate hcl tab 5 mg (Ritalin) modafinil tab 100 mg (Provigil) modafinil tab 200 mg (Provigil) STRATTERA – atomoxetine hcl cap 10 mg (base equiv) STRATTERA – atomoxetine hcl cap 18 mg (base equiv) Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 Quantity Limits Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 37 TECFIDERA – dimethyl fumarate capsule delayed release 120 mg • • galantamine hydrobromide oral soln 4 mg/ml (Razadyne) TECFIDERA – dimethyl fumarate capsule delayed release 240 mg • • galantamine hydrobromide tab 12 mg (Razadyne) TECFIDERA STARTER PACK – dimethyl fumarate capsule dr starter pack 120 mg & 240 mg • • galantamine hydrobromide tab 4 mg (Razadyne) galantamine hydrobromide cap sr 24hr 8 mg (Razadyne er) galantamine hydrobromide tab 8 mg (Razadyne) OTHER CENTRAL NERVOUS SYSTEM DRUGS NAMENDA – memantine hcl tab 5 mg acamprosate calcium tab delayed release 333 mg (Campral) NAMENDA – memantine hcl tab 10 mg bupropion hcl (smoking deterrent) tab sr 12hr 150 mg (Zyban) NAMENDA – memantine hcl oral solution 2 mg/ml CHANTIX – varenicline tartrate tab 0.5 mg (base equiv) NAMENDA TITRATION PAK – memantine hcl tab 5 mg (28) & 10 mg (21) titration pak CHANTIX – varenicline tartrate tab 1 mg (base equiv) NICOTROL INHALER – nicotine inhaler system 10 mg (4 mg delivered) CHANTIX CONTINUING MONTH – varenicline tartrate tab 1 mg (base equiv) NICOTROL NS – nicotine nasal spray 10 mg/ml (0.5 mg/spray) CHANTIX STARTING MONTH PA – varenicline tartrate tab 0.5 mg x 11 & tab 1 mg x 42 pack disulfiram tab 250 mg (Antabuse) olanzapine-fluoxetine hcl cap 12-25 mg (Symbyax) olanzapine-fluoxetine hcl cap 12-50 mg (Symbyax) disulfiram tab 500 mg (Antabuse) olanzapine-fluoxetine hcl cap 3-25 mg (Symbyax) donepezil hydrochloride orally disintegrating tab 10 mg (Aricept odt) olanzapine-fluoxetine hcl cap 6-25 mg (Symbyax) donepezil hydrochloride orally disintegrating tab 5 mg (Aricept odt) olanzapine-fluoxetine hcl cap 6-50 mg (Symbyax) donepezil hydrochloride tab 10 mg (Aricept) ORAP – pimozide tab 1 mg donepezil hydrochloride tab 5 mg (Aricept) galantamine hydrobromide cap sr 24hr 16 mg (Razadyne er) galantamine hydrobromide cap sr 24hr 24 mg (Razadyne er) Quantity Limits • Prior Authorization • Drug Name Specialty Prior Authorization REBIF TITRATION PACK – interferon beta-1a inj 6 x 8.8 mcg/0.2ml & 6 x 22 mcg/0.5ml Drug Name Quantity Limits Specialty 2014 ORAP – pimozide tab 2 mg rivastigmine tartrate cap 1.5 mg (Exelon) rivastigmine tartrate cap 3 mg (Exelon) rivastigmine tartrate cap 4.5 mg (Exelon) rivastigmine tartrate cap 6 mg (Exelon) 38 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 XENAZINE – tetrabenazine tab 12.5 mg XENAZINE – tetrabenazine tab 25 mg PAIN RELIEF DRUGS NON-NARCOTIC DRUGS BUPAP – butalbital-acetaminophen tab 50-650 mg buprenorphine hcl sl tab 8 mg (base equiv) buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv) buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) butalbital-acetaminophen tab 50-325 mg butalbital-acetaminophen-caff w/ cod cap 50-300-40-30 mg (Fioricet/ codeine) butalbital-acetaminophen tab 50-650 mg butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg butalbital-acetaminophen-caffeine cap 50-300-40 mg (Fioricet) butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg (Fiorinal/codeine #3) butalbital-acetaminophen-caffeine cap 50-325-40 mg butorphanol tartrate nasal soln 10 mg/ ml butalbital-acetaminophen-caffeine tab 50-325-40 mg CODEINE SULFATE – codeine sulfate tab 15 mg butalbital-acetaminophen-caffeine tab 50-500-40 mg CODEINE SULFATE – codeine sulfate tab 30 mg butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal) CODEINE SULFATE – codeine sulfate tab 60 mg butalbital-aspirin-caffeine tab 50-325-40 mg fentanyl citrate lollipop 1200 mcg (Actiq) • BUTALBITAL/ASPIRIN/CAFFEI – butalbital-aspirin-caffeine tab 50-325-40 mg fentanyl citrate lollipop 1600 mcg (Actiq) • fentanyl citrate lollipop 200 mcg (Actiq) • • • • diflunisal tab 500 mg salsalate tab 500 mg salsalate tab 750 mg NARCOTIC DRUGS acetaminophen w/ codeine soln 120-12 mg/5ml acetaminophen w/ codeine tab 300-15 mg (Tylenol/codeine) acetaminophen w/ codeine tab 300-30 mg (Tylenol/codeine #3) acetaminophen w/ codeine tab 300-60 mg (Tylenol/codeine #4) buprenorphine hcl sl tab 2 mg (base equiv) Quantity Limits Prior Authorization • • Drug Name Specialty • • Quantity Limits Prior Authorization Drug Name Specialty 2014 fentanyl citrate lollipop 400 mcg (Actiq) fentanyl citrate lollipop 600 mcg (Actiq) fentanyl citrate lollipop 800 mcg (Actiq) fentanyl td patch 72hr 100 mcg/hr (Duragesic) • fentanyl td patch 72hr 12 mcg/hr (Duragesic) • fentanyl td patch 72hr 25 mcg/hr (Duragesic) • fentanyl td patch 72hr 50 mcg/hr (Duragesic) • fentanyl td patch 72hr 75 mcg/hr (Duragesic) • Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 39 hydrocodone-acetaminophen cap 5-500 mg hydrocodone-acetaminophen soln 7.5-325 mg/15ml (Hycet) hydrocodone-acetaminophen soln 7.5-500 mg/15ml hydrocodone-acetaminophen tab 10-300 mg (Xodol) HYDROMORPHONE HCL – hydromorphone hcl suppos 3 mg hydrocodone-acetaminophen tab 10-325 mg (Norco) hydromorphone hcl liqd 1 mg/ml (Dilaudid) hydrocodone-acetaminophen tab 10-500 mg hydromorphone hcl tab 2 mg (Dilaudid) hydrocodone-acetaminophen tab 10-650 mg hydromorphone hcl tab 8 mg (Dilaudid) hydrocodone-acetaminophen tab 10-750 mg hydrocodone-acetaminophen tab 2.5-500 mg hydrocodone-acetaminophen tab 5-300 mg (Xodol) hydrocodone-acetaminophen tab 5-325 mg (Norco) hydrocodone-acetaminophen tab 5-500 mg hydrocodone-acetaminophen tab 7.5-300 mg (Xodol) hydrocodone-acetaminophen tab 7.5-325 mg (Norco) hydrocodone-acetaminophen tab 7.5-750 mg hydrocodone-ibuprofen tab 10-200 mg (Ibudone) hydrocodone-ibuprofen tab 5-200 mg (Reprexain) hydrocodone-ibuprofen tab 7.5-200 mg (Vicoprofen) Quantity Limits HYDROCODONE/ACETAMINOPHEN – hydrocodone-acetaminophen tab 7.5-500 mg HYDROCODONE/ACETAMINOPHEN – hydrocodone-acetaminophen tab 7.5-650 mg hydrocodone-acetaminophen tab 10-660 mg Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 hydromorphone hcl tab 4 mg (Dilaudid) methadone hcl conc 10 mg/ml (Methadose) methadone hcl soln 10 mg/5ml (Methadone hcl) methadone hcl soln 5 mg/5ml (Methadone hcl) methadone hcl tab for oral susp 40 mg methadone hcl tab 10 mg (Dolophine) methadone hcl tab 5 mg (Dolophine hcl) MORPHINE SULFATE – morphine sulfate tab 15 mg MORPHINE SULFATE – morphine sulfate tab 30 mg MORPHINE SULFATE – morphine sulfate suppos 5 mg MORPHINE SULFATE – morphine sulfate suppos 10 mg MORPHINE SULFATE – morphine sulfate suppos 20 mg MORPHINE SULFATE – morphine sulfate suppos 30 mg morphine sulfate (concentrate) oral soln 20 mg/ml morphine sulfate beads cap sr 24hr 120 mg (Avinza) morphine sulfate beads cap sr 24hr 30 mg (Avinza) 40 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 morphine sulfate beads cap sr 24hr 45 mg (Avinza) NUCYNTA ER – tapentadol hcl tab sr 12hr 200 mg morphine sulfate beads cap sr 24hr 60 mg (Avinza) NUCYNTA ER – tapentadol hcl tab sr 12hr 250 mg morphine sulfate beads cap sr 24hr 75 mg (Avinza) OXYCODONE HCL – oxycodone hcl conc 100 mg/5ml (20 mg/ml) morphine sulfate beads cap sr 24hr 90 mg (Avinza) oxycodone hcl cap 5 mg morphine sulfate cap sr 24hr 10 mg (Kadian) morphine sulfate cap sr 24hr 100 mg (Kadian) oxycodone hcl soln 5 mg/5ml (Oxycodone hcl) oxycodone hcl tab 10 mg oxycodone hcl tab 15 mg (Roxicodone) morphine sulfate cap sr 24hr 30 mg (Kadian) oxycodone hcl tab 30 mg (Roxicodone) morphine sulfate cap sr 24hr 60 mg (Kadian) morphine sulfate cap sr 24hr 80 mg (Kadian) morphine sulfate oral soln 10 mg/5ml morphine sulfate oral soln 20 mg/5ml morphine sulfate tab cr 100 mg (Ms contin) morphine sulfate tab cr 15 mg (Ms contin) morphine sulfate tab cr 200 mg (Ms contin) morphine sulfate tab cr 30 mg (Ms contin) morphine sulfate tab cr 60 mg (Ms contin) NUCYNTA ER – tapentadol hcl tab sr 12hr 50 mg NUCYNTA ER – tapentadol hcl tab sr 12hr 100 mg NUCYNTA ER – tapentadol hcl tab sr 12hr 150 mg Quantity Limits oxycodone hcl conc 100 mg/5ml (20 mg/ml) (Oxycodone hcl) morphine sulfate cap sr 24hr 20 mg (Kadian) morphine sulfate cap sr 24hr 50 mg (Kadian) Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 oxycodone hcl tab 20 mg oxycodone hcl tab 5 mg (Roxicodone) oxycodone w/ acetaminophen cap 5-500 mg oxycodone w/ acetaminophen tab 10-325 mg (Percocet) oxycodone w/ acetaminophen tab 10-650 mg oxycodone w/ acetaminophen tab 2.5-325 mg (Percocet) oxycodone w/ acetaminophen tab 5-325 mg (Percocet) oxycodone w/ acetaminophen tab 7.5-325 mg (Percocet) oxycodone w/ acetaminophen tab 7.5-500 mg oxycodone-aspirin tab 4.8355-325 mg (Percodan) OXYCONTIN – oxycodone hcl tab er 12hr deter 10 mg • OXYCONTIN – oxycodone hcl tab er 12hr deter 15 mg • OXYCONTIN – oxycodone hcl tab er 12hr deter 20 mg • Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 41 Prior Authorization diclofenac w/ misoprostol tab delayed release 75-0.2 mg (Arthrotec 75) SUBOXONE – buprenorphine hclnaloxone hcl sl film 8-2 mg (base equiv) ENBREL – etanercept subcutaneous inj 50 mg/ml • • SUBOXONE – buprenorphine hclnaloxone hcl sl film 12-3 mg (base equiv) ENBREL – etanercept subcutaneous inj 25 mg/0.5ml • • ENBREL – etanercept for subcutaneous inj kit 25 mg • • ENBREL SURECLICK – etanercept subcutaneous inj 50 mg/ml • • OXYCONTIN – oxycodone hcl tab er 12hr deter 30 mg • CELEBREX – celecoxib cap 400 mg OXYCONTIN – oxycodone hcl tab er 12hr deter 40 mg • diclofenac potassium tab 50 mg (Cataflam) OXYCONTIN – oxycodone hcl tab er 12hr deter 60 mg • diclofenac sodium tab delayed release 25 mg OXYCONTIN – oxycodone hcl tab er 12hr deter 80 mg • diclofenac sodium tab delayed release 50 mg oxymorphone hcl tab 10 mg (Opana) oxymorphone hcl tab 5 mg (Opana) SUBOXONE – buprenorphine hclnaloxone hcl sl film 2-0.5 mg (base equiv) tramadol hcl tab sr 24hr biphasic release 100 mg tramadol hcl tab sr 24hr biphasic release 200 mg Specialty Drug Name Drug Name diclofenac sodium tab delayed release 75 mg diclofenac sodium tab sr 24hr 100 mg (Voltaren-xr) diclofenac w/ misoprostol tab delayed release 50-0.2 mg (Arthrotec 50) etodolac cap 200 mg tramadol hcl tab sr 24hr biphasic release 300 mg etodolac cap 300 mg tramadol hcl tab sr 24hr 100 mg (Ultram er) etodolac tab sr 24hr 500 mg etodolac tab sr 24hr 400 mg tramadol hcl tab sr 24hr 200 mg (Ultram er) etodolac tab sr 24hr 600 mg tramadol hcl tab sr 24hr 300 mg (Ultram er) etodolac tab 500 mg tramadol hcl tab 50 mg (Ultram) flurbiprofen tab 50 mg tramadol-acetaminophen tab 37.5-325 mg (Ultracet) HUMIRA – adalimumab inj kit 20 mg/0.4ml • • RHEUMATOID AND OSTEOARTHRITIS HUMIRA – adalimumab inj kit 40 mg/0.8ml (50 mg/ml) • • HUMIRA PEN – adalimumab inj kit 40 mg/0.8ml (50 mg/ml) • • CELEBREX – celecoxib cap 50 mg CELEBREX – celecoxib cap 100 mg CELEBREX – celecoxib cap 200 mg 42 Quantity Limits Specialty SUBOXONE – buprenorphine hclnaloxone hcl sl film 4-1 mg (base equiv) Quantity Limits Prior Authorization 2014 etodolac tab 400 mg flurbiprofen tab 100 mg Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 HUMIRA PEN-PSORIASIS STAR – adalimumab inj kit 40 mg/0.8ml (50 mg/ ml) • • ibuprofen tab 800 mg indomethacin cap 50 mg ketoprofen cap 50 mg ketoprofen cap 75 mg ketorolac tromethamine tab 10 mg acetaminophen-isometheptenedichloral cap 325-65-100 mg IMITREX – sumatriptan nasal spray 20 mg/act ibuprofen tab 600 mg indomethacin cap 25 mg MIGRAINE HEADACHES IMITREX – sumatriptan nasal spray 5 mg/ act ibuprofen tab 400 mg indomethacin cap cr 75 mg sulindac tab 150 mg sulindac tab 200 mg ibuprofen susp 100 mg/5ml ILARIS – canakinumab for inj 180 mg • • MIGRANAL – dihydroergotamine mesylate nasal spray 4 mg/ml naratriptan hcl tab 1 mg (base equiv) (Amerge) naratriptan hcl tab 2.5 mg (base equiv) (Amerge) rizatriptan benzoate orally disintegrating tab 10 mg (Maxalt-mlt) leflunomide tab 10 mg (Arava) rizatriptan benzoate orally disintegrating tab 5 mg (Maxalt-mlt) leflunomide tab 20 mg (Arava) rizatriptan benzoate tab 10 mg (Maxalt) mefenamic acid cap 250 mg (Ponstel) rizatriptan benzoate tab 5 mg (Maxalt) meloxicam tab 15 mg (Mobic) SUMATRIPTAN SUCCINATE – sumatriptan succinate solution prefilled syringe 6 mg/0.5ml meloxicam tab 7.5 mg (Mobic) nabumetone tab 500 mg nabumetone tab 750 mg naproxen sodium tab 275 mg (Anaprox) naproxen sodium tab 550 mg (Anaprox ds) naproxen susp 125 mg/5ml (Naprosyn) naproxen tab ec 375 mg (Ec-naprosyn) naproxen tab ec 500 mg (Ec-naprosyn) naproxen tab 250 mg (Naprosyn) naproxen tab 375 mg (Naprosyn) naproxen tab 500 mg (Naprosyn) oxaprozin tab 600 mg (Daypro) piroxicam cap 10 mg (Feldene) piroxicam cap 20 mg (Feldene) Quantity Limits • Prior Authorization • Drug Name Specialty Prior Authorization HUMIRA PEN-CROHNS DISEASE – adalimumab inj kit 40 mg/0.8ml (50 mg/ ml) Drug Name Quantity Limits Specialty 2014 SUMATRIPTAN SUCCINATE – sumatriptan succinate inj 4 mg/0.5ml sumatriptan succinate inj 6 mg/0.5ml (Imitrex) sumatriptan succinate solution autoinjector 4 mg/0.5ml (Imitrex statdose sys) sumatriptan succinate solution autoinjector 6 mg/0.5ml (Imitrex statdose sys) sumatriptan succinate solution cartridge 4 mg/0.5ml (Imitrex statdose ref) sumatriptan succinate solution cartridge 6 mg/0.5ml (Imitrex statdose ref) Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 43 sumatriptan succinate solution prefilled syringe 6 mg/0.5ml clonazepam orally disintegrating tab 0.125 mg sumatriptan succinate tab 100 mg (Imitrex) clonazepam orally disintegrating tab 0.25 mg sumatriptan succinate tab 25 mg (Imitrex) clonazepam orally disintegrating tab 0.5 mg sumatriptan succinate tab 50 mg (Imitrex) clonazepam orally disintegrating tab 1 mg zolmitriptan orally disintegrating tab 2.5 mg (Zomig zmt) clonazepam orally disintegrating tab 2 mg zolmitriptan orally disintegrating tab 5 mg (Zomig zmt) clonazepam tab 0.5 mg (Klonopin) zolmitriptan tab 2.5 mg (Zomig) clonazepam tab 2 mg (Klonopin) zolmitriptan tab 5 mg (Zomig) DIASTAT ACUDIAL – diazepam rectal gel delivery system 10 mg GOUT allopurinol tab 100 mg (Zyloprim) allopurinol tab 300 mg (Zyloprim) colchicine w/ probenecid tab 0.5-500 mg DIASTAT PEDIATRIC – diazepam rectal gel delivery system 2.5 mg probenecid tab 500 mg DILANTIN – phenytoin susp 125 mg/5ml NEUROMUSCULAR DRUGS DILANTIN – phenytoin sodium extended cap 30 mg carbamazepine cap sr 12hr 100 mg (Carbatrol) carbamazepine cap sr 12hr 200 mg (Carbatrol) carbamazepine cap sr 12hr 300 mg (Carbatrol) DILANTIN – phenytoin sodium extended cap 100 mg divalproex sodium cap sprinkle 125 mg (Depakote sprinkles) divalproex sodium tab delayed release 125 mg (Depakote) carbamazepine chew tab 100 mg divalproex sodium tab delayed release 250 mg (Depakote) carbamazepine susp 100 mg/5ml (Tegretol) divalproex sodium tab delayed release 500 mg (Depakote) carbamazepine tab sr 12hr 200 mg (Tegretol-xr) divalproex sodium tab sr 24 hr 250 mg (Depakote er) carbamazepine tab sr 12hr 400 mg (Tegretol-xr) divalproex sodium tab sr 24 hr 500 mg (Depakote er) carbamazepine tab 200 mg (Tegretol) ethosuximide cap 250 mg (Zarontin) CELONTIN – methsuximide cap 300 mg ethosuximide soln 250 mg/5ml (Zarontin) 44 Quantity Limits clonazepam tab 1 mg (Klonopin) DIASTAT ACUDIAL – diazepam rectal gel delivery system 20 mg SEIZURES Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 felbamate susp 600 mg/5ml (Felbatol) levetiracetam tab 500 mg (Keppra) felbamate tab 400 mg (Felbatol) levetiracetam tab 750 mg (Keppra) felbamate tab 600 mg (Felbatol) gabapentin cap 100 mg (Neurontin) oxcarbazepine susp 300 mg/5ml (60 mg/ml) (Trileptal) gabapentin cap 300 mg (Neurontin) oxcarbazepine tab 150 mg (Trileptal) gabapentin cap 400 mg (Neurontin) oxcarbazepine tab 300 mg (Trileptal) gabapentin oral soln 250 mg/5ml (Neurontin) oxcarbazepine tab 600 mg (Trileptal) gabapentin tab 600 mg (Neurontin) gabapentin tab 800 mg (Neurontin) lamotrigine tab chewable dispersible 25 mg (Lamictal chewable di) lamotrigine tab chewable dispersible 5 mg (Lamictal chewable di) lamotrigine tab sr 24hr 100 mg (Lamictal xr) phenytoin sodium extended cap 100 mg (Dilantin) phenytoin sodium extended cap 200 mg (Phenytek) phenytoin sodium extended cap 300 mg (Phenytek) phenytoin susp 125 mg/5ml (Dilantin) primidone tab 250 mg (Mysoline) lamotrigine tab sr 24hr 25 mg (Lamictal xr) SABRIL – vigabatrin tab 500 mg lamotrigine tab sr 24hr 250 mg (Lamictal xr) TEGRETOL-XR – carbamazepine tab sr 12hr 100 mg lamotrigine tab sr 24hr 300 mg (Lamictal xr) tiagabine hcl tab 2 mg (Gabitril) lamotrigine tab 100 mg (Lamictal) primidone tab 50 mg (Mysoline) SABRIL – vigabatrin powd pack 500 mg tiagabine hcl tab 4 mg (Gabitril) topiramate sprinkle cap 15 mg (Topamax sprinkle) lamotrigine tab 150 mg (Lamictal) topiramate sprinkle cap 25 mg (Topamax sprinkle) lamotrigine tab 200 mg (Lamictal) topiramate tab 100 mg (Topamax) lamotrigine tab 25 mg (Lamictal) topiramate tab 200 mg (Topamax) levetiracetam oral soln 100 mg/ml (Keppra) topiramate tab 25 mg (Topamax) levetiracetam tab sr 24hr 500 mg (Keppra xr) levetiracetam tab sr 24hr 750 mg (Keppra xr) Quantity Limits phenytoin chew tab 50 mg (Dilantin infatabs) lamotrigine tab sr 24hr 200 mg (Lamictal xr) lamotrigine tab sr 24hr 50 mg (Lamictal xr) Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 topiramate tab 50 mg (Topamax) valproate sodium syrup 250 mg/5ml (base equiv) (Depakene) valproic acid cap 250 mg (Depakene) levetiracetam tab 1000 mg (Keppra) zonisamide cap 100 mg (Zonegran) levetiracetam tab 250 mg (Keppra) zonisamide cap 25 mg (Zonegran) Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 45 zonisamide cap 50 mg PARKINSON'S DISEASE amantadine hcl cap 100 mg amantadine hcl syrup 50 mg/5ml AZILECT – rasagiline mesylate tab 0.5 mg (base equiv) CARBIDOPA/LEVODOPA/ENTACA – carbidopa-levodopa-entacapone tabs 37.5-150-200 mg CARBIDOPA/LEVODOPA/ENTACA – carbidopa-levodopa-entacapone tabs 50-200-200 mg benztropine mesylate tab 0.5 mg entacapone tab 200 mg (Comtan) benztropine mesylate tab 1 mg benztropine mesylate tab 2 mg pramipexole dihydrochloride tab 0.125 mg (Mirapex) bromocriptine mesylate cap 5 mg (Parlodel) pramipexole dihydrochloride tab 0.25 mg (Mirapex) bromocriptine mesylate tab 2.5 mg (Parlodel) pramipexole dihydrochloride tab 0.5 mg (Mirapex) carbidopa & levodopa orally disintegrating tab 10-100 mg pramipexole dihydrochloride tab 0.75 mg (Mirapex) carbidopa & levodopa orally disintegrating tab 25-100 mg pramipexole dihydrochloride tab 1 mg (Mirapex) carbidopa & levodopa orally disintegrating tab 25-250 mg pramipexole dihydrochloride tab 1.5 mg (Mirapex) carbidopa & levodopa tab cr 25-100 mg (Sinemet cr) ropinirole hydrochloride tab sr 24hr 12 mg (base equivalent) (Requip xl) carbidopa & levodopa tab cr 50-200 mg (Sinemet cr) ropinirole hydrochloride tab sr 24hr 2 mg (base equivalent) (Requip xl) carbidopa & levodopa tab 10-100 mg (Sinemet) ropinirole hydrochloride tab sr 24hr 4 mg (base equivalent) (Requip xl) carbidopa & levodopa tab 25-100 mg (Sinemet) ropinirole hydrochloride tab sr 24hr 6 mg (base equivalent) (Requip xl) carbidopa & levodopa tab 25-250 mg (Sinemet) ropinirole hydrochloride tab sr 24hr 8 mg (base equivalent) (Requip xl) CARBIDOPA/LEVODOPA/ENTACA – carbidopa-levodopa-entacapone tabs 12.5-50-200 mg ropinirole hydrochloride tab 0.25 mg (Requip) CARBIDOPA/LEVODOPA/ENTACA – carbidopa-levodopa-entacapone tabs 25-100-200 mg 46 Quantity Limits CARBIDOPA/LEVODOPA/ENTACA – carbidopa-levodopa-entacapone tabs 31.25-125-200 mg AZILECT – rasagiline mesylate tab 1 mg (base equiv) CARBIDOPA/LEVODOPA/ENTACA – carbidopa-levodopa-entacapone tabs 18.75-75-200 mg Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 ropinirole hydrochloride tab 0.5 mg (Requip) ropinirole hydrochloride tab 1 mg (Requip) ropinirole hydrochloride tab 2 mg (Requip) Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 ropinirole hydrochloride tab 3 mg (Requip) tizanidine hcl tab 2 mg ropinirole hydrochloride tab 4 mg (Requip) OTHER NEUROMUSCULAR DRUGS ropinirole hydrochloride tab 5 mg (Requip) selegiline hcl cap 5 mg (Eldepryl) selegiline hcl tab 5 mg MESTINON – pyridostigmine bromide syrup 60 mg/5ml MESTINON TIMESPAN – pyridostigmine bromide tab cr 180 mg pyridostigmine bromide tab 60 mg (Mestinon) trihexyphenidyl hcl tab 2 mg riluzole tab 50 mg (Rilutek) trihexyphenidyl hcl tab 5 mg SUPPLEMENTS MUSCLE RELAXANTS VITAMINS baclofen tab 10 mg ergocalciferol cap 50000 unit (Drisdol) baclofen tab 20 mg MEPHYTON – phytonadione tab 5 mg chlorzoxazone tab 500 mg (Parafon forte dsc) MULTIVITAMINS cyclobenzaprine hcl tab 5 mg DANTROLENE SODIUM – dantrolene sodium cap 100 mg dantrolene sodium cap 25 mg (Dantrium) dantrolene sodium cap 50 mg (Dantrium) metaxalone tab 800 mg (Skelaxin) methocarbamol tab 500 mg (Robaxin) methocarbamol tab 750 mg (Robaxin-750) orphenadrine citrate tab sr 12hr 100 mg ORPHENADRINE COMPOUND DS – orphenadrine w/ aspirin & caffeine tab 50-770-60 mg pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/ml pediatric multiple vitamins w/ fluoride chew tab 0.25 mg pediatric multiple vitamins w/ fluoride chew tab 0.5 mg pediatric multiple vitamins w/ fluoride chew tab 1 mg pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml pediatric vitamins acd w/ fluoride soln 0.25 mg/ml pediatric vitamins acd w/ fluoride soln 0.5 mg/ml PRENAPLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg orphenadrine w/ aspirin & caffeine tab 25-385-30 mg PRENATABS FA – prenatal vit w/ fe fumarate-fa tab 29-1 mg tizanidine hcl cap 2 mg (Zanaflex) PRENATABS RX – prenatal vit w/ iron carbonyl-fa tab 29-1 mg tizanidine hcl cap 4 mg (Zanaflex) tizanidine hcl cap 6 mg (Zanaflex) Quantity Limits tizanidine hcl tab 4 mg (Zanaflex) trihexyphenidyl hcl elixir 0.4 mg/ml cyclobenzaprine hcl tab 10 mg Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 PRENATAL AD – prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 47 PRENATAL PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg VINATE CARE – prenatal w/o a vit w/ fe fum-fa tab chew 40-1 mg PRENATAL VITAMINS PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg VINATE DHA – prenat w/o a w/fefummethylfol-fa-omegas cap 27-1.53 mg PRENATAL 19 – prenatal vit w/ fe fumarate-fa chew tab 29-1 mg VINATE DHA RF – prenat w/o a w/fefummethylfol-omegas cap 27-1.13 mg PRENATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg VINATE GT – prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg PRENATAL-U – prenatal w/o a vit w/ fe fumarate-fa cap 106.5-1 mg VINATE IC – prenatal w/o a w/fe fum-fe poly-fa cap 162.115.2-1 mg QUFLORA PEDIATRIC – pediatric multiple vitamins w/ fluoride chew tab 0.25 mg VINATE II – prenatal vit w/ fe bisglycinate chelate-fa tab 29-1 mg QUFLORA PEDIATRIC – pediatric multiple vitamins w/ fluoride chew tab 0.5 mg QUFLORA PEDIATRIC – pediatric multiple vitamins w/ fluoride chew tab 1 mg QUFLORA PEDIATRIC – pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml QUFLORA PEDIATRIC – pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml TRI-VIT/FLUORIDE/IRON – pediatric vitamins acd fluoride & fe drops 0.25-10 mg/ml VINATE ONE – prenatal vit w/ fe fumarate-fa tab 60-1 mg VINATE PN CARE – prenatal without a w/ fe asparto gly-doc-fa tab 30-1mg VINATE ULTRA – prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg MINERALS AND ELECTROLYTES FLUOR-A-DAY – sodium fluoride-xylitol chew tab 0.55 (0.25 mg f)-236.79 mg FLUOR-A-DAY – sodium fluoride-xylitol chew tab 1.1 (0.5 mg f)-236.79 mg FLUOR-A-DAY – sodium fluoride-xylitol chew tab 2.2 (1 mg f)-236.79 mg FLURA-DROPS – sodium fluoride soln 0.25 mg/drop f (from 0.55 mg/drop naf) VINACAL – prenatal w/o a w/ fe carbonylfe gluc-dss-fa tab 27-1mg K-PHOS – potassium phosphate monobasic tab 500 mg VINACAL B – prenat w/o a w/fecbn-feglufa tab 20-1 mg & vit b6 tab pak pot bicarbonate & chloride effer tab 25 meq VINATE AZ EXTRA – prenatal vit w/ fe bisglycinate chelate-fa tab 29-1 mg pot phos monobasic w/sod phos di & monobas tab 155-852-130mg (K-phos neutral) VINATE CALCIUM – prenatal vit w/ iron carbonyl-fe gluc-fa tab 27-1 mg 48 Quantity Limits VINATE M – prenatal vit w/ sel-fe fumarate-fa tab 27-1 mg TRINATE – prenatal vit w/ fe fumarate-fa tab 28-1 mg VINATE C – prenatal w/o a vit w/ fe fumarate-fa tab 30-1 mg Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 potassium bicarbonate effer tab 25 meq potassium chloride cap cr 10 meq (Micro-k) Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 potassium chloride microencapsulated crys cr tab 20 meq potassium chloride oral liq 10% (20 meq/15ml) potassium chloride oral liq 20% (40 meq/15ml) potassium chloride powder packet 20 meq potassium chloride tab cr 10 meq (Ktab) potassium chloride tab cr 8 meq (600 mg) SODIUM FLUORIDE – sodium fluoride tab 0.5 mg f (from 1.1 mg naf) SODIUM FLUORIDE – sodium fluoride tab 1 mg f (from 2.2 mg naf) sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) (Luride) sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) (Luride) sodium fluoride chew tab 1 mg f (from 2.2 mg naf) (Luride) sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf) sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) (Luride) SSKI – potassium iodide soln 1 gm/ml BLOOD MODIFYING DRUGS aminocaproic acid syrup 25% (Amicar) anagrelide hcl cap 0.5 mg (Agrylin) anagrelide hcl cap 1 mg ARANESP ALBUMIN FREE – darbepoetin alfa-polysorbate 80 soln inj 25 mcg/ml • • ARANESP ALBUMIN FREE – darbepoetin alfa-polysorbate 80 soln inj 25 mcg/0.42ml • • ARANESP ALBUMIN FREE – darbepoetin alfa-polysorbate 80 soln inj 40 mcg/ml • • ARANESP ALBUMIN FREE – darbepoetin alfa-polysorbate 80 soln inj 40 mcg/0.4ml • • ARANESP ALBUMIN FREE – darbepoetin alfa-polysorbate 80 soln inj 60 mcg/ml • • ARANESP ALBUMIN FREE – darbepoetin alfa-polysorbate 80 soln inj 60 mcg/0.3ml • • ARANESP ALBUMIN FREE – darbepoetin alfa-polysorbate 80 soln inj 100 mcg/ml • • ARANESP ALBUMIN FREE – darbepoetin alfa-polysorbate 80 soln inj 100 mcg/0.5ml • • ARANESP ALBUMIN FREE – darbepoetin alfa-polysorbate 80 soln inj 150 mcg/0.75ml • • ARANESP ALBUMIN FREE – darbepoetin alfa-polysorbate 80 soln inj 150 mcg/0.3ml • • ARANESP ALBUMIN FREE – darbepoetin alfa-polysorbate 80 soln inj 200 mcg/ml • • ARANESP ALBUMIN FREE – darbepoetin alfa-polysorbate 80 soln inj 200 mcg/0.4ml • • ARANESP ALBUMIN FREE – darbepoetin alfa-polysorbate 80 soln inj 300 mcg/ml • • ARANESP ALBUMIN FREE – darbepoetin alfa-polysorbate 80 soln inj 300 mcg/0.6ml • • ARANESP ALBUMIN FREE – darbepoetin alfa-polysorbate 80 soln inj 500 mcg/ml • • Drug Name Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 Quantity Limits Prior Authorization potassium chloride microencapsulated crys cr tab 10 meq Specialty potassium chloride cap cr 8 meq (Micro-k) Quantity Limits Prior Authorization Drug Name Specialty 2014 49 Prior Authorization GRANIX – tbo-filgrastim soln prefilled syringe 480 mcg/0.8ml • • dipyridamole tab 25 mg (Persantine) NEULASTA – pegfilgrastim inj 6 mg/0.6ml dipyridamole tab 50 mg (Persantine) NEUMEGA – oprelvekin for inj 5 mg dipyridamole tab 75 mg (Persantine) NEUPOGEN – filgrastim inj 300 mcg/ml EFFIENT – prasugrel hcl tab 5 mg (base equiv) NEUPOGEN – filgrastim inj 480 mcg/1.6ml (300 mcg/ml) • • • • • • • • EFFIENT – prasugrel hcl tab 10 mg (base equiv) NEUPOGEN – filgrastim inj 300 mcg/0.5ml (600 mcg/ml) • • enoxaparin sodium inj 100 mg/ml (Lovenox) NEUPOGEN – filgrastim inj 480 mcg/0.8ml (600 mcg/ml) • • enoxaparin sodium inj 120 mg/0.8ml (Lovenox) pentoxifylline tab cr 400 mg enoxaparin sodium inj 150 mg/ml (Lovenox) PROCRIT – epoetin alfa inj 3000 unit/ml enoxaparin sodium inj 30 mg/0.3ml (Lovenox) PROCRIT – epoetin alfa inj 10000 unit/ml enoxaparin sodium inj 300 mg/3ml (Lovenox) PROCRIT – epoetin alfa inj 40000 unit/ml • • • • • • • • • • • • Drug Name PROCRIT – epoetin alfa inj 2000 unit/ml PROCRIT – epoetin alfa inj 4000 unit/ml PROCRIT – epoetin alfa inj 20000 unit/ml enoxaparin sodium inj 40 mg/0.4ml (Lovenox) tranexamic acid tab 650 mg (Lysteda) enoxaparin sodium inj 60 mg/0.6ml (Lovenox) warfarin sodium tab 10 mg (Coumadin) enoxaparin sodium inj 80 mg/0.8ml (Lovenox) warfarin sodium tab 2.5 mg (Coumadin) FIRAZYR – icatibant acetate inj 30 mg/3ml (base equivalent) Quantity Limits Specialty clopidogrel bisulfate tab 75 mg (base equiv) (Plavix) cilostazol tab 100 mg (Pletal) Quantity Limits • Specialty • cilostazol tab 50 mg (Pletal) GRANIX – tbo-filgrastim soln prefilled syringe 300 mcg/0.5ml Drug Name Prior Authorization 2014 warfarin sodium tab 1 mg (Coumadin) warfarin sodium tab 2 mg (Coumadin) • • warfarin sodium tab 3 mg (Coumadin) warfarin sodium tab 4 mg (Coumadin) folic acid tab 1 mg warfarin sodium tab 5 mg (Coumadin) fondaparinux sodium inj 10 mg/0.8ml (Arixtra) warfarin sodium tab 6 mg (Coumadin) fondaparinux sodium inj 2.5 mg/0.5ml (Arixtra) XARELTO – rivaroxaban tab 10 mg warfarin sodium tab 7.5 mg (Coumadin) XARELTO – rivaroxaban tab 15 mg fondaparinux sodium inj 5 mg/0.4ml (Arixtra) XARELTO – rivaroxaban tab 20 mg fondaparinux sodium inj 7.5 mg/0.6ml (Arixtra) EYE TOPICAL PRODUCTS Anti-infectives 50 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 BACITRACIN – bacitracin ophth oint 500 unit/gm LOTEMAX – loteprednol etabonate ophth gel 0.5% bacitracin-polymyxin b ophth oint LOTEMAX – loteprednol etabonate ophth oint 0.5% CILOXAN – ciprofloxacin hcl ophth oint 0.3% ciprofloxacin hcl ophth soln 0.3% (Ciloxan) erythromycin ophth oint 5 mg/gm gentamicin sulfate ophth oint 0.3% gentamicin sulfate ophth soln 0.3% (Garamycin) NATACYN – natamycin ophth susp 5% neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml (Neosporin) ofloxacin ophth soln 0.3% (Ocuflox) polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% (Polytrim) sulfacetamide sodium ophth soln 10% (Bleph-10) Quantity Limits Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 neomycin-polymyxin-dexamethasone ophth oint 0.1% (Maxitrol) neomycin-polymyxin-dexamethasone ophth susp 0.1% (Maxitrol) prednisolone acetate ophth susp 1% (Pred forte) sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)% tobramycin-dexamethasone ophth susp 0.3-0.1% (Tobradex) ZYLET – loteprednol etabonatetobramycin ophth susp 0.5-0.3% Glaucoma ALPHAGAN P – brimonidine tartrate ophth soln 0.1% apraclonidine hcl ophth soln 0.5% (base equivalent) (Iopidine) AZOPT – brinzolamide ophth susp 1% tobramycin ophth soln 0.3% (Tobrex) betaxolol hcl ophth soln 0.5% TOBREX – tobramycin sulfate ophth oint 0.3% brimonidine tartrate ophth soln 0.15% (Alphagan p) trifluridine ophth soln 1% (Viroptic) brimonidine tartrate ophth soln 0.2% VIGAMOX – moxifloxacin hcl ophth soln 0.5% (base equiv) carteolol hcl ophth soln 1% Steroids and Combination Products dorzolamide hcl ophth soln 2% (Trusopt) ALREX – loteprednol etabonate ophth susp 0.2% dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml (Cosopt) bacitracin-polymyxin-neomycin-hc ophth oint 1% latanoprost ophth soln 0.005% (Xalatan) dexamethasone sodium phosphate ophth soln 0.1% LEVOBUNOLOL HCL – levobunolol hcl ophth soln 0.25% fluorometholone ophth susp 0.1% (Fml liquifilm) levobunolol hcl ophth soln 0.5% (Betagan) LOTEMAX – loteprednol etabonate ophth susp 0.5% LUMIGAN – bimatoprost ophth soln 0.01% Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 51 LUMIGAN – bimatoprost ophth soln 0.03% ketorolac tromethamine ophth soln 0.4% (Acular ls) METIPRANOLOL – metipranolol ophth soln 0.3% ketorolac tromethamine ophth soln 0.5% (Acular) pilocarpine hcl ophth soln 1% (Isopto carpine) PATADAY – olopatadine hcl ophth soln 0.2% pilocarpine hcl ophth soln 2% (Isopto carpine) EAR pilocarpine hcl ophth soln 4% (Isopto carpine) SIMBRINZA – brinzolamide-brimonidine tartrate ophth susp 1-0.2% timolol maleate ophth gel forming soln 0.25% (Timoptic-xe) timolol maleate ophth gel forming soln 0.5% (Timoptic-xe) acetic acid otic soln 2% antipyrine-benzocaine otic soln 54-14 mg/ml (5.4-1.4%) antipyrine-benzocaine otic soln 55-14 mg/ml (5.5-1.4%) (Auralgan) ANTIPYRINE/BENZOCAINE – antipyrinebenzocaine otic soln 55-14 mg/ml (5.5-1.4%) timolol maleate ophth soln 0.5% (Timoptic) CIPRO HC – ciprofloxacin-hydrocortisone otic susp 0.2-1% TRAVATAN Z – travoprost ophth soln 0.004% (benzalkonium free) (bak free) CIPRODEX – ciprofloxacindexamethasone otic susp 0.3-0.1% Other Eye Products fluocinolone acetonide (otic) oil 0.01% (Dermotic) atropine sulfate ophth soln 1% (Isopto atropine) azelastine hcl ophth soln 0.05% (Optivar) cromolyn sodium ophth soln 4% cyclopentolate hcl ophth soln 1% (Cyclogyl) diclofenac sodium ophth soln 0.1% epinastine hcl ophth soln 0.05% (Elestat) flurbiprofen sodium ophth soln 0.03% (Ocufen) homatropine hbr ophth soln 5% (Isopto homatropine) Quantity Limits antipyrine-benzocaine-polycosanol otic sol 5.4-1.4-0.0097% (Treagan otic) timolol maleate ophth soln 0.25% (Timoptic) ATROPINE SULFATE – atropine sulfate ophth oint 1% Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 hydrocortisone w/ acetic acid otic soln 1-2% (Vosol hc) neomycin-polymyxin-hc otic soln 1% (Cortisporin) neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% ofloxacin otic soln 0.3% pramoxine-chloroxylenol otic liquid 1-0.1% (Pramotic) pramoxine-hc-chloroxylenol aqueous otic soln 10-10-1 mg/ml (Cortane-b aqueous) pramoxine-hc-chloroxylenol otic soln 10-10-1 mg/ml (Cortane-b-otic) MOUTH AND THROAT (LOCAL) cevimeline hcl cap 30 mg (Evoxac) 52 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 chlorhexidine gluconate soln 0.12% (Peridex) clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% (Duac) clotrimazole troche 10 mg clindamycin phosphate foam 1% (Evoclin) lidocaine hcl laryngotracheal soln 4% (Lta 360 kit) lidocaine hcl viscous soln 2% nystatin susp 100000 unit/ml pilocarpine hcl tab 5 mg (Salagen) clindamycin phosphate lotion 1% (Cleocin-t) clindamycin phosphate soln 1% (Cleocin-t) sodium fluoride cream 1.1% (Prevident 5000 plus) clindamycin phosphate swab 1% (Cleocin-t) sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride) clindamycin phosphate-benzoyl peroxide gel 1-5% (Benzaclin) triamcinolone acetonide dental paste 0.1% erythromycin gel 2% (Erygel) CORTIFOAM – hydrocortisone acetate rectal foam 90 mg/dose erythromycin pads 2% erythromycin soln 2% FINACEA – azelaic acid gel 15% hydrocortisone acetate suppos 25 mg (Anusol-hc) isotretinoin cap 10 mg hydrocortisone acetate suppos 30 mg (Proctocort) isotretinoin cap 40 mg hydrocortisone enema 100 mg/60ml (Cortenema) hydrocortisone rectal cream 1% (Proctocort) hydrocortisone rectal cream 2.5% (Anusol-hc) SKIN CONDITIONS/PRODUCTS Acne sulfacetamide sodium-sulfur w/ sunscreens cream 10-5% adapalene cream 0.1% (Differin) adapalene gel 0.1% (Differin) benzoyl peroxide-erythromycin gel 5-3% (Benzamycin) CLARAVIS – isotretinoin cap 30 mg Quantity Limits clindamycin phosphate gel 1% (Cleocin-t) pilocarpine hcl tab 7.5 mg (Salagen) ANORECTAL AGENTS Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 isotretinoin cap 20 mg metronidazole cream 0.75% (Metrocream) metronidazole gel 0.75% metronidazole gel 1% (Metrogel) metronidazole lotion 0.75% (Metrolotion) ORACEA – doxycycline (rosacea) cap delayed release 40 mg sulfacetamide sodium lotion 10% (acne) (Klaron) sulfacetamide sodium w/ sulfur cleanser 10-2% (Avar ls cleanser) sulfacetamide sodium w/ sulfur cream 10-2% (Avar-e ls) sulfacetamide sodium w/ sulfur cream 10-5% sulfacetamide sodium w/ sulfur emulsion 10-1% Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 53 sulfacetamide sodium w/ sulfur emulsion 10-5% clotrimazole w/ betamethasone cream 1-0.05% (Lotrisone) sulfacetamide sodium w/ sulfur foam 10-5% (Clarifoam ef) clotrimazole w/ betamethasone lotion 1-0.05% sulfacetamide sodium w/ sulfur lotion 10-5% econazole nitrate cream 1% sulfacetamide sodium w/ sulfur susp 8-4% (Sumaxin ts) sulfacetamide sodium w/ sulfur wash 9-4.5% (Sumadan wash) sulfacetamide sodium w/ sulfur wash 9-4% (Sumaxin wash) sulfacetamide sodium-sulfur in urea emulsion 10-4% TAZORAC – tazarotene cream 0.05% TAZORAC – tazarotene cream 0.1% TAZORAC – tazarotene gel 0.05% TAZORAC – tazarotene gel 0.1% GENTAMICIN SULFATE – gentamicin sulfate oint 0.1% ketoconazole cream 2% ketoconazole foam 2% (Extina) ketoconazole shampoo 2% (Nizoral) mupirocin calcium cream 2% (Bactroban) mupirocin oint 2% (Bactroban) nystatin cream 100000 unit/gm nystatin oint 100000 unit/gm silver sulfadiazine cream 1% (Silvadene) tretinoin cream 0.05% (Retin-a) VOLTAREN – diclofenac sodium gel 1% tretinoin cream 0.1% (Retin-a) Corticosteroids tretinoin gel 0.01% (Retin-a) alclometasone dipropionate cream 0.05% (Aclovate) tretinoin microsphere gel 0.04% (Retina micro) alclometasone dipropionate oint 0.05% tretinoin microsphere gel 0.1% (Retin-a micro) betamethasone dipropionate augmented cream 0.05% (Diprolene af) Anti-infectives nystatin topical powder amcinonide cream 0.1% ciclopirox gel 0.77% (Loprox) betamethasone dipropionate augmented gel 0.05% ciclopirox olamine cream 0.77% (base equiv) betamethasone dipropionate augmented lotion 0.05% (Diprolene) ciclopirox olamine susp 0.77% (base equiv) betamethasone dipropionate augmented oint 0.05% (Diprolene) ciclopirox shampoo 1% (Loprox shampoo) betamethasone dipropionate cream 0.05% ciclopirox solution 8% (Penlac nail lacquer) betamethasone dipropionate lotion 0.05% 54 Quantity Limits GENTAMICIN SULFATE – gentamicin sulfate cream 0.1% tretinoin cream 0.025% (Retin-a) tretinoin gel 0.025% (Retin-a) Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 betamethasone dipropionate oint 0.05% fluocinolone acetonide cream 0.025% (Synalar) betamethasone valerate aerosol foam 0.12% (Luxiq) fluocinolone acetonide oil 0.01% (Derma-smoothe/fs bod) betamethasone valerate cream 0.1% fluocinolone acetonide oint 0.025% (Synalar) betamethasone valerate lotion 0.1% betamethasone valerate oint 0.1% clobetasol propionate cream 0.05% (Temovate) fluocinonide cream 0.05% fluocinonide emulsified base cream 0.05% clobetasol propionate emulsion foam 0.05% (Olux-e) fluocinonide gel 0.05% clobetasol propionate foam 0.05% (Olux) fluocinonide soln 0.05% clobetasol propionate lotion 0.05% (Clobex) clobetasol propionate oint 0.05% (Temovate) clobetasol propionate shampoo 0.05% (Clobex) clobetasol propionate soln 0.05% (Temovate) desonide cream 0.05% (Desowen) desonide lotion 0.05% (Desowen) desonide oint 0.05% (Desowen) Quantity Limits fluocinolone acetonide soln 0.01% (Synalar) clobetasol propionate emollient base cream 0.05% (Temovate e) clobetasol propionate gel 0.05% (Temovate) Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 fluocinonide oint 0.05% fluticasone propionate cream 0.05% (Cutivate) fluticasone propionate lotion 0.05% (Cutivate) fluticasone propionate oint 0.005% (Cutivate) halobetasol propionate cream 0.05% (Ultravate) halobetasol propionate oint 0.05% (Ultravate) hydrocortisone butyrate cream 0.1% (Locoid) hydrocortisone butyrate soln 0.1% (Locoid) DESOXIMETASONE – desoximetasone cream 0.05% hydrocortisone cream 2.5% desoximetasone cream 0.25% (Topicort) hydrocortisone oint 2.5% desoximetasone gel 0.05% (Topicort) desoximetasone oint 0.25% (Topicort) hydrocortisone valerate oint 0.2% (Westcort) DIFLORASONE DIACETATE – diflorasone diacetate cream 0.05% mometasone furoate cream 0.1% (Elocon) diflorasone diacetate oint 0.05% mometasone furoate oint 0.1% (Elocon) fluocinolone acetonide cream 0.01% mometasone furoate solution 0.1% (lotion) (Elocon) hydrocortisone lotion 2.5% hydrocortisone valerate cream 0.2% Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 55 lindane lotion 1% TRIAMCINOLONE ACETONIDE – triamcinolone acetonide oint 0.5% lindane shampoo 1% triamcinolone acetonide cream 0.025% permethrin cream 5% (Elimite) triamcinolone acetonide cream 0.1% PICATO – ingenol mebutate gel 0.015% triamcinolone acetonide cream 0.5% PICATO – ingenol mebutate gel 0.05% triamcinolone acetonide lotion 0.025% podofilox soln 0.5% (Condylox) triamcinolone acetonide lotion 0.1% PROTOPIC – tacrolimus oint 0.03% triamcinolone acetonide oint 0.025% PROTOPIC – tacrolimus oint 0.1% triamcinolone acetonide oint 0.1% selenium sulfide lotion 2.5% Other Skin Products ULESFIA – benzyl alcohol lotion 5% acitretin cap 10 mg (Soriatane) VALCHLOR – mechlorethamine hcl gel 0.016% (base equivalent) malathion lotion 0.5% (Ovide) aluminum chloride soln 20% (Drysol) XERAC AC – aluminum chloride in alcohol solution 6.25% calcipotriene cream 0.005% (Dovonex) ZYCLARA – imiquimod cream 3.75% calcipotriene oint 0.005% ZYCLARA PUMP – imiquimod cream 2.5% CARAC – fluorouracil cream 0.5% ZYCLARA PUMP – imiquimod cream 3.75% diclofenac sodium (actinic keratoses) gel 3% (Solaraze) MISCELLANEOUS CATEGORIES ELIDEL – pimecrolimus cream 1% FLUOROPLEX – fluorouracil cream 1% fluorouracil cream 5% (Efudex) fluorouracil soln 2% fluorouracil soln 5% imiquimod cream 5% (Aldara) lidocaine hcl cream 3% lidocaine hcl gel 2% lidocaine hcl soln 4% (Xylocaine) Quantity Limits Quantity Limits prednicarbate oint 0.1% (Dermatop) calcipotriene soln 0.005% (50 mcg/ml) • lidocaine-prilocaine cream 2.5-2.5% (Emla) LIDOCAINE/PRILOCAINE – lidocaineprilocaine kit 2.5-2.5% acitretin cap 25 mg (Soriatane) • lidocaine patch 5% (Lidoderm) prednicarbate cream 0.1% (Dermatop) acitretin cap 17.5 mg (Soriatane) Prior Authorization nystatin-triamcinolone oint 100000-0.1 unit/gm-% Drug Name Specialty nystatin-triamcinolone cream 100000-0.1 unit/gm-% Prior Authorization Drug Name Specialty 2014 DIABETIC SUPPLIES Many other diabetic supplies including Insulin Syringes, Lancets and Lancet Devices are Preferred for plans that cover them, however, only commonly prescribed products are shown on the Preferred Drug List. Blood Glucose Monitors, Test Strips, and Monitor Calibration Liquids ACCU-CHEK ACTIVE GLUCOSE – blood glucose calibration - liquid ACCU-CHEK ACTIVE STRIPS – glucose blood test strip lidocaine oint 5% 56 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 ACCU-CHEK AVIVA – glucose blood test strip ASCENSIA AUTODISC LOW AND – blood glucose calibration - liquid ACCU-CHEK AVIVA – blood glucose calibration - liquid ASCENSIA AUTODISC NORMAL – blood glucose calibration - liquid - normal ACCU-CHEK AVIVA PLUS – glucose blood test strip ASCENSIA AUTODISC TEST ST – glucose blood test disk ACCU-CHEK AVIVA PLUS – blood glucose monitoring kit w/ device BAYER BREEZE 2 BLOOD GLUC – blood glucose monitoring kit w/ device ACCU-CHEK COMFORT CURVE C – blood glucose calibration - liquid BAYER BREEZE 2 HIGH CONTR – blood glucose calibration - liquid - high ACCU-CHEK COMFORT CURVE L – blood glucose calibration - liquid BAYER BREEZE 2 LOW CONTRO – blood glucose calibration - liquid - low ACCU-CHEK COMFORT CURVE T – glucose blood test strip BAYER BREEZE 2 NORMAL CON – blood glucose calibration - liquid normal ACCU-CHEK COMPACT BLUE CO – blood glucose calibration - liquid ACCU-CHEK COMPACT PLUS – glucose blood test strip ACCU-CHEK COMPACT PLUS CA – blood glucose monitoring kit ACCU-CHEK COMPACT PLUS CL – blood glucose calibration - liquid ACCU-CHEK COMPACT TEST DR – glucose blood test strip ACCU-CHEK INSTANT GLUCOSE – blood glucose calibration - liquid ACCU-CHEK NANO SMARTVIEW – blood glucose monitoring kit w/ device ACCU-CHEK SMARTVIEW CONTR – blood glucose calibration - liquid ACCU-CHEK SMARTVIEW STRIP – glucose blood test strip ACCU-CHEK VOICEMATE – blood glucose monitoring kit w/ device Quantity Limits Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 BAYER BREEZE 2 TEST DISC – glucose blood test disk BAYER CONTOUR BLOOD GLUCO – glucose blood test strip BAYER CONTOUR BLOOD GLUCO – blood glucose monitoring devices BAYER CONTOUR BLOOD GLUCO – blood glucose monitoring kit w/ device BAYER CONTOUR HIGH CONTRO – blood glucose calibration - liquid - high BAYER CONTOUR LINK BLOOD – blood glucose monitoring kit w/ device BAYER CONTOUR LOW CONTROL – blood glucose calibration - liquid - low BAYER CONTOUR NEXT BLOOD – glucose blood test strip BAYER CONTOUR NEXT BLOOD – blood glucose monitoring kit w/ device ACCUTREND GLUCOSE – glucose blood test strip BAYER CONTOUR NEXT CONTRO – blood glucose calibration - liquid normal ACCUTREND GLUCOSE CONTROL – blood glucose calibration - liquid BAYER CONTOUR NEXT CONTRO – blood glucose calibration - liquid - low ACETEST – acetone (urine) test tab BAYER CONTOUR NEXT EZ BLO – blood glucose monitoring kit w/ device Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 57 BAYER CONTOUR NEXT LINK B – blood glucose monitoring kit w/ device sodium polystyrene sulfonate powder (Kayexalate) BAYER CONTOUR NEXT USB BL – blood glucose monitoring kit w/ device azathioprine tab 50 mg (Imuran) • • • • • • • • • • • • Quantity Limits • CHEMET – succimer cap 100 mg CUPRIMINE – penicillamine cap 250 mg BAYER CONTOUR USB BLOOD G – blood glucose monitoring kit w/ device cyclosporine cap 100 mg (Sandimmune) BREEZE 2 BLOOD GLUCOSE MO – blood glucose monitoring devices cyclosporine cap 25 mg (Sandimmune) CHEMSTRIP UGK – urine glucoseketones test strips cyclosporine modified cap 100 mg (Neoral) CHEMSTRIP-K – acetone (urine) test strip cyclosporine modified cap 25 mg (Neoral) DIDGET – blood glucose monitoring kit w/ device cyclosporine modified oral soln 100 mg/ml (Neoral) KETO-DIASTIX – urine glucose-ketones test strips mycophenolate mofetil cap 250 mg (Cellcept) KETOSTIX – acetone (urine) test strip mycophenolate mofetil tab 500 mg (Cellcept) PRECISION XTRA – ketone blood test strip mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) (Myfortic) Other Diabetic Supplies ALCOHOL SWABS - VARIOUS mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) (Myfortic) INJECTION DEVICE FOR INSULIN VARIOUS naltrexone hcl tab 50 mg (Revia) RAPAMUNE – sirolimus tab 1 mg INSULIN PEN NEEDLES - NOVOFINE RAPAMUNE – sirolimus tab 2 mg INSULIN PEN NEEDLES - NOVOTWIST RAPAMUNE – sirolimus oral soln 1 mg/ml INSULIN PEN NEEDLES - VARIOUS REVLIMID – lenalidomide caps 2.5 mg INSULIN SYRINGES - VARIOUS REVLIMID – lenalidomide cap 5 mg LANCET DEVICES - VARIOUS REVLIMID – lenalidomide cap 10 mg LANCETS - VARIOUS RESPIRATORY INHALER-ASSIST DEVICES The Preferred Drug List includes most spacer devices. The most commonly prescribed products are AEROCHAMBER, EASIVENT, E-Z SPACER, INSPIREASE, and MICROCHAMBER. 58 • CELLCEPT – mycophenolate mofetil for oral susp 200 mg/ml BAYER CONTOUR NORMAL CONT – blood glucose calibration - liquid normal MISCELLANEOUS DRUGS Prior Authorization Drug Name Specialty Quantity Limits Prior Authorization Drug Name Specialty 2014 REVLIMID – lenalidomide cap 15 mg REVLIMID – lenalidomide cap 20 mg REVLIMID – lenalidomide cap 25 mg SANDIMMUNE – cyclosporine cap 25 mg SANDIMMUNE – cyclosporine cap 100 mg Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 • • • • • • • • Quantity Limits Prior Authorization Drug Name Specialty 2014 SANDIMMUNE – cyclosporine oral soln 100 mg/ml sirolimus tab 0.5 mg (Rapamune) sodium polystyrene sulfonate oral susp 15 gm/60ml (Sps) sodium polystyrene sulfonate rectal susp 30 gm/120ml tacrolimus cap 0.5 mg (Prograf) tacrolimus cap 1 mg (Prograf) tacrolimus cap 5 mg (Prograf) THALOMID – thalidomide cap 50 mg THALOMID – thalidomide cap 100 mg THALOMID – thalidomide cap 150 mg THALOMID – thalidomide cap 200 mg ZORTRESS – everolimus tab 0.25 mg ZORTRESS – everolimus tab 0.5 mg ZORTRESS – everolimus tab 0.75 mg Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 59 2014 INDEX A abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg (Trizivir).................................................4 abacavir sulfate tab 300 mg (base equiv) (Ziagen).........4 acamprosate calcium tab delayed release 333 mg (Campral)........................................................................ 38 acarbose tab 100 mg (Precose)..................................... 13 acarbose tab 25 mg (Precose)....................................... 13 acarbose tab 50 mg (Precose)....................................... 13 ACCU-CHEK ACTIVE GLUCOSE – blood glucose calibration - liquid............................................................ 56 ACCU-CHEK ACTIVE STRIPS – glucose blood test strip.................................................................................. 56 ACCU-CHEK AVIVA – blood glucose calibration liquid.................................................................................57 ACCU-CHEK AVIVA – glucose blood test strip.................57 ACCU-CHEK AVIVA PLUS – blood glucose monitoring kit w/ device..........................................................................57 ACCU-CHEK AVIVA PLUS – glucose blood test strip.......57 ACCU-CHEK COMFORT CURVE C – blood glucose calibration - liquid............................................................ 57 ACCU-CHEK COMFORT CURVE L – blood glucose calibration - liquid............................................................ 57 ACCU-CHEK COMFORT CURVE T – glucose blood test strip.................................................................................. 57 ACCU-CHEK COMPACT BLUE CO – blood glucose calibration - liquid............................................................ 57 ACCU-CHEK COMPACT PLUS CA – blood glucose monitoring kit................................................................... 57 ACCU-CHEK COMPACT PLUS CL – blood glucose calibration - liquid............................................................ 57 ACCU-CHEK COMPACT PLUS – glucose blood test strip.................................................................................. 57 ACCU-CHEK COMPACT TEST DR – glucose blood test strip.................................................................................. 57 ACCU-CHEK INSTANT GLUCOSE – blood glucose calibration - liquid............................................................ 57 ACCU-CHEK NANO SMARTVIEW – blood glucose monitoring kit w/ device...................................................57 ACCU-CHEK SMARTVIEW CONTR – blood glucose calibration - liquid............................................................ 57 ACCU-CHEK SMARTVIEW STRIP – glucose blood test strip.................................................................................. 57 ACCU-CHEK VOICEMATE – blood glucose monitoring kit w/ device..........................................................................57 ACCUTREND GLUCOSE CONTROL – blood glucose calibration - liquid............................................................ 57 ACCUTREND GLUCOSE – glucose blood test strip.........57 acebutolol hcl cap 200 mg (Sectral).............................. 19 acebutolol hcl cap 400 mg (Sectral)..............................19 acetaminophen-isometheptene-dichloral cap 325-65-100 mg................................................................ 43 60 acetaminophen w/ codeine soln 120-12 mg/5ml...........39 acetaminophen w/ codeine tab 300-15 mg (Tylenol/ codeine).......................................................................... 39 acetaminophen w/ codeine tab 300-30 mg (Tylenol/ codeine #3).....................................................................39 acetaminophen w/ codeine tab 300-60 mg (Tylenol/ codeine #4).....................................................................39 ACETAZOLAMIDE – acetazolamide tab 125 mg.............. 23 acetazolamide cap sr 12hr 500 mg (Diamox)................23 acetazolamide tab 250 mg..............................................23 ACETEST – acetone (urine) test tab................................ 57 acetic acid otic soln 2%................................................. 52 acetylcysteine inhal soln 10%........................................26 acetylcysteine inhal soln 20%........................................26 acitretin cap 10 mg (Soriatane)......................................56 acitretin cap 17.5 mg (Soriatane)...................................56 acitretin cap 25 mg (Soriatane)......................................56 ACTONEL – risedronate sodium tab 150 mg....................16 ACTONEL – risedronate sodium tab 30 mg......................16 ACTONEL – risedronate sodium tab 35 mg......................16 ACTONEL – risedronate sodium tab 5 mg........................16 acyclovir cap 200 mg (Zovirax)........................................4 acyclovir susp 200 mg/5ml (Zovirax).............................. 4 acyclovir tab 400 mg (Zovirax)........................................ 4 acyclovir tab 800 mg (Zovirax)........................................ 4 adapalene cream 0.1% (Differin)....................................53 adapalene gel 0.1% (Differin)......................................... 53 ADCIRCA – tadalafil tab 20 mg (pah)............................... 25 adefovir dipivoxil tab 10 mg (Hepsera)........................... 4 ADVAIR DISKUS – fluticasone-salmeterol aer powder ba 100-50 mcg/dose............................................................. 26 ADVAIR DISKUS – fluticasone-salmeterol aer powder ba 250-50 mcg/dose............................................................. 26 ADVAIR DISKUS – fluticasone-salmeterol aer powder ba 500-50 mcg/dose............................................................. 26 ADVAIR HFA – fluticasone-salmeterol inhal aerosol 115-21 mcg/act................................................................ 26 ADVAIR HFA – fluticasone-salmeterol inhal aerosol 230-21 mcg/act................................................................ 26 ADVAIR HFA – fluticasone-salmeterol inhal aerosol 45-21 mcg/act............................................................................ 26 AFINITOR DISPERZ – everolimus tab for oral susp 2 mg...................................................................................... 7 AFINITOR DISPERZ – everolimus tab for oral susp 3 mg...................................................................................... 7 AFINITOR DISPERZ – everolimus tab for oral susp 5 mg...................................................................................... 7 AFINITOR – everolimus tab 10 mg.....................................7 AFINITOR – everolimus tab 2.5 mg....................................7 AFINITOR – everolimus tab 5 mg.......................................7 AFINITOR – everolimus tab 7.5 mg....................................7 ALBENZA – albendazole tab 200 mg................................. 6 albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)..........26 albuterol sulfate soln nebu 0.5% (5 mg/ml).................. 26 albuterol sulfate soln nebu 0.63 mg/3ml (base equiv).............................................................................. 26 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 2014 albuterol sulfate soln nebu 1.25 mg/3ml (base equiv).............................................................................. 26 albuterol sulfate syrup 2 mg/5ml................................... 26 albuterol sulfate tab 2 mg.............................................. 26 albuterol sulfate tab 4 mg.............................................. 26 albuterol sulfate tab sr 12hr 4 mg (Vospire er).............26 albuterol sulfate tab sr 12hr 8 mg (Vospire er).............26 alclometasone dipropionate cream 0.05% (Aclovate)........................................................................54 alclometasone dipropionate oint 0.05%........................ 54 ALCOHOL SWABS - VARIOUS........................................58 ALENDRONATE SODIUM – alendronate sodium tab 40 mg.................................................................................... 16 alendronate sodium tab 10 mg...................................... 16 alendronate sodium tab 35 mg...................................... 16 alendronate sodium tab 5 mg........................................ 16 alendronate sodium tab 70 mg (Fosamax)................... 16 alfuzosin hcl tab sr 24hr 10 mg (Uroxatral).................. 31 ALKERAN – melphalan tab 2 mg....................................... 7 allopurinol tab 100 mg (Zyloprim)................................. 44 allopurinol tab 300 mg (Zyloprim)................................. 44 ALPHAGAN P – brimonidine tartrate ophth soln 0.1%...... 51 alprazolam orally disintegrating tab 0.25 mg (Niravam)........................................................................ 32 alprazolam orally disintegrating tab 0.5 mg................. 32 alprazolam orally disintegrating tab 1 mg.................... 32 alprazolam orally disintegrating tab 2 mg.................... 32 alprazolam tab 0.25 mg (Xanax).................................... 32 alprazolam tab 0.5 mg (Xanax)...................................... 32 alprazolam tab 1 mg (Xanax)......................................... 32 alprazolam tab 2 mg (Xanax)......................................... 32 alprazolam tab sr 24hr 0.5 mg (Xanax xr)..................... 32 alprazolam tab sr 24hr 1 mg (Xanax xr)........................ 32 alprazolam tab sr 24hr 2 mg (Xanax xr)........................ 32 alprazolam tab sr 24hr 3 mg (Xanax xr)........................ 32 ALREX – loteprednol etabonate ophth susp 0.2%............ 51 aluminum chloride soln 20% (Drysol)........................... 56 amantadine hcl cap 100 mg........................................... 46 amantadine hcl syrup 50 mg/5ml...................................46 amcinonide cream 0.1%................................................. 54 AMETHYST – levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg................................................................. 12 amiloride & hydrochlorothiazide tab 5-50 mg...............23 amiloride hcl tab 5 mg....................................................23 aminocaproic acid syrup 25% (Amicar)........................ 49 amiodarone hcl tab 100 mg........................................... 24 amiodarone hcl tab 200 mg (Cordarone)...................... 24 amiodarone hcl tab 400 mg........................................... 24 amitriptyline hcl tab 100 mg...........................................32 amitriptyline hcl tab 10 mg............................................ 32 amitriptyline hcl tab 150 mg...........................................32 amitriptyline hcl tab 25 mg............................................ 32 amitriptyline hcl tab 50 mg............................................ 32 amitriptyline hcl tab 75 mg............................................ 32 amlodipine besylate-atorvastatin calcium tab 10-10 mg (Caduet).......................................................................... 20 amlodipine besylate-atorvastatin calcium tab 10-20 mg (Caduet).......................................................................... 20 amlodipine besylate-atorvastatin calcium tab 10-40 mg (Caduet).......................................................................... 20 amlodipine besylate-atorvastatin calcium tab 10-80 mg (Caduet).......................................................................... 20 amlodipine besylate-atorvastatin calcium tab 2.5-10 mg (Caduet)....................................................................20 amlodipine besylate-atorvastatin calcium tab 2.5-20 mg (Caduet)....................................................................20 amlodipine besylate-atorvastatin calcium tab 2.5-40 mg (Caduet)....................................................................20 amlodipine besylate-atorvastatin calcium tab 5-10 mg (Caduet).......................................................................... 20 amlodipine besylate-atorvastatin calcium tab 5-20 mg (Caduet).......................................................................... 20 amlodipine besylate-atorvastatin calcium tab 5-40 mg (Caduet).......................................................................... 21 amlodipine besylate-atorvastatin calcium tab 5-80 mg (Caduet).......................................................................... 21 amlodipine besylate-benazepril hcl cap 10-20 mg (Lotrel).............................................................................21 amlodipine besylate-benazepril hcl cap 10-40 mg (Lotrel).............................................................................21 amlodipine besylate-benazepril hcl cap 2.5-10 mg (Lotrel).............................................................................21 amlodipine besylate-benazepril hcl cap 5-10 mg (Lotrel).............................................................................21 amlodipine besylate-benazepril hcl cap 5-20 mg (Lotrel).............................................................................21 amlodipine besylate-benazepril hcl cap 5-40 mg (Lotrel).............................................................................21 amlodipine besylate tab 10 mg (Norvasc).....................20 amlodipine besylate tab 2.5 mg (Norvasc)....................20 amlodipine besylate tab 5 mg (Norvasc)...................... 20 amoxicillin (trihydrate) cap 250 mg................................. 1 amoxicillin (trihydrate) cap 500 mg................................. 1 amoxicillin (trihydrate) for susp 125 mg/5ml.................. 1 amoxicillin (trihydrate) for susp 200 mg/5ml.................. 1 amoxicillin (trihydrate) for susp 250 mg/5ml.................. 1 amoxicillin (trihydrate) for susp 400 mg/5ml.................. 1 amoxicillin (trihydrate) tab 500 mg..................................1 amoxicillin (trihydrate) tab 875 mg..................................1 amoxicillin & k clavulanate chew tab 200-28.5 mg.........1 amoxicillin & k clavulanate chew tab 400-57 mg............1 amoxicillin & k clavulanate for susp 200-28.5 mg/5ml.............................................................................. 1 amoxicillin & k clavulanate for susp 250-62.5 mg/5ml (Augmentin)......................................................................1 amoxicillin & k clavulanate for susp 400-57 mg/5ml...... 1 amoxicillin & k clavulanate for susp 600-42.9 mg/5ml (Augmentin es-600)......................................................... 1 amoxicillin & k clavulanate tab 250-125 mg................... 1 amoxicillin & k clavulanate tab 500-125 mg (Augmentin)......................................................................1 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 61 2014 amoxicillin & k clavulanate tab 875-125 mg (Augmentin)......................................................................1 amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg (Augmentin xr)................................................................. 1 AMOXICILLIN – amoxicillin (trihydrate) chew tab 125 mg...................................................................................... 1 AMOXICILLIN – amoxicillin (trihydrate) chew tab 250 mg...................................................................................... 1 amphetamine-dextroamphetamine cap sr 24hr 10 mg (Adderall xr)................................................................... 36 amphetamine-dextroamphetamine cap sr 24hr 15 mg (Adderall xr)................................................................... 36 amphetamine-dextroamphetamine cap sr 24hr 20 mg (Adderall xr)................................................................... 36 amphetamine-dextroamphetamine cap sr 24hr 25 mg (Adderall xr)................................................................... 36 amphetamine-dextroamphetamine cap sr 24hr 30 mg (Adderall xr)................................................................... 36 amphetamine-dextroamphetamine cap sr 24hr 5 mg (Adderall xr)................................................................... 36 amphetamine-dextroamphetamine tab 10 mg (Adderall)........................................................................ 36 amphetamine-dextroamphetamine tab 12.5 mg (Adderall)........................................................................ 36 amphetamine-dextroamphetamine tab 15 mg (Adderall)........................................................................ 36 amphetamine-dextroamphetamine tab 20 mg (Adderall)........................................................................ 36 amphetamine-dextroamphetamine tab 30 mg (Adderall)........................................................................ 36 amphetamine-dextroamphetamine tab 5 mg (Adderall)........................................................................ 36 amphetamine-dextroamphetamine tab 7.5 mg (Adderall)........................................................................ 37 AMPICILLIN – ampicillin for susp 125 mg/5ml.................... 1 AMPICILLIN – ampicillin for susp 250 mg/5ml.................... 1 ampicillin cap 250 mg.......................................................1 ampicillin cap 500 mg.......................................................1 anagrelide hcl cap 0.5 mg (Agrylin).............................. 49 anagrelide hcl cap 1 mg................................................. 49 anastrozole tab 1 mg (Arimidex)..................................... 7 ANDRODERM – testosterone td patch 24hr 2 mg/24hr............................................................................10 ANDRODERM – testosterone td patch 24hr 4 mg/24hr............................................................................10 ANDROGEL PUMP – testosterone td gel 12.5 mg/act (1%)................................................................................. 10 ANDROGEL PUMP – testosterone td gel 20.25 mg/act (1.62%)............................................................................ 10 ANDROGEL – testosterone td gel 20.25 mg/1.25gm (1.62%)............................................................................ 10 ANDROGEL – testosterone td gel 25 mg/2.5gm (1%)...... 10 ANDROGEL – testosterone td gel 40.5 mg/2.5gm (1.62%)............................................................................ 10 ANDROGEL – testosterone td gel 50 mg/5gm (1%)......... 10 ANDROXY – fluoxymesterone tab 10 mg......................... 10 62 ANORO ELLIPTA – umeclidinium-vilanterol aero powd ba 62.5-25 mcg/inh............................................................... 26 ANTIPYRINE/BENZOCAINE – antipyrine-benzocaine otic soln 55-14 mg/ml (5.5-1.4%)........................................... 52 antipyrine-benzocaine otic soln 54-14 mg/ml (5.4-1.4%)........................................................................ 52 antipyrine-benzocaine otic soln 55-14 mg/ml (5.5-1.4%) (Auralgan)....................................................................... 52 antipyrine-benzocaine-polycosanol otic sol 5.4-1.4-0.0097% (Treagan otic)..................................... 52 apraclonidine hcl ophth soln 0.5% (base equivalent) (Iopidine).........................................................................51 APTIVUS – tipranavir cap 250 mg......................................4 APTIVUS – tipranavir oral soln 100 mg/ml......................... 4 ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 100 mcg/0.5ml............................ 49 ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 100 mcg/ml.................................49 ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 150 mcg/0.3ml............................ 49 ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 150 mcg/0.75ml.......................... 49 ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 200 mcg/0.4ml............................ 49 ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 200 mcg/ml.................................49 ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 25 mcg/0.42ml............................ 49 ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 25 mcg/ml...................................49 ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 300 mcg/0.6ml............................ 49 ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 300 mcg/ml.................................49 ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 40 mcg/0.4ml.............................. 49 ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 40 mcg/ml...................................49 ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 500 mcg/ml.................................49 ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 60 mcg/0.3ml.............................. 49 ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 60 mcg/ml...................................49 ASACOL HD – mesalamine tab delayed release 800 mg.................................................................................... 30 ASACOL – mesalamine tab delayed release 400 mg....... 30 ASCENSIA AUTODISC LOW AND – blood glucose calibration - liquid............................................................ 57 ASCENSIA AUTODISC NORMAL – blood glucose calibration - liquid - normal.............................................. 57 ASCENSIA AUTODISC TEST ST – glucose blood test disk...................................................................................57 ASMANEX TWISTHALER 120 ME – mometasone furoate inhal powd 220 mcg/inh (breath activated)......................26 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 2014 ASMANEX TWISTHALER 14 MET – mometasone furoate inhal powd 220 mcg/inh (breath activated)......................26 ASMANEX TWISTHALER 30 ME – mometasone furoate inhal powd 220 mcg/inh (breath activated)......................27 ASMANEX TWISTHALER 30 MET – mometasone furoate inhal powd 110 mcg/inh (breath activated)......................27 ASMANEX TWISTHALER 60 MET – mometasone furoate inhal powd 220 mcg/inh (breath activated)......................27 ASTEPRO – azelastine hcl nasal spray 0.15% (205.5 mcg/spray)....................................................................... 26 atenolol & chlorthalidone tab 100-25 mg (Tenoretic 100)..................................................................................19 atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50)....................................................................................19 atenolol tab 100 mg (Tenormin).....................................19 atenolol tab 25 mg (Tenormin).......................................19 atenolol tab 50 mg (Tenormin).......................................19 atorvastatin calcium tab 10 mg (base equivalent) (Lipitor)........................................................................... 22 atorvastatin calcium tab 20 mg (base equivalent) (Lipitor)........................................................................... 22 atorvastatin calcium tab 40 mg (base equivalent) (Lipitor)........................................................................... 22 atorvastatin calcium tab 80 mg (base equivalent) (Lipitor)........................................................................... 23 atovaquone-proguanil hcl tab 250-100 mg (Malarone).........................................................................6 atovaquone-proguanil hcl tab 62.5-25 mg (Malarone).........................................................................6 atovaquone susp 750 mg/5ml (Mepron)..........................6 ATRIPLA – efavirenz-emtricitabine-tenofovir df tab 600-200-300 mg................................................................ 4 ATROPINE SULFATE – atropine sulfate ophth oint 1%....................................................................................52 atropine sulfate ophth soln 1% (Isopto atropine)......... 52 ATROVENT HFA – ipratropium bromide hfa inhal aerosol 17 mcg/act....................................................................... 27 AUGMENTIN – amoxicillin & k clavulanate for susp 125-31.25 mg/5ml..............................................................1 AVODART – dutasteride cap 0.5 mg................................ 31 azathioprine tab 50 mg (Imuran)....................................58 azelastine hcl nasal spray 0.15% (205.5 mcg/spray) (Astepro)......................................................................... 26 azelastine hcl nasal spray 137 mcg/spray (1 mg/ ml)....................................................................................26 azelastine hcl ophth soln 0.05% (Optivar).................... 52 AZILECT – rasagiline mesylate tab 0.5 mg (base equiv)............................................................................... 46 AZILECT – rasagiline mesylate tab 1 mg (base equiv)..... 46 AZITHROMYCIN – azithromycin powd pack for susp 1 gm...................................................................................... 2 azithromycin for susp 100 mg/5ml (Zithromax)..............2 azithromycin for susp 200 mg/5ml (Zithromax)..............2 azithromycin tab 250 mg (Zithromax)............................. 2 azithromycin tab 500 mg (Zithromax)............................. 2 azithromycin tab 600 mg (Zithromax)............................. 2 AZOPT – brinzolamide ophth susp 1%............................. 51 B BACITRACIN – bacitracin ophth oint 500 unit/gm.............51 bacitracin-polymyxin b ophth oint.................................51 bacitracin-polymyxin-neomycin-hc ophth oint 1%.......51 baclofen tab 10 mg......................................................... 47 baclofen tab 20 mg......................................................... 47 BACTROBAN NASAL – mupirocin calcium nasal oint 2%....................................................................................26 balsalazide disodium cap 750 mg (Colazal)..................30 BARACLUDE – entecavir oral soln 0.05 mg/ml.................. 4 BARACLUDE – entecavir tab 0.5 mg................................. 4 BARACLUDE – entecavir tab 1 mg.................................... 4 BAYER BREEZE 2 BLOOD GLUC – blood glucose monitoring kit w/ device...................................................57 BAYER BREEZE 2 HIGH CONTR – blood glucose calibration - liquid - high.................................................. 57 BAYER BREEZE 2 LOW CONTRO – blood glucose calibration - liquid - low................................................... 57 BAYER BREEZE 2 NORMAL CON – blood glucose calibration - liquid - normal.............................................. 57 BAYER BREEZE 2 TEST DISC – glucose blood test disk...................................................................................57 BAYER CONTOUR BLOOD GLUCO – blood glucose monitoring devices...........................................................57 BAYER CONTOUR BLOOD GLUCO – blood glucose monitoring kit w/ device...................................................57 BAYER CONTOUR BLOOD GLUCO – glucose blood test strip.................................................................................. 57 BAYER CONTOUR HIGH CONTRO – blood glucose calibration - liquid - high.................................................. 57 BAYER CONTOUR LINK BLOOD – blood glucose monitoring kit w/ device...................................................57 BAYER CONTOUR LOW CONTROL – blood glucose calibration - liquid - low................................................... 57 BAYER CONTOUR NEXT BLOOD – blood glucose monitoring kit w/ device...................................................57 BAYER CONTOUR NEXT BLOOD – glucose blood test strip.................................................................................. 57 BAYER CONTOUR NEXT CONTRO – blood glucose calibration - liquid - low................................................... 57 BAYER CONTOUR NEXT CONTRO – blood glucose calibration - liquid - normal.............................................. 57 BAYER CONTOUR NEXT EZ BLO – blood glucose monitoring kit w/ device...................................................57 BAYER CONTOUR NEXT LINK B – blood glucose monitoring kit w/ device...................................................58 BAYER CONTOUR NEXT USB BL – blood glucose monitoring kit w/ device...................................................58 BAYER CONTOUR NORMAL CONT – blood glucose calibration - liquid - normal.............................................. 58 BAYER CONTOUR USB BLOOD G – blood glucose monitoring kit w/ device...................................................58 benazepril & hydrochlorothiazide tab 10-12.5 mg (Lotensin hct)................................................................. 17 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 63 2014 benazepril & hydrochlorothiazide tab 20-12.5 mg (Lotensin hct)................................................................. 17 benazepril & hydrochlorothiazide tab 20-25 mg (Lotensin hct)................................................................. 17 benazepril & hydrochlorothiazide tab 5-6.25 mg..........17 benazepril hcl tab 10 mg (Lotensin).............................. 17 benazepril hcl tab 20 mg (Lotensin).............................. 17 benazepril hcl tab 40 mg (Lotensin).............................. 17 benazepril hcl tab 5 mg.................................................. 17 benzoyl peroxide-erythromycin gel 5-3% (Benzamycin)..................................................................53 benztropine mesylate tab 0.5 mg...................................46 benztropine mesylate tab 1 mg..................................... 46 benztropine mesylate tab 2 mg..................................... 46 betamethasone dipropionate augmented cream 0.05% (Diprolene af)................................................................. 54 betamethasone dipropionate augmented gel 0.05%...............................................................................54 betamethasone dipropionate augmented lotion 0.05% (Diprolene)...................................................................... 54 betamethasone dipropionate augmented oint 0.05% (Diprolene)...................................................................... 54 betamethasone dipropionate cream 0.05%...................54 betamethasone dipropionate lotion 0.05%................... 54 betamethasone dipropionate oint 0.05%...................... 55 betamethasone valerate aerosol foam 0.12% (Luxiq)............................................................................. 55 betamethasone valerate cream 0.1%.............................55 betamethasone valerate lotion 0.1%............................. 55 betamethasone valerate oint 0.1%.................................55 BETASERON – interferon beta-1b for inj kit 0.3 mg..........37 betaxolol hcl ophth soln 0.5%....................................... 51 bethanechol chloride tab 10 mg (Urecholine)...............31 bethanechol chloride tab 25 mg (Urecholine)...............31 bethanechol chloride tab 50 mg (Urecholine)...............31 bethanechol chloride tab 5 mg (Urecholine)................ 31 bicalutamide tab 50 mg (Casodex).................................. 7 BILTRICIDE – praziquantel tab 600 mg..............................6 bisoprolol & hydrochlorothiazide tab 10-6.25 mg (Ziac)............................................................................... 19 bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg (Ziac)............................................................................... 19 bisoprolol & hydrochlorothiazide tab 5-6.25 mg (Ziac)............................................................................... 19 bisoprolol fumarate tab 10 mg (Zebeta)........................19 bisoprolol fumarate tab 5 mg (Zebeta)..........................19 BOSULIF – bosutinib tab 100 mg....................................... 7 BOSULIF – bosutinib tab 500 mg....................................... 7 BREEZE 2 BLOOD GLUCOSE MO – blood glucose monitoring devices...........................................................58 BREO ELLIPTA – fluticasone furoate-vilanterol aero powd ba 100-25 mcg/inh...........................................................27 brimonidine tartrate ophth soln 0.15% (Alphagan p)......................................................................................51 brimonidine tartrate ophth soln 0.2%............................51 bromocriptine mesylate cap 5 mg (Parlodel)................46 64 bromocriptine mesylate tab 2.5 mg (Parlodel)..............46 budesonide cap sr 24hr 3 mg (Entocort ec)................. 10 budesonide inhalation susp 0.25 mg/2ml (Pulmicort)...................................................................... 27 budesonide inhalation susp 0.5 mg/2ml (Pulmicort)...................................................................... 27 bumetanide tab 0.5 mg................................................... 24 bumetanide tab 1 mg...................................................... 24 bumetanide tab 2 mg...................................................... 24 BUPAP – butalbital-acetaminophen tab 50-650 mg.......... 39 buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv).............................................................................. 39 buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv).............................................................................. 39 buprenorphine hcl sl tab 2 mg (base equiv)................. 39 buprenorphine hcl sl tab 8 mg (base equiv)................. 39 bupropion hcl (smoking deterrent) tab sr 12hr 150 mg (Zyban)............................................................................ 38 bupropion hcl tab 100 mg (Wellbutrin)......................... 33 bupropion hcl tab 75 mg (Wellbutrin)........................... 33 bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr)........ 32 bupropion hcl tab sr 12hr 150 mg (Wellbutrin sr)........ 32 bupropion hcl tab sr 12hr 200 mg (Wellbutrin sr)........ 32 bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl).........32 bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl).........33 buspirone hcl tab 10 mg................................................ 32 buspirone hcl tab 15 mg................................................ 32 buspirone hcl tab 30 mg................................................ 32 buspirone hcl tab 5 mg.................................................. 32 buspirone hcl tab 7.5 mg............................................... 32 BUTALBITAL/ASPIRIN/CAFFEI – butalbital-aspirincaffeine tab 50-325-40 mg.............................................. 39 butalbital-acetaminophen-caffeine cap 50-300-40 mg (Fioricet)..........................................................................39 butalbital-acetaminophen-caffeine cap 50-325-40 mg....................................................................................39 butalbital-acetaminophen-caffeine tab 50-325-40 mg....................................................................................39 butalbital-acetaminophen-caffeine tab 50-500-40 mg....................................................................................39 butalbital-acetaminophen-caff w/ cod cap 50-300-40-30 mg (Fioricet/codeine).................................................... 39 butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg....................................................................................39 butalbital-acetaminophen tab 50-325 mg...................... 39 butalbital-acetaminophen tab 50-650 mg...................... 39 butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal)..........................................................................39 butalbital-aspirin-caffeine tab 50-325-40 mg.................39 butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg (Fiorinal/codeine #3)......................................................39 butorphanol tartrate nasal soln 10 mg/ml.....................39 BYDUREON – exenatide extended release for inj susp 2 mg.................................................................................... 13 BYDUREON – exenatide extended release for susp peninjector 2 mg....................................................................13 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 2014 BYETTA – exenatide soln pen-injector 10 mcg/0.04ml..... 13 BYETTA – exenatide soln pen-injector 5 mcg/0.02ml....... 13 C cabergoline tab 0.5 mg................................................... 16 caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv) (Cafcit).................................................................37 calcipotriene cream 0.005% (Dovonex).........................56 calcipotriene oint 0.005%............................................... 56 calcipotriene soln 0.005% (50 mcg/ml)..........................56 calcitonin (salmon) nasal soln 200 unit/act (Miacalcin)...................................................................... 16 calcitriol cap 0.25 mcg (Rocaltrol).................................16 calcitriol cap 0.5 mcg (Rocaltrol)...................................16 calcitriol oral soln 1 mcg/ml (Rocaltrol)........................16 calcium acetate (phosphate binder) cap 667 mg (169 mg ca) (Phoslo)............................................................. 30 calcium acetate (phosphate binder) tab 667 mg (Eliphos)..........................................................................30 CANASA – mesalamine suppos 1000 mg........................ 30 candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg (Atacand hct)........................................................... 18 candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg (Atacand hct)........................................................... 18 candesartan cilexetil-hydrochlorothiazide tab 32-25 mg (Atacand hct)........................................................... 18 candesartan cilexetil tab 16 mg (Atacand)....................18 candesartan cilexetil tab 32 mg (Atacand)....................18 candesartan cilexetil tab 4 mg (Atacand)......................18 candesartan cilexetil tab 8 mg (Atacand)......................18 capecitabine tab 150 mg (Xeloda)................................... 7 capecitabine tab 500 mg (Xeloda)................................... 7 CAPRELSA – vandetanib tab 100 mg................................ 7 CAPRELSA – vandetanib tab 300 mg................................ 7 CAPTOPRIL/HYDROCHLOROTHIA – captopril & hydrochlorothiazide tab 25-15 mg................................... 17 CAPTOPRIL/HYDROCHLOROTHIA – captopril & hydrochlorothiazide tab 25-25 mg................................... 17 CAPTOPRIL/HYDROCHLOROTHIA – captopril & hydrochlorothiazide tab 50-15 mg................................... 17 CAPTOPRIL/HYDROCHLOROTHIA – captopril & hydrochlorothiazide tab 50-25 mg................................... 17 captopril tab 100 mg....................................................... 17 captopril tab 12.5 mg...................................................... 17 captopril tab 25 mg......................................................... 17 captopril tab 50 mg......................................................... 17 CARAC – fluorouracil cream 0.5%....................................56 CARAFATE – sucralfate susp 1 gm/10ml......................... 28 carbamazepine cap sr 12hr 100 mg (Carbatrol)............44 carbamazepine cap sr 12hr 200 mg (Carbatrol)............44 carbamazepine cap sr 12hr 300 mg (Carbatrol)............44 carbamazepine chew tab 100 mg.................................. 44 carbamazepine susp 100 mg/5ml (Tegretol)................. 44 carbamazepine tab 200 mg (Tegretol)........................... 44 carbamazepine tab sr 12hr 200 mg (Tegretol-xr)..........44 carbamazepine tab sr 12hr 400 mg (Tegretol-xr)..........44 CARBIDOPA/LEVODOPA/ENTACA – carbidopalevodopa-entacapone tabs 12.5-50-200 mg.................... 46 CARBIDOPA/LEVODOPA/ENTACA – carbidopalevodopa-entacapone tabs 18.75-75-200 mg.................. 46 CARBIDOPA/LEVODOPA/ENTACA – carbidopalevodopa-entacapone tabs 25-100-200 mg..................... 46 CARBIDOPA/LEVODOPA/ENTACA – carbidopalevodopa-entacapone tabs 31.25-125-200 mg................ 46 CARBIDOPA/LEVODOPA/ENTACA – carbidopalevodopa-entacapone tabs 37.5-150-200 mg.................. 46 CARBIDOPA/LEVODOPA/ENTACA – carbidopalevodopa-entacapone tabs 50-200-200 mg..................... 46 carbidopa & levodopa orally disintegrating tab 10-100 mg....................................................................................46 carbidopa & levodopa orally disintegrating tab 25-100 mg....................................................................................46 carbidopa & levodopa orally disintegrating tab 25-250 mg....................................................................................46 carbidopa & levodopa tab 10-100 mg (Sinemet)...........46 carbidopa & levodopa tab 25-100 mg (Sinemet)...........46 carbidopa & levodopa tab 25-250 mg (Sinemet)...........46 carbidopa & levodopa tab cr 25-100 mg (Sinemet cr).................................................................................... 46 carbidopa & levodopa tab cr 50-200 mg (Sinemet cr).................................................................................... 46 carteolol hcl ophth soln 1%........................................... 51 carvedilol tab 12.5 mg (Coreg).......................................19 carvedilol tab 25 mg (Coreg)..........................................19 carvedilol tab 3.125 mg (Coreg).....................................19 carvedilol tab 6.25 mg (Coreg).......................................19 CEENU – lomustine cap 100 mg........................................ 7 CEENU – lomustine cap 10 mg.......................................... 7 CEENU – lomustine cap 40 mg.......................................... 7 cefaclor cap 250 mg......................................................... 1 cefaclor cap 500 mg......................................................... 1 cefadroxil cap 500 mg...................................................... 1 cefadroxil for susp 250 mg/5ml....................................... 1 cefadroxil for susp 500 mg/5ml....................................... 1 cefadroxil tab 1 gm........................................................... 1 cefdinir cap 300 mg.......................................................... 1 cefdinir for susp 125 mg/5ml........................................... 1 cefdinir for susp 250 mg/5ml........................................... 1 cefpodoxime proxetil for susp 100 mg/5ml.................... 1 cefpodoxime proxetil for susp 50 mg/5ml...................... 1 cefpodoxime proxetil tab 100 mg.................................... 1 cefpodoxime proxetil tab 200 mg.................................... 1 cefprozil for susp 125 mg/5ml......................................... 1 cefprozil for susp 250 mg/5ml......................................... 1 cefprozil tab 250 mg......................................................... 1 cefprozil tab 500 mg......................................................... 1 cefuroxime axetil for susp 125 mg/5ml (Ceftin)..............2 cefuroxime axetil tab 250 mg (Ceftin)............................. 2 cefuroxime axetil tab 500 mg (Ceftin)............................. 2 CELEBREX – celecoxib cap 100 mg................................ 42 CELEBREX – celecoxib cap 200 mg................................ 42 CELEBREX – celecoxib cap 400 mg................................ 42 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 65 2014 CELEBREX – celecoxib cap 50 mg.................................. 42 CELLCEPT – mycophenolate mofetil for oral susp 200 mg/ ml..................................................................................... 58 CELONTIN – methsuximide cap 300 mg.......................... 44 cephalexin cap 250 mg (Keflex).......................................2 cephalexin cap 500 mg (Keflex).......................................2 cephalexin for susp 125 mg/5ml......................................2 cephalexin for susp 250 mg/5ml......................................2 CETROTIDE – cetrorelix acetate for inj kit 0.25 mg.......... 13 CETROTIDE – cetrorelix acetate for inj kit 3 mg...............13 cevimeline hcl cap 30 mg (Evoxac)...............................52 CHANTIX CONTINUING MONTH – varenicline tartrate tab 1 mg (base equiv)........................................................... 38 CHANTIX STARTING MONTH PA – varenicline tartrate tab 0.5 mg x 11 & tab 1 mg x 42 pack............................ 38 CHANTIX – varenicline tartrate tab 0.5 mg (base equiv)............................................................................... 38 CHANTIX – varenicline tartrate tab 1 mg (base equiv)......38 CHEMET – succimer cap 100 mg.................................... 58 CHEMSTRIP-K – acetone (urine) test strip.......................58 CHEMSTRIP UGK – urine glucose-ketones test strips..... 58 CHENODAL – chenodiol tab 250 mg................................30 chlordiazepoxide hcl cap 10 mg.................................... 32 chlordiazepoxide hcl cap 25 mg.................................... 32 chlordiazepoxide hcl cap 5 mg......................................32 chlorhexidine gluconate soln 0.12% (Peridex)............. 53 chloroquine phosphate tab 250 mg.................................6 chloroquine phosphate tab 500 mg (Aralen).................. 6 CHLOROTHIAZIDE – chlorothiazide tab 250 mg..............24 chlorothiazide tab 250 mg.............................................. 24 chlorothiazide tab 500 mg.............................................. 24 chlorpromazine hcl tab 100 mg..................................... 34 chlorpromazine hcl tab 10 mg....................................... 34 chlorpromazine hcl tab 200 mg..................................... 34 chlorpromazine hcl tab 25 mg....................................... 34 chlorpromazine hcl tab 50 mg....................................... 34 CHLORTHALIDONE – chlorthalidone tab 25 mg.............. 24 CHLORTHALIDONE – chlorthalidone tab 50 mg.............. 24 chlorzoxazone tab 500 mg (Parafon forte dsc).............47 cholestyramine light powder 4 gm/dose (Questran light)................................................................................ 23 cholestyramine light powder packets 4 gm..................23 cholestyramine powder 4 gm/dose (Questran)............ 23 cholestyramine powder packets 4 gm (Questran)........23 choline fenofibrate cap dr 135 mg (fenofibric acid equiv) (Trilipix)............................................................... 23 choline fenofibrate cap dr 45 mg (fenofibric acid equiv) (Trilipix)............................................................... 23 chorionic gonadotropin for inj 10000 unit.................... 13 ciclopirox gel 0.77% (Loprox)........................................ 54 ciclopirox olamine cream 0.77% (base equiv).............. 54 ciclopirox olamine susp 0.77% (base equiv)................ 54 ciclopirox shampoo 1% (Loprox shampoo)..................54 ciclopirox solution 8% (Penlac nail lacquer)................ 54 cilostazol tab 100 mg (Pletal).........................................50 cilostazol tab 50 mg (Pletal)...........................................50 66 CILOXAN – ciprofloxacin hcl ophth oint 0.3%................... 51 cimetidine hcl soln 300 mg/5ml..................................... 28 cimetidine tab 200 mg.................................................... 28 cimetidine tab 300 mg.................................................... 28 cimetidine tab 400 mg.................................................... 28 cimetidine tab 800 mg.................................................... 28 CIPRODEX – ciprofloxacin-dexamethasone otic susp 0.3-0.1%...........................................................................52 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq) (Cipro xr)....................................................3 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq) (Cipro xr)......................................................... 3 ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) (Cipro)............................................................ 3 ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) (Cipro)............................................................ 3 ciprofloxacin hcl ophth soln 0.3% (Ciloxan).................51 ciprofloxacin hcl tab 100 mg (base equiv)......................3 ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)......... 3 ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)......... 3 ciprofloxacin hcl tab 750 mg (base equiv)......................3 CIPRO HC – ciprofloxacin-hydrocortisone otic susp 0.2-1%..............................................................................52 citalopram hydrobromide oral soln 10 mg/5ml.............33 citalopram hydrobromide tab 10 mg (base equiv) (Celexa)........................................................................... 33 citalopram hydrobromide tab 20 mg (base equiv) (Celexa)........................................................................... 33 citalopram hydrobromide tab 40 mg (base equiv) (Celexa)........................................................................... 33 CLARAVIS – isotretinoin cap 30 mg................................. 53 clarithromycin for susp 125 mg/5ml................................2 clarithromycin for susp 250 mg/5ml (Biaxin)..................2 clarithromycin tab 250 mg (Biaxin)................................. 2 clarithromycin tab 500 mg (Biaxin)................................. 2 clarithromycin tab sr 24hr 500 mg (Biaxin xl pac)..........2 CLEOCIN – clindamycin phosphate vaginal suppos 100 mg.................................................................................... 31 CLIMARA PRO – estradiol-levonorgestrel td patch weekly 0.045-0.015 mg/day.........................................................11 clindamycin hcl cap 150 mg (Cleocin)............................ 6 clindamycin hcl cap 300 mg (Cleocin)............................ 6 clindamycin hcl cap 75 mg (Cleocin).............................. 6 clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) (Cleocin pediatric gr)...........................................7 clindamycin phosphate-benzoyl peroxide gel 1-5% (Benzaclin)......................................................................53 clindamycin phosphate foam 1% (Evoclin).................. 53 clindamycin phosphate gel 1% (Cleocin-t)................... 53 clindamycin phosphate lotion 1% (Cleocin-t)...............53 clindamycin phosphate soln 1% (Cleocin-t)................. 53 clindamycin phosphate swab 1% (Cleocin-t)................53 clindamycin phosphate vaginal cream 2% (Cleocin)..........................................................................31 clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% (Duac)..................................................................53 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 2014 clobetasol propionate cream 0.05% (Temovate).......... 55 clobetasol propionate emollient base cream 0.05% (Temovate e).................................................................. 55 clobetasol propionate emulsion foam 0.05% (Oluxe)......................................................................................55 clobetasol propionate foam 0.05% (Olux).....................55 clobetasol propionate gel 0.05% (Temovate)................55 clobetasol propionate lotion 0.05% (Clobex)................55 clobetasol propionate oint 0.05% (Temovate).............. 55 clobetasol propionate shampoo 0.05% (Clobex)..........55 clobetasol propionate soln 0.05% (Temovate)............. 55 clomiphene citrate tab 50 mg (Clomid)......................... 13 clomipramine hcl cap 25 mg (Anafranil)....................... 33 clomipramine hcl cap 50 mg (Anafranil)....................... 33 clomipramine hcl cap 75 mg (Anafranil)....................... 33 clonazepam orally disintegrating tab 0.125 mg............44 clonazepam orally disintegrating tab 0.25 mg..............44 clonazepam orally disintegrating tab 0.5 mg................44 clonazepam orally disintegrating tab 1 mg...................44 clonazepam orally disintegrating tab 2 mg...................44 clonazepam tab 0.5 mg (Klonopin)................................44 clonazepam tab 1 mg (Klonopin)...................................44 clonazepam tab 2 mg (Klonopin)...................................44 clonidine hcl tab 0.1 mg (Catapres).............................. 25 clonidine hcl tab 0.2 mg (Catapres).............................. 25 clonidine hcl tab 0.3 mg (Catapres).............................. 25 clonidine hcl tab sr 12hr 0.1 mg (Kapvay).................... 37 clonidine hcl td patch weekly 0.1 mg/24hr (Cataprestts-1)................................................................................ 25 clonidine hcl td patch weekly 0.2 mg/24hr (Cataprestts-2)................................................................................ 25 clonidine hcl td patch weekly 0.3 mg/24hr (Cataprestts-3)................................................................................ 25 clopidogrel bisulfate tab 75 mg (base equiv) (Plavix)............................................................................ 50 clorazepate dipotassium tab 15 mg (Tranxene t)......... 32 clorazepate dipotassium tab 3.75 mg (Tranxene t)...... 32 clorazepate dipotassium tab 7.5 mg (Tranxene t)........ 32 clotrimazole troche 10 mg..............................................53 clotrimazole w/ betamethasone cream 1-0.05% (Lotrisone)...................................................................... 54 clotrimazole w/ betamethasone lotion 1-0.05%............ 54 clozapine tab 100 mg (Clozaril)..................................... 34 clozapine tab 200 mg......................................................34 clozapine tab 25 mg (Clozaril)....................................... 34 clozapine tab 50 mg........................................................34 COARTEM – artemether-lumefantrine tab 20-120 mg........ 6 CODEINE SULFATE – codeine sulfate tab 15 mg............39 CODEINE SULFATE – codeine sulfate tab 30 mg............39 CODEINE SULFATE – codeine sulfate tab 60 mg............39 colchicine w/ probenecid tab 0.5-500 mg......................44 colestipol hcl granule packets 5 gm (Colestid flavored)..........................................................................23 colestipol hcl granules 5 gm (Colestid flavored)..........23 colestipol hcl tab 1 gm (Colestid)..................................23 COMBIVENT – ipratropium-albuterol aerosol 18-103 mcg/ act (20-120mcg/act).........................................................27 COMBIVENT RESPIMAT – ipratropium-albuterol inhal aerosol soln 20-100 mcg/act........................................... 27 COMETRIQ – cabozantinib s-malate cap 3 x 20 mg (60 mg dose) kit.......................................................................7 COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 1 x 20 mg (100 dose) kit.............................................................. 7 COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 3 x 20 mg (140 dose) kit.............................................................. 7 COMPLERA – emtricitabine-rilpivirine-tenofovir df tab 200-25-300 mg.................................................................. 4 COPAXONE – glatiramer acetate inj kit 20 mg/ml............ 37 COPAXONE – glatiramer acetate soln prefilled syringe 40 mg/ml............................................................................... 37 CORTIFOAM – hydrocortisone acetate rectal foam 90 mg/ dose................................................................................. 53 CORTISONE ACETATE – cortisone acetate tab 25 mg.................................................................................... 10 CREON – pancrelipase (lip-prot-amyl) dr cap 12000-38000-60000 unit..................................................30 CREON – pancrelipase (lip-prot-amyl) dr cap 24000-76000-120000 unit................................................30 CREON – pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000 unit......................................................29 CREON – pancrelipase (lip-prot-amyl) dr cap 36000-114000-180000 unit..............................................30 CREON – pancrelipase (lip-prot-amyl) dr cap 6000-19000-30000 unit....................................................29 CRESTOR – rosuvastatin calcium tab 10 mg................... 23 CRESTOR – rosuvastatin calcium tab 20 mg................... 23 CRESTOR – rosuvastatin calcium tab 40 mg................... 23 CRESTOR – rosuvastatin calcium tab 5 mg..................... 23 CRIXIVAN – indinavir sulfate cap 200 mg.......................... 4 CRIXIVAN – indinavir sulfate cap 400 mg.......................... 5 cromolyn sodium ophth soln 4%...................................52 cromolyn sodium oral conc 100 mg/5ml (Gastrocrom).................................................................. 30 cromolyn sodium soln nebu 20 mg/2ml........................27 CUPRIMINE – penicillamine cap 250 mg......................... 58 cyclobenzaprine hcl tab 10 mg......................................47 cyclobenzaprine hcl tab 5 mg........................................47 cyclopentolate hcl ophth soln 1% (Cyclogyl)............... 52 CYCLOPHOSPHAMIDE – cyclophosphamide cap 25 mg...................................................................................... 7 CYCLOPHOSPHAMIDE – cyclophosphamide cap 50 mg...................................................................................... 7 CYCLOPHOSPHAMIDE – cyclophosphamide tab 25 mg...................................................................................... 7 CYCLOPHOSPHAMIDE – cyclophosphamide tab 50 mg...................................................................................... 7 cyclosporine cap 100 mg (Sandimmune)......................58 cyclosporine cap 25 mg (Sandimmune)........................58 cyclosporine modified cap 100 mg (Neoral)................. 58 cyclosporine modified cap 25 mg (Neoral)................... 58 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 67 2014 cyclosporine modified oral soln 100 mg/ml (Neoral)........................................................................... 58 cyproheptadine hcl syrup 2 mg/5ml..............................26 cyproheptadine hcl tab 4 mg......................................... 26 CYSTAGON – cysteamine bitartrate cap 150 mg............. 31 CYSTAGON – cysteamine bitartrate cap 50 mg............... 31 CYTRA-3 – pot & sod citrates w/ cit ac syrup 550-500-334 mg/5ml............................................................................. 31 CYTRA-K – potassium citrate & citric acid soln 1100-334 mg/5ml............................................................................. 31 D danazol cap 100 mg........................................................ 10 danazol cap 200 mg........................................................ 10 danazol cap 50 mg..........................................................10 dantrolene sodium cap 25 mg (Dantrium).................... 47 dantrolene sodium cap 50 mg (Dantrium).................... 47 DANTROLENE SODIUM – dantrolene sodium cap 100 mg.................................................................................... 47 DAPSONE – dapsone tab 100 mg..................................... 7 DAPSONE – dapsone tab 25 mg....................................... 7 DARAPRIM – pyrimethamine tab 25 mg.............................6 DELZICOL – mesalamine cap dr 400 mg......................... 30 demeclocycline hcl tab 150 mg....................................... 2 demeclocycline hcl tab 300 mg....................................... 2 desipramine hcl tab 100 mg (Norpramin)......................33 desipramine hcl tab 10 mg (Norpramin)....................... 33 desipramine hcl tab 150 mg (Norpramin)......................33 desipramine hcl tab 25 mg (Norpramin)....................... 33 desipramine hcl tab 50 mg (Norpramin)....................... 33 desipramine hcl tab 75 mg (Norpramin)....................... 33 desmopressin acetate nasal soln 0.01% (refrigerated) (Ddavp)............................................................................16 desmopressin acetate nasal spray soln 0.01% (Ddavp)............................................................................16 desmopressin acetate nasal spray soln 0.01% (refrigerated)...................................................................16 desmopressin acetate tab 0.1 mg (Ddavp)................... 16 desmopressin acetate tab 0.2 mg (Ddavp)................... 17 desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5) (Mircette).........................................................12 desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg-mg (Cyclessa)....................................................................... 12 desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg (Desogen)....................................................................... 12 desonide cream 0.05% (Desowen).................................55 desonide lotion 0.05% (Desowen)................................. 55 desonide oint 0.05% (Desowen).................................... 55 desoximetasone cream 0.25% (Topicort)......................55 DESOXIMETASONE – desoximetasone cream 0.05%.....55 desoximetasone gel 0.05% (Topicort)........................... 55 desoximetasone oint 0.25% (Topicort)..........................55 DEXAMETHASONE – dexamethasone soln 0.5 mg/5ml............................................................................. 10 DEXAMETHASONE – dexamethasone tab 1 mg............. 10 68 DEXAMETHASONE – dexamethasone tab 2 mg............. 10 dexamethasone elixir 0.5 mg/5ml.................................. 10 DEXAMETHASONE INTENSOL – dexamethasone conc 1 mg/ml............................................................................... 10 dexamethasone sodium phosphate ophth soln 0.1%.................................................................................51 dexamethasone tab 0.5 mg............................................ 10 dexamethasone tab 0.75 mg.......................................... 10 dexamethasone tab 1.5 mg............................................ 10 dexamethasone tab 4 mg............................................... 10 dexamethasone tab 6 mg............................................... 10 dexmethylphenidate hcl cap sr 24 hr 15 mg (Focalin xr).................................................................................... 37 dexmethylphenidate hcl cap sr 24 hr 30 mg (Focalin xr).................................................................................... 37 dexmethylphenidate hcl cap sr 24 hr 40 mg (Focalin xr).................................................................................... 37 dexmethylphenidate hcl tab 10 mg (Focalin)................37 dexmethylphenidate hcl tab 2.5 mg (Focalin)...............37 dexmethylphenidate hcl tab 5 mg (Focalin)..................37 dextroamphetamine sulfate cap sr 24hr 10 mg (Dexedrine)..................................................................... 37 dextroamphetamine sulfate cap sr 24hr 15 mg (Dexedrine)..................................................................... 37 dextroamphetamine sulfate cap sr 24hr 5 mg (Dexedrine)..................................................................... 37 dextroamphetamine sulfate tab 10 mg..........................37 dextroamphetamine sulfate tab 5 mg............................37 DIASTAT ACUDIAL – diazepam rectal gel delivery system 10 mg...............................................................................44 DIASTAT ACUDIAL – diazepam rectal gel delivery system 20 mg...............................................................................44 DIASTAT PEDIATRIC – diazepam rectal gel delivery system 2.5 mg................................................................. 44 DIAZEPAM – diazepam soln 1 mg/ml...............................32 diazepam tab 10 mg (Valium).........................................32 diazepam tab 2 mg (Valium)...........................................32 diazepam tab 5 mg (Valium)...........................................32 DIBENZYLINE – phenoxybenzamine hcl cap 10 mg........ 25 diclofenac potassium tab 50 mg (Cataflam)................. 42 diclofenac sodium (actinic keratoses) gel 3% (Solaraze)........................................................................56 diclofenac sodium ophth soln 0.1%.............................. 52 diclofenac sodium tab delayed release 25 mg............. 42 diclofenac sodium tab delayed release 50 mg............. 42 diclofenac sodium tab delayed release 75 mg............. 42 diclofenac sodium tab sr 24hr 100 mg (Voltarenxr).................................................................................... 42 diclofenac w/ misoprostol tab delayed release 50-0.2 mg (Arthrotec 50).......................................................... 42 diclofenac w/ misoprostol tab delayed release 75-0.2 mg (Arthrotec 75).......................................................... 42 dicloxacillin sodium cap 250 mg..................................... 1 dicloxacillin sodium cap 500 mg..................................... 1 dicyclomine hcl cap 10 mg (Bentyl).............................. 28 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 2014 DICYCLOMINE HCL – dicyclomine hcl oral soln 10 mg/5ml............................................................................. 28 dicyclomine hcl tab 20 mg (Bentyl)...............................28 didanosine delayed release capsule 125 mg (Videx ec)......................................................................................5 didanosine delayed release capsule 200 mg (Videx ec)......................................................................................5 didanosine delayed release capsule 250 mg (Videx ec)......................................................................................5 didanosine delayed release capsule 400 mg (Videx ec)......................................................................................5 DIDGET – blood glucose monitoring kit w/ device............ 58 DIFLORASONE DIACETATE – diflorasone diacetate cream 0.05%................................................................... 55 diflorasone diacetate oint 0.05%................................... 55 diflunisal tab 500 mg...................................................... 39 DIGOXIN – digoxin oral soln 0.05 mg/ml.......................... 25 digoxin tab 125 mcg (0.125 mg) (Lanoxin)....................25 digoxin tab 250 mcg (0.25 mg) (Lanoxin)......................25 DILANTIN – phenytoin sodium extended cap 100 mg.......44 DILANTIN – phenytoin sodium extended cap 30 mg........ 44 DILANTIN – phenytoin susp 125 mg/5ml..........................44 diltiazem hcl cap sr 12hr 120 mg...................................21 diltiazem hcl cap sr 12hr 60 mg.................................... 21 diltiazem hcl cap sr 12hr 90 mg.................................... 21 diltiazem hcl cap sr 24hr 120 mg...................................21 diltiazem hcl cap sr 24hr 180 mg...................................21 diltiazem hcl cap sr 24hr 240 mg...................................21 diltiazem hcl coated beads cap sr 24hr 120 mg (Cardizem cd)................................................................. 21 diltiazem hcl coated beads cap sr 24hr 180 mg (Cardizem cd)................................................................. 21 diltiazem hcl coated beads cap sr 24hr 240 mg (Cardizem cd)................................................................. 21 diltiazem hcl coated beads cap sr 24hr 300 mg (Cardizem cd)................................................................. 21 diltiazem hcl coated beads cap sr 24hr 360 mg (Cardizem cd)................................................................. 21 diltiazem hcl coated beads tab sr 24hr 180 mg (Cardizem la).................................................................. 21 diltiazem hcl coated beads tab sr 24hr 240 mg (Cardizem la).................................................................. 21 diltiazem hcl coated beads tab sr 24hr 300 mg (Cardizem la).................................................................. 21 diltiazem hcl coated beads tab sr 24hr 360 mg (Cardizem la).................................................................. 21 diltiazem hcl coated beads tab sr 24hr 420 mg (Cardizem la).................................................................. 21 diltiazem hcl extended release beads cap sr 24hr 120 mg (Tiazac).....................................................................21 diltiazem hcl extended release beads cap sr 24hr 180 mg (Tiazac).....................................................................21 diltiazem hcl extended release beads cap sr 24hr 240 mg (Tiazac).....................................................................21 diltiazem hcl extended release beads cap sr 24hr 300 mg (Tiazac).....................................................................21 diltiazem hcl extended release beads cap sr 24hr 360 mg (Tiazac).....................................................................21 diltiazem hcl extended release beads cap sr 24hr 420 mg (Tiazac).....................................................................21 diltiazem hcl tab 120 mg (Cardizem)............................. 21 diltiazem hcl tab 30 mg (Cardizem)............................... 21 diltiazem hcl tab 60 mg (Cardizem)............................... 21 diltiazem hcl tab 90 mg.................................................. 21 DIPHENOXYLATE/ATROPINE – diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml..........................................28 diphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil)..........................................................................28 dipyridamole tab 25 mg (Persantine)............................ 50 dipyridamole tab 50 mg (Persantine)............................ 50 dipyridamole tab 75 mg (Persantine)............................ 50 disopyramide phosphate cap 100 mg (Norpace)..........24 disopyramide phosphate cap 150 mg (Norpace)..........24 disulfiram tab 250 mg (Antabuse)................................. 38 disulfiram tab 500 mg (Antabuse)................................. 38 divalproex sodium cap sprinkle 125 mg (Depakote sprinkles)........................................................................ 44 divalproex sodium tab delayed release 125 mg (Depakote)...................................................................... 44 divalproex sodium tab delayed release 250 mg (Depakote)...................................................................... 44 divalproex sodium tab delayed release 500 mg (Depakote)...................................................................... 44 divalproex sodium tab sr 24 hr 250 mg (Depakote er).................................................................................... 44 divalproex sodium tab sr 24 hr 500 mg (Depakote er).................................................................................... 44 DIVIGEL – estradiol td gel 0.25 mg/0.25gm (0.1%).......... 11 DIVIGEL – estradiol td gel 0.5 mg/0.5gm (0.1%).............. 11 DIVIGEL – estradiol td gel 1 mg/gm (0.1%)...................... 11 donepezil hydrochloride orally disintegrating tab 10 mg (Aricept odt).............................................................38 donepezil hydrochloride orally disintegrating tab 5 mg (Aricept odt)................................................................... 38 donepezil hydrochloride tab 10 mg (Aricept)............... 38 donepezil hydrochloride tab 5 mg (Aricept)................. 38 dorzolamide hcl ophth soln 2% (Trusopt).....................51 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml (Cosopt).............................................................. 51 doxazosin mesylate tab 1 mg (Cardura)....................... 25 doxazosin mesylate tab 2 mg (Cardura)....................... 25 doxazosin mesylate tab 4 mg (Cardura)....................... 25 doxazosin mesylate tab 8 mg (Cardura)....................... 25 doxepin hcl cap 100 mg................................................. 33 doxepin hcl cap 10 mg................................................... 33 doxepin hcl cap 150 mg................................................. 33 doxepin hcl cap 25 mg................................................... 33 doxepin hcl cap 50 mg................................................... 33 doxepin hcl conc 10 mg/ml............................................ 33 DOXEPIN HCL – doxepin hcl cap 75 mg..........................33 doxercalciferol cap 0.5 mcg (Hectorol)......................... 17 doxercalciferol cap 1 mcg (Hectorol)............................ 17 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 69 2014 doxercalciferol cap 2.5 mcg (Hectorol)......................... 17 doxycycline hyclate cap 100 mg (Vibramycin)............... 2 doxycycline hyclate cap 50 mg....................................... 2 doxycycline hyclate tab 100 mg...................................... 2 doxycycline hyclate tab 20 mg........................................ 2 doxycycline hyclate tab delayed release 100 mg........... 2 doxycycline hyclate tab delayed release 150 mg (Doryx).............................................................................. 2 doxycycline hyclate tab delayed release 75 mg............. 2 doxycycline monohydrate cap 100 mg (Monodox)........ 2 doxycycline monohydrate cap 150 mg (Adoxa)............. 2 doxycycline monohydrate cap 50 mg............................. 2 doxycycline monohydrate cap 75 mg (Monodox).......... 2 doxycycline monohydrate tab 100 mg (Adoxa pak 1/100).................................................................................2 doxycycline monohydrate tab 150 mg (Adoxa pak 1/150).................................................................................2 doxycycline monohydrate tab 50 mg (Adoxa)................ 3 doxycycline monohydrate tab 75 mg (Adoxa)................ 3 dronabinol cap 10 mg (Marinol).....................................29 dronabinol cap 2.5 mg (Marinol)....................................29 dronabinol cap 5 mg (Marinol).......................................29 drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz)..... 12 drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin 28)....................................................................................12 DULERA – mometasone furoate-formoterol fumarate aerosol 100-5 mcg/act..................................................... 27 DULERA – mometasone furoate-formoterol fumarate aerosol 200-5 mcg/act..................................................... 27 duloxetine hcl enteric coated pellets cap 20 mg (Cymbalta)...................................................................... 33 duloxetine hcl enteric coated pellets cap 30 mg (Cymbalta)...................................................................... 33 duloxetine hcl enteric coated pellets cap 60 mg (Cymbalta)...................................................................... 33 DUTOPROL – metoprolol & hydrochlorothiazide tab sr 24hr 100-12.5 mg............................................................ 19 DUTOPROL – metoprolol & hydrochlorothiazide tab sr 24hr 25-12.5 mg.............................................................. 19 DUTOPROL – metoprolol & hydrochlorothiazide tab sr 24hr 50-12.5 mg.............................................................. 19 E E.E.S. 400 – erythromycin ethylsuccinate tab 400 mg........ 2 econazole nitrate cream 1%........................................... 54 EDURANT – rilpivirine hcl tab 25 mg (base equivalent)...... 5 EFFIENT – prasugrel hcl tab 10 mg (base equiv)............. 50 EFFIENT – prasugrel hcl tab 5 mg (base equiv)............... 50 ELIDEL – pimecrolimus cream 1%................................... 56 ELIGARD – leuprolide acetate (3 month) for subcutaneous inj kit 22.5mg..................................................................... 7 ELIGARD – leuprolide acetate (4 month) for subcutaneous inj kit 30 mg.......................................................................7 ELIGARD – leuprolide acetate (6 month) for subcutaneous inj kit 45 mg.......................................................................8 70 ELIGARD – leuprolide acetate for subcutaneous inj kit 7.5 mg...................................................................................... 7 ELLA – ulipristal acetate tab 30 mg.................................. 12 ELMIRON – pentosan polysulfate sodium caps 100 mg.................................................................................... 31 EMCYT – estramustine phosphate sodium cap 140 mg..... 8 EMEND – aprepitant capsule 125 mg...............................29 EMEND – aprepitant capsule 40 mg.................................29 EMEND – aprepitant capsule 80 mg.................................29 EMEND – aprepitant capsule therapy pack 80 & 125 mg.................................................................................... 29 EMTRIVA – emtricitabine caps 200 mg.............................. 5 EMTRIVA – emtricitabine soln 10 mg/ml............................ 5 enalapril maleate & hydrochlorothiazide tab 10-25 mg (Vaseretic).......................................................................17 enalapril maleate & hydrochlorothiazide tab 5-12.5 mg....................................................................................17 enalapril maleate tab 10 mg (Vasotec).......................... 17 enalapril maleate tab 2.5 mg (Vasotec)......................... 17 enalapril maleate tab 20 mg (Vasotec).......................... 17 enalapril maleate tab 5 mg (Vasotec)............................ 17 ENBREL – etanercept for subcutaneous inj kit 25 mg...... 42 ENBREL – etanercept subcutaneous inj 25 mg/0.5ml.......42 ENBREL – etanercept subcutaneous inj 50 mg/ml........... 42 ENBREL SURECLICK – etanercept subcutaneous inj 50 mg/ml............................................................................... 42 enoxaparin sodium inj 100 mg/ml (Lovenox)............... 50 enoxaparin sodium inj 120 mg/0.8ml (Lovenox)...........50 enoxaparin sodium inj 150 mg/ml (Lovenox)............... 50 enoxaparin sodium inj 300 mg/3ml (Lovenox)..............50 enoxaparin sodium inj 30 mg/0.3ml (Lovenox).............50 enoxaparin sodium inj 40 mg/0.4ml (Lovenox).............50 enoxaparin sodium inj 60 mg/0.6ml (Lovenox).............50 enoxaparin sodium inj 80 mg/0.8ml (Lovenox).............50 entacapone tab 200 mg (Comtan)..................................46 epinastine hcl ophth soln 0.05% (Elestat).....................52 EPIPEN 2-PAK – epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)............................................................26 EPIPEN-JR 2-PAK – epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000)................................................... 26 EPIVIR HBV – lamivudine oral soln 5 mg/ml...................... 4 EPIVIR – lamivudine oral soln 10 mg/ml.............................5 eplerenone tab 25 mg (Inspra).......................................25 eplerenone tab 50 mg (Inspra).......................................25 eprosartan mesylate tab 600 mg (Teveten)...................18 EPZICOM – abacavir sulfate-lamivudine tab 600-300 mg...................................................................................... 5 ergocalciferol cap 50000 unit (Drisdol)......................... 47 ERIVEDGE – vismodegib cap 150 mg............................... 8 ERY-TAB – erythromycin tab delayed release 250 mg....... 2 ERY-TAB – erythromycin tab delayed release 333 mg....... 2 ERY-TAB – erythromycin tab delayed release 500 mg....... 2 ERYTHROCIN STEARATE – erythromycin stearate tab 250 mg...............................................................................2 ERYTHROMYCIN BASE – erythromycin tab 250 mg......... 2 ERYTHROMYCIN BASE – erythromycin tab 500 mg......... 2 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 2014 ERYTHROMYCIN ETHYLSUCCINA – erythromycin ethylsuccinate tab 400 mg................................................ 2 erythromycin gel 2% (Erygel).........................................53 erythromycin ophth oint 5 mg/gm................................. 51 erythromycin pads 2%....................................................53 erythromycin soln 2%.....................................................53 erythromycin-sulfisoxazole for susp 200-600 mg/5ml.............................................................................. 7 erythromycin w/ delayed release particles cap 250 mg......................................................................................2 escitalopram oxalate soln 5 mg/5ml (base equiv) (Lexapro).........................................................................33 escitalopram oxalate tab 10 mg (base equiv) (Lexapro).........................................................................33 escitalopram oxalate tab 20 mg (base equiv) (Lexapro).........................................................................33 escitalopram oxalate tab 5 mg (base equiv) (Lexapro).........................................................................33 estazolam tab 1 mg.........................................................36 estazolam tab 2 mg.........................................................36 estradiol & norethindrone acetate tab 0.5-0.1 mg (Activella)........................................................................11 estradiol & norethindrone acetate tab 1-0.5 mg (Activella)........................................................................11 estradiol tab 0.5 mg (Estrace)........................................11 estradiol tab 1 mg (Estrace)...........................................11 estradiol tab 2 mg (Estrace)...........................................11 estradiol td patch weekly 0.025 mg/24hr (Climara)...... 11 estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) (Climara)....................................................... 11 estradiol td patch weekly 0.05 mg/24hr (Climara)........ 11 estradiol td patch weekly 0.06 mg/24hr (Climara)........ 11 estradiol td patch weekly 0.075 mg/24hr (Climara)...... 11 estradiol td patch weekly 0.1 mg/24hr (Climara).......... 11 ESTROPIPATE – estropipate tab 3 mg............................ 11 estropipate tab 0.75 mg..................................................11 estropipate tab 1.5 mg....................................................11 ethambutol hcl tab 100 mg (Myambutol)........................ 3 ethambutol hcl tab 400 mg (Myambutol)........................ 3 ethosuximide cap 250 mg (Zarontin).............................44 ethosuximide soln 250 mg/5ml (Zarontin).................... 44 ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg..................................................................................12 ETIDRONATE DISODIUM – etidronate disodium tab 200 mg.................................................................................... 17 ETIDRONATE DISODIUM – etidronate disodium tab 400 mg.................................................................................... 17 etodolac cap 200 mg.......................................................42 etodolac cap 300 mg.......................................................42 etodolac tab 400 mg....................................................... 42 etodolac tab 500 mg....................................................... 42 etodolac tab sr 24hr 400 mg.......................................... 42 etodolac tab sr 24hr 500 mg.......................................... 42 etodolac tab sr 24hr 600 mg.......................................... 42 ETOPOSIDE – etoposide cap 50 mg..................................8 exemestane tab 25 mg (Aromasin)..................................8 EXFORGE – amlodipine besylate-valsartan tab 10-160 mg.................................................................................... 21 EXFORGE – amlodipine besylate-valsartan tab 10-320 mg.................................................................................... 21 EXFORGE – amlodipine besylate-valsartan tab 5-160 mg.................................................................................... 21 EXFORGE – amlodipine besylate-valsartan tab 5-320 mg.................................................................................... 21 EXFORGE HCT – amlodipine-valsartanhydrochlorothiazide tab 10-160-12.5 mg......................... 18 EXFORGE HCT – amlodipine-valsartanhydrochlorothiazide tab 10-160-25 mg............................ 18 EXFORGE HCT – amlodipine-valsartanhydrochlorothiazide tab 10-320-25 mg............................ 18 EXFORGE HCT – amlodipine-valsartanhydrochlorothiazide tab 5-160-12.5 mg........................... 18 EXFORGE HCT – amlodipine-valsartanhydrochlorothiazide tab 5-160-25 mg.............................. 18 F famciclovir tab 125 mg (Famvir)...................................... 4 famciclovir tab 250 mg (Famvir)...................................... 4 famciclovir tab 500 mg (Famvir)...................................... 4 famotidine for susp 40 mg/5ml (Pepcid)....................... 28 famotidine tab 20 mg (Pepcid).......................................28 famotidine tab 40 mg (Pepcid).......................................28 FARESTON – toremifene citrate tab 60 mg (base equivalent)......................................................................... 8 felbamate susp 600 mg/5ml (Felbatol).......................... 45 felbamate tab 400 mg (Felbatol).................................... 45 felbamate tab 600 mg (Felbatol).................................... 45 felodipine tab sr 24hr 10 mg.......................................... 21 felodipine tab sr 24hr 2.5 mg......................................... 21 felodipine tab sr 24hr 5 mg............................................21 FEMHRT LOW DOSE – norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg...........................................11 fenofibrate micronized cap 130 mg (Antara)................ 23 fenofibrate micronized cap 134 mg (Lofibra)................23 fenofibrate micronized cap 200 mg (Lofibra)................23 fenofibrate micronized cap 43 mg (Antara).................. 23 fenofibrate micronized cap 67 mg (Lofibra)..................23 fenofibrate tab 145 mg (Tricor)...................................... 23 fenofibrate tab 160 mg (Lofibra).................................... 23 fenofibrate tab 48 mg (Tricor)........................................ 23 fenofibrate tab 54 mg (Lofibra)...................................... 23 fentanyl citrate lollipop 1200 mcg (Actiq)..................... 39 fentanyl citrate lollipop 1600 mcg (Actiq)..................... 39 fentanyl citrate lollipop 200 mcg (Actiq)....................... 39 fentanyl citrate lollipop 400 mcg (Actiq)....................... 39 fentanyl citrate lollipop 600 mcg (Actiq)....................... 39 fentanyl citrate lollipop 800 mcg (Actiq)....................... 39 fentanyl td patch 72hr 100 mcg/hr (Duragesic)............ 39 fentanyl td patch 72hr 12 mcg/hr (Duragesic).............. 39 fentanyl td patch 72hr 25 mcg/hr (Duragesic).............. 39 fentanyl td patch 72hr 50 mcg/hr (Duragesic).............. 39 fentanyl td patch 72hr 75 mcg/hr (Duragesic).............. 39 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 71 2014 FINACEA – azelaic acid gel 15%..................................... 53 finasteride tab 5 mg (Proscar)....................................... 31 FIRAZYR – icatibant acetate inj 30 mg/3ml (base equivalent)....................................................................... 50 FIRMAGON – degarelix acetate for inj 120 mg (base equiv)................................................................................. 8 FIRMAGON – degarelix acetate for inj 80 mg (base equiv)................................................................................. 8 flecainide acetate tab 100 mg........................................ 24 flecainide acetate tab 150 mg........................................ 24 flecainide acetate tab 50 mg.......................................... 24 FLOVENT DISKUS – fluticasone propionate aer pow ba 100 mcg/blister................................................................ 27 FLOVENT DISKUS – fluticasone propionate aer pow ba 250 mcg/blister................................................................ 27 FLOVENT DISKUS – fluticasone propionate aer pow ba 50 mcg/blister.................................................................. 27 FLOVENT HFA – fluticasone propionate hfa inhal aer 110 mcg/act (125/valve)......................................................... 27 FLOVENT HFA – fluticasone propionate hfa inhal aer 220 mcg/act (250/valve)......................................................... 27 FLOVENT HFA – fluticasone propionate hfa inhal aero 44 mcg/act (50/valve)........................................................... 27 fluconazole for susp 10 mg/ml (Diflucan)....................... 3 fluconazole for susp 40 mg/ml (Diflucan)....................... 3 fluconazole tab 100 mg (Diflucan)................................... 3 fluconazole tab 150 mg (Diflucan)................................... 3 fluconazole tab 200 mg (Diflucan)................................... 3 fluconazole tab 50 mg (Diflucan).....................................3 flucytosine cap 250 mg (Ancobon)..................................4 flucytosine cap 500 mg (Ancobon)..................................4 fludrocortisone acetate tab 0.1 mg................................10 FLUNISOLIDE – flunisolide nasal soln 29 mcg/act (0.025%).......................................................................... 26 flunisolide nasal soln 0.025% (Flunisolide).................. 26 fluocinolone acetonide (otic) oil 0.01% (Dermotic)...... 52 fluocinolone acetonide cream 0.01%............................ 55 fluocinolone acetonide cream 0.025% (Synalar).......... 55 fluocinolone acetonide oil 0.01% (Derma-smoothe/fs bod)................................................................................. 55 fluocinolone acetonide oint 0.025% (Synalar).............. 55 fluocinolone acetonide soln 0.01% (Synalar)............... 55 fluocinonide cream 0.05%.............................................. 55 fluocinonide emulsified base cream 0.05%.................. 55 fluocinonide gel 0.05%................................................... 55 fluocinonide oint 0.05%.................................................. 55 fluocinonide soln 0.05%................................................. 55 FLUOR-A-DAY – sodium fluoride-xylitol chew tab 0.55 (0.25 mg f)-236.79 mg.....................................................48 FLUOR-A-DAY – sodium fluoride-xylitol chew tab 1.1 (0.5 mg f)-236.79 mg.............................................................. 48 FLUOR-A-DAY – sodium fluoride-xylitol chew tab 2.2 (1 mg f)-236.79 mg.............................................................. 48 fluorometholone ophth susp 0.1% (Fml liquifilm)........ 51 FLUOROPLEX – fluorouracil cream 1%........................... 56 fluorouracil cream 5% (Efudex)..................................... 56 72 fluorouracil soln 2%........................................................56 fluorouracil soln 5%........................................................56 fluoxetine hcl cap 10 mg (Prozac)................................. 33 fluoxetine hcl cap 20 mg (Prozac)................................. 33 fluoxetine hcl cap 40 mg (Prozac)................................. 33 fluoxetine hcl cap delayed release 90 mg (Prozac weekly)............................................................................ 33 fluoxetine hcl solution 20 mg/5ml................................. 33 fluoxetine hcl tab 10 mg.................................................33 fluoxetine hcl tab 20 mg.................................................33 FLUPHENAZINE HCL – fluphenazine hcl elixir 2.5 mg/5ml............................................................................. 34 FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/ ml..................................................................................... 34 fluphenazine hcl tab 10 mg............................................ 34 fluphenazine hcl tab 1 mg..............................................34 fluphenazine hcl tab 2.5 mg........................................... 34 fluphenazine hcl tab 5 mg..............................................34 FLURA-DROPS – sodium fluoride soln 0.25 mg/drop f (from 0.55 mg/drop naf).................................................. 48 flurazepam hcl cap 15 mg.............................................. 36 flurazepam hcl cap 30 mg.............................................. 36 flurbiprofen sodium ophth soln 0.03% (Ocufen).......... 52 flurbiprofen tab 100 mg.................................................. 42 flurbiprofen tab 50 mg.................................................... 42 flutamide cap 125 mg....................................................... 8 fluticasone propionate cream 0.05% (Cutivate)............55 fluticasone propionate lotion 0.05% (Cutivate)............ 55 fluticasone propionate nasal susp 50 mcg/act (Flonase)......................................................................... 26 fluticasone propionate oint 0.005% (Cutivate)..............55 fluvastatin sodium cap 20 mg (Lescol)......................... 23 fluvastatin sodium cap 40 mg (Lescol)......................... 23 fluvoxamine maleate cap sr 24hr 100 mg (Luvox cr).................................................................................... 33 fluvoxamine maleate cap sr 24hr 150 mg (Luvox cr).................................................................................... 33 fluvoxamine maleate tab 100 mg................................... 33 fluvoxamine maleate tab 25 mg.....................................33 fluvoxamine maleate tab 50 mg.....................................33 folic acid tab 1 mg.......................................................... 50 FOLLISTIM AQ – follitropin beta inj 150 unit/0.5ml........... 13 FOLLISTIM AQ – follitropin beta inj 300 unit/0.36ml......... 13 FOLLISTIM AQ – follitropin beta inj 600 unit/0.72ml......... 13 FOLLISTIM AQ – follitropin beta inj 75 unit/0.5ml............. 13 FOLLISTIM AQ – follitropin beta inj 900 unit/1.08ml......... 13 fondaparinux sodium inj 10 mg/0.8ml (Arixtra)............ 50 fondaparinux sodium inj 2.5 mg/0.5ml (Arixtra)........... 50 fondaparinux sodium inj 5 mg/0.4ml (Arixtra).............. 50 fondaparinux sodium inj 7.5 mg/0.6ml (Arixtra)........... 50 FORADIL AEROLIZER – formoterol fumarate inhal cap 12 mcg.................................................................................. 27 FORTEO – teriparatide (recombinant) inj 600 mcg/2.4ml........................................................................ 17 fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg....................................................................................17 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 2014 fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg....................................................................................18 fosinopril sodium tab 10 mg.......................................... 18 fosinopril sodium tab 20 mg.......................................... 18 fosinopril sodium tab 40 mg.......................................... 18 furosemide oral soln 10 mg/ml...................................... 24 furosemide tab 20 mg (Lasix)........................................ 24 furosemide tab 40 mg (Lasix)........................................ 24 furosemide tab 80 mg (Lasix)........................................ 24 FUZEON – enfuvirtide for inj 90 mg....................................5 G gabapentin cap 100 mg (Neurontin).............................. 45 gabapentin cap 300 mg (Neurontin).............................. 45 gabapentin cap 400 mg (Neurontin).............................. 45 gabapentin oral soln 250 mg/5ml (Neurontin).............. 45 gabapentin tab 600 mg (Neurontin)...............................45 gabapentin tab 800 mg (Neurontin)...............................45 galantamine hydrobromide cap sr 24hr 16 mg (Razadyne er)................................................................. 38 galantamine hydrobromide cap sr 24hr 24 mg (Razadyne er)................................................................. 38 galantamine hydrobromide cap sr 24hr 8 mg (Razadyne er)................................................................. 38 galantamine hydrobromide oral soln 4 mg/ml (Razadyne)......................................................................38 galantamine hydrobromide tab 12 mg (Razadyne).......38 galantamine hydrobromide tab 4 mg (Razadyne)........ 38 galantamine hydrobromide tab 8 mg (Razadyne)........ 38 GASTRINEX NF – hyoscyamine-phenyltoloxamine cap 0.0625-15 mg.................................................................. 28 gemfibrozil tab 600 mg (Lopid)......................................23 GENTAMICIN SULFATE – gentamicin sulfate cream 0.1%.................................................................................54 GENTAMICIN SULFATE – gentamicin sulfate oint 0.1%.................................................................................54 gentamicin sulfate ophth oint 0.3%...............................51 gentamicin sulfate ophth soln 0.3% (Garamycin)........ 51 GILOTRIF – afatinib dimaleate tab 20 mg (base equivalent)......................................................................... 8 GILOTRIF – afatinib dimaleate tab 30 mg (base equivalent)......................................................................... 8 GILOTRIF – afatinib dimaleate tab 40 mg (base equivalent)......................................................................... 8 GLEEVEC – imatinib mesylate tab 100 mg (base equivalent)......................................................................... 8 GLEEVEC – imatinib mesylate tab 400 mg (base equivalent)......................................................................... 8 glimepiride tab 1 mg (Amaryl)....................................... 13 glimepiride tab 2 mg (Amaryl)....................................... 13 glimepiride tab 4 mg (Amaryl)....................................... 13 glipizide-metformin hcl tab 2.5-250 mg......................... 13 glipizide-metformin hcl tab 2.5-500 mg......................... 13 glipizide-metformin hcl tab 5-500 mg............................ 13 glipizide tab 10 mg (Glucotrol)...................................... 13 glipizide tab 5 mg (Glucotrol)........................................ 13 glipizide tab sr 24hr 10 mg (Glucotrol xl)......................13 glipizide tab sr 24hr 2.5 mg (Glucotrol xl).....................13 glipizide tab sr 24hr 5 mg (Glucotrol xl)....................... 13 GLUCAGON EMERGENCY KIT – glucagon (rdna) for inj kit 1 mg............................................................................14 GLYBURIDE – glyburide tab 1.25 mg...............................14 GLYBURIDE – glyburide tab 2.5 mg.................................14 GLYBURIDE – glyburide tab 5 mg................................... 14 glyburide-metformin tab 1.25-250 mg (Glucovance).................................................................. 14 glyburide-metformin tab 2.5-500 mg (Glucovance)...... 14 glyburide-metformin tab 5-500 mg (Glucovance)......... 14 glyburide micronized tab 1.5 mg (Glynase).................. 14 glyburide micronized tab 3 mg (Glynase)..................... 14 glyburide micronized tab 6 mg (Glynase)..................... 14 glyburide tab 1.25 mg..................................................... 14 glyburide tab 2.5 mg....................................................... 14 glyburide tab 5 mg..........................................................14 glycopyrrolate tab 1 mg (Robinul).................................28 glycopyrrolate tab 2 mg (Robinul forte)........................28 GONAL-F – follitropin alfa for inj 1050 unit....................... 13 GONAL-F – follitropin alfa for inj 450 unit......................... 13 GONAL-F RFF – follitropin alfa for inj 75 unit................... 13 GONAL-F RFF PEN – follitropin alfa inj 300 unit/0.5ml..... 13 GONAL-F RFF PEN – follitropin alfa inj 450 unit/0.75ml....................................................................... 13 GONAL-F RFF PEN – follitropin alfa inj 900 unit/1.5ml..... 13 GONAL-F RFF REDIJECT – follitropin alfa inj 300 unit/0.5ml......................................................................... 13 GONAL-F RFF REDIJECT – follitropin alfa inj 450 unit/0.75ml....................................................................... 13 GONAL-F RFF REDIJECT – follitropin alfa inj 900 unit/1.5ml......................................................................... 13 granisetron hcl tab 1 mg................................................ 29 GRANIX – tbo-filgrastim soln prefilled syringe 300 mcg/0.5ml........................................................................ 50 GRANIX – tbo-filgrastim soln prefilled syringe 480 mcg/0.8ml........................................................................ 50 griseofulvin microsize susp 125 mg/5ml........................ 4 griseofulvin microsize tab 500 mg (Grifulvin v)............. 4 griseofulvin ultramicrosize tab 125 mg (Gris-peg)......... 4 griseofulvin ultramicrosize tab 250 mg (Gris-peg)......... 4 guanfacine hcl tab 1 mg (Tenex)................................... 25 guanfacine hcl tab 2 mg (Tenex)................................... 25 H halobetasol propionate cream 0.05% (Ultravate)......... 55 halobetasol propionate oint 0.05% (Ultravate)............. 55 haloperidol lactate oral conc 2 mg/ml...........................34 haloperidol tab 0.5 mg....................................................34 haloperidol tab 10 mg.....................................................34 haloperidol tab 1 mg.......................................................34 haloperidol tab 20 mg.....................................................35 haloperidol tab 2 mg.......................................................35 haloperidol tab 5 mg.......................................................35 HEXALEN – altretamine cap 50 mg................................... 8 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 73 2014 homatropine hbr ophth soln 5% (Isopto homatropine).................................................................. 52 HUMALOG – insulin lispro (human) inj 100 unit/ml........... 15 HUMALOG – insulin lispro (human) soln cartridge 100 unit/ml.............................................................................. 15 HUMALOG KWIKPEN – insulin lispro (human) soln peninjector 100 unit/ml.......................................................... 15 HUMALOG MIX 50/50 – insulin lispro prot & lispro (human) inj 100 unit/ml (50-50)....................................... 15 HUMALOG MIX 50/50 KWIKPEN – insulin lispro prot & lispro sus pen-inj 100 unit/ml (50-50).............................. 15 HUMALOG MIX 75/25 – insulin lispro prot & lispro (human) inj 100 unit/ml (75-25)....................................... 15 HUMALOG MIX 75/25 KWIKPEN – insulin lispro prot & lispro sus pen-inj 100 unit/ml (75-25).............................. 15 HUMIRA – adalimumab inj kit 20 mg/0.4ml...................... 42 HUMIRA – adalimumab inj kit 40 mg/0.8ml (50 mg/ml).....42 HUMIRA PEN – adalimumab inj kit 40 mg/0.8ml (50 mg/ ml).................................................................................... 42 HUMIRA PEN-CROHNS DISEASE – adalimumab inj kit 40 mg/0.8ml (50 mg/ml).................................................. 43 HUMIRA PEN-PSORIASIS STAR – adalimumab inj kit 40 mg/0.8ml (50 mg/ml)....................................................... 43 HUMULIN 70/30 – insulin isophane & regular (human) inj 100 unit/ml (70-30).......................................................... 15 HUMULIN 70/30 KWIKPEN – insulin isophane & regular susp pen-inj 100 unit/ml (70-30)......................................15 HUMULIN 70/30 PEN – insulin isophane & regular susp pen-inj 100 unit/ml (70-30).............................................. 15 HUMULIN N – insulin isophane (human) inj 100 unit/ ml..................................................................................... 15 HUMULIN N KWIKPEN – insulin isophane (human) susp pen-injector 100 unit/ml................................................... 15 HUMULIN N U-100 PEN – insulin isophane (human) susp pen-injector 100 unit/ml................................................... 15 HUMULIN R – insulin regular (human) inj 100 unit/ml.......15 HUMULIN R U-500 (CONCENTR – insulin regular (human) inj 500 unit/ml....................................................15 HYCAMTIN – topotecan hcl cap 0.25 mg (base equiv)....... 8 HYCAMTIN – topotecan hcl cap 1 mg (base equiv)............8 hydralazine hcl tab 100 mg............................................ 25 hydralazine hcl tab 10 mg.............................................. 25 hydralazine hcl tab 25 mg.............................................. 25 hydralazine hcl tab 50 mg.............................................. 25 hydrochlorothiazide cap 12.5 mg (Microzide)...............24 hydrochlorothiazide tab 12.5 mg................................... 24 hydrochlorothiazide tab 25 mg...................................... 24 hydrochlorothiazide tab 50 mg...................................... 24 HYDROCODONE/ACETAMINOPHEN – hydrocodoneacetaminophen tab 7.5-500 mg.......................................40 HYDROCODONE/ACETAMINOPHEN – hydrocodoneacetaminophen tab 7.5-650 mg.......................................40 hydrocodone-acetaminophen cap 5-500 mg................ 40 hydrocodone-acetaminophen soln 7.5-325 mg/15ml (Hycet).............................................................................40 74 hydrocodone-acetaminophen soln 7.5-500 mg/15ml.......................................................................... 40 hydrocodone-acetaminophen tab 10-300 mg (Xodol).............................................................................40 hydrocodone-acetaminophen tab 10-325 mg (Norco)............................................................................ 40 hydrocodone-acetaminophen tab 10-500 mg............... 40 hydrocodone-acetaminophen tab 10-650 mg............... 40 hydrocodone-acetaminophen tab 10-660 mg............... 40 hydrocodone-acetaminophen tab 10-750 mg............... 40 hydrocodone-acetaminophen tab 2.5-500 mg.............. 40 hydrocodone-acetaminophen tab 5-300 mg (Xodol).............................................................................40 hydrocodone-acetaminophen tab 5-325 mg (Norco)............................................................................ 40 hydrocodone-acetaminophen tab 5-500 mg................. 40 hydrocodone-acetaminophen tab 7.5-300 mg (Xodol).............................................................................40 hydrocodone-acetaminophen tab 7.5-325 mg (Norco)............................................................................ 40 hydrocodone-acetaminophen tab 7.5-750 mg.............. 40 hydrocodone-ibuprofen tab 10-200 mg (Ibudone)........40 hydrocodone-ibuprofen tab 5-200 mg (Reprexain)...... 40 hydrocodone-ibuprofen tab 7.5-200 mg (Vicoprofen)....................................................................40 hydrocortisone acetate suppos 25 mg (Anusol-hc)..... 53 hydrocortisone acetate suppos 30 mg (Proctocort).................................................................... 53 hydrocortisone butyrate cream 0.1% (Locoid)............. 55 hydrocortisone butyrate soln 0.1% (Locoid)................ 55 hydrocortisone cream 2.5%........................................... 55 hydrocortisone enema 100 mg/60ml (Cortenema)....... 53 hydrocortisone lotion 2.5%............................................ 55 hydrocortisone oint 2.5%............................................... 55 hydrocortisone rectal cream 1% (Proctocort).............. 53 hydrocortisone rectal cream 2.5% (Anusol-hc)............ 53 hydrocortisone tab 10 mg (Cortef)................................ 10 hydrocortisone tab 20 mg (Cortef)................................ 10 hydrocortisone tab 5 mg (Cortef).................................. 10 hydrocortisone valerate cream 0.2%.............................55 hydrocortisone valerate oint 0.2% (Westcort).............. 55 hydrocortisone w/ acetic acid otic soln 1-2% (Vosol hc)....................................................................................52 HYDROMORPHONE HCL – hydromorphone hcl suppos 3 mg.................................................................................... 40 hydromorphone hcl liqd 1 mg/ml (Dilaudid)................. 40 hydromorphone hcl tab 2 mg (Dilaudid)....................... 40 hydromorphone hcl tab 4 mg (Dilaudid)....................... 40 hydromorphone hcl tab 8 mg (Dilaudid)....................... 40 hydroxychloroquine sulfate tab 200 mg (Plaquenil)...... 6 hydroxyurea cap 500 mg (Hydrea).................................. 8 hydroxyzine hcl syrup 10 mg/5ml..................................32 hydroxyzine hcl tab 10 mg.............................................32 hydroxyzine hcl tab 25 mg.............................................32 hydroxyzine hcl tab 50 mg.............................................32 hydroxyzine pamoate cap 25 mg (Vistaril)....................32 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 2014 hydroxyzine pamoate cap 50 mg (Vistaril)....................32 HYDROXYZINE PAMOATE – hydroxyzine pamoate cap 100 mg.............................................................................32 hyoscyamine sulfate elixir 0.125 mg/5ml...................... 28 hyoscyamine sulfate soln 0.125 mg/ml......................... 28 hyoscyamine sulfate tab 0.125 mg (Levsin)................. 28 hyoscyamine sulfate tab disp 0.125 mg (Anaspaz)...... 28 hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl)..........28 hyoscyamine sulfate tab sr 12hr 0.375 mg (Levbid).....28 I ibandronate sodium tab 150 mg (base equivalent) (Boniva)...........................................................................17 ibuprofen susp 100 mg/5ml............................................43 ibuprofen tab 400 mg......................................................43 ibuprofen tab 600 mg......................................................43 ibuprofen tab 800 mg......................................................43 ICLUSIG – ponatinib hcl tab 15 mg (base equiv)................ 8 ICLUSIG – ponatinib hcl tab 45 mg (base equiv)................ 8 ILARIS – canakinumab for inj 180 mg.............................. 43 IMBRUVICA – ibrutinib cap 140 mg....................................8 imipramine hcl tab 10 mg (Tofranil).............................. 33 imipramine hcl tab 25 mg (Tofranil).............................. 33 imipramine hcl tab 50 mg (Tofranil).............................. 33 imipramine pamoate cap 100 mg (Tofranil-pm)............33 imipramine pamoate cap 125 mg (Tofranil-pm)............33 imipramine pamoate cap 150 mg (Tofranil-pm)............33 imipramine pamoate cap 75 mg (Tofranil-pm)..............33 imiquimod cream 5% (Aldara)........................................56 IMITREX – sumatriptan nasal spray 20 mg/act.................43 IMITREX – sumatriptan nasal spray 5 mg/act...................43 INCRELEX – mecasermin inj 40 mg/4ml (10 mg/ml)........ 16 indapamide tab 1.25 mg................................................. 24 indapamide tab 2.5 mg................................................... 24 indomethacin cap 25 mg................................................ 43 indomethacin cap 50 mg................................................ 43 indomethacin cap cr 75 mg........................................... 43 INJECTION DEVICE FOR INSULIN -VARIOUS............... 58 INLYTA – axitinib tab 1 mg.................................................8 INLYTA – axitinib tab 5 mg.................................................8 INSULIN PEN NEEDLES - NOVOFINE............................ 58 INSULIN PEN NEEDLES - NOVOTWIST......................... 58 INSULIN PEN NEEDLES - VARIOUS.............................. 58 INSULIN SYRINGES - VARIOUS..................................... 58 INTELENCE – etravirine tab 100 mg.................................. 5 INTELENCE – etravirine tab 200 mg.................................. 5 INTELENCE – etravirine tab 25 mg.................................... 5 INVIRASE – saquinavir mesylate cap 200 mg.................... 5 INVIRASE – saquinavir mesylate tab 500 mg.....................5 INVOKANA – canagliflozin tab 100 mg.............................14 INVOKANA – canagliflozin tab 300 mg.............................14 ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml (Duoneb)......................................................................... 27 ipratropium bromide inhal soln 0.02%.......................... 27 ipratropium bromide nasal soln 0.03% (21 mcg/spray) (Atrovent)........................................................................26 ipratropium bromide nasal soln 0.06% (42 mcg/spray) (Atrovent)........................................................................26 irbesartan-hydrochlorothiazide tab 150-12.5 mg (Avalide)..........................................................................19 irbesartan-hydrochlorothiazide tab 300-12.5 mg (Avalide)..........................................................................19 irbesartan tab 150 mg (Avapro)..................................... 19 irbesartan tab 300 mg (Avapro)..................................... 19 irbesartan tab 75 mg (Avapro)....................................... 19 ISENTRESS – raltegravir potassium chew tab 100 mg (base equiv).......................................................................5 ISENTRESS – raltegravir potassium chew tab 25 mg (base equiv).......................................................................5 ISENTRESS – raltegravir potassium packet for susp 100 mg (base equiv).................................................................5 ISENTRESS – raltegravir potassium tab 400 mg (base equiv)................................................................................. 5 isoniazid & rifampin cap 150-300 mg.............................. 3 ISONIAZID – isoniazid syrup 50 mg/5ml.............................3 isoniazid tab 100 mg.........................................................3 isoniazid tab 300 mg.........................................................3 ISOSORBIDE DINITRATE – isosorbide dinitrate tab 30 mg.................................................................................... 22 isosorbide dinitrate tab 10 mg.......................................22 isosorbide dinitrate tab 20 mg.......................................22 isosorbide dinitrate tab 30 mg.......................................22 isosorbide dinitrate tab 5 mg (Isordil titradose)........... 22 isosorbide dinitrate tab cr 40 mg.................................. 22 isosorbide mononitrate tab 10 mg................................ 22 isosorbide mononitrate tab 20 mg................................ 22 isosorbide mononitrate tab sr 24hr 120 mg (Imdur).....22 isosorbide mononitrate tab sr 24hr 30 mg (Imdur).......22 isosorbide mononitrate tab sr 24hr 60 mg (Imdur).......22 isotretinoin cap 10 mg....................................................53 isotretinoin cap 20 mg....................................................53 isotretinoin cap 40 mg....................................................53 itraconazole cap 100 mg (Sporanox)...............................4 J JAKAFI – ruxolitinib phosphate tab 10 mg (base equivalent)......................................................................... 8 JAKAFI – ruxolitinib phosphate tab 15 mg (base equivalent)......................................................................... 8 JAKAFI – ruxolitinib phosphate tab 20 mg (base equivalent)......................................................................... 8 JAKAFI – ruxolitinib phosphate tab 25 mg (base equivalent)......................................................................... 8 JAKAFI – ruxolitinib phosphate tab 5 mg (base equivalent)......................................................................... 8 JANUMET – sitagliptin-metformin hcl tab 50-1000 mg......14 JANUMET – sitagliptin-metformin hcl tab 50-500 mg........14 JANUMET XR – sitagliptin-metformin hcl tab sr 24hr 100-1000 mg................................................................... 14 JANUMET XR – sitagliptin-metformin hcl tab sr 24hr 50-1000 mg..................................................................... 14 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 75 2014 JANUMET XR – sitagliptin-metformin hcl tab sr 24hr 50-500 mg....................................................................... 14 JANUVIA – sitagliptin phosphate tab 100 mg (base equiv)............................................................................... 14 JANUVIA – sitagliptin phosphate tab 25 mg (base equiv)............................................................................... 14 JANUVIA – sitagliptin phosphate tab 50 mg (base equiv)............................................................................... 14 JINTELI – norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg.........................................................................11 JUVISYNC – sitagliptin-simvastatin tab 100-10 mg.......... 14 JUVISYNC – sitagliptin-simvastatin tab 100-20 mg.......... 14 JUVISYNC – sitagliptin-simvastatin tab 100-40 mg.......... 14 JUVISYNC – sitagliptin-simvastatin tab 50-10 mg............ 14 JUVISYNC – sitagliptin-simvastatin tab 50-20 mg............ 14 JUVISYNC – sitagliptin-simvastatin tab 50-40 mg............ 14 K KALETRA – lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml).................................................................... 5 KALETRA – lopinavir-ritonavir tab 100-25 mg.................... 5 KALETRA – lopinavir-ritonavir tab 200-50 mg.................... 5 KALYDECO – ivacaftor tab 150 mg..................................28 ketoconazole cream 2%..................................................54 ketoconazole foam 2% (Extina)..................................... 54 ketoconazole shampoo 2% (Nizoral)............................. 54 KETO-DIASTIX – urine glucose-ketones test strips.......... 58 ketoprofen cap 50 mg.....................................................43 ketoprofen cap 75 mg.....................................................43 ketorolac tromethamine ophth soln 0.4% (Acular ls).....................................................................................52 ketorolac tromethamine ophth soln 0.5% (Acular).......52 ketorolac tromethamine tab 10 mg................................43 KETOSTIX – acetone (urine) test strip............................. 58 KOMBIGLYZE XR – saxagliptin-metformin hcl tab sr 24hr 2.5-1000 mg.................................................................... 14 KOMBIGLYZE XR – saxagliptin-metformin hcl tab sr 24hr 5-1000 mg....................................................................... 14 KOMBIGLYZE XR – saxagliptin-metformin hcl tab sr 24hr 5-500 mg......................................................................... 14 K-PHOS NO 2 – potassium & sodium acid phosphates tab 305-700 mg..................................................................... 31 K-PHOS – potassium phosphate monobasic tab 500 mg.................................................................................... 48 L labetalol hcl tab 100 mg (Trandate)...............................19 labetalol hcl tab 200 mg (Trandate)...............................19 labetalol hcl tab 300 mg (Trandate)...............................19 lactulose (encephalopathy) solution 10 gm/15ml.........30 lactulose solution 10 gm/15ml....................................... 28 LAMISIL – terbinafine hcl oral granules packet 125 mg...... 4 LAMISIL – terbinafine hcl oral granules packet 187.5 mg...................................................................................... 4 lamivudine tab 100 mg (Epivir hbv).................................4 lamivudine tab 150 mg (Epivir)........................................ 5 76 lamivudine tab 300 mg (Epivir)........................................ 5 lamivudine-zidovudine tab 150-300 mg (Combivir)........ 5 lamotrigine tab 100 mg (Lamictal)................................. 45 lamotrigine tab 150 mg (Lamictal)................................. 45 lamotrigine tab 200 mg (Lamictal)................................. 45 lamotrigine tab 25 mg (Lamictal)................................... 45 lamotrigine tab chewable dispersible 25 mg (Lamictal chewable di)................................................................... 45 lamotrigine tab chewable dispersible 5 mg (Lamictal chewable di)................................................................... 45 lamotrigine tab sr 24hr 100 mg (Lamictal xr)................45 lamotrigine tab sr 24hr 200 mg (Lamictal xr)................45 lamotrigine tab sr 24hr 250 mg (Lamictal xr)................45 lamotrigine tab sr 24hr 25 mg (Lamictal xr)..................45 lamotrigine tab sr 24hr 300 mg (Lamictal xr)................45 lamotrigine tab sr 24hr 50 mg (Lamictal xr)..................45 LANCET DEVICES - VARIOUS........................................58 LANCETS - VARIOUS...................................................... 58 LANOXIN – digoxin tab 125 mcg (0.125 mg)....................25 LANOXIN – digoxin tab 187.5 mcg (0.1875 mg)............... 25 LANOXIN – digoxin tab 250 mcg (0.25 mg)......................25 LANOXIN – digoxin tab 62.5 mcg (0.0625 mg)................. 25 lansoprazole cap delayed release 15 mg (Prevacid)........................................................................28 lansoprazole cap delayed release 30 mg (Prevacid)........................................................................28 LANTUS – insulin glargine inj 100 unit/ml.........................15 LANTUS SOLOSTAR – insulin glargine soln pen-injector 100 unit/ml....................................................................... 16 latanoprost ophth soln 0.005% (Xalatan)...................... 51 leflunomide tab 10 mg (Arava).......................................43 leflunomide tab 20 mg (Arava).......................................43 LETAIRIS – ambrisentan tab 10 mg................................. 25 LETAIRIS – ambrisentan tab 5 mg................................... 25 letrozole tab 2.5 mg (Femara).......................................... 8 LEUCOVORIN CALCIUM – leucovorin calcium tab 10 mg...................................................................................... 8 LEUCOVORIN CALCIUM – leucovorin calcium tab 15 mg...................................................................................... 8 leucovorin calcium tab 25 mg..........................................8 leucovorin calcium tab 5 mg........................................... 8 LEUKERAN – chlorambucil tab 2 mg................................. 8 levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv) (Xopenex)........................................................................27 levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv) (Xopenex)........................................................................27 levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) (Xopenex)........................................................................27 levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) (Xopenex concentrate)...................................... 27 LEVEMIR FLEXPEN – insulin detemir soln pen-injector 100 unit/ml....................................................................... 16 LEVEMIR FLEXTOUCH – insulin detemir soln pen-injector 100 unit/ml....................................................................... 16 LEVEMIR – insulin detemir inj 100 unit/ml........................ 16 levetiracetam oral soln 100 mg/ml (Keppra)................. 45 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 2014 levetiracetam tab 1000 mg (Keppra)..............................45 levetiracetam tab 250 mg (Keppra)................................45 levetiracetam tab 500 mg (Keppra)................................45 levetiracetam tab 750 mg (Keppra)................................45 levetiracetam tab sr 24hr 500 mg (Keppra xr).............. 45 levetiracetam tab sr 24hr 750 mg (Keppra xr).............. 45 LEVOBUNOLOL HCL – levobunolol hcl ophth soln 0.25%...............................................................................51 levobunolol hcl ophth soln 0.5% (Betagan)..................51 levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)...... 17 levocarnitine tab 330 mg (Carnitor)...............................17 levofloxacin oral soln 25 mg/ml (Levaquin)....................3 levofloxacin tab 250 mg (Levaquin)................................ 3 levofloxacin tab 500 mg (Levaquin)................................ 3 levofloxacin tab 750 mg (Levaquin)................................ 3 levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg................................................................... 12 levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg..................................................................................12 levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg..................................................................................12 levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg................................ 12 levonorgestrel tab 0.75 mg (Plan b).............................. 12 levonorgestrel tab 1.5 mg (Plan b one-step).................12 levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) (Loseasonique)............................................ 12 levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) (Seasonique)................................................ 12 levothyroxine sodium tab 100 mcg (Synthroid)........... 16 levothyroxine sodium tab 112 mcg (Synthroid)........... 16 levothyroxine sodium tab 125 mcg (Synthroid)........... 16 levothyroxine sodium tab 137 mcg (Synthroid)........... 16 levothyroxine sodium tab 150 mcg (Synthroid)........... 16 levothyroxine sodium tab 175 mcg (Synthroid)........... 16 levothyroxine sodium tab 200 mcg (Synthroid)........... 16 levothyroxine sodium tab 25 mcg (Synthroid)............. 16 levothyroxine sodium tab 300 mcg (Synthroid)........... 16 levothyroxine sodium tab 50 mcg (Synthroid)............. 16 levothyroxine sodium tab 75 mcg (Synthroid)............. 16 levothyroxine sodium tab 88 mcg (Synthroid)............. 16 LEXIVA – fosamprenavir calcium susp 50 mg/ml (base equiv)................................................................................. 5 LEXIVA – fosamprenavir calcium tab 700 mg (base equiv)................................................................................. 5 LIALDA – mesalamine tab delayed release 1.2 gm.......... 30 LIDOCAINE/PRILOCAINE – lidocaine-prilocaine kit 2.5-2.5%...........................................................................56 lidocaine hcl cream 3%.................................................. 56 lidocaine hcl gel 2%........................................................56 lidocaine hcl laryngotracheal soln 4% (Lta 360 kit)......53 lidocaine hcl soln 4% (Xylocaine)..................................56 lidocaine hcl viscous soln 2%....................................... 53 lidocaine oint 5%.............................................................56 lidocaine patch 5% (Lidoderm)...................................... 56 lidocaine-prilocaine cream 2.5-2.5% (Emla)..................56 lindane lotion 1%.............................................................56 lindane shampoo 1%...................................................... 56 liothyronine sodium tab 25 mcg (Cytomel)...................16 liothyronine sodium tab 50 mcg (Cytomel)...................16 liothyronine sodium tab 5 mcg (Cytomel).....................16 lisinopril & hydrochlorothiazide tab 10-12.5 mg (Zestoretic)..................................................................... 18 lisinopril & hydrochlorothiazide tab 20-12.5 mg (Zestoretic)..................................................................... 18 lisinopril & hydrochlorothiazide tab 20-25 mg (Zestoretic)..................................................................... 18 lisinopril tab 10 mg (Prinivil)..........................................18 lisinopril tab 2.5 mg (Zestril).......................................... 18 lisinopril tab 20 mg (Prinivil)..........................................18 lisinopril tab 30 mg (Zestril)........................................... 18 lisinopril tab 40 mg (Zestril)........................................... 18 lisinopril tab 5 mg (Prinivil)............................................18 lithium carbonate cap 150 mg (Lithium carbonate)......35 lithium carbonate cap 300 mg....................................... 35 lithium carbonate cap 600 mg (Lithium carbonate)......35 LITHIUM CARBONATE – lithium carbonate cap 150 mg.................................................................................... 35 lithium carbonate tab 300 mg........................................ 35 lithium carbonate tab cr 300 mg (Lithobid)...................35 lithium carbonate tab cr 450 mg....................................35 LITHIUM CITRATE – lithium citrate oral soln 8 meq/5ml........................................................................... 35 LOMUSTINE – lomustine cap 100 mg................................8 LOMUSTINE – lomustine cap 10 mg..................................8 LOMUSTINE – lomustine cap 40 mg..................................8 loperamide hcl cap 2 mg................................................28 lorazepam conc 2 mg/ml (Lorazepam intensol)............32 lorazepam tab 0.5 mg (Ativan)....................................... 32 lorazepam tab 1 mg (Ativan).......................................... 32 lorazepam tab 2 mg (Ativan).......................................... 32 losartan potassium & hydrochlorothiazide tab 100-12.5 mg (Hyzaar).....................................................19 losartan potassium & hydrochlorothiazide tab 100-25 mg (Hyzaar).................................................................... 19 losartan potassium & hydrochlorothiazide tab 50-12.5 mg (Hyzaar).................................................................... 19 losartan potassium tab 100 mg (Cozaar)...................... 19 losartan potassium tab 25 mg (Cozaar)........................ 19 losartan potassium tab 50 mg (Cozaar)........................ 19 LOTEMAX – loteprednol etabonate ophth gel 0.5%..........51 LOTEMAX – loteprednol etabonate ophth oint 0.5%.........51 LOTEMAX – loteprednol etabonate ophth susp 0.5%....... 51 lovastatin tab 10 mg....................................................... 23 lovastatin tab 20 mg (Mevacor)..................................... 23 lovastatin tab 40 mg (Mevacor)..................................... 23 loxapine succinate cap 10 mg....................................... 35 loxapine succinate cap 25 mg....................................... 35 loxapine succinate cap 50 mg....................................... 35 loxapine succinate cap 5 mg (Loxitane)....................... 35 LUMIGAN – bimatoprost ophth soln 0.01%...................... 51 LUMIGAN – bimatoprost ophth soln 0.03%...................... 52 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 77 2014 LYSODREN – mitotane tab 500 mg................................... 8 M MACRODANTIN – nitrofurantoin macrocrystalline cap 25 mg.................................................................................... 30 malathion lotion 0.5% (Ovide)........................................56 MATULANE – procarbazine hcl cap 50 mg........................ 8 meclizine hcl tab 12.5 mg...............................................29 meclizine hcl tab 25 mg..................................................29 meclizine hcl tab 32 mg..................................................29 medroxyprogesterone acetate tab 10 mg (Provera).....12 medroxyprogesterone acetate tab 2.5 mg (Provera)......................................................................... 12 medroxyprogesterone acetate tab 5 mg (Provera).......12 mefenamic acid cap 250 mg (Ponstel).......................... 43 mefloquine hcl tab 250 mg...............................................6 megestrol acetate susp 40 mg/ml (Megace oral)............8 megestrol acetate tab 20 mg........................................... 8 megestrol acetate tab 40 mg........................................... 8 MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg (base equivalent)............................................................... 8 MEKINIST – trametinib dimethyl sulfoxide tab 2 mg (base equivalent)......................................................................... 8 meloxicam tab 15 mg (Mobic)........................................43 meloxicam tab 7.5 mg (Mobic).......................................43 MEPHYTON – phytonadione tab 5 mg............................. 47 mercaptopurine tab 50 mg (Purinethol).......................... 8 mesalamine enema 4 gm................................................30 MESNEX – mesna tab 400 mg...........................................8 MESTINON – pyridostigmine bromide syrup 60 mg/5ml............................................................................. 47 MESTINON TIMESPAN – pyridostigmine bromide tab cr 180 mg.............................................................................47 metaxalone tab 800 mg (Skelaxin).................................47 metformin hcl tab 1000 mg (Glucophage).....................14 metformin hcl tab 500 mg (Glucophage)...................... 14 metformin hcl tab 850 mg (Glucophage)...................... 14 metformin hcl tab sr 24hr 500 mg (Glucophage xr)......14 metformin hcl tab sr 24hr 750 mg (Glucophage xr)......14 metformin hcl tab sr 24hr osmotic 1000 mg (Fortamet)....................................................................... 14 metformin hcl tab sr 24hr osmotic 500 mg (Fortamet)....................................................................... 14 methadone hcl conc 10 mg/ml (Methadose).................40 methadone hcl soln 10 mg/5ml (Methadone hcl)..........40 methadone hcl soln 5 mg/5ml (Methadone hcl)............40 methadone hcl tab 10 mg (Dolophine).......................... 40 methadone hcl tab 5 mg (Dolophine hcl)......................40 methadone hcl tab for oral susp 40 mg........................ 40 methazolamide tab 25 mg (Neptazane)......................... 24 methazolamide tab 50 mg (Neptazane)......................... 24 methenamine hippurate tab 1 gm (Hiprex)................... 30 methenamine-hyosamine-meth blue-sod phos tab 81.6 mg (Urogesic-blue)........................................................ 30 methenamine-hyosc-meth blue-benz acid-phenyl sal tab 81.6mg (Prosed/ds)................................................. 30 78 methenamine-hyosc-meth blue-sod phos-phen sal cap 120 mg ...........................................................................30 methenamine-hyos-meth blue-sod phos-phen sal tab 81.6 mg ..........................................................................30 methenamine mandelate tab 1 gm................................ 30 methimazole tab 10 mg (Tapazole)................................16 methimazole tab 5 mg (Tapazole)..................................16 methocarbamol tab 500 mg (Robaxin).......................... 47 methocarbamol tab 750 mg (Robaxin-750)................... 47 methotrexate sodium for inj 1 gm................................... 8 methotrexate sodium tab 2.5 mg (base equiv)............... 8 methscopolamine bromide tab 2.5 mg (Pamine)..........28 methscopolamine bromide tab 5 mg (Pamine forte)................................................................................28 methyldopa tab 250 mg.................................................. 25 methyldopa tab 500 mg.................................................. 25 methylergonovine maleate tab 0.2 mg.......................... 17 METHYLPHENIDATE HCL ER – methylphenidate hcl tab cr 10 mg.......................................................................... 37 methylphenidate hcl tab 10 mg (Ritalin)....................... 37 methylphenidate hcl tab 20 mg (Ritalin)....................... 37 methylphenidate hcl tab 5 mg (Ritalin)......................... 37 methylphenidate hcl tab cr 20 mg (Ritalin sr)...............37 methylprednisolone tab 16 mg (Medrol)....................... 10 methylprednisolone tab 32 mg (Medrol)....................... 10 methylprednisolone tab 4 mg (Medrol)......................... 10 methylprednisolone tab 4 mg dose pack (Medrol dosepak)......................................................................... 10 methylprednisolone tab 8 mg (Medrol)......................... 10 METIPRANOLOL – metipranolol ophth soln 0.3%............ 52 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml).........30 metoclopramide hcl tab 10 mg (Reglan)....................... 30 metoclopramide hcl tab 5 mg (Reglan)......................... 30 metolazone tab 10 mg.................................................... 24 metolazone tab 2.5 mg (Zaroxolyn)............................... 24 metolazone tab 5 mg (Zaroxolyn).................................. 24 metoprolol & hydrochlorothiazide tab 100-25 mg (Lopressor hct).............................................................. 20 metoprolol & hydrochlorothiazide tab 100-50 mg........ 20 metoprolol & hydrochlorothiazide tab 50-25 mg (Lopressor hct).............................................................. 20 metoprolol succinate tab sr 24hr 100 mg (Toprol xl).....................................................................................20 metoprolol succinate tab sr 24hr 200 mg (Toprol xl).....................................................................................20 metoprolol succinate tab sr 24hr 25 mg (Toprol xl)..... 20 metoprolol succinate tab sr 24hr 50 mg (Toprol xl)..... 20 metoprolol tartrate tab 100 mg (Lopressor)..................20 metoprolol tartrate tab 25 mg........................................ 20 metoprolol tartrate tab 50 mg (Lopressor)....................20 metronidazole cream 0.75% (Metrocream)....................53 metronidazole gel 0.75%................................................ 53 metronidazole gel 1% (Metrogel)................................... 53 metronidazole lotion 0.75% (Metrolotion)..................... 53 metronidazole tab 250 mg (Flagyl).................................. 7 metronidazole tab 500 mg (Flagyl).................................. 7 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 2014 metronidazole vaginal gel 0.75% (Metrogelvaginal)........................................................................... 31 mexiletine hcl cap 150 mg............................................. 24 mexiletine hcl cap 200 mg............................................. 24 mexiletine hcl cap 250 mg............................................. 24 midazolam hcl syrup 2 mg/ml (base equivalent).......... 36 midodrine hcl tab 10 mg................................................ 25 midodrine hcl tab 2.5 mg............................................... 25 midodrine hcl tab 5 mg.................................................. 25 MIGRANAL – dihydroergotamine mesylate nasal spray 4 mg/ml............................................................................... 43 minocycline hcl cap 100 mg (Minocin)............................3 minocycline hcl cap 50 mg (Minocin)............................. 3 minocycline hcl cap 75 mg (Minocin)............................. 3 minocycline hcl tab 100 mg............................................. 3 minocycline hcl tab 50 mg............................................... 3 minocycline hcl tab 75 mg............................................... 3 minocycline hcl tab sr 24hr 135 mg................................ 3 minocycline hcl tab sr 24hr 45 mg.................................. 3 minocycline hcl tab sr 24hr 90 mg.................................. 3 minoxidil tab 10 mg........................................................ 25 minoxidil tab 2.5 mg....................................................... 25 mirtazapine orally disintegrating tab 15 mg (Remeron soltab)............................................................................. 33 mirtazapine orally disintegrating tab 30 mg (Remeron soltab)............................................................................. 33 mirtazapine orally disintegrating tab 45 mg (Remeron soltab)............................................................................. 33 mirtazapine tab 15 mg (Remeron)................................. 34 mirtazapine tab 30 mg (Remeron)................................. 34 mirtazapine tab 45 mg (Remeron)................................. 34 mirtazapine tab 7.5 mg................................................... 34 misoprostol tab 100 mcg (Cytotec)............................... 28 misoprostol tab 200 mcg (Cytotec)............................... 29 modafinil tab 100 mg (Provigil)......................................37 modafinil tab 200 mg (Provigil)......................................37 moexipril hcl tab 15 mg (Univasc).................................18 moexipril hcl tab 7.5 mg (Univasc)................................18 moexipril-hydrochlorothiazide tab 15-12.5 mg (Uniretic)......................................................................... 18 moexipril-hydrochlorothiazide tab 15-25 mg................ 18 moexipril-hydrochlorothiazide tab 7.5-12.5 mg............ 18 mometasone furoate cream 0.1% (Elocon)................... 55 mometasone furoate oint 0.1% (Elocon).......................55 mometasone furoate solution 0.1% (lotion) (Elocon)...........................................................................55 montelukast sodium chew tab 4 mg (base equiv) (Singulair)....................................................................... 27 montelukast sodium chew tab 5 mg (base equiv) (Singulair)....................................................................... 27 montelukast sodium oral granules packet 4 mg (base equiv) (Singulair)........................................................... 27 montelukast sodium tab 10 mg (base equiv) (Singulair)....................................................................... 27 morphine sulfate (concentrate) oral soln 20 mg/ml..... 40 morphine sulfate beads cap sr 24hr 120 mg (Avinza)........................................................................... 40 morphine sulfate beads cap sr 24hr 30 mg (Avinza)........................................................................... 40 morphine sulfate beads cap sr 24hr 45 mg (Avinza)........................................................................... 41 morphine sulfate beads cap sr 24hr 60 mg (Avinza)........................................................................... 41 morphine sulfate beads cap sr 24hr 75 mg (Avinza)........................................................................... 41 morphine sulfate beads cap sr 24hr 90 mg (Avinza)........................................................................... 41 morphine sulfate cap sr 24hr 100 mg (Kadian)............ 41 morphine sulfate cap sr 24hr 10 mg (Kadian).............. 41 morphine sulfate cap sr 24hr 20 mg (Kadian).............. 41 morphine sulfate cap sr 24hr 30 mg (Kadian).............. 41 morphine sulfate cap sr 24hr 50 mg (Kadian).............. 41 morphine sulfate cap sr 24hr 60 mg (Kadian).............. 41 morphine sulfate cap sr 24hr 80 mg (Kadian).............. 41 MORPHINE SULFATE – morphine sulfate suppos 10 mg.................................................................................... 40 MORPHINE SULFATE – morphine sulfate suppos 20 mg.................................................................................... 40 MORPHINE SULFATE – morphine sulfate suppos 30 mg.................................................................................... 40 MORPHINE SULFATE – morphine sulfate suppos 5 mg.................................................................................... 40 MORPHINE SULFATE – morphine sulfate tab 15 mg.......40 MORPHINE SULFATE – morphine sulfate tab 30 mg.......40 morphine sulfate oral soln 10 mg/5ml...........................41 morphine sulfate oral soln 20 mg/5ml...........................41 morphine sulfate tab cr 100 mg (Ms contin)................. 41 morphine sulfate tab cr 15 mg (Ms contin)...................41 morphine sulfate tab cr 200 mg (Ms contin)................. 41 morphine sulfate tab cr 30 mg (Ms contin)...................41 morphine sulfate tab cr 60 mg (Ms contin)...................41 moxifloxacin hcl tab 400 mg (base equiv) (Avelox)....... 3 mupirocin calcium cream 2% (Bactroban)....................54 mupirocin oint 2% (Bactroban)......................................54 mycophenolate mofetil cap 250 mg (Cellcept)............. 58 mycophenolate mofetil tab 500 mg (Cellcept).............. 58 mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) (Myfortic).................................................... 58 mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) (Myfortic).................................................... 58 MYLERAN – busulfan tab 2 mg..........................................8 MYRBETRIQ – mirabegron tab sr 24 hr 25 mg................ 31 MYRBETRIQ – mirabegron tab sr 24 hr 50 mg................ 31 N nabumetone tab 500 mg.................................................43 nabumetone tab 750 mg.................................................43 nadolol tab 20 mg (Corgard).......................................... 20 nadolol tab 40 mg (Corgard).......................................... 20 nadolol tab 80 mg (Corgard).......................................... 20 naltrexone hcl tab 50 mg (Revia)...................................58 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 79 2014 NAMENDA – memantine hcl oral solution 2 mg/ml........... 38 NAMENDA – memantine hcl tab 10 mg............................38 NAMENDA – memantine hcl tab 5 mg..............................38 NAMENDA TITRATION PAK – memantine hcl tab 5 mg (28) & 10 mg (21) titration pak........................................ 38 naproxen sodium tab 275 mg (Anaprox)...................... 43 naproxen sodium tab 550 mg (Anaprox ds)................. 43 naproxen susp 125 mg/5ml (Naprosyn)........................ 43 naproxen tab 250 mg (Naprosyn).................................. 43 naproxen tab 375 mg (Naprosyn).................................. 43 naproxen tab 500 mg (Naprosyn).................................. 43 naproxen tab ec 375 mg (Ec-naprosyn)........................ 43 naproxen tab ec 500 mg (Ec-naprosyn)........................ 43 naratriptan hcl tab 1 mg (base equiv) (Amerge)........... 43 naratriptan hcl tab 2.5 mg (base equiv) (Amerge)........ 43 NATACYN – natamycin ophth susp 5%............................51 nateglinide tab 120 mg (Starlix).....................................14 nateglinide tab 60 mg (Starlix).......................................14 NEBUPENT – pentamidine isethionate for nebulization soln 300 mg.......................................................................7 NECON 1/50-28 – norethindrone & mestranol tab 1 mg-50 mcg.................................................................................. 12 NECON 10/11-28 – norethindrone-eth estradiol tab 0.5-35/1-35 mg-mcg (10/11)............................................12 neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin.................................51 neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml (Neosporin)............... 51 neomycin-polymyxin-dexamethasone ophth oint 0.1% (Maxitrol).........................................................................51 neomycin-polymyxin-dexamethasone ophth susp 0.1% (Maxitrol)............................................................... 51 neomycin-polymyxin-hc otic soln 1% (Cortisporin).....52 neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%.......................................................................52 neomycin sulfate tab 500 mg...........................................3 NEULASTA – pegfilgrastim inj 6 mg/0.6ml....................... 50 NEUMEGA – oprelvekin for inj 5 mg................................ 50 NEUPOGEN – filgrastim inj 300 mcg/0.5ml (600 mcg/ ml).................................................................................... 50 NEUPOGEN – filgrastim inj 300 mcg/ml........................... 50 NEUPOGEN – filgrastim inj 480 mcg/0.8ml (600 mcg/ ml).................................................................................... 50 NEUPOGEN – filgrastim inj 480 mcg/1.6ml (300 mcg/ ml).................................................................................... 50 nevirapine tab 200 mg (Viramune)...................................5 nevirapine tab sr 24hr 400 mg (Viramune xr)................. 5 NEXAVAR – sorafenib tosylate tab 200 mg (base equivalent)......................................................................... 8 NEXIUM – esomeprazole magnesium cap delayed release 20 mg...............................................................................29 NEXIUM – esomeprazole magnesium cap delayed release 40 mg...............................................................................29 NEXIUM – esomeprazole magnesium for delayed release susp pack 2.5 mg............................................................29 80 NEXIUM – esomeprazole magnesium for delayed release susp packet 10 mg.......................................................... 29 NEXIUM – esomeprazole magnesium for delayed release susp packet 20 mg.......................................................... 29 NEXIUM – esomeprazole magnesium for delayed release susp packet 40 mg.......................................................... 29 NEXIUM – esomeprazole magnesium for delayed release susp packet 5 mg............................................................29 niacin tab cr 1000 mg (antihyperlipidemic) (Niaspan).........................................................................23 niacin tab cr 500 mg (antihyperlipidemic) (Niaspan).........................................................................23 niacin tab cr 750 mg (antihyperlipidemic) (Niaspan).........................................................................23 nicardipine hcl cap 20 mg..............................................21 nicardipine hcl cap 30 mg..............................................21 NICOTROL INHALER – nicotine inhaler system 10 mg (4 mg delivered)...................................................................38 NICOTROL NS – nicotine nasal spray 10 mg/ml (0.5 mg/ spray)............................................................................... 38 nifedipine cap 10 mg (Procardia)...................................21 nifedipine cap 20 mg...................................................... 21 nifedipine tab sr 24hr 30 mg (Adalat cc).......................22 nifedipine tab sr 24hr 60 mg (Adalat cc).......................22 nifedipine tab sr 24hr 90 mg (Adalat cc).......................22 nifedipine tab sr 24hr osmotic 30 mg (Procardia xl).....................................................................................21 nifedipine tab sr 24hr osmotic 60 mg (Procardia xl).....................................................................................22 nifedipine tab sr 24hr osmotic 90 mg (Procardia xl).....................................................................................22 NILANDRON – nilutamide tab 150 mg............................... 9 nimodipine cap 30 mg.................................................... 22 NITRO-BID – nitroglycerin oint 2%................................... 22 nitrofurantoin macrocrystalline cap 100 mg (Macrodantin)................................................................. 30 nitrofurantoin macrocrystalline cap 50 mg (Macrodantin)................................................................. 30 nitrofurantoin monohydrate macrocrystalline cap 100 mg (Macrobid)................................................................ 31 nitrofurantoin susp 25 mg/5ml (Furadantin)................. 31 nitroglycerin cap cr 2.5 mg............................................ 22 nitroglycerin cap cr 6.5 mg............................................ 22 nitroglycerin cap cr 9 mg............................................... 22 nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)......... 22 nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur)......... 22 nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur)......... 22 nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)......... 22 NITROSTAT – nitroglycerin sl tab 0.3 mg.........................22 NITROSTAT – nitroglycerin sl tab 0.4 mg.........................22 NITROSTAT – nitroglycerin sl tab 0.6 mg.........................22 nizatidine cap 150 mg.....................................................29 nizatidine cap 300 mg (Axid)..........................................29 nizatidine oral soln 15 mg/ml (Axid)..............................29 norelgestromin-ethinyl estradiol td ptwk 150-35 mcg/24hr (Ortho evra)................................................... 12 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 2014 norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg (Femcon fe)................................................ 12 norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg (Ovcon-35)...................................................................... 12 norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg (Brevicon-28).................................................................. 12 norethindrone & ethinyl estradiol tab 1 mg-35 mcg (Norinyl 1+35).................................................................12 norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg (Loestrin fe 1.5/30)................................................ 12 norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg (Loestrin fe 1/20)................................................... 12 norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg (Loestrin 1.5/30-21)............................................... 12 norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg (Loestrin 1/20-21)........................................................... 12 norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg..................................................................................11 norethindrone acetate tab 5 mg (Aygestin).................. 12 norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg (Estrostep fe).................................................. 12 norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg (Ortho-novum 7/7/7)....................................... 12 norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mgmcg (Tri-norinyl 28).......................................................12 norethindrone tab 0.35 mg (Nor-qd)..............................12 norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg (Ortho-cyclen)................................................................ 12 norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg (Ortho tri-cyclen)............................................ 13 norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg........ 13 nortriptyline hcl cap 10 mg (Pamelor)...........................34 nortriptyline hcl cap 25 mg (Pamelor)...........................34 nortriptyline hcl cap 50 mg (Pamelor)...........................34 nortriptyline hcl cap 75 mg (Pamelor)...........................34 NORTRIPTYLINE HCL – nortriptyline hcl soln 10 mg/5ml............................................................................. 34 NORVIR – ritonavir cap 100 mg......................................... 5 NORVIR – ritonavir oral soln 80 mg/ml...............................5 NORVIR – ritonavir tab 100 mg.......................................... 5 NOVOLIN 70/30 – insulin isophane & regular (human) inj 100 unit/ml (70-30).......................................................... 15 NOVOLIN 70/30 RELION – insulin isophane & regular (human) inj 100 unit/ml (70-30)....................................... 15 NOVOLIN N – insulin isophane (human) inj 100 unit/ ml..................................................................................... 15 NOVOLIN N RELION – insulin isophane (human) inj 100 unit/ml.............................................................................. 15 NOVOLIN R – insulin regular (human) inj 100 unit/ml....... 15 NOVOLIN R RELION – insulin regular (human) inj 100 unit/ml.............................................................................. 15 NOVOLOG FLEXPEN – insulin aspart soln pen-injector 100 unit/ml....................................................................... 15 NOVOLOG – insulin aspart inj 100 unit/ml........................15 NOVOLOG MIX 70/30 – insulin aspart prot & aspart (human) inj 100 unit/ml (70-30)....................................... 15 NOVOLOG MIX 70/30 PREFILL – insulin aspart prot & aspart sus pen-inj 100 unit/ml (70-30).............................15 NOVOLOG PENFILL – insulin aspart soln cartridge 100 unit/ml.............................................................................. 15 NOXAFIL – posaconazole susp 40 mg/ml.......................... 4 NUCYNTA ER – tapentadol hcl tab sr 12hr 100 mg..........41 NUCYNTA ER – tapentadol hcl tab sr 12hr 150 mg..........41 NUCYNTA ER – tapentadol hcl tab sr 12hr 200 mg..........41 NUCYNTA ER – tapentadol hcl tab sr 12hr 250 mg..........41 NUCYNTA ER – tapentadol hcl tab sr 12hr 50 mg........... 41 NUVARING – etonogestrel-ethinyl estradiol va ring 0.120-0.015 mg/24hr....................................................... 13 nystatin cream 100000 unit/gm......................................54 nystatin oint 100000 unit/gm..........................................54 nystatin oral powder ........................................................3 nystatin susp 100000 unit/ml......................................... 53 nystatin tab 500000 unit................................................... 4 nystatin topical powder .................................................54 nystatin-triamcinolone cream 100000-0.1 unit/gm%......................................................................................56 nystatin-triamcinolone oint 100000-0.1 unit/gm-%....... 56 O OFLOXACIN – ofloxacin tab 400 mg.................................. 3 ofloxacin ophth soln 0.3% (Ocuflox)............................. 51 ofloxacin otic soln 0.3%................................................. 52 ofloxacin tab 200 mg........................................................ 3 ofloxacin tab 300 mg........................................................ 3 ofloxacin tab 400 mg........................................................ 3 OGESTREL – norgestrel & ethinyl estradiol tab 0.5 mg-50 mcg.................................................................................. 13 olanzapine-fluoxetine hcl cap 12-25 mg (Symbyax).....38 olanzapine-fluoxetine hcl cap 12-50 mg (Symbyax).....38 olanzapine-fluoxetine hcl cap 3-25 mg (Symbyax).......38 olanzapine-fluoxetine hcl cap 6-25 mg (Symbyax).......38 olanzapine-fluoxetine hcl cap 6-50 mg (Symbyax).......38 olanzapine orally disintegrating tab 10 mg (Zyprexa zydis)...............................................................................35 olanzapine orally disintegrating tab 15 mg (Zyprexa zydis)...............................................................................35 olanzapine orally disintegrating tab 20 mg (Zyprexa zydis)...............................................................................35 olanzapine orally disintegrating tab 5 mg (Zyprexa zydis)...............................................................................35 olanzapine tab 10 mg (Zyprexa).................................... 35 olanzapine tab 15 mg (Zyprexa).................................... 35 olanzapine tab 2.5 mg (Zyprexa)................................... 35 olanzapine tab 20 mg (Zyprexa).................................... 35 olanzapine tab 5 mg (Zyprexa)...................................... 35 olanzapine tab 7.5 mg (Zyprexa)................................... 35 OLYSIO – simeprevir sodium cap 150 mg (base equivalent)......................................................................... 4 omeprazole cap delayed release 10 mg (Prilosec)....... 29 omeprazole cap delayed release 20 mg (Prilosec)....... 29 omeprazole cap delayed release 40 mg (Prilosec)....... 29 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 81 2014 omeprazole-sodium bicarbonate cap 40-1100 mg (Zegerid)..........................................................................29 OMNITROPE – somatropin for inj 5.8 mg.........................16 OMNITROPE – somatropin inj 10 mg/1.5ml..................... 16 OMNITROPE – somatropin inj 5 mg/1.5ml....................... 16 ondansetron hcl oral soln 4 mg/5ml (Zofran)............... 29 ondansetron hcl tab 24 mg............................................ 29 ondansetron hcl tab 4 mg (Zofran)................................29 ondansetron hcl tab 8 mg (Zofran)................................29 ondansetron orally disintegrating tab 4 mg (Zofran odt).................................................................................. 29 ondansetron orally disintegrating tab 8 mg (Zofran odt).................................................................................. 29 ONGLYZA – saxagliptin hcl tab 2.5 mg (base equiv)........ 14 ONGLYZA – saxagliptin hcl tab 5 mg (base equiv)........... 14 OPSUMIT – macitentan tab 10 mg................................... 25 ORACEA – doxycycline (rosacea) cap delayed release 40 mg.................................................................................... 53 ORAP – pimozide tab 1 mg.............................................. 38 ORAP – pimozide tab 2 mg.............................................. 38 ORFADIN – nitisinone cap 10 mg.....................................17 ORFADIN – nitisinone cap 2 mg.......................................17 ORFADIN – nitisinone cap 5 mg.......................................17 orphenadrine citrate tab sr 12hr 100 mg.......................47 ORPHENADRINE COMPOUND DS – orphenadrine w/ aspirin & caffeine tab 50-770-60 mg............................... 47 orphenadrine w/ aspirin & caffeine tab 25-385-30 mg....................................................................................47 ORTHO TRI-CYCLEN LO – norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg.................................. 13 OVIDREL – choriogonadotropin alfa inj 250 mcg/0.5ml........................................................................ 13 oxandrolone tab 10 mg (Oxandrin)................................10 oxandrolone tab 2.5 mg (Oxandrin)...............................11 oxaprozin tab 600 mg (Daypro)..................................... 43 oxazepam cap 10 mg...................................................... 32 oxazepam cap 15 mg...................................................... 32 oxazepam cap 30 mg...................................................... 32 oxcarbazepine susp 300 mg/5ml (60 mg/ml) (Trileptal).........................................................................45 oxcarbazepine tab 150 mg (Trileptal)............................ 45 oxcarbazepine tab 300 mg (Trileptal)............................ 45 oxcarbazepine tab 600 mg (Trileptal)............................ 45 oxybutynin chloride syrup 5 mg/5ml.............................31 oxybutynin chloride tab 5 mg........................................ 31 oxybutynin chloride tab sr 24hr 10 mg (Ditropan xl).....................................................................................31 oxybutynin chloride tab sr 24hr 15 mg (Ditropan xl).....................................................................................31 oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl)......31 oxycodone-aspirin tab 4.8355-325 mg (Percodan)....... 41 oxycodone hcl cap 5 mg................................................ 41 oxycodone hcl conc 100 mg/5ml (20 mg/ml) (Oxycodone hcl).............................................................41 OXYCODONE HCL – oxycodone hcl conc 100 mg/5ml (20 mg/ml).............................................................................. 41 82 oxycodone hcl soln 5 mg/5ml (Oxycodone hcl)........... 41 oxycodone hcl tab 10 mg...............................................41 oxycodone hcl tab 15 mg (Roxicodone)....................... 41 oxycodone hcl tab 20 mg...............................................41 oxycodone hcl tab 30 mg (Roxicodone)....................... 41 oxycodone hcl tab 5 mg (Roxicodone)......................... 41 oxycodone w/ acetaminophen cap 5-500 mg............... 41 oxycodone w/ acetaminophen tab 10-325 mg (Percocet)....................................................................... 41 oxycodone w/ acetaminophen tab 10-650 mg.............. 41 oxycodone w/ acetaminophen tab 2.5-325 mg (Percocet)....................................................................... 41 oxycodone w/ acetaminophen tab 5-325 mg (Percocet)....................................................................... 41 oxycodone w/ acetaminophen tab 7.5-325 mg (Percocet)....................................................................... 41 oxycodone w/ acetaminophen tab 7.5-500 mg............. 41 OXYCONTIN – oxycodone hcl tab er 12hr deter 10 mg.................................................................................... 41 OXYCONTIN – oxycodone hcl tab er 12hr deter 15 mg.................................................................................... 41 OXYCONTIN – oxycodone hcl tab er 12hr deter 20 mg.................................................................................... 41 OXYCONTIN – oxycodone hcl tab er 12hr deter 30 mg.................................................................................... 42 OXYCONTIN – oxycodone hcl tab er 12hr deter 40 mg.................................................................................... 42 OXYCONTIN – oxycodone hcl tab er 12hr deter 60 mg.................................................................................... 42 OXYCONTIN – oxycodone hcl tab er 12hr deter 80 mg.................................................................................... 42 oxymorphone hcl tab 10 mg (Opana)............................42 oxymorphone hcl tab 5 mg (Opana)..............................42 P pantoprazole sodium ec tab 20 mg (base equiv) (Protonix)........................................................................ 29 pantoprazole sodium ec tab 40 mg (base equiv) (Protonix)........................................................................ 29 paricalcitol cap 1 mcg (Zemplar)................................... 17 paricalcitol cap 2 mcg (Zemplar)................................... 17 paricalcitol cap 4 mcg (Zemplar)................................... 17 paromomycin sulfate cap 250 mg................................... 3 paroxetine hcl tab 10 mg (Paxil).................................... 34 paroxetine hcl tab 20 mg (Paxil).................................... 34 paroxetine hcl tab 30 mg (Paxil).................................... 34 paroxetine hcl tab 40 mg (Paxil).................................... 34 paroxetine hcl tab sr 24hr 12.5 mg (Paxil cr)................ 34 paroxetine hcl tab sr 24hr 25 mg (Paxil cr)...................34 paroxetine hcl tab sr 24hr 37.5 mg (Paxil cr)................ 34 PATADAY – olopatadine hcl ophth soln 0.2%...................52 pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/ ml ................................................................................... 47 pediatric multiple vitamins w/ fluoride chew tab 0.25 mg .................................................................................. 47 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 2014 pediatric multiple vitamins w/ fluoride chew tab 0.5 mg ......................................................................................... 47 pediatric multiple vitamins w/ fluoride chew tab 1 mg ......................................................................................... 47 pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml ......................................................................................... 47 pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml ......................................................................................... 47 pediatric vitamins acd w/ fluoride soln 0.25 mg/ml ..... 47 pediatric vitamins acd w/ fluoride soln 0.5 mg/ml ....... 47 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm (Golytely)........................................................................ 28 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm (Colyte-flavor packs)..................................................... 28 peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/flavor pack).................................................... 28 PEGASYS – peginterferon alfa-2a inj 180 mcg/0.5ml......... 4 PEGASYS – peginterferon alfa-2a inj 180 mcg/ml.............. 4 PEGASYS – peginterferon alfa-2a inj kit 180 mcg/0.5ml.....4 PEGASYS PROCLICK – peginterferon alfa-2a inj 135 mcg/0.5ml.......................................................................... 4 PEGASYS PROCLICK – peginterferon alfa-2a inj 180 mcg/0.5ml.......................................................................... 4 penicillin v potassium for soln 125 mg/5ml.................... 1 penicillin v potassium for soln 250 mg/5ml.................... 1 penicillin v potassium tab 250 mg...................................1 penicillin v potassium tab 500 mg...................................1 PENTASA – mesalamine cap cr 250 mg.......................... 30 PENTASA – mesalamine cap cr 500 mg.......................... 30 pentoxifylline tab cr 400 mg...........................................50 perindopril erbumine tab 2 mg...................................... 18 perindopril erbumine tab 4 mg (Aceon)........................ 18 perindopril erbumine tab 8 mg (Aceon)........................ 18 permethrin cream 5% (Elimite)...................................... 56 perphenazine tab 16 mg................................................. 35 perphenazine tab 2 mg................................................... 35 perphenazine tab 4 mg................................................... 35 perphenazine tab 8 mg................................................... 35 phenelzine sulfate tab 15 mg (Nardil)............................34 phenobarbital elixir 20 mg/5ml...................................... 36 PHENOBARBITAL – phenobarbital tab 100 mg............... 36 PHENOBARBITAL – phenobarbital tab 15 mg................. 36 PHENOBARBITAL – phenobarbital tab 30 mg................. 36 PHENOBARBITAL – phenobarbital tab 60 mg................. 36 phenobarbital tab 16.2 mg............................................. 36 phenobarbital tab 32.4 mg............................................. 36 phenytoin chew tab 50 mg (Dilantin infatabs).............. 45 phenytoin sodium extended cap 100 mg (Dilantin)......45 phenytoin sodium extended cap 200 mg (Phenytek).......................................................................45 phenytoin sodium extended cap 300 mg (Phenytek).......................................................................45 phenytoin susp 125 mg/5ml (Dilantin).......................... 45 PICATO – ingenol mebutate gel 0.015%.......................... 56 PICATO – ingenol mebutate gel 0.05%............................ 56 pilocarpine hcl ophth soln 1% (Isopto carpine)............52 pilocarpine hcl ophth soln 2% (Isopto carpine)............52 pilocarpine hcl ophth soln 4% (Isopto carpine)............52 pilocarpine hcl tab 5 mg (Salagen)................................53 pilocarpine hcl tab 7.5 mg (Salagen).............................53 pindolol tab 10 mg.......................................................... 20 pindolol tab 5 mg............................................................ 20 pioglitazone hcl-metformin hcl tab 15-500 mg (Actoplus met)............................................................... 15 pioglitazone hcl-metformin hcl tab 15-850 mg (Actoplus met)............................................................... 15 pioglitazone hcl tab 15 mg (base equiv) (Actos).......... 14 pioglitazone hcl tab 30 mg (base equiv) (Actos).......... 14 pioglitazone hcl tab 45 mg (base equiv) (Actos).......... 15 piroxicam cap 10 mg (Feldene)..................................... 43 piroxicam cap 20 mg (Feldene)..................................... 43 podofilox soln 0.5% (Condylox).....................................56 polyethylene glycol 3350 oral packet............................28 polyethylene glycol 3350 oral powder.......................... 28 polymyxin b-trimethoprim ophth soln 10000 unit/ ml-0.1% (Polytrim)......................................................... 51 POMALYST – pomalidomide cap 1 mg.............................. 9 POMALYST – pomalidomide cap 2 mg.............................. 9 POMALYST – pomalidomide cap 3 mg.............................. 9 POMALYST – pomalidomide cap 4 mg.............................. 9 potassium bicarbonate effer tab 25 meq...................... 48 potassium chloride cap cr 10 meq (Micro-k)................ 48 potassium chloride cap cr 8 meq (Micro-k).................. 49 potassium chloride microencapsulated crys cr tab 10 meq..................................................................................49 potassium chloride microencapsulated crys cr tab 20 meq..................................................................................49 potassium chloride oral liq 10% (20 meq/15ml)............49 potassium chloride oral liq 20% (40 meq/15ml)............49 potassium chloride powder packet 20 meq..................49 potassium chloride tab cr 10 meq (K-tab).................... 49 potassium chloride tab cr 8 meq (600 mg)................... 49 potassium citrate & citric acid powder pack 3300-1002 mg....................................................................................31 potassium citrate tab cr 10 meq (1080 mg) (Urocit-k 10)....................................................................................31 potassium citrate tab cr 5 meq (540 mg) (Urocit-k 5)......................................................................................31 pot bicarbonate & chloride effer tab 25 meq................ 48 pot phos monobasic w/sod phos di & monobas tab 155-852-130mg (K-phos neutral).................................. 48 pramipexole dihydrochloride tab 0.125 mg (Mirapex)......................................................................... 46 pramipexole dihydrochloride tab 0.25 mg (Mirapex)......................................................................... 46 pramipexole dihydrochloride tab 0.5 mg (Mirapex)......46 pramipexole dihydrochloride tab 0.75 mg (Mirapex)......................................................................... 46 pramipexole dihydrochloride tab 1.5 mg (Mirapex)......46 pramipexole dihydrochloride tab 1 mg (Mirapex)........ 46 pramoxine-chloroxylenol otic liquid 1-0.1% (Pramotic)....................................................................... 52 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 83 2014 pramoxine-hc-chloroxylenol aqueous otic soln 10-10-1 mg/ml (Cortane-b aqueous)..........................................52 pramoxine-hc-chloroxylenol otic soln 10-10-1 mg/ml (Cortane-b-otic).............................................................. 52 pravastatin sodium tab 10 mg....................................... 23 pravastatin sodium tab 20 mg (Pravachol)................... 23 pravastatin sodium tab 40 mg (Pravachol)................... 23 pravastatin sodium tab 80 mg (Pravachol)................... 23 prazosin hcl cap 1 mg (Minipress)................................ 25 prazosin hcl cap 2 mg (Minipress)................................ 25 prazosin hcl cap 5 mg (Minipress)................................ 25 PRECISION XTRA – ketone blood test strip.....................58 prednicarbate cream 0.1% (Dermatop)..........................56 prednicarbate oint 0.1% (Dermatop)..............................56 prednisolone acetate ophth susp 1% (Pred forte)........51 prednisolone sod phosphate oral soln 15 mg/5ml (base equiv)....................................................................10 prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) (Pediapred).............................................10 prednisolone syrup 15 mg/5ml (usp solution equivalent) (Prelone)..................................................... 10 PREDNISONE – prednisone oral soln 5 mg/5ml.............. 10 PREDNISONE – prednisone tab 10 mg dose pack...........10 PREDNISONE – prednisone tab 50 mg............................10 PREDNISONE – prednisone tab 5 mg dose pack............ 10 prednisone tab 10 mg.....................................................10 prednisone tab 10 mg dose pack.................................. 10 prednisone tab 1 mg.......................................................10 prednisone tab 2.5 mg....................................................10 prednisone tab 20 mg.....................................................10 prednisone tab 5 mg.......................................................10 prednisone tab 5 mg dose pack.................................... 10 PREMARIN – estrogens, conjugated tab 0.3 mg.............. 11 PREMARIN – estrogens, conjugated tab 0.45 mg............ 11 PREMARIN – estrogens, conjugated tab 0.625 mg.......... 11 PREMARIN – estrogens, conjugated tab 0.9 mg.............. 11 PREMARIN – estrogens, conjugated tab 1.25 mg............ 11 PREMARIN – estrogens, conjugated vaginal cream 0.625 mg/gm.............................................................................. 31 PREMPHASE – conj est 0.625(14)/conj est-medroxypro ac tab 0.625-5mg(14)...................................................... 11 PREMPRO – conjugated estrogen-medroxyprogest acetate tab 0.3-1.5 mg.................................................... 11 PREMPRO – conjugated estrogen-medroxyprogest acetate tab 0.45-1.5 mg.................................................. 11 PREMPRO – conjugated estrogen-medroxyprogest acetate tab 0.625-2.5 mg................................................ 11 PREMPRO – conjugated estrogen-medroxyprogest acetate tab 0.625-5 mg................................................... 11 PRENAPLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg.................................................................................... 47 PRENATABS FA – prenatal vit w/ fe fumarate-fa tab 29-1 mg.................................................................................... 47 PRENATABS RX – prenatal vit w/ iron carbonyl-fa tab 29-1 mg........................................................................... 47 84 PRENATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg........................................................................... 48 PRENATAL 19 – prenatal vit w/ fe fumarate-fa chew tab 29-1 mg........................................................................... 48 PRENATAL AD – prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg........................................................................... 47 PRENATAL PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg.................................................................................... 48 PRENATAL-U – prenatal w/o a vit w/ fe fumarate-fa cap 106.5-1 mg...................................................................... 48 PRENATAL VITAMINS PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg..................................................48 PREZISTA – darunavir ethanolate susp 100 mg/ml (base equiv)................................................................................. 5 PREZISTA – darunavir ethanolate tab 150 mg (base equiv)................................................................................. 5 PREZISTA – darunavir ethanolate tab 400 mg (base equiv)................................................................................. 5 PREZISTA – darunavir ethanolate tab 600 mg (base equiv)................................................................................. 5 PREZISTA – darunavir ethanolate tab 75 mg (base equiv)................................................................................. 5 PREZISTA – darunavir ethanolate tab 800 mg (base equiv)................................................................................. 5 PRIFTIN – rifapentine tab 150 mg...................................... 3 PRIMAQUINE PHOSPHATE – primaquine phosphate tab 26.3 mg..............................................................................6 primidone tab 250 mg (Mysoline).................................. 45 primidone tab 50 mg (Mysoline).................................... 45 PROAIR HFA – albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv).........................................................27 probenecid tab 500 mg...................................................44 prochlorperazine maleate tab 10 mg (Compazine).......35 prochlorperazine maleate tab 5 mg (Compazine).........35 prochlorperazine suppos 25 mg....................................35 PROCRIT – epoetin alfa inj 10000 unit/ml........................ 50 PROCRIT – epoetin alfa inj 20000 unit/ml........................ 50 PROCRIT – epoetin alfa inj 2000 unit/ml.......................... 50 PROCRIT – epoetin alfa inj 3000 unit/ml.......................... 50 PROCRIT – epoetin alfa inj 40000 unit/ml........................ 50 PROCRIT – epoetin alfa inj 4000 unit/ml.......................... 50 progesterone micronized cap 100 mg (Prometrium).................................................................. 12 progesterone micronized cap 200 mg (Prometrium).................................................................. 12 promethazine hcl suppos 12.5 mg................................ 26 promethazine hcl suppos 25 mg................................... 26 promethazine hcl suppos 50 mg................................... 26 promethazine hcl syrup 6.25 mg/5ml............................ 26 promethazine hcl tab 12.5 mg........................................26 promethazine hcl tab 25 mg...........................................26 promethazine hcl tab 50 mg...........................................26 propafenone hcl cap sr 12hr 225 mg (Rythmol sr)....... 24 propafenone hcl cap sr 12hr 325 mg (Rythmol sr)....... 24 propafenone hcl cap sr 12hr 425 mg (Rythmol sr)....... 24 propafenone hcl tab 150 mg (Rythmol).........................24 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 2014 propafenone hcl tab 225 mg (Rythmol).........................24 propafenone hcl tab 300 mg.......................................... 24 PROPANTHELINE BROMIDE – propantheline bromide tab 15 mg........................................................................ 29 PROPRANOLOL/HYDROCHLOROTH – propranolol & hydrochlorothiazide tab 40-25 mg................................... 20 PROPRANOLOL/HYDROCHLOROTH – propranolol & hydrochlorothiazide tab 80-25 mg................................... 20 propranolol hcl cap sr 24hr 120 mg (Inderal la)........... 20 propranolol hcl cap sr 24hr 160 mg (Inderal la)........... 20 propranolol hcl cap sr 24hr 60 mg (Inderal la)............. 20 propranolol hcl cap sr 24hr 80 mg (Inderal la)............. 20 PROPRANOLOL HCL – propranolol hcl oral soln 20 mg/5ml............................................................................. 20 PROPRANOLOL HCL – propranolol hcl oral soln 40 mg/5ml............................................................................. 20 propranolol hcl tab 10 mg..............................................20 propranolol hcl tab 20 mg..............................................20 propranolol hcl tab 40 mg..............................................20 propranolol hcl tab 60 mg..............................................20 propranolol hcl tab 80 mg..............................................20 propylthiouracil tab 50 mg............................................. 16 PROTOPIC – tacrolimus oint 0.03%................................. 56 PROTOPIC – tacrolimus oint 0.1%................................... 56 protriptyline hcl tab 10 mg (Vivactil)............................. 34 protriptyline hcl tab 5 mg (Vivactil)............................... 34 PULMICORT – budesonide inhalation susp 1 mg/2ml...... 27 PULMOZYME – dornase alfa inhal soln 1 mg/ml..............28 PURIXAN – mercaptopurine susp 2000 mg/100ml (20 mg/ ml)...................................................................................... 9 PYLERA – bismuth subcit-metronidazole-tetracycline cap 140-125-125 mg.............................................................. 29 pyrazinamide tab 500 mg................................................. 3 pyridostigmine bromide tab 60 mg (Mestinon).............47 Q quetiapine fumarate tab 100 mg (Seroquel)..................35 quetiapine fumarate tab 200 mg (Seroquel)..................35 quetiapine fumarate tab 25 mg (Seroquel)....................35 quetiapine fumarate tab 300 mg (Seroquel)..................35 quetiapine fumarate tab 400 mg (Seroquel)..................35 quetiapine fumarate tab 50 mg (Seroquel)....................35 QUFLORA PEDIATRIC – pediatric multiple vitamins w/ fluoride chew tab 0.25 mg...............................................48 QUFLORA PEDIATRIC – pediatric multiple vitamins w/ fluoride chew tab 0.5 mg.................................................48 QUFLORA PEDIATRIC – pediatric multiple vitamins w/ fluoride chew tab 1 mg....................................................48 QUFLORA PEDIATRIC – pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml.................................................. 48 QUFLORA PEDIATRIC – pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml.................................................... 48 quinapril hcl tab 10 mg (Accupril)................................. 18 quinapril hcl tab 20 mg (Accupril)................................. 18 quinapril hcl tab 40 mg (Accupril)................................. 18 quinapril hcl tab 5 mg (Accupril)................................... 18 quinapril-hydrochlorothiazide tab 10-12.5 mg (Accuretic)...................................................................... 18 quinapril-hydrochlorothiazide tab 20-12.5 mg (Accuretic)...................................................................... 18 quinapril-hydrochlorothiazide tab 20-25 mg (Accuretic)...................................................................... 18 quinidine gluconate tab cr 324 mg................................24 QUINIDINE SULFATE ER – quinidine sulfate tab cr 300 mg.................................................................................... 24 QUINIDINE SULFATE – quinidine sulfate tab 200 mg...... 24 quinidine sulfate tab 200 mg..........................................24 quinidine sulfate tab 300 mg..........................................25 quinine sulfate cap 324 mg (Qualaquin)......................... 6 QVAR – beclomethasone dipropionate inhal aero soln 40 mcg/act............................................................................ 27 QVAR – beclomethasone dipropionate inhal aero soln 80 mcg/act............................................................................ 27 R rabeprazole sodium ec tab 20 mg (Aciphex)................ 29 raloxifene hcl tab 60 mg (Evista)................................... 17 ramipril cap 1.25 mg (Altace)......................................... 18 ramipril cap 10 mg (Altace)............................................ 18 ramipril cap 2.5 mg (Altace)........................................... 18 ramipril cap 5 mg (Altace)..............................................18 ranitidine hcl cap 150 mg...............................................29 ranitidine hcl cap 300 mg...............................................29 ranitidine hcl syrup 15 mg/ml (75 mg/5ml)................... 29 ranitidine hcl tab 150 mg (Zantac).................................29 ranitidine hcl tab 300 mg (Zantac).................................29 RAPAMUNE – sirolimus oral soln 1 mg/ml....................... 58 RAPAMUNE – sirolimus tab 1 mg.................................... 58 RAPAMUNE – sirolimus tab 2 mg.................................... 58 REBIF – interferon beta-1a inj 22 mcg/0.5ml (12mu/ml) (44 mcg/ml)......................................................................37 REBIF – interferon beta-1a inj 44 mcg/0.5ml (24mu/ml) (88 mcg/ml)......................................................................37 REBIF REBIDOSE – interferon beta-1a inj 22 mcg/0.5ml (12mu/ml) (44 mcg/ml).................................................... 37 REBIF REBIDOSE – interferon beta-1a inj 44 mcg/0.5ml (24mu/ml) (88 mcg/ml).................................................... 37 REBIF REBIDOSE TITRATION – interferon beta-1a inj 6 x 8.8 mcg/0.2ml & 6 x 22 mcg/0.5ml..................................37 REBIF TITRATION PACK – interferon beta-1a inj 6 x 8.8 mcg/0.2ml & 6 x 22 mcg/0.5ml........................................38 RELENZA DISKHALER – zanamivir aero powder breath activated 5 mg/blister........................................................ 6 RENVELA – sevelamer carbonate packet 0.8 gm.............30 RENVELA – sevelamer carbonate packet 2.4 gm.............30 RENVELA – sevelamer carbonate tab 800 mg................. 30 repaglinide tab 0.5 mg (Prandin)................................... 15 repaglinide tab 1 mg (Prandin)...................................... 15 repaglinide tab 2 mg (Prandin)...................................... 15 REPRONEX – menotropins for inj 75 unit.........................13 RESCRIPTOR – delavirdine mesylate tab 100 mg............. 5 RESCRIPTOR – delavirdine mesylate tab 200 mg............. 5 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 85 2014 REVLIMID – lenalidomide cap 10 mg............................... 58 REVLIMID – lenalidomide cap 15 mg............................... 58 REVLIMID – lenalidomide cap 20 mg............................... 58 REVLIMID – lenalidomide cap 25 mg............................... 58 REVLIMID – lenalidomide cap 5 mg................................. 58 REVLIMID – lenalidomide caps 2.5 mg............................ 58 REYATAZ – atazanavir sulfate cap 100 mg (base equiv)................................................................................. 5 REYATAZ – atazanavir sulfate cap 150 mg (base equiv)................................................................................. 5 REYATAZ – atazanavir sulfate cap 200 mg (base equiv)................................................................................. 5 REYATAZ – atazanavir sulfate cap 300 mg (base equiv)................................................................................. 5 ribavirin cap 200 mg (Rebetol).........................................4 ribavirin tab 200 mg (Copegus)....................................... 4 rifabutin cap 150 mg (Mycobutin)....................................3 RIFAMATE – isoniazid & rifampin cap 150-300 mg............ 3 rifampin cap 150 mg (Rifadin)..........................................3 rifampin cap 300 mg (Rifadin)..........................................3 riluzole tab 50 mg (Rilutek)............................................ 47 risedronate sodium tab 150 mg (Actonel).....................17 risperidone orally disintegrating tab 0.25 mg...............35 risperidone orally disintegrating tab 0.5 mg (Risperdal m-tab).............................................................................. 35 risperidone orally disintegrating tab 1 mg (Risperdal m-tab).............................................................................. 35 risperidone orally disintegrating tab 2 mg (Risperdal m-tab).............................................................................. 35 risperidone orally disintegrating tab 3 mg (Risperdal m-tab).............................................................................. 35 risperidone orally disintegrating tab 4 mg (Risperdal m-tab).............................................................................. 35 risperidone soln 1 mg/ml (Risperdal)............................35 risperidone tab 0.25 mg (Risperdal).............................. 35 risperidone tab 0.5 mg (Risperdal)................................ 35 risperidone tab 1 mg (Risperdal)................................... 35 risperidone tab 2 mg (Risperdal)................................... 35 risperidone tab 3 mg (Risperdal)................................... 35 risperidone tab 4 mg (Risperdal)................................... 35 rivastigmine tartrate cap 1.5 mg (Exelon)..................... 38 rivastigmine tartrate cap 3 mg (Exelon)........................38 rivastigmine tartrate cap 4.5 mg (Exelon)..................... 38 rivastigmine tartrate cap 6 mg (Exelon)........................38 rizatriptan benzoate orally disintegrating tab 10 mg (Maxalt-mlt).....................................................................43 rizatriptan benzoate orally disintegrating tab 5 mg (Maxalt-mlt).....................................................................43 rizatriptan benzoate tab 10 mg (Maxalt)........................43 rizatriptan benzoate tab 5 mg (Maxalt)..........................43 ropinirole hydrochloride tab 0.25 mg (Requip).............46 ropinirole hydrochloride tab 0.5 mg (Requip)...............46 ropinirole hydrochloride tab 1 mg (Requip)................. 46 ropinirole hydrochloride tab 2 mg (Requip)................. 46 ropinirole hydrochloride tab 3 mg (Requip)................. 47 ropinirole hydrochloride tab 4 mg (Requip)................. 47 86 ropinirole hydrochloride tab 5 mg (Requip)................. 47 ropinirole hydrochloride tab sr 24hr 12 mg (base equivalent) (Requip xl).................................................. 46 ropinirole hydrochloride tab sr 24hr 2 mg (base equivalent) (Requip xl).................................................. 46 ropinirole hydrochloride tab sr 24hr 4 mg (base equivalent) (Requip xl).................................................. 46 ropinirole hydrochloride tab sr 24hr 6 mg (base equivalent) (Requip xl).................................................. 46 ropinirole hydrochloride tab sr 24hr 8 mg (base equivalent) (Requip xl).................................................. 46 S SABRIL – vigabatrin powd pack 500 mg.......................... 45 SABRIL – vigabatrin tab 500 mg...................................... 45 salsalate tab 500 mg....................................................... 39 salsalate tab 750 mg....................................................... 39 SANDIMMUNE – cyclosporine cap 100 mg...................... 58 SANDIMMUNE – cyclosporine cap 25 mg........................58 SANDIMMUNE – cyclosporine oral soln 100 mg/ml..........59 selegiline hcl cap 5 mg (Eldepryl)................................. 47 selegiline hcl tab 5 mg................................................... 47 selenium sulfide lotion 2.5%.......................................... 56 SELZENTRY – maraviroc tab 150 mg................................ 5 SELZENTRY – maraviroc tab 300 mg................................ 5 SENSIPAR – cinacalcet hcl tab 30 mg (base equiv)......... 17 SENSIPAR – cinacalcet hcl tab 60 mg (base equiv)......... 17 SENSIPAR – cinacalcet hcl tab 90 mg (base equiv)......... 17 SEREVENT DISKUS – salmeterol xinafoate aer pow ba 50 mcg/dose (base equiv)............................................... 27 SEROQUEL XR – quetiapine fumarate tab sr 24hr 150 mg.................................................................................... 36 SEROQUEL XR – quetiapine fumarate tab sr 24hr 200 mg.................................................................................... 36 SEROQUEL XR – quetiapine fumarate tab sr 24hr 300 mg.................................................................................... 36 SEROQUEL XR – quetiapine fumarate tab sr 24hr 400 mg.................................................................................... 36 SEROQUEL XR – quetiapine fumarate tab sr 24hr 50 mg.................................................................................... 35 sertraline hcl oral conc 20 mg/ml (Zoloft).....................34 sertraline hcl tab 100 mg (Zoloft).................................. 34 sertraline hcl tab 25 mg (Zoloft).................................... 34 sertraline hcl tab 50 mg (Zoloft).................................... 34 sildenafil citrate tab 20 mg (Revatio).............................25 silver sulfadiazine cream 1% (Silvadene)..................... 54 SIMBRINZA – brinzolamide-brimonidine tartrate ophth susp 1-0.2%.....................................................................52 simvastatin tab 10 mg (Zocor)....................................... 23 simvastatin tab 20 mg (Zocor)....................................... 23 simvastatin tab 40 mg (Zocor)....................................... 23 simvastatin tab 5 mg (Zocor)......................................... 23 simvastatin tab 80 mg (Zocor)....................................... 23 sirolimus tab 0.5 mg (Rapamune)..................................59 sodium citrate & citric acid soln 500-334 mg/5ml (Shohls solution modi)..................................................31 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 2014 sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) (Luride)............................................................................49 sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) (Luride)............................................................................49 sodium fluoride chew tab 1 mg f (from 2.2 mg naf) (Luride)............................................................................49 sodium fluoride cream 1.1% (Prevident 5000 plus)......53 sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride)...........................................................................53 SODIUM FLUORIDE – sodium fluoride tab 0.5 mg f (from 1.1 mg naf)...................................................................... 49 SODIUM FLUORIDE – sodium fluoride tab 1 mg f (from 2.2 mg naf)...................................................................... 49 sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf).................................................................................. 49 sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) (Luride)............................................................................49 sodium polystyrene sulfonate oral susp 15 gm/60ml (Sps)................................................................................ 59 sodium polystyrene sulfonate powder (Kayexalate)....................................................................58 sodium polystyrene sulfonate rectal susp 30 gm/120ml........................................................................ 59 SOLTAMOX – tamoxifen citrate oral soln 10 mg/5ml (base equivalent)......................................................................... 9 sotalol hcl (afib/afl) tab 120 mg (Betapace af).............. 25 sotalol hcl (afib/afl) tab 160 mg (Betapace af).............. 25 sotalol hcl (afib/afl) tab 80 mg (Betapace af)................ 25 sotalol hcl tab 120 mg (Betapace)................................. 25 sotalol hcl tab 160 mg (Betapace)................................. 25 sotalol hcl tab 240 mg.................................................... 25 sotalol hcl tab 80 mg (Betapace)................................... 25 SOVALDI – sofosbuvir tab 400 mg.....................................4 SPIRIVA HANDIHALER – tiotropium bromide monohydrate inhal cap 18 mcg (base equiv)...................27 spironolactone & hydrochlorothiazide tab 25-25 mg (Aldactazide)...................................................................24 spironolactone tab 100 mg (Aldactone)........................ 24 spironolactone tab 25 mg (Aldactone).......................... 24 spironolactone tab 50 mg (Aldactone).......................... 24 SPORANOX – itraconazole oral soln 10 mg/ml.................. 4 SPRYCEL – dasatinib tab 100 mg......................................9 SPRYCEL – dasatinib tab 140 mg......................................9 SPRYCEL – dasatinib tab 20 mg........................................9 SPRYCEL – dasatinib tab 50 mg........................................9 SPRYCEL – dasatinib tab 70 mg........................................9 SPRYCEL – dasatinib tab 80 mg........................................9 SSKI – potassium iodide soln 1 gm/ml............................. 26 SSKI – potassium iodide soln 1 gm/ml............................. 49 stavudine cap 15 mg (Zerit)............................................. 6 stavudine cap 20 mg (Zerit)............................................. 6 stavudine cap 30 mg (Zerit)............................................. 6 stavudine cap 40 mg (Zerit)............................................. 6 stavudine for oral soln 1 mg/ml (Zerit)............................6 STIMATE – desmopressin acetate nasal soln 1.5 mg/ ml..................................................................................... 17 STIVARGA – regorafenib tab 40 mg...................................9 STRATTERA – atomoxetine hcl cap 100 mg (base equiv)............................................................................... 37 STRATTERA – atomoxetine hcl cap 10 mg (base equiv)............................................................................... 37 STRATTERA – atomoxetine hcl cap 18 mg (base equiv)............................................................................... 37 STRATTERA – atomoxetine hcl cap 25 mg (base equiv)............................................................................... 37 STRATTERA – atomoxetine hcl cap 40 mg (base equiv)............................................................................... 37 STRATTERA – atomoxetine hcl cap 60 mg (base equiv)............................................................................... 37 STRATTERA – atomoxetine hcl cap 80 mg (base equiv)............................................................................... 37 STRIBILD – elvitegrav-cobicis-emtricitab-tenofov tab 150-150-200-300 mg......................................................... 6 STROMECTOL – ivermectin tab 3 mg................................6 SUBOXONE – buprenorphine hcl-naloxone hcl sl film 12-3 mg (base equiv)...............................................................42 SUBOXONE – buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (base equiv)..................................................... 42 SUBOXONE – buprenorphine hcl-naloxone hcl sl film 4-1 mg (base equiv)...............................................................42 SUBOXONE – buprenorphine hcl-naloxone hcl sl film 8-2 mg (base equiv)...............................................................42 sucralfate tab 1 gm (Carafate)....................................... 29 sulfacetamide sodium lotion 10% (acne) (Klaron)........53 sulfacetamide sodium ophth soln 10% (Bleph-10).......51 sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)%................................................................ 51 sulfacetamide sodium-sulfur in urea emulsion 10-4%...............................................................................54 sulfacetamide sodium-sulfur w/ sunscreens cream 10-5% ............................................................................. 53 sulfacetamide sodium w/ sulfur cleanser 10-2% (Avar ls cleanser).....................................................................53 sulfacetamide sodium w/ sulfur cream 10-2% (Avar-e ls).....................................................................................53 sulfacetamide sodium w/ sulfur cream 10-5%.............. 53 sulfacetamide sodium w/ sulfur emulsion 10-1%......... 53 sulfacetamide sodium w/ sulfur emulsion 10-5%......... 54 sulfacetamide sodium w/ sulfur foam 10-5% (Clarifoam ef).....................................................................................54 sulfacetamide sodium w/ sulfur lotion 10-5%...............54 sulfacetamide sodium w/ sulfur susp 8-4% (Sumaxin ts).....................................................................................54 sulfacetamide sodium w/ sulfur wash 9-4.5% (Sumadan wash)............................................................ 54 sulfacetamide sodium w/ sulfur wash 9-4% (Sumaxin wash)...............................................................................54 sulfamethoxazole-trimethoprim susp 200-40 mg/5ml.............................................................................. 7 sulfamethoxazole-trimethoprim tab 400-80 mg (Bactrim)........................................................................... 7 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 87 2014 sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrim ds)......................................................................7 sulfasalazine tab 500 mg (Azulfidine)........................... 30 sulfasalazine tab delayed release 500 mg (Azulfidine en-tabs)........................................................................... 30 sulindac tab 150 mg........................................................43 sulindac tab 200 mg........................................................43 sumatriptan succinate inj 6 mg/0.5ml (Imitrex)............ 43 sumatriptan succinate solution auto-injector 4 mg/0.5ml (Imitrex statdose sys)................................... 43 sumatriptan succinate solution auto-injector 6 mg/0.5ml (Imitrex statdose sys)................................... 43 sumatriptan succinate solution cartridge 4 mg/0.5ml (Imitrex statdose ref)..................................................... 43 sumatriptan succinate solution cartridge 6 mg/0.5ml (Imitrex statdose ref)..................................................... 43 sumatriptan succinate solution prefilled syringe 6 mg/0.5ml......................................................................... 44 SUMATRIPTAN SUCCINATE – sumatriptan succinate inj 4 mg/0.5ml.......................................................................43 SUMATRIPTAN SUCCINATE – sumatriptan succinate solution prefilled syringe 6 mg/0.5ml............................... 43 sumatriptan succinate tab 100 mg (Imitrex)................. 44 sumatriptan succinate tab 25 mg (Imitrex)................... 44 sumatriptan succinate tab 50 mg (Imitrex)................... 44 SUPRAX – cefixime cap 400 mg........................................ 2 SUPRAX – cefixime chew tab 100 mg............................... 2 SUPRAX – cefixime chew tab 200 mg............................... 2 SUPRAX – cefixime for susp 100 mg/5ml.......................... 2 SUPRAX – cefixime for susp 200 mg/5ml.......................... 2 SUPRAX – cefixime for susp 500 mg/5ml.......................... 2 SUPRAX – cefixime tab 400 mg.........................................2 SUSTIVA – efavirenz cap 200 mg...................................... 6 SUSTIVA – efavirenz cap 50 mg........................................ 6 SUSTIVA – efavirenz tab 600 mg.......................................6 SUTENT – sunitinib malate cap 12.5 mg (base equivalent)......................................................................... 9 SUTENT – sunitinib malate cap 25 mg (base equivalent)......................................................................... 9 SUTENT – sunitinib malate cap 37.5 mg (base equivalent)......................................................................... 9 SUTENT – sunitinib malate cap 50 mg (base equivalent)......................................................................... 9 SYLATRON – peginterferon alfa-2b for inj kit 296 mcg....... 9 SYLATRON – peginterferon alfa-2b for inj kit 444 mcg....... 9 SYLATRON – peginterferon alfa-2b for inj kit 4 x 296 mcg.................................................................................... 9 SYLATRON – peginterferon alfa-2b for inj kit 4 x 444 mcg.................................................................................... 9 SYLATRON – peginterferon alfa-2b for inj kit 4 x 888 mcg.................................................................................... 9 SYLATRON – peginterferon alfa-2b for inj kit 888 mcg....... 9 SYMBICORT – budesonide-formoterol fumarate dihyd aerosol 160-4.5 mcg/act.................................................. 28 SYMBICORT – budesonide-formoterol fumarate dihyd aerosol 80-4.5 mcg/act.................................................... 27 88 SYNAREL – nafarelin acetate nasal soln 2 mg/ml............ 13 T TABLOID – thioguanine tab 40 mg.....................................9 tacrolimus cap 0.5 mg (Prograf).................................... 59 tacrolimus cap 1 mg (Prograf)....................................... 59 tacrolimus cap 5 mg (Prograf)....................................... 59 TAFINLAR – dabrafenib mesylate cap 50 mg (base equivalent)......................................................................... 9 TAFINLAR – dabrafenib mesylate cap 75 mg (base equivalent)......................................................................... 9 TAMIFLU – oseltamivir phosphate cap 30 mg (base equiv)................................................................................. 6 TAMIFLU – oseltamivir phosphate cap 45 mg (base equiv)................................................................................. 6 TAMIFLU – oseltamivir phosphate cap 75 mg (base equiv)................................................................................. 6 TAMIFLU – oseltamivir phosphate for susp 6 mg/ml (base equiv)................................................................................. 6 tamoxifen citrate tab 10 mg (base equivalent)............... 9 tamoxifen citrate tab 20 mg (base equivalent)............... 9 tamsulosin hcl cap 0.4 mg (Flomax)............................. 32 TARCEVA – erlotinib tab 100 mg....................................... 9 TARCEVA – erlotinib tab 150 mg....................................... 9 TARCEVA – erlotinib tab 25 mg......................................... 9 TARGRETIN – bexarotene cap 75 mg............................... 9 TASIGNA – nilotinib cap 150 mg........................................ 9 TASIGNA – nilotinib cap 200 mg........................................ 9 TAZORAC – tazarotene cream 0.05%..............................54 TAZORAC – tazarotene cream 0.1%................................54 TAZORAC – tazarotene gel 0.05%................................... 54 TAZORAC – tazarotene gel 0.1%.....................................54 TECFIDERA – dimethyl fumarate capsule delayed release 120 mg.............................................................................38 TECFIDERA – dimethyl fumarate capsule delayed release 240 mg.............................................................................38 TECFIDERA STARTER PACK – dimethyl fumarate capsule dr starter pack 120 mg & 240 mg...................... 38 TEGRETOL-XR – carbamazepine tab sr 12hr 100 mg..... 45 telmisartan-amlodipine tab 40-10 mg (Twynsta).......... 22 telmisartan-amlodipine tab 40-5 mg (Twynsta)............ 22 telmisartan-amlodipine tab 80-10 mg (Twynsta).......... 22 telmisartan-amlodipine tab 80-5 mg (Twynsta)............ 22 telmisartan-hydrochlorothiazide tab 40-12.5 mg (Micardis hct)................................................................. 19 telmisartan-hydrochlorothiazide tab 80-12.5 mg (Micardis hct)................................................................. 19 telmisartan-hydrochlorothiazide tab 80-25 mg (Micardis hct)................................................................. 19 telmisartan tab 20 mg (Micardis)................................... 19 telmisartan tab 40 mg (Micardis)................................... 19 telmisartan tab 80 mg (Micardis)................................... 19 temazepam cap 15 mg (Restoril)................................... 36 temazepam cap 22.5 mg (Restoril)................................ 36 temazepam cap 30 mg (Restoril)................................... 36 temazepam cap 7.5 mg (Restoril).................................. 36 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 2014 temozolomide cap 100 mg (Temodar).............................9 temozolomide cap 140 mg (Temodar).............................9 temozolomide cap 180 mg (Temodar).............................9 temozolomide cap 20 mg (Temodar)...............................9 temozolomide cap 250 mg (Temodar).............................9 temozolomide cap 5 mg (Temodar).................................9 terazosin hcl cap 10 mg................................................. 25 terazosin hcl cap 1 mg................................................... 25 terazosin hcl cap 2 mg................................................... 25 terazosin hcl cap 5 mg................................................... 25 terbinafine hcl tab 250 mg (Lamisil)................................4 terbutaline sulfate tab 2.5 mg........................................ 28 terbutaline sulfate tab 5 mg........................................... 28 terconazole vaginal cream 0.4% (Terazol 7)................. 31 terconazole vaginal cream 0.8% (Terazol 3)................. 31 terconazole vaginal suppos 80 mg................................31 testosterone cypionate im in oil 100 mg/ml (Depotestosterone).................................................................. 11 testosterone cypionate im in oil 200 mg/ml (Depotestosterone).................................................................. 11 testosterone enanthate im in oil 200 mg/ml..................11 TETRACYCLINE HCL – tetracycline hcl cap 250 mg......... 3 TETRACYCLINE HCL – tetracycline hcl cap 500 mg......... 3 THALOMID – thalidomide cap 100 mg............................. 59 THALOMID – thalidomide cap 150 mg............................. 59 THALOMID – thalidomide cap 200 mg............................. 59 THALOMID – thalidomide cap 50 mg............................... 59 theophylline soln 80 mg/15ml........................................ 28 theophylline tab sr 12hr 100 mg.................................... 28 theophylline tab sr 12hr 200 mg.................................... 28 theophylline tab sr 12hr 300 mg.................................... 28 theophylline tab sr 12hr 450 mg.................................... 28 theophylline tab sr 24hr 400 mg.................................... 28 theophylline tab sr 24hr 600 mg.................................... 28 thiothixene cap 10 mg.................................................... 36 thiothixene cap 1 mg...................................................... 36 thiothixene cap 2 mg...................................................... 36 thiothixene cap 5 mg...................................................... 36 tiagabine hcl tab 2 mg (Gabitril).................................... 45 tiagabine hcl tab 4 mg (Gabitril).................................... 45 timolol maleate ophth gel forming soln 0.25% (Timoptic-xe).................................................................. 52 timolol maleate ophth gel forming soln 0.5% (Timoptic-xe).................................................................. 52 timolol maleate ophth soln 0.25% (Timoptic)............... 52 timolol maleate ophth soln 0.5% (Timoptic)................. 52 TIMOLOL MALEATE – timolol maleate tab 10 mg............20 TIMOLOL MALEATE – timolol maleate tab 20 mg............20 TIMOLOL MALEATE – timolol maleate tab 5 mg..............20 TIVICAY – dolutegravir sodium tab 50 mg (base equiv)......6 tizanidine hcl cap 2 mg (Zanaflex).................................47 tizanidine hcl cap 4 mg (Zanaflex).................................47 tizanidine hcl cap 6 mg (Zanaflex).................................47 tizanidine hcl tab 2 mg................................................... 47 tizanidine hcl tab 4 mg (Zanaflex)................................. 47 tobramycin-dexamethasone ophth susp 0.3-0.1% (Tobradex)...................................................................... 51 tobramycin nebu soln 300 mg/5ml (Tobi)....................... 3 tobramycin ophth soln 0.3% (Tobrex)........................... 51 TOBREX – tobramycin sulfate ophth oint 0.3%................ 51 tolazamide tab 250 mg....................................................15 tolterodine tartrate cap sr 24hr 2 mg (Detrol la)........... 31 tolterodine tartrate cap sr 24hr 4 mg (Detrol la)........... 31 tolterodine tartrate tab 1 mg (Detrol).............................31 tolterodine tartrate tab 2 mg (Detrol).............................31 topiramate sprinkle cap 15 mg (Topamax sprinkle)..... 45 topiramate sprinkle cap 25 mg (Topamax sprinkle)..... 45 topiramate tab 100 mg (Topamax).................................45 topiramate tab 200 mg (Topamax).................................45 topiramate tab 25 mg (Topamax)...................................45 topiramate tab 50 mg (Topamax)...................................45 torsemide tab 100 mg (Demadex)..................................24 torsemide tab 10 mg (Demadex)....................................24 torsemide tab 20 mg (Demadex)....................................24 torsemide tab 5 mg (Demadex)......................................24 TRACLEER – bosentan tab 125 mg................................. 25 TRACLEER – bosentan tab 62.5 mg................................ 25 tramadol-acetaminophen tab 37.5-325 mg (Ultracet)......................................................................... 42 tramadol hcl tab 50 mg (Ultram).................................... 42 tramadol hcl tab sr 24hr 100 mg (Ultram er).................42 tramadol hcl tab sr 24hr 200 mg (Ultram er).................42 tramadol hcl tab sr 24hr 300 mg (Ultram er).................42 tramadol hcl tab sr 24hr biphasic release 100 mg....... 42 tramadol hcl tab sr 24hr biphasic release 200 mg....... 42 tramadol hcl tab sr 24hr biphasic release 300 mg....... 42 trandolapril tab 1 mg (Mavik)......................................... 18 trandolapril tab 2 mg (Mavik)......................................... 18 trandolapril tab 4 mg (Mavik)......................................... 18 tranexamic acid tab 650 mg (Lysteda).......................... 50 TRANSDERM-SCOP – scopolamine td patch 72hr 1.5 mg.................................................................................... 29 tranylcypromine sulfate tab 10 mg (Parnate)............... 34 TRAVATAN Z – travoprost ophth soln 0.004% (benzalkonium free) (bak free)........................................ 52 trazodone hcl tab 100 mg...............................................34 trazodone hcl tab 150 mg...............................................34 trazodone hcl tab 300 mg...............................................34 trazodone hcl tab 50 mg.................................................34 tretinoin cap 10 mg...........................................................9 tretinoin cream 0.025% (Retin-a)................................... 54 tretinoin cream 0.05% (Retin-a)..................................... 54 tretinoin cream 0.1% (Retin-a)....................................... 54 tretinoin gel 0.01% (Retin-a)...........................................54 tretinoin gel 0.025% (Retin-a).........................................54 tretinoin microsphere gel 0.04% (Retin-a micro)..........54 tretinoin microsphere gel 0.1% (Retin-a micro)............54 triamcinolone acetonide cream 0.025%........................ 56 triamcinolone acetonide cream 0.1%............................ 56 triamcinolone acetonide cream 0.5%............................ 56 triamcinolone acetonide dental paste 0.1%.................. 53 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 89 2014 triamcinolone acetonide lotion 0.025%......................... 56 triamcinolone acetonide lotion 0.1%............................. 56 triamcinolone acetonide nasal inhal 55 mcg/act (Nasacort aq)..................................................................26 triamcinolone acetonide oint 0.025%............................ 56 triamcinolone acetonide oint 0.1%................................ 56 TRIAMCINOLONE ACETONIDE – triamcinolone acetonide oint 0.5%.........................................................56 TRIAMTERENE/HYDROCHLOROTH – triamterene & hydrochlorothiazide cap 50-25 mg.................................. 24 triamterene & hydrochlorothiazide cap 37.5-25 mg (Dyazide)......................................................................... 24 triamterene & hydrochlorothiazide tab 37.5-25 mg (Maxzide-25)................................................................... 24 triamterene & hydrochlorothiazide tab 75-50 mg (Maxzide).........................................................................24 TRICITRATES – pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml........................................................32 trifluoperazine hcl tab 10 mg......................................... 36 trifluoperazine hcl tab 1 mg........................................... 36 trifluoperazine hcl tab 2 mg........................................... 36 trifluoperazine hcl tab 5 mg........................................... 36 trifluridine ophth soln 1% (Viroptic).............................. 51 trihexyphenidyl hcl elixir 0.4 mg/ml.............................. 47 trihexyphenidyl hcl tab 2 mg......................................... 47 trihexyphenidyl hcl tab 5 mg......................................... 47 trimethobenzamide hcl cap 300 mg (Tigan)..................29 trimethoprim tab 100 mg.................................................. 7 TRINATE – prenatal vit w/ fe fumarate-fa tab 28-1 mg......48 TRI-VIT/FLUORIDE/IRON – pediatric vitamins acd fluoride & fe drops 0.25-10 mg/ml................................................48 trospium chloride cap sr 24hr 60 mg............................ 31 trospium chloride tab 20 mg (Sanctura)....................... 31 TRUVADA – emtricitabine-tenofovir disoproxil fumarate tab 200-300 mg................................................................. 6 TYKERB – lapatinib ditosylate tab 250 mg (base equiv)..... 9 U ULESFIA – benzyl alcohol lotion 5%................................ 56 ursodiol cap 300 mg (Actigall).......................................30 ursodiol tab 250 mg (Urso 250)..................................... 30 ursodiol tab 500 mg (Urso forte)................................... 30 V VAGIFEM – estradiol vaginal tab 10 mcg......................... 31 valacyclovir hcl tab 1 gm (Valtrex).................................. 4 valacyclovir hcl tab 500 mg (Valtrex).............................. 4 VALCHLOR – mechlorethamine hcl gel 0.016% (base equivalent)....................................................................... 56 VALCYTE – valganciclovir hcl for soln 50 mg/ml (base equiv)................................................................................. 4 VALCYTE – valganciclovir hcl tab 450 mg......................... 4 valproate sodium syrup 250 mg/5ml (base equiv) (Depakene)......................................................................45 valproic acid cap 250 mg (Depakene)........................... 45 90 valsartan-hydrochlorothiazide tab 160-12.5 mg (Diovan hct).................................................................... 19 valsartan-hydrochlorothiazide tab 160-25 mg (Diovan hct).................................................................................. 19 valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovan hct).................................................................... 19 valsartan-hydrochlorothiazide tab 320-25 mg (Diovan hct).................................................................................. 19 valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan hct).................................................................................. 19 valsartan tab 160 mg (Diovan)....................................... 19 valsartan tab 320 mg (Diovan)....................................... 19 valsartan tab 40 mg (Diovan)......................................... 19 valsartan tab 80 mg (Diovan)......................................... 19 vancomycin hcl cap 125 mg (Vancocin hcl)................... 7 vancomycin hcl cap 250 mg (Vancocin hcl)................... 7 VANDETANIB – vandetanib tab 100 mg............................ 9 VANDETANIB – vandetanib tab 300 mg............................ 9 VANTAS – histrelin acetate implant kit 50 mg.................... 9 venlafaxine hcl cap sr 24hr 150 mg (base equivalent) (Effexor xr)..................................................................... 34 venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) (Effexor xr)..................................................................... 34 venlafaxine hcl cap sr 24hr 75 mg (base equivalent) (Effexor xr)..................................................................... 34 venlafaxine hcl tab 100 mg............................................ 34 venlafaxine hcl tab 25 mg.............................................. 34 venlafaxine hcl tab 37.5 mg........................................... 34 venlafaxine hcl tab 50 mg.............................................. 34 venlafaxine hcl tab 75 mg.............................................. 34 venlafaxine hcl tab sr 24hr 150 mg (base equivalent) (Venlafaxine hcl er)....................................................... 34 venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent) (Venlafaxine hcl er)....................................................... 34 venlafaxine hcl tab sr 24hr 75 mg (base equivalent) (Venlafaxine hcl er)....................................................... 34 VENTOLIN HFA – albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv).........................................................28 verapamil hcl cap sr 24hr 100 mg (Verelan pm)........... 22 verapamil hcl cap sr 24hr 120 mg (Verelan)................. 22 verapamil hcl cap sr 24hr 180 mg (Verelan)................. 22 verapamil hcl cap sr 24hr 200 mg (Verelan pm)........... 22 verapamil hcl cap sr 24hr 240 mg (Verelan)................. 22 verapamil hcl cap sr 24hr 300 mg (Verelan pm)........... 22 verapamil hcl cap sr 24hr 360 mg (Verelan)................. 22 verapamil hcl tab 120 mg (Calan).................................. 22 verapamil hcl tab 80 mg (Calan).................................... 22 verapamil hcl tab cr 120 mg (Calan sr)......................... 22 verapamil hcl tab cr 180 mg (Calan sr)......................... 22 verapamil hcl tab cr 240 mg (Calan sr)......................... 22 VERAPAMIL HCL – verapamil hcl tab 40 mg................... 22 VESICARE – solifenacin succinate tab 10 mg.................. 31 VESICARE – solifenacin succinate tab 5 mg....................31 VIAGRA – sildenafil citrate tab 100 mg.............................25 VIAGRA – sildenafil citrate tab 25 mg.............................. 25 VIAGRA – sildenafil citrate tab 50 mg.............................. 25 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 2014 VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/ ml).................................................................................... 15 VIDEX – didanosine for soln 2 gm......................................6 VIDEX – didanosine for soln 4 gm......................................6 VIGAMOX – moxifloxacin hcl ophth soln 0.5% (base equiv)............................................................................... 51 VINACAL B – prenat w/o a w/fecbn-feglu-fa tab 20-1 mg & vit b6 tab pak...................................................................48 VINACAL – prenatal w/o a w/ fe carbonyl-fe gluc-dss-fa tab 27-1mg...................................................................... 48 VINATE AZ EXTRA – prenatal vit w/ fe bisglycinate chelate-fa tab 29-1 mg.................................................... 48 VINATE CALCIUM – prenatal vit w/ iron carbonyl-fe glucfa tab 27-1 mg.................................................................48 VINATE CARE – prenatal w/o a vit w/ fe fum-fa tab chew 40-1 mg........................................................................... 48 VINATE C – prenatal w/o a vit w/ fe fumarate-fa tab 30-1 mg.................................................................................... 48 VINATE DHA – prenat w/o a w/fefum-methylfol-fa-omegas cap 27-1.53 mg............................................................... 48 VINATE DHA RF – prenat w/o a w/fefum-methylfolomegas cap 27-1.13 mg................................................. 48 VINATE GT – prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg.................................................................................... 48 VINATE IC – prenatal w/o a w/fe fum-fe poly-fa cap 162.115.2-1 mg............................................................... 48 VINATE II – prenatal vit w/ fe bisglycinate chelate-fa tab 29-1 mg........................................................................... 48 VINATE M – prenatal vit w/ sel-fe fumarate-fa tab 27-1 mg.................................................................................... 48 VINATE ONE – prenatal vit w/ fe fumarate-fa tab 60-1 mg.................................................................................... 48 VINATE PN CARE – prenatal without a w/ fe asparto glydoc-fa tab 30-1mg........................................................... 48 VINATE ULTRA – prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg........................................................................... 48 VIRACEPT – nelfinavir mesylate tab 250 mg..................... 6 VIRACEPT – nelfinavir mesylate tab 625 mg..................... 6 VIRAMUNE – nevirapine susp 50 mg/5ml.......................... 6 VIRAMUNE XR – nevirapine tab sr 24hr 100 mg............... 6 VIREAD – tenofovir disoproxil fumarate oral powder 40 mg/gm................................................................................ 6 VIREAD – tenofovir disoproxil fumarate tab 150 mg........... 6 VIREAD – tenofovir disoproxil fumarate tab 200 mg........... 6 VIREAD – tenofovir disoproxil fumarate tab 250 mg........... 6 VIREAD – tenofovir disoproxil fumarate tab 300 mg........... 6 VIVELLE-DOT – estradiol td patch biweekly 0.025 mg/24hr............................................................................11 VIVELLE-DOT – estradiol td patch biweekly 0.0375 mg/24hr............................................................................11 VIVELLE-DOT – estradiol td patch biweekly 0.05 mg/24hr............................................................................11 VIVELLE-DOT – estradiol td patch biweekly 0.075 mg/24hr............................................................................11 VIVELLE-DOT – estradiol td patch biweekly 0.1 mg/24hr............................................................................11 VOLTAREN – diclofenac sodium gel 1%.......................... 54 voriconazole for susp 40 mg/ml (Vfend)......................... 4 voriconazole tab 200 mg (Vfend).....................................4 voriconazole tab 50 mg (Vfend).......................................4 VOTRIENT – pazopanib hcl tab 200 mg (base equiv)........ 9 VYVANSE – lisdexamfetamine dimesylate cap 20 mg......37 VYVANSE – lisdexamfetamine dimesylate cap 30 mg......37 VYVANSE – lisdexamfetamine dimesylate cap 40 mg......37 VYVANSE – lisdexamfetamine dimesylate cap 50 mg......37 VYVANSE – lisdexamfetamine dimesylate cap 60 mg......37 VYVANSE – lisdexamfetamine dimesylate cap 70 mg......37 W warfarin sodium tab 10 mg (Coumadin)........................50 warfarin sodium tab 1 mg (Coumadin)..........................50 warfarin sodium tab 2.5 mg (Coumadin).......................50 warfarin sodium tab 2 mg (Coumadin)..........................50 warfarin sodium tab 3 mg (Coumadin)..........................50 warfarin sodium tab 4 mg (Coumadin)..........................50 warfarin sodium tab 5 mg (Coumadin)..........................50 warfarin sodium tab 6 mg (Coumadin)..........................50 warfarin sodium tab 7.5 mg (Coumadin).......................50 WELCHOL – colesevelam hcl packet for susp 3.75 gm.................................................................................... 23 WELCHOL – colesevelam hcl tab 625 mg........................23 X XALKORI – crizotinib cap 200 mg...................................... 9 XALKORI – crizotinib cap 250 mg...................................... 9 XARELTO – rivaroxaban tab 10 mg................................. 50 XARELTO – rivaroxaban tab 15 mg................................. 50 XARELTO – rivaroxaban tab 20 mg................................. 50 XENAZINE – tetrabenazine tab 12.5 mg.......................... 39 XENAZINE – tetrabenazine tab 25 mg............................. 39 XERAC AC – aluminum chloride in alcohol solution 6.25%...............................................................................56 XIFAXAN – rifaximin tab 550 mg........................................ 7 XTANDI – enzalutamide cap 40 mg................................... 9 Y Z zafirlukast tab 10 mg (Accolate).................................... 28 zafirlukast tab 20 mg (Accolate).................................... 28 zaleplon cap 10 mg (Sonata)..........................................36 zaleplon cap 5 mg (Sonata)........................................... 36 ZELBORAF – vemurafenib tab 240 mg (base equivalent)......................................................................... 9 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 10000-34000-55000 unit..................................................30 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 15000-51000-82000 unit..................................................30 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 20000-68000-109000 unit................................................30 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 25000-85000-136000 unit................................................30 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014 91 2014 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 3000-10000-16000 unit....................................................30 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 5000-17000-27000 unit....................................................30 ZIAGEN – abacavir sulfate soln 20 mg/ml (base equiv)...... 6 zidovudine cap 100 mg (Retrovir)................................... 6 zidovudine syrup 10 mg/ml (Retrovir).............................6 zidovudine tab 300 mg..................................................... 6 ziprasidone hcl cap 20 mg (Geodon)............................ 36 ziprasidone hcl cap 40 mg (Geodon)............................ 36 ziprasidone hcl cap 60 mg (Geodon)............................ 36 ziprasidone hcl cap 80 mg (Geodon)............................ 36 ZOLINZA – vorinostat cap 100 mg..................................... 9 zolmitriptan orally disintegrating tab 2.5 mg (Zomig zmt)..................................................................................44 zolmitriptan orally disintegrating tab 5 mg (Zomig zmt)..................................................................................44 zolmitriptan tab 2.5 mg (Zomig).....................................44 zolmitriptan tab 5 mg (Zomig)........................................44 zolpidem tartrate tab 10 mg (Ambien)...........................36 zolpidem tartrate tab 5 mg (Ambien).............................36 zolpidem tartrate tab cr 12.5 mg (Ambien cr)............... 36 zolpidem tartrate tab cr 6.25 mg (Ambien cr)............... 36 zonisamide cap 100 mg (Zonegran).............................. 45 zonisamide cap 25 mg (Zonegran)................................ 45 zonisamide cap 50 mg....................................................46 ZORTRESS – everolimus tab 0.25 mg............................. 59 ZORTRESS – everolimus tab 0.5 mg............................... 59 ZORTRESS – everolimus tab 0.75 mg............................. 59 ZOVIA 1/50E – ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg................................................................... 13 ZYCLARA – imiquimod cream 3.75%............................... 56 ZYCLARA PUMP – imiquimod cream 2.5%......................56 ZYCLARA PUMP – imiquimod cream 3.75%....................56 ZYDELIG – idelalisib tab 100 mg........................................9 ZYDELIG – idelalisib tab 150 mg........................................9 ZYKADIA – ceritinib cap 150 mg...................................... 10 ZYLET – loteprednol etabonate-tobramycin ophth susp 0.5-0.3%...........................................................................51 ZYTIGA – abiraterone acetate tab 250 mg....................... 10 ZYVOX – linezolid for susp 100 mg/5ml............................. 7 ZYVOX – linezolid tab 600 mg........................................... 7 92 Blue Cross Blue Shield of Wyoming Standard Drug List, October 2014
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