1. health and fitness
2. drugs

January 2015
Closed Formulary Medication Guide
Click to search for a drug name in this document
Contents
Introduction ...................................................................... I
Drugs not covered ........................................................ 1
Closed Formulary ........................................................... II
Anti-Infective Drugs ...................................................... 2
Changes to the formulary ............................................... II
Immunizing Agents ....................................................... 4
Pharmacy benefit ........................................................... III
Cancer Drugs ................................................................ 4
Pharmacy options .......................................................... III
Hormones, Diabetes and Related Drugs ...................... 5
Formulary exception process ........................................ IV
Heart and Circulatory Drugs ......................................... 7
Generic drugs ................................................................ IV
Respiratory Drugs ....................................................... 10
Contraceptive coverage ................................................. IV
Gastrointestinal Drugs ................................................ 11
Responsible RX programs ............................................. IV
Genitourinary Drugs ................................................... 12
Mail Order Pharmacy .................................................... VII
Central Nervous System Drugs .................................. 12
Preventive Medications ................................................ VII
Pain Relief Drugs ........................................................ 14
Immunizations ............................................................... VII
Neuromuscular Drugs ................................................. 15
Women’s preventive services ....................................... VII
Supplements ............................................................... 16
Specialty Pharmacy medications ................................. VIII
Blood Modifying Drugs ............................................... 16
Using the Medication Guide ........................................... X
Topical Products ......................................................... 17
Abbreviation/acronym key ............................................. XI
Miscellaneous Categories .......................................... 20
Index ............................................................................. 21
Please consider talking to your doctor about prescribing formulary medications, which may help reduce your
out-of-pocket costs. This list may help guide you and your doctor in selecting an appropriate medication for you.
The drug formulary is regularly updated. Please visit www.FloridaBlue.com for the most up-to-date information.
To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to Edit in
the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click on Search.
3022-J FL © Prime Therapeutics LLC 01/15
Introduction
Florida Blue is pleased to present the Closed Formulary Medication Guide. The Guide will provide helpful tips on how to
make the most of your pharmacy benefits and details on the various coverage programs that are designed to provide safe
and appropriate medication when you need it. Please refer to your Benefit Booklet, Certificate of Coverage, Contract,
Member Handbook or prescription drug endorsement for complete coverage details.
The Closed Formulary Medication Guide also includes an abbreviated listing of Generic, and a complete listing of Brand
Prescription Drugs (the formulary) that are covered under your plan. Changes in the formulary can occur over time and the
most up-to-date listing can always be found by viewing the Closed Formulary Medication Guide online at
www.FloridaBlue.com or by calling the customer service number listed on your member ID card. For the hearing impaired,
call Florida TTY Relay Service 711.
Si desea hablar sobre esta guía en español con uno de nuestros representantes, por favor llame al número de
atención al cliente indicado en su tarjeta de asegurado y pida ser transferido a un representante bilingüe.
We reserve the right to add or remove or change the tier of any prescription medication in this Medication Guide at any time.
Note: The decision concerning whether a prescription medication should be prescribed must be made by you and your
physician. Any and all decisions that require or pertain to independent professional medical judgments or training, or the
need for, and dosage of, a prescription medication, must be made solely by you and your treating physician in accordance with
the patient/physician relationship.
Key Tips and Coverage Guidelines
By following these simple guidelines, you will be assured that you are getting the maximum benefit from your plan.
• When you have your prescriptions filled, ask your pharmacist if a Generic equivalent is available. Generic Prescription
Drugs are usually less expensive and are covered unless specifically excluded under your Pharmacy Program
Endorsement. You can check your Schedule of Benefits to determine your copay amount.
• Select Brand Name Prescription Drugs are included in the formulary and are therefore available to you through your plan.
The Closed Formulary List includes all covered Brand Name Prescription Drugs. You can determine your out-of-pocket
amount for Brand Name Prescription Drugs by reviewing your Schedule of Benefits.
• Brand Name Prescription Drugs not listed in the Closed Formulary List are not covered. If you are currently taking a
medication, take a moment to review the formulary to determine if it is covered. If not, check with your doctor to understand
available options and review the PHARMACY BENEFIT section of this Guide for exception procedures.
• If you or your provider request a covered Brand Name Prescription Drug when there is a Generic Prescription Drug
available; you will be responsible for: (1) the difference in cost between the Generic Prescription Drug and the Brand Name
Prescription Drug; and (2) the cost share applicable to Brand Name Prescription Drugs, as indicated on your Schedule of
Benefits
• Take this Guide with you when you visit your doctor or health care provider so that he or she is aware of the drugs listed in
the Closed Formulary and cost impacts when you discuss medication options.
Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of
Health Options, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent
Licensees of the Blue Cross and Blue Shield Association.
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January 2015 Closed Formulary Medication Guide
Preface
Closed Formulary
The Closed Formulary Medication Guide includes the Closed Formulary list and reflects the current recommendations of
Florida Blue and is developed in conjunction with Prime Therapeutics’ National Pharmacy & Therapeutics Committee.
Florida Blue reserves the right to add or remove or change the tier of any prescription drug in this Medication Guide at any
time.
All Generic Prescription Drugs are covered unless specifically excluded by your plan. Brand Name Prescription Drugs are
covered only if they are included in the Closed Formulary list.
For your out-of-pocket expenses to be as low as possible, please consider asking your doctor to prescribe Generic drugs, or
if necessary, Brand Name Prescription Drugs that are included on the Closed Formulary List. This will help ensure that your
covered prescription drugs are allowed and reimbursed under your plan. In addition, consider using a participating pharmacy
to obtain your covered prescription drugs because your out-of-pocket expenses should be lower than if you used a nonparticipating pharmacy.
To save the most money on prescription drugs, share this Medication Guide with your doctor or health care provider at each
visit. When you have your prescriptions filled, ask your pharmacist if a Generic Drug is available. Generic Drugs save you the
most money.
Changes to the formulary
The Closed Formulary List is subject to change at any time. It is reviewed quarterly to examine new medications and new
information about medications that are already on the market concerning safety, effectiveness and current use in therapy.
The most up to date information about modifications to the medications listed in this Closed Formulary Medication Guide can
be found by:
Going to www.FloridaBlue.com.
• Click on the Members tab
• Click on the Login Now button and either Login or Register
• Once Logged in, click on My Plan, then select Pharmacy from the drop down menu
• Under Medication Guide/Approved Drug Lists, click Closed Formulary Medication Guide or
Closed Formulary Medication Guide Updates
Medication Guides are posted every January and July, and Medication Guide Updates are posted January, April, July and
October.
Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of
Health Options, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent
Licensees of the Blue Cross and Blue Shield Association.
January 2015 Closed Formulary Medication Guide
II
Pharmacy benefit
The pharmacy benefit has two parts/components, called Tiers. This means that covered Prescription Drugs must be included
in one of the following Tiers:
Tier 1: Generic Prescription Drugs whether listed in the Closed Formulary List or not.
Tier 2: Only those Brand Name Prescription drugs listed in the Closed Formulary List.
Specialty Medications: Covered Specialty Medications as indicated in the Medication List
Condition Care Rx* Value/HSA Preventive Prescription Medications
* Refer to the Condition Care Rx Program section of this Medication Guide for a description of the program
Brand Name Drugs not listed in the Closed Formulary List are not covered. If you and your doctor or health care provider
think that your condition cannot be treated by any of the medication(s) listed on the Closed Formulary List, your doctor may
submit a request for an exception. If your exception request is approved, coverage will be available for the approved
medication.
Pharmacy options

There are two different types of pharmacies for you to be aware of as you decide where to get your prescriptions
filled – retail pharmacies and specialty pharmacies. To save the most money, before you get a prescription filled,
you should confirm which pharmacy is considered ‘in-network’ for that particular medication.

Retail Pharmacy Network – Non-Specialty ‘Generic’ medications and ‘Brand Name’ medications listed in the
Medication Guide can be filled at these pharmacies at a lower cost to you than other pharmacies in your area. If you
go to a non-participating pharmacy, your prescription will cost you more.

Specialty Pharmacy Network – We have identified certain drugs as specialty drugs due to requirements such as
special handling, storage, training, distribution, and management of the therapy. These drugs are listed as a
‘Specialty Drug’ in this Medication Guide. To be covered under your pharmacy program at the
in-network cost share, they must be purchased at a preferred Specialty Pharmacy. These pharmacies are different
than the retail pharmacies and are identified in both the Provider Directory and this Medication Guide. Using an innetwork Specialty Pharmacy to provide these Specialty Drugs lowers the amount you pay for these medications.

Non-Participating Pharmacy – If your plan offers out-of-network pharmacy coverage, choosing a non-participating
pharmacy will cost you more money. You may have to pay the full cost of the medication and then file a claim to be
reimbursed. Our payment will be based on our Non-Participating Pharmacy Allowance minus your cost share. You
will be responsible for your cost share and the difference between our Allowance and the cost of the medication.
Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of
Health Options, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent
Licensees of the Blue Cross and Blue Shield Association.
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January 2015 Closed Formulary Medication Guide
Formulary exception process
A formulary exception process is provided to allow for cases where the Closed Formulary List may not accommodate the
unique medical needs of a member (e.g. documented allergy, ineffectiveness, or intolerable adverse effects from drugs on
the formulary).The formulary exception form is available at www.FloridaBlue.com.

Click on the Providers tab

Click Pharmacy Info & Resources then click Medication Guides

Click Formulary Exception Physician Fax Form
Florida Blue is not obligated to approve any exception or continue a previously approved exception.
Generic drugs
Florida Blue encourages the use of Generic Drugs as a way to provide high-quality medications at a reduced cost. Generic
Drugs are as safe and effective as their Brand Name counterparts, and are usually less expensive.
A Food and Drug Administration (FDA) approved Generic Drug may be substituted for its Brand name counterpart
because it:

Contains the same active ingredient(s) as the Brand Name 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
Check with your doctor or health care provider to determine if switching to a Generic Drug is appropriate for you.
Contraceptive coverage
If your pharmacy plan includes contraceptives at no cost, as a result of the expanded PPACA Preventive Services benefits,
only generic contraceptive medications or devices (e.g., oral contraceptives, emergency contraceptive, and diaphragms) are
covered at no cost share when purchased at a participating pharmacy.
Note: Check your Benefit Booklet, Certificate of Coverage, Contract, Member Handbook or prescription drug endorsement to
determine if this benefit applies to your plan. Coverage details are also available to you by calling the customer service
number listed on your member ID card.
Responsible Rx programs
Some covered medications may have additional requirements or limits on coverage. These requirements and limits may
include:
Prior Authorization Program
The Prior Authorization Program encourages the appropriate, safe and cost-effective use of medication. If you are currently
taking or are prescribed a medication that is included in the Prior Authorization Program list of medications, your physician
will need to submit a Prior Authorization request in order for your prescription to be considered for coverage. If you do not
request and/or receive prior approval, the medication will not be covered.
A current listing of drugs requiring Prior Authorization may be found at: Prior Authorization Program Information and
Forms
Florida Blue reserves the right to change the medications that require Prior Authorization at any time and for any reason.
Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of
Health Options, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent
Licensees of the Blue Cross and Blue Shield Association.
January 2015 Closed Formulary Medication Guide
IV
Prior Authorization Program Information and Obtaining Prior Coverage Authorization
Information about Prior Authorization and forms for how to obtain a Prior Authorization approval can be found here:
Prior Authorization Program Information and Forms
NOTE: Your provider is required to complete and submit the Prior Authorization form in order for a coverage determination to
be made.
1. Once a decision is made, you and/or your doctor will be informed of the decision.
2. If the decision is made to authorize coverage, the medication(s) and/or supplies may be obtained from a
participating pharmacy or at the appropriate location if the medication(s) will be administered by a health
professional. Prior Authorization approval does not waive your financial responsibility.
3. If a decision is made to deny authorization, you are free to purchase the prescription medication, supplies or
over-the-counter (OTC) medication, but you will have to pay the full cost of the medication and will not be entitled to
reimbursement under your plan.
NOTE: You have the right to request an appeal if coverage authorization is denied. Please refer to the “How to Appeal an
Adverse Benefit Determination” subsection of the Claims Processing or Appeal and Grievance Process section in your
current Benefit Booklet, Certificate of Coverage, Contract or Member Handbook for information on how to file an appeal.
Responsible Quantity Program
The Responsible Quantity Program encourages the appropriate, safe and cost-effective use of medication by setting a
maximum quantity per month for a medication or supply. The quantity limitations are based on the Food and Drug
Administration guidelines and the manufacturer’s dosing recommendations.
Florida Blue reserves the right to change the Drugs and the quantity limits subject to the Responsible Quantity Program at
any time and for any reason. In cases where a larger quantity of a Responsible Quantity Drug is medically required, your
doctor or health care provider can request an override.
A list of current drugs included in the Responsible Quantity Program may be found here:
Responsible Quantity Program Information
Responsible Steps Program
The Responsible Steps Program promotes the appropriate, safe, and effective use of medications and helps you save on
prescriptions. Responsible Steps is based on nationally recognized therapeutic guidelines, clinical evidence, and research.
For certain prescription medications, you are required to try designated or prerequisite medication(s) prior to trying a
medication subject to the Responsible Steps Program.
A list of current drugs included in the Responsible Steps Program may be found here:
Responsible Steps Program Information
Responsible Steps (Medical Pharmacy) Program
Certain physician-administered prescription drugs which are rendered in a physician’s office may be included in the
Responsible Steps for Medical Pharmacy Program. If you are taking a medication in the Responsible Steps Program, please
contact your physician/provider to discuss what medication options are best for you.
Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of
Health Options, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent
Licensees of the Blue Cross and Blue Shield Association.
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January 2015 Closed Formulary Medication Guide
If, due to medical reasons, you cannot use the prerequisite drug and require the Responsible Steps Medication, your doctor
or health care provider may request prior authorization for an override. If the override request is approved, coverage will be
provided for the Responsible Steps Medication. Florida Blue reserves the right to change the drugs subject to the
Responsible Steps Program at any time and for any reason.
A list of current drugs included in the Responsible Steps Program may be found here:
Responsible Steps for Medical Pharmacy Program Information.
Exception Requests
If, for medical reasons, you require a quantity of medication outside the Responsible Quantity Program limits or you cannot
use one of the alternative medications and require the medication listed in the Responsible Steps or Responsible Steps for
Medical Pharmacy Programs, or you require a tier exception for an oral contraceptive drug, your physician may submit an
exception request by completing one of the forms below
Formulary Exception Request
Prior Authorization Forms
Responsible Quantity Authorization Form
Responsible Steps Program Information and Authorization Forms
Responsible Steps for Medical Pharmacy Information and Authorization Forms
Oral Contraceptives Tier Exception Request Form
Drugs That Are Not Covered
Your pharmacy benefit may not cover select medications. Some of the reasons a medication may not be covered are:

The medication has been shown to have excessive adverse effects and/or safer alternatives

The medication has a preferred formulary alternative or over-the-counter (OTC) alternative

The medication is no longer marketed

The medication has a widely available/distributed AB rated generic equivalent formulation

The medication has not been approved by the FDA

The medication has been repackaged – a pharmaceutical product that is removed from the original manufacturer
container (Brand Originator) and repackaged by another manufacturer with a different NDC.
A list of medications that are not covered may be found at Medications Not Covered
Select Generic and Brand Name drugs are not covered because of safety or effectiveness concerns.
Covered Over-the-Counter (OTC) Products
Your pharmacy benefit may provide coverage for certain OTC Drugs, if your doctor or health care provider prescribes them.
However, only those OTC Drugs designated on the Closed Formulary List with “OTC” following the product name are eligible
for coverage. Florida Blue reserves the right to change the OTC Drugs covered under the Closed Formulary Listat any time
and for any reason.
Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of
Health Options, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent
Licensees of the Blue Cross and Blue Shield Association.
January 2015 Closed Formulary Medication Guide
VI
Mail Order Pharmacy
Obtaining prescription medications through the Mail Order Pharmacy may reduce the cost you pay for your prescription
medications.
Members who have pharmacy benefits through Florida Blue can access and print out the Mail Order Pharmacy Form on
our website, www.FloridaBlue.com.
Note: If the original prescription was filled at a pharmacy other than the Mail Order Pharmacy, you must submit a new
prescription with a quantity of up to a three-month supply and not less than a two-month supply along with the Registration
and Prescription Order Form. Prescriptions may not be transferred from a retail pharmacy to the Mail Order Pharmacy.
Note: Medications listed in the Self-Administered Specialty Drug List are not available through mail order.
Self-Administered Injectables
Self-administered injectable medications are designated in the Medication List with “inj” following the medication name
(e.g., enoxaparin inj). No other Self-administered injectables will be covered unless such injectable is identified as a
Specialty Drug in this Medication Guide. Self-administered injectables will be subject to the Brand or Generic cost share, as
described in your Schedule of Benefits. Florida Blue reserves the right to change the Self-administered injectables covered
through the Closed Formulary List at any time and for any reason.
Patient Protection Affordable Care Act (PPACA) Mandated Coverage
Preventive medications
The Patient Protection and Affordable Care Act (PPACA) provides for members to receive coverage for certain preventive
care services, medications, and immunizations at no out-of-pocket costs based on recommendations from the U.S.
Preventive Services Task Force (USPSTF). These USPSTF recommendations include services that have been shown to be
important in preventing disease as well as providing for additional women’s services such as FDA-approved contraception.
A list of drugs covered under our Preventive Medications Program may be found at: Preventive Medications List
Immunizations
Certain vaccines which are covered under your preventive benefit can be administered by Pharmacists that are certified. Not
all pharmacies provide services for vaccine administration. It is important to contact the pharmacy prior to your visit to ensure
availability and administration of the vaccine.
A list of vaccines that are covered under your pharmacy benefits may be found at: Pharmacy Benefit Vaccines List
Women’s preventive services
As a result of the expanded PPACA Preventive Services benefits for women’s services, certain generic contraceptive
medications or devices (e.g., oral contraceptives, emergency contraceptive, and diaphragms) are covered at no cost share
when purchased at a participating pharmacy.
A list of medications and devices covered under this benefit may be found at: Women’s Preventive Services List
Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of
Health Options, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent
Licensees of the Blue Cross and Blue Shield Association.
VII
January 2015 Closed Formulary Medication Guide
Condition Care Rx Program
The Condition Care Rx Program is designed to help manage the cost of medications used to treat certain chronic conditions
and encourage medication adherence. Members who have the Condition Care Rx Program as part of their benefits are
eligible to receive medications from the Condition Care Rx Program Value/Health Savings Account Preventive List at a
reduced cost.
A list of medications that are part of the Condition Care Rx Value Program may be found at: Condition Care Rx Program
Value List
A list of medications that are part of the Condition Care Rx Program for Health Savings Account (HSA) compatible plans may
be found at: Condition Care Rx Program HSA Preventive List
Note: Check your Benefit Booklet, Certificate of Coverage, Contract, Member Handbook or prescription drug endorsement to
determine if the Condition Care Rx Program applies to your plan and the cost share. Coverage details may also be available
to you by logging into the member section of www.FloridaBlue.com or by calling the customer service number listed on your
member ID card.
Specialty Pharmacy medications
Specialty Pharmacy medications are high-cost injectable, infused, oral or inhaled medications that generally require close
supervision and monitoring of the patient’s therapy.
NOTE: Check your Benefit Booklet, Certificate of Coverage, Contract, Member Handbook or prescription drug endorsement
for information on how Specialty Pharmacy medications are covered on your plan. Coverage details are also available by
calling the customer service number listed on your member ID card.
Specialty Medications are divided into two categories:

Self-Administered – Patients self-administer these Specialty Pharmacy medications themselves. Because these
medications are intended to be self-administered, these medications may not be covered if administered in a
physician’s office. If these medications are not obtained from a participating Specialty Pharmacy, out-of-network
cost shares will apply (where out-of-network coverage is available).
A current listing of Self-Administered Specialty Medications can be found here
Provider-Administered – These medications require the administration to be performed by a physician. The
Specialty Pharmacy medications are ordered by a provider and administered in an office or outpatient setting.
Provider-administered Specialty Pharmacy medications are covered under your medical benefit. A current listing
of Provider-Administered Specialty Medications can be found here
Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of
Health Options, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent
Licensees of the Blue Cross and Blue Shield Association.
January 2015 Closed Formulary Medication Guide
VIII
Participating Specialty Pharmacy Provider
If you are currently taking a Specialty Pharmacy medication, then your network for Specialty Pharmacies is limited to the
following participating Specialty Pharmacy providers. Unless indicated below, any other pharmacy is considered a nonparticipating Specialty Pharmacy even if it participates in Florida Blue’s networks for non-Specialty Pharmacy medications.
Caremark Specialty Pharmacy Services
All Products
Phone: 1.866.278.5108
Fax: 1.800.323.2445
Caremark Specialty Pharmacy
Caremark Hemophilia Services
Hemophilia Products
Telephone: 1.866.792.2731
(Mon-Fri., 9:00 a.m. to 7:30 p.m. EST)
Fax: 1.866.811.7450
Caremark Hemophilia
Prime Therapeutics Specialty Pharmacy
(Prime Specialty Pharmacy)
Telephone: 1.877.627.(MEDS) 6337
Fax: 1.877.828.3939
TTY 711
Prime Specialty Pharmacy
Prime Therapeutics Specialty Pharmacy
(Prime Specialty Pharmacy) is a wholly owned subsidiary
of Prime Therapeutics LLC.
Note: Specialty Pharmacy medications are not covered when purchased through the Mail Order Pharmacy.
Self-administered specialty medications as classified by Florida Blue outside of the state of Florida may be obtained by a
member with a written prescription through the preferred specialty pharmacy providers Prime Specialty Pharmacy or
Caremark Specialty.
If a member resides or is traveling outsides the state of Florida and needs to receive a provider-administered specialty
medication, the prescribing physician should coordinate with the participating specialty pharmacy provider for their area or
contact the local BlueCross and BlueShield Plan. This coordination can help ensure members receive their medications at
the in-network cost share.
Members that receive a written prescription directly from their provider for a provider-administered specialty medication
should contact customer service for further assistance.
Notice
This Closed Formulary Medication Guide shall not extend, vary, alter, replace, or waive any of the provisions, benefits,
exclusions, limitations, or conditions contained in the Benefit Booklet, Certificate of Coverage, Contract, Member Handbook
or prescription drug endorsement. In the event of any inconsistencies between the Closed Formulary Medication Guide and
the provisions contained in the Benefit Booklet, Certificate of Coverage, Contract, Member Handbook or prescription drug
endorsement, the provisions contained in the Benefit Booklet, Certificate of Coverage, Contract, Member Handbook or
prescription drug endorsement shall control to the extent necessary to effectuate the intent of Florida Blue.
Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of
Health Options, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent
Licensees of the Blue Cross and Blue Shield Association.
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January 2015 Closed Formulary Medication Guide
Using the Medication Guide
The Medication List is organized into broad categories (e.g., Antibacterials).
The first column of the chart lists the medication name. Generic medications are listed in lowercase boldface
(e.g., metformin) Brand Name medications are capitalized (e.g., CRESTOR)
Separate medication entries are required for some dosage forms or routes of administration including extended-release,
delayed-release, rectal, injectable, otic, ophthalmic, vaginal, nasal, orally disintegrating, patches, and topical products.
Note: Self-administered injectable medications are designated in the Medication List with “inj” following the medication
name (e.g., enoxaparin inj).
The second column indicates the Tier level:
1 (Lowest Cost): Covered Generic Prescription Medications
2 (Higher Cost): Covered Preferred Brand Prescription Medications
3 (Highest Cost): Covered Non-Preferred Brand Prescription Medications and are not listed
The third column indicates if the medication is a Self-Administered Specialty* medication.
* If your Pharmacy plan has a separate cost share for Specialty medications, then all Specialty medications will
apply that cost share regardless of the Tier level displayed in the Medication List. Check your Benefit Booklet,
Certificate of Coverage, Contract, Member Handbook or prescription drug endorsement to determine how
coverage of Self-Administered Specialty medications applies to your plan.
The remaining columns indicate the Responsible Rx Pharmacy Program(s) that apply to the prescription medication
(e.g., Prior Authorization, Responsible Quantity and Responsible Steps). If an indicator is present in the column(s),
then the Responsible Rx Program applies.
An asterisk (*) next to a drug name signifies that this drug may not be covered. Please refer to your Benefit Booklet,
Certificate of Coverage, Contract, Member Handbook or prescription drug endorsement.
Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of
Health Options, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent
Licensees of the Blue Cross and Blue Shield Association.
January 2015 Closed Formulary Medication Guide
X
Abbreviation/acronym key
caps ..............................................................capsules
chew tabs ........................................ chewable tablets
oint ........................................................................ ointment
PA.............................. Prior Coverage Authorization required
conc ......................................................... concentrate
crm .................................................................... cream
QL.......Responsible Quantity Program–quantity limit applies
RS .. Responsible Steps Program–prerequisite drug required
ext-release ...................................... extended-release
inhal ............................................................ inhalation
SI ...............................................Self-Administered Injectable
SL .......................................................................... sublingual
inj ...................................................................injection
lotn ..................................................................... lotion
SP ............................. Self-Administered Specialty Pharmacy
soln ........................................................................... solution
NP.......................................................... non-preferred
ODT .................................. orally disintegrating tablets
supp ................................................................. suppositories
susp .................................................................... suspension
OSM .................................................. osmotic-release
OTC .......................................... over-the-counter drug
tabs ............................................................................. tablets
Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of
Health Options, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent
Licensees of the Blue Cross and Blue Shield Association.
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January 2015 Closed Formulary Medication Guide
Selected generic and brand name drugs are not covered because of safety or effectiveness concerns. This list is
subject to change.
acetaminophen/salicylamide/phenyltoloxamine
Nefazodone 50 mg, 100 mg, 150 mg, 200 mg
Ala Quin
Novacort
Alcortin A
Omontys
Amoxapine
Opium Tincture
Armour Thyroid
opium tincture 1%
Avandamet
pentazocine/naloxone
Avandaryl
phendimetrazine
Avandia
Phendimetrazine ext-release
benzphetamine
Phospholine Iodide
Bontril PDM
Pramosone
Butisol
pramoxine
Carisoprodol 250 mg
pramoxine/hydrocortisone topical
carisoprodol 350 mg
Regimex
carisoprodol/aspirin
Reserpine
carisoprodol/aspirin/codeine
Seconal
chlordiazepoxide/clidinium
sodium thiosulfate/salicylic acid lotn, 25-1%
Demerol tabs
Soma
Didrex
thioridazine
diethylpropion
thyroid tabs, 30 mg, 60 mg, 90 mg
Diethylpropion
Thyrolar
diethylpropion ext-release
ticlopidine
Donnatal
triazolam
Donnatal Extentabs
Westhroid
Epifoam
WP Thyroid
Equagesic
Zyflo
ergoloid mesylates
Zyflo CR
esterified estrogens/methyltestosterone
flavoxate
Halcion
hydrocortisone/iodoquinol
isoxsuprine 10 mg
Isoxsuprine 20 mg
Ketek
ketoconazole tabs
Librax
Meperidine oral soln
meperidine tabs
meprobamate
Nature-Throid
nefazodone 250 mg
Florida Blue January 2015 Closed Medication Drug Guide
1
ANTI-INFECTIVE DRUGS
PENICILLINS
ERYTHROMYCIN
ETHYLSUCCINATE
2
2
AMOXICILLIN chew tabs, 250 mg
2
ZITHROMAX packets
amoxicillin/potassium
clavulanate (Augmentin)
1
TETRACYCLINES
amoxicillin/potassium
clavulanate extrelease (Augmentin XR)
1
amoxicillin, NP = chew tabs,
125 mg
1
ampicillin caps
1
AMPICILLIN susp
2
AUGMENTIN susp, 125 mg/5 mL
2
dicloxacillin
1
penicillin v potassium
1
CEPHALOSPORINS
demeclocycline
1
doxycycline hyclate
caps (Vibramycin)
1
doxycycline hyclate tabs
1
doxycycline
monohydrate (Adoxa, Monodox)
1
minocycline (Dynacin, Minocin)
1
TETRACYCLINE
2
ciprofloxacin (Cipro)
1
ciprofloxacin ext-release (Cipro
XR)
1
1
levofloxacin (Levaquin)
1
cefadroxil
1
ofloxacin 200 mg, 300 mg
1
cefdinir
1
SULFONAMIDES
cefpodoxime
1
SULFADIAZINE
cefprozil
1
AMINOGLYCOSIDES
cefuroxime (Ceftin)
1
BETHKIS
2
cephalexin, NP = tabs (Keflex)
1
neomycin sulfate
1
paromomycin
1
TOBI PODHALER
2
tobramycin (Tobi)
1
azithromycin susp,
tabs (Zithromax)
1
clarithromycin (Biaxin)
1
clarithromycin ext-release (Biaxin
XL)
1
ERY-TAB
2
ERYTHROMYCIN BASE
2
erythromycin delayed-release
caps
1
KEY
2
Tier
1 = Covered Generic Drugs
2 = Preferred Brand Drugs
•
*
Responsible Steps
Quanitity Limits
Prior Authorization
FLUOROQUINOLONES
cefaclor caps
MACROLIDES
Specialty
Drug Name
Drug Tier
Responsible Steps
Quanitity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2015
2
X
X
X
TUBERCULOSIS
ethambutol (Myambutol)
1
ISONIAZID syrup
2
isoniazid tabs
1
PRIFTIN
2
pyrazinamide
1
rifabutin (Mycobutin)
1
= Responsible Rx Program
X = Self-Administered Specialty Medication
= May not be covered – see endorsement
Florida Blue January 2015 Closed Medication Drug Guide
1
1
fluconazole (Diflucan)
1
abacavir/lamivudine/
zidovudine (Trizivir)
flucytosine (Ancobon)
1
APTIVUS
2
griseofulvin microsize (Grifulvin
V)
1
ATRIPLA
2
COMPLERA
2
itraconazole (Sporanox)
1
CRIXIVAN
2
NOXAFIL
2
•
•
1
nystatin oral
1
didanosine delayedrelease (Videx EC)
SPORANOX soln
2
•
•
•
EDURANT
2
EMTRIVA
2
EPIVIR soln
2
VIRAL INFECTIONS
EPZICOM
2
Cytomegalovirus
FUZEON
2
INTELENCE
2
INVIRASE
2
FUNGAL INFECTIONS
terbinafine (Lamisil)
1
voriconazole (Vfend)
1
VALCYTE
2
Hepatitis
adefovir (Hepsera)
1
ISENTRESS
2
BARACLUDE soln
2
KALETRA
2
entecavir (Baraclude)
1
lamivudine (Epivir)
1
EPIVIR HBV soln
2
lamivudine/zidovudine (Combivir)
1
INTRON-A
2
LEXIVA
2
lamivudine (Epivir HBV)
1
NEVIRAPINE susp
2
OLYSIO
2
nevirapine tabs (Viramune)
1
PEGASYS
2
1
RIBATAB
2
nevirapine ext-release (Viramune
XR)
1
NORVIR
2
ribavirin (Copegus, Rebetol)
SOVALDI
2
PREZISTA tabs
2
RESCRIPTOR
2
REYATAZ
2
SELZENTRY
2
stavudine (Zerit)
1
X
X
X
X
X
X
•
•
•
•
•
Herpes
acyclovir (Zovirax)
1
famciclovir (Famvir)
1
valacyclovir (Valtrex)
1
KEY
Tier
1 = Covered Generic Drugs
2 = Preferred Brand Drugs
•
*
Responsible Steps
abacavir (Ziagen)
Quanitity Limits
rifampin (Rifadin)
Prior Authorization
HIV/AIDS
1
Specialty
2
Drug Name
Drug Tier
Responsible Steps
Quanitity Limits
RIFAMATE
Specialty
Drug Name
Drug Tier
Prior Authorization
2015
•
•
•
•
•
•
•
X
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
= Responsible Rx Program
X = Self-Administered Specialty Medication
= May not be covered – see endorsement
Florida Blue January 2015 Closed Medication Drug Guide
3
VIDEX
2
VIRACEPT
2
VIRAMUNE susp
2
VIRAMUNE XR 100 mg
2
VIREAD
2
ZIAGEN soln
2
zidovudine (Retrovir)
1
NEBUPENT
2
PRIMSOL
2
SIVEXTRO tabs
2
sulfamethoxazole/
trimethoprim (Bactrim)
1
trimethoprim
1
vancomycin (Vancocin)
1
XIFAXAN 550 mg
2
YODOXIN
2
ZYVOX
2
• •
FLU VACCINES, NP = FLUBLOK
2
•
GAMMAGARD LIQUID
2
2
MALARIA
•
atovaquone/proguanil (Malarone)
1
GAMMAKED
2
chloroquine phosphate (Aralen)
1
GAMUNEX-C
2
DARAPRIM
2
HIZENTRA
2
hydroxychloroquine (Plaquenil)
1
MENACTRA
2
mefloquine
1
MENOMUNE-A/C/Y/W-135
2
PRIMAQUINE
2
MENVEO
2
PNEUMOVAX 23
2
WORM INFECTIONS
ALBENZA
2
PREVNAR 13
2
BILTRICIDE
2
ZOSTAVAX
2
ivermectin (Stromectol)
1
CANCER DRUGS
OTHER ANTI-INFECTIVES
ACTIMMUNE
2
ALINIA
2
AFINITOR
2
CAYSTON
2
AFINITOR DISPERZ
2
clindamycin (Cleocin, Cleocin
Pediatric)
1
ALKERAN tabs
2
anastrozole (Arimidex)
1
colistimethate (Coly-Mycin M)
1
bicalutamide (Casodex)
1
DAPSONE
2
BOSULIF
2
erythromycin/sulfisoxazole
1
capecitabine (Xeloda)
1
KEY
4
Tier
1 = Covered Generic Drugs
2 = Preferred Brand Drugs
• •
• •
IMMUNIZING AGENTS
Influenza
TAMIFLU
1
Responsible Steps
2
Quanitity Limits
TRUVADA
Prior Authorization
2
metronidazole oral (Flagyl)
Specialty
TIVICAY
Drug Name
Drug Tier
2
•
•
•
•
•
•
•
•
•
•
•
Responsible Steps
SUSTIVA
Quanitity Limits
2
Prior Authorization
STRIBILD
Specialty
Drug Name
Drug Tier
2015
•
*
X
X
X
X
•
•
•
•
X
X • •
X • •
X • •
X • •
= Responsible Rx Program
X = Self-Administered Specialty Medication
= May not be covered – see endorsement
Florida Blue January 2015 Closed Medication Drug Guide
1
2
MYLERAN
2
CYCLOPHOSPHAMIDE tabs
2
NEXAVAR
2
EMCYT
2
NILANDRON
2
ERIVEDGE
2
POMALYST
2
ETOPOSIDE caps
2
PURIXAN
2
exemestane (Aromasin)
1
SPRYCEL
2
FARESTON
2
STIVARGA
2
flutamide
1
SUTENT
2
GILOTRIF
2
SYLATRON
2
GLEEVEC
2
TABLOID
2
HEXALEN
2
TAFINLAR
2
HYCAMTIN caps
2
tamoxifen
1
hydroxyurea (Hydrea)
1
TARCEVA
2
ICLUSIG
2
TARGRETIN caps
2
IMBRUVICA
2
TASIGNA
2
INLYTA
2
temozolomide (Temodar)
1
JAKAFI
2
tretinoin caps
1
letrozole (Femara)
1
TYKERB
2
LEUCOVORIN CALCIUM tabs,
10 mg, 15 mg
2
VOTRIENT
2
XALKORI
2
leucovorin calcium tabs, 5 mg,
25 mg
1
XTANDI
2
2
ZELBORAF
2
LEUKERAN
1
X •
ZOLINZA
2
leuprolide acetate
2
ZYDELIG
2
LOMUSTINE
2
ZYKADIA
2
ZYTIGA
2
MATULANE
X
X
2
LYSODREN
megestrol (Megace)
1
MEKINIST
2
X • •
CORTICOSTEROIDS
mercaptopurine (Purinethol)
1
MESNEX tabs
2
KEY
Tier
1 = Covered Generic Drugs
2 = Preferred Brand Drugs
•
*
X • •
X • •
X • •
X
X •
X
X
X
X
•
•
•
•
•
•
•
•
Responsible Steps
methotrexate
Quanitity Limits
COMETRIQ
X • •
X • •
Prior Authorization
2
Specialty
Drug Name
Drug Tier
CAPRELSA
Responsible Steps
Specialty
Quanitity Limits
Drug Name
Drug Tier
Prior Authorization
2015
X • •
X
X
X
X
X
X
• •
• •
• •
• •
X • •
X
X
X
X
X
X
X
X
X
X
X
X
X
X
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
HORMONES, DIABETES AND RELATED DRUGS
budesonide ext-release (Entocort
EC)
1
CORTISONE
2
= Responsible Rx Program
X = Self-Administered Specialty Medication
= May not be covered – see endorsement
Florida Blue January 2015 Closed Medication Drug Guide
5
dexamethasone elixir; tabs,
0.5 mg, 0.75 mg, 1.5 mg, 4 mg,
6 mg
1
DEXAMETHASONE soln; tabs,
1 mg, 2 mg
2
fludrocortisone
1
hydrocortisone (Cortef)
1
methylprednisolone (Medrol)
1
prednisolone (Prelone)
1
prednisolone sodium
phosphate (Orapred)
medroxyprogesterone acetate
tabs (Provera)
1
norethindrone acetate (Aygestin)
1
progesterone
micronized (Prometrium)
1
2
levonorgestrel (Plan B, Plan B
One-Step)
1
1
norelgestromin/ethinyl
estradiol (Ortho Evra)
1
prednisolone sodium phosphate
soln, 5 mg/5 mL
1
oral contraceptives –
all generics
1
PREDNISONE soln, 5 mg/5 mL;
tabs, 50 mg; NP = dose packs
2
DIABETES
prednisone tabs, 1 mg, 2.5 mg,
5 mg, 10 mg, 20 mg
1
MALE HORMONES
2
ANDROGEL
2
danazol
1
• •
• •
ESTROGENS
CLIMARA PRO
2
DIVIGEL
2
estradiol patches (Climara)
1
estradiol tabs (Estrace)
1
estradiol/norethindrone
acetate (Activella)
1
•
•
•
acarbose (Precose)
1
BYDUREON
2
BYETTA inj
2
glimepiride (Amaryl)
1
glipizide (Glucotrol)
1
GLUCAGON EMERGENCY inj kit
2
glyburide (Micronase)
1
glyburide micronized (Glynase)
1
INVOKAMET
2
1
INVOKANA
MENEST
2
JANUMET
2
PREMARIN
2
JANUMET XR
2
PREMPHASE
2
JANUVIA
2
PREMPRO
2
KOMBIGLYZE XR
2
metformin (Glucophage)
1
6
Tier
1 = Covered Generic Drugs
2 = Preferred Brand Drugs
•
*
Responsible Steps
Quanitity Limits
glyburide/metformin (Glucovance) 1
GLYBURIDE, distributor of Diabeta 2
estropipate 0.75 mg, 1.5 mg
KEY
• •
• •
glipizide ext-release (Glucotrol XL) 1
1
glipizide/metformin
2
PROGESTINS
Prior Authorization
BIRTH CONTROL
ELLA
ANDRODERM
Specialty
Drug Name
Drug Tier
Responsible Steps
Quanitity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2015
•
•
•
•
•
•
= Responsible Rx Program
X = Self-Administered Specialty Medication
= May not be covered – see endorsement
Florida Blue January 2015 Closed Medication Drug Guide
•
•
•
•
•
•
metformin ext-release
OSM (Fortamet)
1
nateglinide (Starlix)
1
ONGLYZA
2
pioglitazone (Actos)
1
pioglitazone/metformin (Actoplus
Met)
1
PROGLYCEM
2
repaglinide (Prandin)
1
SYMLINPEN inj
2
Insulins
Rapid-Acting Insulins
NOVOLOG inj
2
Short-Acting Insulins
NOVOLIN R inj
2
RELION R inj
2
Intermediate-Acting Insulins
NOVOLIN N inj
2
NOVOLIN 70/30 inj
2
NOVOLOG MIX 70/30 inj
2
Basal Insulins
LANTUS inj
LEVEMIR inj
2
2
OTHER HORMONES AND RELATED DRUGS
1
alendronate tabs, 5 mg, 10 mg,
35 mg, 70 mg (Fosamax)
1
cabergoline
calcitonin-salmon (Miacalcin)
1
calcitriol (Rocaltrol)
1
desmopressin inj, nasal,
tabs (DDAVP)
1
ibandronate (Boniva)
1
levocarnitine (Carnitor)
1
methylergonovine
1
octreotide (Sandostatin)
1
ORFADIN
2
paricalcitol (Zemplar)
1
raloxifene (Evista)
1
risedronate (Actonel)
1
SENSIPAR
2
SOMAVERT
2
STIMATE
2
SYNAREL
2
Responsible Steps
NORDITROPIN
X •
X •
Quanitity Limits
2
•
•
X •
X •
•
X
X
ANGIOTENSIN CONVERTING ENZYME (ACE)
INHIBITORS AND COMBINATIONS
1
benazepril (Lotensin)
THYROID REGULATION
levothyroxine (Synthroid)
1
liothyronine (Cytomel)
1
methimazole (Tapazole)
1
propylthiouracil
1
SYNTHROID
2
GROWTH HORMONE
Tier
1 = Covered Generic Drugs
2 = Preferred Brand Drugs
INCRELEX
HEART AND CIRCULATORY DRUGS
2
KEY
Prior Authorization
Responsible Steps
Quanitity Limits
Prior Authorization
• •
•
•
Specialty
1
Drug Name
Drug Tier
metformin extrelease (Glucophage XR)
Specialty
Drug Name
Drug Tier
2015
•
*
benazepril/
hydrochlorothiazide (Lotensin
HCT)
1
captopril
1
CAPTOPRIL/
HYDROCHLOROTHIAZIDE
25-15 mg, 50-15 mg
2
= Responsible Rx Program
X = Self-Administered Specialty Medication
= May not be covered – see endorsement
Florida Blue January 2015 Closed Medication Drug Guide
7
bisoprolol (Zebeta)
1
1
1
bisoprolol/
hydrochlorothiazide (Ziac)
lisinopril (Prinivil, Zestril)
1
carvedilol (Coreg)
1
lisinopril/
hydrochlorothiazide (Prinzide,
Zestoretic)
1
labetalol (Trandate)
1
metoprolol succinate extrelease (Toprol XL)
1
moexipril (Univasc)
1
metoprolol tartrate (Lopressor)
1
moexipril/
hydrochlorothiazide (Uniretic)
1
nadolol (Corgard)
1
pindolol
1
perindopril (Aceon)
1
quinapril (Accupril)
propranolol ext-release (Inderal
LA)
1
1
quinapril/
hydrochlorothiazide (Accuretic)
1
PROPRANOLOL soln, 20 mg/5 mL
2
propranolol tabs
1
ramipril (Altace)
1
trandolapril (Mavik)
PROPRANOLOL/
HYDROCHLOROTHIAZIDE
80-25 mg
2
1
TIMOLOL tabs
2
ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS)
AND COMBINATIONS
1
•
irbesartan (Avapro)
irbesartan/
hydrochlorothiazide (Avalide)
1
•
losartan (Cozaar)
1
losartan/
hydrochlorothiazide (Hyzaar)
1
•
•
valsartan (Diovan)
1
valsartan/
hydrochlorothiazide (Diovan
HCT)
1
•
•
BETA BLOCKERS AND COMBINATIONS
1
acebutolol (Sectral)
atenolol (Tenormin)
KEY
8
Tier
1 = Covered Generic Drugs
2 = Preferred Brand Drugs
1
•
*
Responsible Steps
Quanitity Limits
fosinopril/hydrochlorothiazide
1
Prior Authorization
1
atenolol/
chlorthalidone (Tenoretic)
Specialty
fosinopril
Drug Name
Drug Tier
1
Responsible Steps
enalapril/
hydrochlorothiazide (Vaseretic)
Quanitity Limits
1
Prior Authorization
enalapril (Vasotec)
Specialty
Drug Name
Drug Tier
2015
CALCIUM CHANNEL BLOCKERS AND
COMBINATIONS
1
amlodipine (Norvasc)
amlodipine/benazepril (Lotrel)
1
amlodipine/valsartan (Exforge)
1
diltiazem (Cardizem)
1
diltiazem ext-release (Cardizem
CD, Tiazac)
1
felodipine ext-release
1
ISRADIPINE caps, 2.5 mg
2
nifedipine ext-release (Adalat CC,
Procardia XL)
1
NISOLDIPINE ext-release 25.5 mg
2
VERAPAMIL 40 mg
2
•
= Responsible Rx Program
X = Self-Administered Specialty Medication
= May not be covered – see endorsement
Florida Blue January 2015 Closed Medication Drug Guide
1
acetazolamide extrelease (Diamox Sequels)
1
amiloride
1
amiloride/hydrochlorothiazide
1
bumetanide
1
chlorothiazide 500 mg
1
CHLORTHALIDONE 25 mg, 50 mg
2
furosemide, NP = soln, 8 mg/
mL (Lasix)
1
hydrochlorothiazide
caps (Microzide)
1
hydrochlorothiazide tabs
1
indapamide
1
methazolamide (Neptazane)
1
metolazone (Zaroxolyn)
1
spironolactone (Aldactone)
1
CHEST PAIN
ISOSORBIDE DINITRATE tabs,
30 mg
2
isosorbide dinitrate tabs, 5 mg,
10 mg, 20 mg (Isordil)
1
isosorbide mononitrate (Monoket) 1
1
isosorbide mononitrate extrelease (Imdur)
2
NITRO-BID
nitroglycerin 0.1 mg/hr, 0.2 mg/
hr, 0.4 mg/hr, 0.6 mg/hr (NitroDur)
1
NITROSTAT
2
CHOLESTEROL LOWERING
atorvastatin (Lipitor)
1
cholestyramine (Questran,
Questran Light)
1
colestipol (Colestid)
1
CRESTOR
2
fenofibrate (Lofibra, Tricor)
1
fenofibrate micronized (Lofibra)
1
fenofibric acid delayedrelease (Trilipix)
1
gemfibrozil (Lopid)
1
lovastatin (Mevacor)
1
niacin ext-release (Niaspan)
1
pravastatin (Pravachol)
1
simvastatin (Zocor)
1
WELCHOL
2
•
1
spironolactone/
hydrochlorothiazide (Aldactazide)
1
torsemide (Demadex)
KEY
Tier
1 = Covered Generic Drugs
2 = Preferred Brand Drugs
1
• •
•
•
•
triamterene/hydrochlorothiazide,
NP = caps, 50-25 mg (Dyazide,
Maxzide, Maxzide-25)
amiodarone (Cordarone)
1
•
•
disopyramide (Norpace)
1
flecainide
1
mexiletine
1
•
•
propafenone (Rythmol)
1
propafenone ext-release (Rythmol
SR)
1
quinidine gluconate ext-release
1
QUINIDINE SULFATE ext-release
2
FLUID RETENTION
ACETAZOLAMIDE 125 mg
Responsible Steps
1
Quanitity Limits
acetazolamide 250 mg
Prior Authorization
1
Specialty
Drug Tier
Responsible Steps
verapamil ext-release (Calan SR,
Isoptin SR, Verelan, Verelan PM)
Quanitity Limits
verapamil 80 mg, 120 mg (Calan)
Prior Authorization
Drug Name
Specialty
Drug Name
Drug Tier
2015
HEART RHYTHM
2
•
*
= Responsible Rx Program
X = Self-Administered Specialty Medication
= May not be covered – see endorsement
Florida Blue January 2015 Closed Medication Drug Guide
9
quinidine sulfate 300 mg
1
NASAL PRODUCTS
sotalol (Betapace, Betapace AF)
1
azelastine (Astepro)
1
1
OTHER HEART RELATED DRUGS
amlodipine/atorvastatin (Caduet)
1
flunisolide 25 mcg/
spray (Flunisolide)
clonidine (Catapres, CatapresTTS)
1
fluticasone propionate (Flonase)
1
ipratropium (Atrovent)
1
DIGOXIN soln
2
triamcinolone (Nasacort AQ)
1
digoxin tabs (Lanoxin)
1
COUGH/COLD/ALLERGY
doxazosin (Cardura)
1
acetylcysteine
1
eplerenone (Inspra)
1
1
guanfacine (Tenex)
1
hydralazine
1
loratadine/
pseudoephedrine (Claritin-D –
OTC)
LETAIRIS
2
methyldopa
1
midodrine (Proamatine)
1
minoxidil
1
OPSUMIT
2
prazosin (Minipress)
1
sildenafil (Revatio)
1
terazosin
1
TRACLEER
2
VENTAVIS
2
X • •
1
ATROVENT HFA
2
budesonide (Pulmicort Respules)
1
X • •
COMBIVENT RESPIMAT
2
cromolyn sodium inhal soln
1
X • •
DULERA
2
FORADIL AEROLIZER
2
X • •
X • •
ipratropium inhal soln
1
ipratropium/albuterol (Duoneb)
1
levalbuterol, NP =
1.25 mg/0.5 mL (Xopenex)
1
montelukast (Singulair)
1
PROAIR HFA
2
PULMICORT FLEXHALER
2
PULMICORT RESPULES
1 mg/2 mL
2
RESPIRATORY DRUGS
ANTIHISTAMINES
QVAR
2
LEVITRA*
2
ALLERGIC REACTION KITS
EPIPEN inj
2
EPIPEN-JR inj
2
cyproheptadine
1
SPIRIVA HANDIHALER
2
loratadine (Claritin – OTC)
1
SPIRIVA RESPIMAT
2
KEY
10
Tier
1 = Covered Generic Drugs
2 = Preferred Brand Drugs
•
*
•
•
•
•
•
ASTHMA/COPD
albuterol
ERECTILE DYSFUNCTION
Responsible Steps
1
Quanitity Limits
promethazine
Prior Authorization
2
Specialty
Drug Tier
Responsible Steps
Quanitity Limits
QUINIDINE SULFATE 200 mg
Prior Authorization
Drug Name
Specialty
Drug Name
Drug Tier
2015
•
•
•
•
•
•
•
•
•
•
= Responsible Rx Program
X = Self-Administered Specialty Medication
= May not be covered – see endorsement
Florida Blue January 2015 Closed Medication Drug Guide
sucralfate (Carafate)
1
theophylline ext-release
1
SYMAX DUOTAB
2
VENTOLIN HFA
2
zafirlukast (Accolate)
1
•
•
NAUSEA AND VOMITING
EMEND caps, therapy pack
2
granisetron
1
meclizine
1
ondansetron (Zofran, Zofran ODT)
1
GASTROINTESTINAL DRUGS
ondansetron tabs, 24 mg
1
LAXATIVES
trimethobenzamide (Tigan)
1
OTHER RESPIRATORY DRUGS
KALYDECO
2
PULMOZYME
2
lactulose
1
PEG – electrolytes for
soln (Colyte, Golytely, Nulytely)
1
X • •
X
CREON
2
ZENPEP
2
CARAFATE susp
2
cimetidine
1
OTHER GASTROINTESTINAL DRUGS
2
ASACOL HD
dicyclomine caps, tabs (Bentyl)
1
balsalazide (Colazal)
1
famotidine (Pepcid)
1
calcium acetate (Eliphos, Phoslo)
1
glycopyrrolate (Robinul)
1
CANASA
2
hyoscyamine (Anaspaz, Levsin,
Levsin/SL)
1
CHENODAL
2
DELZICOL
2
hyoscyamine ext-release (Levbid)
1
1
diphenoxylate/atropine
tabs (Lomotil)
1
lansoprazole delayedrelease (Prevacid)
lactulose
1
methscopolamine (Pamine,
Pamine Forte)
1
LIALDA
2
1
loperamide
1
misoprostol (Cytotec)
2
mesalamine
1
OMEPRAZOLE (Prilosec OTC)
1
•
metoclopramide (Reglan)
1
omeprazole delayedrelease (Prilosec)
PENTASA
2
pantoprazole delayedrelease (Protonix)
1
•
RENVELA
2
sulfasalazine (Azulfidine)
1
PROPANTHELINE 15 mg
2
Tier
1 = Covered Generic Drugs
2 = Preferred Brand Drugs
•
*
•
•
•
•
DIGESTIVE ENZYMES
– Pancreatic enzyme products:
ULCER/GERD
KEY
Responsible Steps
1
Quanitity Limits
1
Prior Authorization
ranitidine (Zantac)
•
Specialty
Drug Tier
terbutaline
Responsible Steps
2
Quanitity Limits
SYMBICORT
Prior Authorization
Drug Name
Specialty
Drug Name
Drug Tier
2015
•
= Responsible Rx Program
X = Self-Administered Specialty Medication
= May not be covered – see endorsement
Florida Blue January 2015 Closed Medication Drug Guide
11
sulfasalazine delayedrelease (Azulfidine EN-Tabs)
1
potassium citrate/citric
acid (Polycitra-K)
ursodiol (Actigall, Urso 250, Urso
Forte)
1
sodium citrate/citric acid (Shohl's) 1
1
tamsulosin (Flomax)
GENITOURINARY DRUGS
1
CENTRAL NERVOUS SYSTEM DRUGS
URINARY TRACT INFECTIONS
ANXIETY
nitrofurantoin (Furadantin)
1
nitrofurantoin
macrocrystalline (Macrodantin)
1
nitrofurantoin monohydrate/
macrocrystalline (Macrobid)
1
URINARY TRACT SPASMS
oxybutynin
1
oxybutynin ext-release (Ditropan
XL)
1
tolterodine (Detrol)
1
tolterodine ext-release (Detrol LA)
1
VESICARE
2
VAGINAL PRODUCTS
•
•
•
•
•
alprazolam (Xanax)
1
alprazolam ext-release (Xanax
XR)
1
buspirone
1
DIAZEPAM oral soln, 1 mg/mL
2
diazepam tabs (Valium)
1
hydroxyzine hcl
1
hydroxyzine pamoate 25 mg,
50 mg (Vistaril)
1
lorazepam (Ativan)
1
lorazepam conc (Lorazepam
Intensol)
1
DEPRESSION
AVC
2
CLEOCIN supp
2
clindamycin (Cleocin)
1
metronidazole (MetroGel-Vaginal)
amitriptyline
1
bupropion (Wellbutrin)
1
1
1
bupropion ext-release (Wellbutrin
SR, Wellbutrin XL)
•
•
PREMARIN
2
citalopram (Celexa)
1
•
terconazole (Terazol)
1
clomipramine (Anafranil)
1
VAGIFEM
2
desipramine (Norpramin)
1
doxepin
1
OTHER GENITOURINARY DRUGS
alfuzosin ext-release (Uroxatral)
1
DOXEPIN 75 mg
2
CYSTAGON
2
1
•
finasteride (Proscar)
1
duloxetine delayedrelease (Cymbalta)
K-PHOS NO. 2
2
escitalopram (Lexapro)
1
potassium citrate extrelease (Urocit-K)
1
fluoxetine, 60 mg not
covered (Prozac)
1
•
•
KEY
12
Tier
1 = Covered Generic Drugs
2 = Preferred Brand Drugs
Responsible Steps
Quanitity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quanitity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2015
•
*
= Responsible Rx Program
X = Self-Administered Specialty Medication
= May not be covered – see endorsement
Florida Blue January 2015 Closed Medication Drug Guide
loxapine (Loxitane)
1
1
•
olanzapine (Zyprexa, Zyprexa
Zydis)
1
perphenazine
1
nortriptyline caps (Pamelor)
1
prochlorperazine
1
paroxetine hcl (Paxil)
1
quetiapine (Seroquel)
1
1
•
•
risperidone (Risperdal, Risperdal
M-Tab)
1
•
•
paroxetine hcl ext-release (Paxil
CR)
PAXIL susp
2
• •
SEROQUEL XR
2
•
phenelzine (Nardil)
1
thiothixene
1
sertraline (Zoloft)
1
trifluoperazine
1
tranylcypromine (Parnate)
1
ziprasidone (Geodon)
1
trazodone
1
SLEEP AIDS
venlafaxine
1
venlafaxine ext-release
caps (Effexor XR)
•
estazolam
1
1
•
•
phenobarbital soln; tabs,
16.2 mg, 32.4 mg
1
VENLAFAXINE ext-release tabs,
225 mg
2
• •
2
venlafaxine ext-release tabs,
37.5 mg, 75 mg, 150 mg
1
•
PHENOBARBITAL tabs, 15 mg,
30 mg, 60 mg, 64.8 mg, 100 mg;
NP = 97.2 mg
temazepam (Restoril)
1
zaleplon (Sonata)
1
zolpidem (Ambien)
1
PSYCHOTIC AND BIPOLAR DISORDERS
1
chlorpromazine
•
•
•
•
•
•
clozapine (Clozaril)
1
fluphenazine hcl tabs
1
HYPERACTIVITY/NARCOLEPSY
haloperidol lactate oral soln
1
1
• •
haloperidol tabs
1
amphetamine/
dextroamphetamine (Adderall)
LITHIUM soln
2
1
• •
lithium carbonate
1
amphetamine/
dextroamphetamine extrelease (Adderall XR)
LITHIUM CARBONATE caps,
600 mg
2
caffeine citrate (Cafcit)
1
1
dextroamphetamine
1
lithium carbonate ext-release
300 mg (Lithobid)
1
lithium carbonate ext-release
450 mg
1
dextroamphetamine extrelease (Dexedrine Spansule)
• •
• •
methylphenidate tabs (Ritalin)
1
• •
KEY
Tier
1 = Covered Generic Drugs
2 = Preferred Brand Drugs
•
*
zolpidem ext-release (Ambien CR) 1
Responsible Steps
mirtazapine (Remeron, Remeron
SolTab)
Quanitity Limits
1
Prior Authorization
•
Specialty
Drug Tier
imipramine hcl (Tofranil)
Responsible Steps
1
Quanitity Limits
fluvoxamine
Prior Authorization
Drug Name
Specialty
Drug Name
Drug Tier
2015
= Responsible Rx Program
X = Self-Administered Specialty Medication
= May not be covered – see endorsement
Florida Blue January 2015 Closed Medication Drug Guide
13
1
modafinil (Provigil)
1
NARCOTIC DRUGS
• •
MULTIPLE SCLEROSIS
BETASERON
2
COPAXONE
2
PLEGRIDY
2
REBIF
2
TECFIDERA
2
X
X
X
X
X
•
•
•
•
•
•
•
•
•
•
OTHER CENTRAL NERVOUS SYSTEM DRUGS
1
acamprosate delayedrelease (Campral)
1
disulfiram (Antabuse)
acetaminophen/codeine (Tylenol
w/Codeine)
1
•
buprenorphine
1
buprenorphine/naloxone
1
butalbital/aspirin/caffeine/
codeine (Fiorinal w/Codeine)
1
• •
• •
•
butorphanol nasal
1
fentanyl (Duragesic)
1
fentanyl (Actiq)
1
hydrocodone/acetaminophen,
NP = soln, 10-325 mg/15 mL
1
•
•
• •
•
hydrocodone/ibuprofen (Ibudone,
Reprexain, Vicoprofen)
1
•
hydromorphone soln,
tabs (Dilaudid)
1
•
methadone conc, soln
1
methadone tabs (Dolophine)
1
•
•
•
•
donepezil (Aricept, Aricept ODT)
1
EXELON patches
2
galantamine (Razadyne)
1
galantamine extrelease (Razadyne ER)
1
naltrexone (ReVia)
1
morphine sulfate conc, soln
1
rivastigmine (Exelon)
1
morphine sulfate extrelease (Avinza, Kadian, MS
Contin)
1
MORPHINE SULFATE tabs
2
oxycodone
1
oxycodone/
acetaminophen (Percocet)
1
•
•
•
oxycodone/acetaminophen caps,
5-500 mg
1
•
oxycodone/aspirin (Percodan)
1
OXYCONTIN
2
ROXICET soln
2
SUBOXONE film
2
tramadol (Ultram)
1
•
•
•
• •
•
TOBACCO CESSATION
bupropion ext-release (Zyban)
1
CHANTIX*
2
NICOTROL INHALER*
2
NICOTROL NS*
2
PAIN RELIEF DRUGS
NON-NARCOTIC DRUGS
butalbital/acetaminophen
1
butalbital/acetaminophen/
caffeine (Esgic, Fioricet)
1
butalbital/aspirin/caffeine
caps (Fiorinal)
1
KEY
14
Tier
1 = Covered Generic Drugs
2 = Preferred Brand Drugs
Responsible Steps
Quanitity Limits
1
Prior Authorization
salsalate
Specialty
Responsible Steps
Quanitity Limits
Prior Authorization
• •
Drug Name
Drug Tier
methylphenidate ext-release
caps; tabs, 20 mg (Metadate
CD, Ritalin LA)
Specialty
Drug Name
Drug Tier
2015
•
*
•
•
•
= Responsible Rx Program
X = Self-Administered Specialty Medication
= May not be covered – see endorsement
Florida Blue January 2015 Closed Medication Drug Guide
•
•
RHEUMATOID AND OSTEOARTHRITIS
1
diclofenac potassium (Cataflam)
diclofenac sodium delayedrelease
1
diclofenac sodium extrelease (Voltaren-XR)
1
ENBREL
2
etodolac
1
etodolac ext-release
1
flurbiprofen
1
HUMIRA
2
ibuprofen
1
indomethacin
1
sumatriptan auto-injector;
cartridge; inj, 6 mg/0.5 mL;
tabs (Imitrex)
1
SUMATRIPTAN inj, 4 mg/0.5 mL
2
•
Responsible Steps
rizatriptan (Maxalt, Maxalt-MLT)
•
•
•
GOUT
X • •
allopurinol (Zyloprim)
1
COLCRYS
2
probenecid
1
probenecid/colchicine
1
NEUROMUSCULAR DRUGS
X • •
SEIZURES
1
carbamazepine extrelease (Carbatrol, Tegretol-XR)
1
1
ketoprofen
1
clonazepam (Klonopin)
1
leflunomide (Arava)
1
DIASTAT
2
MELOXICAM susp
2
DILANTIN caps
2
meloxicam tabs (Mobic)
1
1
nabumetone
1
naproxen (Naprosyn)
1
divalproex delayedrelease (Depakote, Depakote
Sprinkles)
1
divalproex ext-release (Depakote
ER)
1
naproxen delayed-release (ECNaprosyn)
1
ethosuximide (Zarontin)
1
naproxen sodium (Anaprox)
1
gabapentin (Neurontin)
1
oxaprozin (Daypro)
1
lamotrigine (Lamictal)
1
piroxicam (Feldene)
2
levetiracetam (Keppra)
1
SIMPONI
1
oxcarbazepine (Trileptal)
1
sulindac
phenytoin (Dilantin)
1
phenytoin sodium extrelease (Dilantin, Phenytek)
1
primidone (Mysoline)
1
X • •
MIGRAINE HEADACHES
acetaminophen/isometheptene/
dichloralphenazone
1
IMITREX nasal
2
Tier
1 = Covered Generic Drugs
2 = Preferred Brand Drugs
Quanitity Limits
1
carbamazepine (Tegretol)
KEY
Prior Authorization
naratriptan (Amerge)
Specialty
Drug Name
Drug Tier
1
Responsible Steps
tramadol/
acetaminophen (Ultracet)
Quanitity Limits
1
Prior Authorization
tramadol ext-release (Ultram ER)
Specialty
Drug Name
Drug Tier
2015
•
*
•
= Responsible Rx Program
X = Self-Administered Specialty Medication
= May not be covered – see endorsement
Florida Blue January 2015 Closed Medication Drug Guide
15
PARKINSON'S DISEASE
amantadine caps, syrup
1
AMANTADINE tabs
2
benztropine
1
bromocriptine (Parlodel)
1
carbidopa/levodopa (Parcopa,
Sinemet)
1
carbidopa/levodopa extrelease (Sinemet CR)
1
entacapone (Comtan)
1
pramipexole (Mirapex)
1
ropinirole (Requip)
1
selegiline caps (Eldepryl)
1
selegiline tabs
1
trihexyphenidyl
1
MUSCLE RELAXANTS
baclofen
1
chlorzoxazone (Parafon Forte)
1
cyclobenzaprine
1
DANTROLENE 100 mg
2
dantrolene 25 mg,
50 mg (Dantrium)
1
metaxalone (Skelaxin)
1
methocarbamol (Robaxin)
1
orphenadrine citrate ext-release
1
orphenadrine/aspirin/caffeine
25-385-30 mg
1
tizanidine (Zanaflex)
1
KEY
16
Tier
1 = Covered Generic Drugs
2 = Preferred Brand Drugs
•
*
Responsible Steps
Quanitity Limits
Prior Authorization
Specialty
zonisamide (Zonegran)
1
Drug Name
Drug Tier
valproic acid (Depakene)
1
Responsible Steps
topiramate (Topamax, Topamax
Sprinkle)
1
Quanitity Limits
2
Prior Authorization
SABRIL
Specialty
Drug Name
Drug Tier
2015
OTHER NEUROMUSCULAR DRUGS
2
MESTINON syrup
MESTINON TIMESPAN
2
PROSTIGMIN tabs
2
pyridostigmine (Mestinon)
1
riluzole (Rilutek)
1
SUPPLEMENTS
VITAMINS
ergocalciferol (Drisdol)
1
MEPHYTON
2
MULTIVITAMINS
PRENATAL MULTIVITAMINS/
FOLIC ACID
2
MINERALS AND ELECTROLYTES
potassium bicarbonate/chloride
effervescent tabs, 25 mEq
1
potassium chloride packets;
soln
1
potassium chloride ext-release,
NP = 20 mEq
1
potassium phosphate/sodium
phosphates (K-Phos Neutral)
1
SODIUM FLUORIDE tabs, 2.2 mg
2
sodium fluoride, NP = tabs,
1.1 mg (Luride)
1
BLOOD MODIFYING DRUGS
anagrelide (Agrylin)
1
ARANESP
2
cilostazol (Pletal)
1
CINRYZE
2
clopidogrel (Plavix)
1
cyanocobalamin inj
1
dipyridamole (Persantine)
1
X •
X •
= Responsible Rx Program
X = Self-Administered Specialty Medication
= May not be covered – see endorsement
Florida Blue January 2015 Closed Medication Drug Guide
FIRAZYR
2
folic acid tabs, 1 mg
1
LEUKINE
2
NEULASTA
2
NEUPOGEN
2
X
X • •
X •
pentoxifylline ext-release (Trental) 1
2
PRADAXA
•
PROCRIT
2
warfarin (Coumadin)
1
XARELTO
2
ZAVESCA
2
X •
2
ALPHANATE/VWF
2
ALPHANINE SD
2
ALPROLIX
2
BEBULIN/VH
2
BENEFIX
2
CORIFACT
2
ELOCTATE
2
FEIBA NF
2
HELIXATE FS
2
HEMOFIL M
2
HUMATE-P
2
KOATE-DVI
2
KOGENATE FS
2
MONOCLATE-P
2
MONONINE
2
NOVOSEVEN/RT
2
KEY
Tier
1 = Covered Generic Drugs
2 = Preferred Brand Drugs
•
*
RECOMBINATE
2
RIXUBIS
2
TRETTEN
2
WILATE
2
XYNTHA/SOLOFUSE
2
X
X
X
X
X
X
•
•
•
•
•
•
TOPICAL PRODUCTS
EYE
Anti-infectives
X •
•
X •
COAGULATION FACTORS
ADVATE
2
Responsible Steps
1
PROFILNINE SD
Quanitity Limits
enoxaparin inj (Lovenox)
•
•
Prior Authorization
2
Specialty
ELIQUIS
Drug Name
Drug Tier
2
Responsible Steps
Quanitity Limits
DROXIA
Specialty
Drug Name
Drug Tier
Prior Authorization
2015
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
BACITRACIN oint
2
bacitracin/polymyxin B oint
1
ciprofloxacin soln (Ciloxan)
1
erythromycin oint
1
gentamicin oint, soln (Garamycin)
1
NATACYN
2
neomycin/polymyxin B/
bacitracin oint
1
neomycin/polymyxin B/
gramicidin soln (Neosporin)
1
ofloxacin soln (Ocuflox)
1
polymyxin B/trimethoprim
soln (Polytrim)
1
sulfacetamide sodium
soln (Bleph-10)
1
tobramycin soln (Tobrex)
1
trifluridine soln (Viroptic)
1
VIGAMOX
2
Steroids and Combination Products
1
dexamethasone sodium
phosphate soln
fluorometholone susp, 0.1% (FML 1
Liquifilm)
= Responsible Rx Program
X = Self-Administered Specialty Medication
= May not be covered – see endorsement
Florida Blue January 2015 Closed Medication Drug Guide
17
neomycin/polymyxin B/
bacitracin/hydrocortisone oint
1
homatropine soln (Isopto
Homatropine)
1
neomycin/polymyxin B/
dexamethasone oint,
susp (Maxitrol)
1
ketorolac soln (Acular, Acular LS)
1
tropicamide soln (Mydriacyl)
1
prednisolone acetate susp (Pred
Forte)
1
sulfacetamide sodium/
prednisolone soln
1
1
ACETIC ACID/ALUMINUM
ACETATE soln
2
TOBRADEX oint
2
benzocaine/antipyrine soln
1
tobramycin/dexamethasone
susp (Tobradex)
1
CIPRODEX
2
hydrocortisone/acetic acid
soln (Vosol HC)
1
neomycin/polymyxin B/
hydrocortisone soln,
susp (Cortisporin)
1
ofloxacin soln
1
Glaucoma
1
brimonidine soln, 0.2%
1
carteolol soln
1
dorzolamide soln (Trusopt)
1
dorzolamide/timolol maleate
soln (Cosopt)
1
latanoprost soln (Xalatan)
1
levobunolol soln, 0.5% (Betagan)
1
chlorhexidine rinse (Peridex)
1
clotrimazole troche
1
1
lidocaine viscous
1
pilocarpine soln (Isopto Carpine)
1
nystatin susp
1
timolol maleate soln (Timoptic,
Timoptic-XE)
1
pilocarpine (Salagen)
1
triamcinolone paste
1
•
ATROPINE SULFATE oint
atropine sulfate soln (Isopto
Atropine)
1
1
hydrocortisone acetate crm,
supp (Anusol-HC, Proctocort)
1
azelastine soln (Optivar)
1
hydrocortisone
enema (Cortenema)
cromolyn sodium soln
1
PROCTOFOAM HC
2
cyclopentolate soln (Cyclogyl)
1
SKIN CONDITIONS/PRODUCTS
diclofenac soln (Voltaren)
1
Acne
flurbiprofen soln (Ocufen)
1
adapalene* (Differin)
18
Tier
1 = Covered Generic Drugs
2 = Preferred Brand Drugs
Responsible Steps
ANORECTAL AGENTS
2
KEY
Quanitity Limits
MOUTH AND THROAT (LOCAL)
cevimeline (Evoxac)
Other Eye Products
Prior Authorization
EAR
acetic acid soln
brimonidine soln,
0.15% (Alphagan P)
Specialty
Drug Name
Drug Tier
Responsible Steps
Quanitity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2015
•
*
1
= Responsible Rx Program
X = Self-Administered Specialty Medication
= May not be covered – see endorsement
Florida Blue January 2015 Closed Medication Drug Guide
1
1
betamethasone dipropionate,
augmented (Diprolene)
clindamycin/benzoyl
peroxide (Benzaclin, Duac)
1
betamethasone valerate
1
clobetasol (Olux, Temovate)
1
erythromycin (Erygel)
1
desonide (Desowen)
1
erythromycin pads, soln
1
1
erythromycin/benzoyl
peroxide (Benzamycin)
1
desoximetasone crm, 0.25%; gel;
oint, 0.25% (Topicort)
diflorasone oint
1
FINACEA
2
1
isotretinoin 10 mg, 20 mg,
40 mg – Amnesteem, Claravis,
Myorisan, Zenatane
1
fluocinolone (Derma-Smoothe/FS,
Synalar)
fluocinonide
1
fluticasone propionate (Cutivate)
1
metronidazole (Metrocream,
Metrogel, Metrolotion)
1
halobetasol (Ultravate)
1
1
hydrocortisone topical
1
sulfacetamide sodium (Klaron)
1
hydrocortisone
valerate (Westcort)
1
sulfacetamide sodium/sulfur, NP
= susp, 10-5% (Plexion)
2
mometasone (Elocon)
1
TAZORAC*
1
nystatin/triamcinolone
1
tretinoin microsphere* (Retin-A
Micro)
triamcinolone, NP = oint, 0.5%
1
tretinoin* (Retin-A)
1
•
acitretin (Soriatane)
1
calcipotriene (Dovonex)
1
diclofenac sodium (Solaraze)
1
fluorouracil (Efudex)
1
ciclopirox crm, gel, shampoo,
susp (Loprox)
1
ciclopirox soln, 8% (Penlac)
1
econazole
1
imiquimod (Aldara)
1
ketoconazole (Nizoral)
1
1
mupirocin (Bactroban)
1
lidocaine jelly, 2%; oint, 5%;
soln, 4% (Xylocaine)
nystatin topical
1
lidocaine patches (Lidoderm)
1
silver sulfadiazine (Silvadene)
1
lidocaine/prilocaine crm (Emla)
1
ZOVIRAX crm
2
lindane
1
malathion (Ovide)
1
•
Corticosteroids
alclometasone (Aclovate)
1
permethrin crm
1
betamethasone dipropionate
1
podofilox (Condylox)
1
Tier
1 = Covered Generic Drugs
2 = Preferred Brand Drugs
•
*
Responsible Steps
Quanitity Limits
Prior Authorization
Other Skin Products
Anti-infectives
KEY
Specialty
Drug Name
Drug Tier
Responsible Steps
clindamycin (Cleocin-T)
Quanitity Limits
2
Prior Authorization
CLARAVIS 30 mg
Specialty
Drug Name
Drug Tier
2015
•
= Responsible Rx Program
X = Self-Administered Specialty Medication
= May not be covered – see endorsement
Florida Blue January 2015 Closed Medication Drug Guide
19
2
EXJADE
2
MISCELLANEOUS CATEGORIES
mycophenolate mofetil (Cellcept)
1
DIABETIC SUPPLIES
mycophenolate sodium delayedrelease (Myfortic)
1
naloxone inj, 0.4 mg/mL
1
RAPAMUNE soln
2
REVLIMID
2
sirolimus (Rapamune)
1
sodium polystyrene sulfonate
1
tacrolimus (Prograf)
1
THALOMID
2
ZORTRESS
2
BLOOD GLUCOSE METERS –
BAYER BREEZE 2
2
BLOOD GLUCOSE METERS –
BAYER CONTOUR
2
BLOOD GLUCOSE METERS –
BAYER CONTOUR NEXT/EZ/
LINK/USB
2
INSULIN PEN NEEDLES –
NOVOFINE, NOVOTWIST,
OTHER VARIOUS
MANUFACTURERS
2
LANCET DEVICES – VARIOUS
MANUFACTURERS
2
LANCETS – VARIOUS
MANUFACTURERS
2
SYRINGES/NEEDLES – VARIOUS
MANUFACTURERS – for selfinjectable drug administration
2
TEST DISCS – BAYER BREEZE 2
2
TEST STRIPS – BAYER
CONTOUR/NEXT
2
X • •
X
Responsible Steps
Quanitity Limits
Prior Authorization
2
CYCLOSPORINE modified caps,
50 mg
Specialty
VALCHLOR
Drug Name
Drug Tier
2
Responsible Steps
STELARA
Quanitity Limits
1
Prior Authorization
selenium sulfide 2.5%
Specialty
Drug Name
Drug Tier
2015
X
X • •
X • •
•
•
MISCELLANEOUS DRUGS
azathioprine (Imuran)
1
CELLCEPT oral susp
2
CHEMET
2
CUPRIMINE
2
cyclosporine (Sandimmune)
1
cyclosporine modified caps,
25 mg, 100 mg; soln (Neoral)
1
KEY
20
Tier
1 = Covered Generic Drugs
2 = Preferred Brand Drugs
•
*
= Responsible Rx Program
X = Self-Administered Specialty Medication
= May not be covered – see endorsement
Florida Blue January 2015 Closed Medication Drug Guide
2015
INDEX
A
abacavir.............................................................................. 3
abacavir/lamivudine/zidovudine.......................................3
acamprosate delayed-release........................................ 14
acarbose............................................................................. 6
acebutolol...........................................................................8
acetaminophen/codeine..................................................14
acetaminophen/isometheptene/
dichloralphenazone....................................................... 15
ACETAZOLAMIDE 125 mg................................................. 9
acetazolamide 250 mg...................................................... 9
acetazolamide ext-release................................................ 9
ACETIC ACID/ALUMINUM ACETATE ear soln................ 18
acetic acid ear soln.........................................................18
acetylcysteine.................................................................. 10
acitretin.............................................................................19
ACTIMMUNE....................................................................... 4
acyclovir oral..................................................................... 3
adapalene......................................................................... 18
adefovir...............................................................................3
ADVATE............................................................................ 17
AFINITOR............................................................................ 4
AFINITOR DISPERZ........................................................... 4
ALBENZA............................................................................ 4
albuterol............................................................................10
alclometasone..................................................................19
alendronate tabs, 5 mg, 10 mg, 35 mg, 70 mg................7
alfuzosin ext-release....................................................... 12
ALINIA................................................................................. 4
ALKERAN tabs....................................................................4
allopurinol........................................................................ 15
ALPHANATE/VWF............................................................ 17
ALPHANINE SD................................................................ 17
alprazolam........................................................................ 12
alprazolam ext-release.................................................... 12
ALPROLIX......................................................................... 17
amantadine caps, syrup................................................. 16
AMANTADINE tabs........................................................... 16
amiloride.............................................................................9
amiloride/hydrochlorothiazide......................................... 9
amiodarone........................................................................ 9
amitriptyline..................................................................... 12
amlodipine..........................................................................8
amlodipine/atorvastatin.................................................. 10
amlodipine/benazepril....................................................... 8
amlodipine/valsartan......................................................... 8
amoxicillin, NP = chew tabs, 125 mg.............................. 2
amoxicillin/potassium clavulanate.................................. 2
amoxicillin/potassium clavulanate ext-release...............2
AMOXICILLIN chew tabs, 250 mg...................................... 2
amphetamine/dextroamphetamine................................ 13
amphetamine/dextroamphetamine ext-release.............13
Florida Blue January 2015 Closed Medication Drug Guide
ampicillin caps...................................................................2
AMPICILLIN susp................................................................2
anagrelide.........................................................................16
anastrozole.........................................................................4
ANDRODERM..................................................................... 6
ANDROGEL.........................................................................6
APTIVUS............................................................................. 3
ARANESP..........................................................................16
ASACOL HD......................................................................11
atenolol............................................................................... 8
atenolol/chlorthalidone..................................................... 8
atorvastatin........................................................................ 9
atovaquone/proguanil....................................................... 4
ATRIPLA..............................................................................3
ATROPINE SULFATE eye oint......................................... 18
atropine sulfate eye soln................................................18
ATROVENT HFA...............................................................10
AUGMENTIN susp, 125 mg/5 mL.......................................2
AVC................................................................................... 12
azathioprine......................................................................20
azelastine eye soln..........................................................18
azelastine nasal............................................................... 10
azithromycin susp, tabs................................................... 2
B
bacitracin/polymyxin B eye oint.................................... 17
BACITRACIN eye oint.......................................................17
baclofen............................................................................ 16
balsalazide........................................................................11
BARACLUDE soln...............................................................3
BEBULIN/VH..................................................................... 17
benazepril........................................................................... 7
benazepril/hydrochlorothiazide........................................7
BENEFIX........................................................................... 17
benzocaine/antipyrine ear soln......................................18
benztropine...................................................................... 16
betamethasone dipropionate......................................... 19
betamethasone dipropionate, augmented.................... 19
betamethasone valerate..................................................19
BETASERON.....................................................................14
BETHKIS............................................................................. 2
bicalutamide.......................................................................4
BILTRICIDE......................................................................... 4
bisoprolol........................................................................... 8
bisoprolol/hydrochlorothiazide........................................ 8
BLOOD GLUCOSE METERS – BAYER BREEZE 2.........20
BLOOD GLUCOSE METERS – BAYER CONTOUR........ 20
BLOOD GLUCOSE METERS – BAYER CONTOUR
NEXT/EZ/LINK/USB........................................................ 20
BOSULIF............................................................................. 4
brimonidine eye soln, 0.15%.......................................... 18
brimonidine eye soln, 0.2%............................................ 18
bromocriptine...................................................................16
budesonide.......................................................................10
budesonide ext-release.....................................................5
bumetanide.........................................................................9
21
2015
buprenorphine................................................................. 14
buprenorphine/naloxone.................................................14
bupropion......................................................................... 12
bupropion ext-release..................................................... 12
bupropion ext-release – smoking deterrent..................14
buspirone......................................................................... 12
butalbital/acetaminophen............................................... 14
butalbital/acetaminophen/caffeine.................................14
butalbital/aspirin/caffeine/codeine.................................14
butalbital/aspirin/caffeine caps...................................... 14
butorphanol nasal........................................................... 14
BYDUREON........................................................................ 6
BYETTA inj..........................................................................6
C
cabergoline.........................................................................7
caffeine citrate................................................................. 13
calcipotriene.....................................................................19
calcitonin-salmon.............................................................. 7
calcitriol.............................................................................. 7
calcium acetate................................................................11
CANASA............................................................................ 11
capecitabine....................................................................... 4
CAPRELSA..........................................................................5
captopril..............................................................................7
CAPTOPRIL/HYDROCHLOROTHIAZIDE 25-15 mg,
50-15 mg........................................................................... 7
CARAFATE susp...............................................................11
carbamazepine.................................................................15
carbamazepine ext-release.............................................15
carbidopa/levodopa.........................................................16
carbidopa/levodopa ext-release.....................................16
carteolol eye soln............................................................18
carvedilol............................................................................ 8
CAYSTON........................................................................... 4
cefaclor caps..................................................................... 2
cefadroxil............................................................................2
cefdinir................................................................................2
cefpodoxime.......................................................................2
cefprozil.............................................................................. 2
cefuroxime..........................................................................2
CELLCEPT oral susp........................................................ 20
cephalexin, NP = tabs.......................................................2
cevimeline........................................................................ 18
CHANTIX........................................................................... 14
CHEMET............................................................................20
CHENODAL.......................................................................11
chlorhexidine oral rinse..................................................18
chloroquine phosphate.....................................................4
chlorothiazide 500 mg...................................................... 9
chlorpromazine................................................................ 13
CHLORTHALIDONE 25 mg, 50 mg.................................... 9
chlorzoxazone..................................................................16
cholestyramine.................................................................. 9
ciclopirox crm, gel, shampoo, susp.............................. 19
ciclopirox soln................................................................. 19
22
cilostazol.......................................................................... 16
cimetidine......................................................................... 11
CINRYZE........................................................................... 16
CIPRODEX........................................................................ 18
ciprofloxacin ext-release.................................................. 2
ciprofloxacin eye soln.................................................... 17
ciprofloxacin oral.............................................................. 2
citalopram.........................................................................12
CLARAVIS 30 mg............................................................. 19
clarithromycin.................................................................... 2
clarithromycin ext-release................................................ 2
CLEOCIN supp..................................................................12
CLIMARA PRO....................................................................6
clindamycin/benzoyl peroxide....................................... 19
clindamycin oral................................................................ 4
clindamycin topical......................................................... 19
clindamycin vaginal crm................................................ 12
clobetasol......................................................................... 19
clomipramine................................................................... 12
clonazepam...................................................................... 15
clonidine........................................................................... 10
clopidogrel....................................................................... 16
clotrimazole troche......................................................... 18
clozapine.......................................................................... 13
COLCRYS......................................................................... 15
colestipol............................................................................ 9
colistimethate.....................................................................4
COMBIVENT RESPIMAT..................................................10
COMETRIQ......................................................................... 5
COMPLERA.........................................................................3
COPAXONE...................................................................... 14
CORIFACT........................................................................ 17
CORTISONE....................................................................... 5
CREON..............................................................................11
CRESTOR........................................................................... 9
CRIXIVAN............................................................................3
cromolyn sodium eye soln.............................................18
cromolyn sodium inhal soln.......................................... 10
CUPRIMINE.......................................................................20
cyanocobalamin inj......................................................... 16
cyclobenzaprine...............................................................16
cyclopentolate eye soln..................................................18
CYCLOPHOSPHAMIDE tabs..............................................5
cyclosporine.....................................................................20
cyclosporine modified caps, 25 mg, 100 mg; soln....... 20
CYCLOSPORINE modified caps, 50 mg.......................... 20
cyproheptadine................................................................ 10
CYSTAGON.......................................................................12
D
danazol............................................................................... 6
DANTROLENE 100 mg.....................................................16
dantrolene 25 mg, 50 mg................................................16
DAPSONE........................................................................... 4
DARAPRIM..........................................................................4
DELZICOL......................................................................... 11
Florida Blue January 2015 Closed Medication Drug Guide
2015
demeclocycline.................................................................. 2
desipramine......................................................................12
desmopressin inj, nasal, tabs.......................................... 7
desonide........................................................................... 19
desoximetasone crm, 0.25%; gel; oint, 0.25%.............. 19
dexamethasone elixir; tabs, 0.5 mg, 0.75 mg, 1.5 mg, 4
mg, 6 mg.......................................................................... 6
dexamethasone sodium phosphate eye soln............... 17
DEXAMETHASONE soln; tabs, 1 mg, 2 mg....................... 6
dextroamphetamine.........................................................13
dextroamphetamine ext-release.....................................13
DIASTAT............................................................................15
DIAZEPAM oral soln, 1 mg/mL......................................... 12
diazepam tabs..................................................................12
diclofenac eye soln......................................................... 18
diclofenac potassium......................................................15
diclofenac sodium delayed-release............................... 15
diclofenac sodium ext-release....................................... 15
diclofenac sodium gel.................................................... 19
dicloxacillin........................................................................ 2
dicyclomine caps, tabs...................................................11
didanosine delayed-release..............................................3
diflorasone oint............................................................... 19
DIGOXIN soln....................................................................10
digoxin tabs..................................................................... 10
DILANTIN caps................................................................. 15
diltiazem............................................................................. 8
diltiazem ext-release......................................................... 8
diphenoxylate/atropine tabs...........................................11
dipyridamole.................................................................... 16
disopyramide..................................................................... 9
disulfiram..........................................................................14
divalproex delayed-release.............................................15
divalproex ext-release.....................................................15
DIVIGEL...............................................................................6
donepezil.......................................................................... 14
dorzolamide/timolol maleate eye soln...........................18
dorzolamide eye soln......................................................18
doxazosin......................................................................... 10
doxepin............................................................................. 12
DOXEPIN 75 mg............................................................... 12
doxycycline hyclate caps................................................. 2
doxycycline hyclate tabs..................................................2
doxycycline monohydrate................................................ 2
DROXIA............................................................................. 17
DULERA............................................................................ 10
duloxetine delayed-release.............................................12
E
econazole......................................................................... 19
EDURANT........................................................................... 3
ELIQUIS.............................................................................17
ELLA.................................................................................... 6
ELOCTATE........................................................................17
EMCYT................................................................................ 5
EMEND caps, therapy pack.............................................. 11
Florida Blue January 2015 Closed Medication Drug Guide
EMTRIVA.............................................................................3
enalapril.............................................................................. 8
enalapril/hydrochlorothiazide...........................................8
ENBREL............................................................................ 15
enoxaparin inj.................................................................. 17
entacapone.......................................................................16
entecavir............................................................................. 3
EPIPEN inj.........................................................................10
EPIPEN-JR inj................................................................... 10
EPIVIR HBV soln................................................................ 3
EPIVIR soln......................................................................... 3
eplerenone........................................................................10
EPZICOM............................................................................ 3
ergocalciferol................................................................... 16
ERIVEDGE.......................................................................... 5
ERY-TAB............................................................................. 2
erythromycin/benzoyl peroxide..................................... 19
erythromycin/sulfisoxazole.............................................. 4
ERYTHROMYCIN BASE.....................................................2
erythromycin delayed-release caps................................ 2
ERYTHROMYCIN ETHYLSUCCINATE.............................. 2
erythromycin eye oint.....................................................17
erythromycin gel............................................................. 19
erythromycin topical pads, soln.................................... 19
escitalopram.....................................................................12
estazolam......................................................................... 13
estradiol/norethindrone acetate.......................................6
estradiol patches...............................................................6
estradiol tabs..................................................................... 6
estropipate 0.75 mg, 1.5 mg.............................................6
ethambutol......................................................................... 2
ethosuximide....................................................................15
etodolac............................................................................ 15
etodolac ext-release........................................................ 15
ETOPOSIDE caps...............................................................5
EXELON patches.............................................................. 14
exemestane........................................................................ 5
EXJADE.............................................................................20
F
famciclovir..........................................................................3
famotidine.........................................................................11
FARESTON......................................................................... 5
FEIBA NF.......................................................................... 17
felodipine ext-release........................................................8
fenofibrate.......................................................................... 9
fenofibrate micronized...................................................... 9
fenofibric acid delayed-release........................................9
fentanyl lozenges............................................................ 14
fentanyl patches.............................................................. 14
FINACEA........................................................................... 19
finasteride.........................................................................12
FIRAZYR........................................................................... 17
flecainide............................................................................ 9
fluconazole......................................................................... 3
flucytosine..........................................................................3
23
2015
fludrocortisone.................................................................. 6
flunisolide 25 mcg/spray................................................ 10
fluocinolone..................................................................... 19
fluocinonide..................................................................... 19
fluorometholone eye susp, 0.1%................................... 17
fluorouracil....................................................................... 19
fluoxetine, 60 mg not covered....................................... 12
fluphenazine hcl tabs......................................................13
flurbiprofen eye soln.......................................................18
flurbiprofen tabs..............................................................15
flutamide.............................................................................5
fluticasone propionate nasal..........................................10
fluticasone propionate topical....................................... 19
FLU VACCINES, NP = FLUBLOK...................................... 4
fluvoxamine......................................................................13
folic acid tabs, 1 mg....................................................... 17
FORADIL AEROLIZER......................................................10
fosinopril............................................................................ 8
fosinopril/hydrochlorothiazide......................................... 8
furosemide, NP = soln, 8 mg/mL..................................... 9
FUZEON.............................................................................. 3
G
gabapentin........................................................................15
galantamine......................................................................14
galantamine ext-release..................................................14
GAMMAGARD LIQUID........................................................4
GAMMAKED........................................................................4
GAMUNEX-C.......................................................................4
gemfibrozil..........................................................................9
gentamicin eye oint, soln............................................... 17
GILOTRIF............................................................................ 5
GLEEVEC............................................................................5
glimepiride..........................................................................6
glipizide.............................................................................. 6
glipizide/metformin............................................................6
glipizide ext-release.......................................................... 6
GLUCAGON EMERGENCY inj kit...................................... 6
glyburide.............................................................................6
GLYBURIDE, distributor of Diabeta.................................... 6
glyburide/metformin.......................................................... 6
glyburide micronized........................................................ 6
glycopyrrolate.................................................................. 11
granisetron....................................................................... 11
griseofulvin microsize.......................................................3
guanfacine........................................................................10
H
halobetasol.......................................................................19
haloperidol lactate oral soln.......................................... 13
haloperidol tabs...............................................................13
HELIXATE FS................................................................... 17
HEMOFIL M...................................................................... 17
HEXALEN............................................................................ 5
HIZENTRA...........................................................................4
homatropine eye soln..................................................... 18
24
HUMATE-P........................................................................ 17
HUMIRA.............................................................................15
HYCAMTIN caps................................................................. 5
hydralazine....................................................................... 10
hydrochlorothiazide caps................................................. 9
hydrochlorothiazide tabs..................................................9
hydrocodone/acetaminophen, NP = soln, 10-325 mg/15
mL....................................................................................14
hydrocodone/ibuprofen.................................................. 14
hydrocortisone/acetic acid ear soln.............................. 18
hydrocortisone acetate rectal crm, supp...................... 18
hydrocortisone enema.................................................... 18
hydrocortisone oral...........................................................6
hydrocortisone topical....................................................19
hydrocortisone valerate..................................................19
hydromorphone soln, tabs............................................. 14
hydroxychloroquine.......................................................... 4
hydroxyurea....................................................................... 5
hydroxyzine hcl............................................................... 12
hydroxyzine pamoate 25 mg, 50 mg............................. 12
hyoscyamine.................................................................... 11
hyoscyamine ext-release................................................ 11
I
ibandronate........................................................................ 7
ibuprofen.......................................................................... 15
ICLUSIG.............................................................................. 5
IMBRUVICA.........................................................................5
imipramine hcl................................................................. 13
imiquimod.........................................................................19
IMITREX nasal.................................................................. 15
INCRELEX...........................................................................7
indapamide.........................................................................9
indomethacin................................................................... 15
INLYTA................................................................................ 5
INSULIN PEN NEEDLES – NOVOFINE, NOVOTWIST,
OTHER VARIOUS MANUFACTURERS......................... 20
INTELENCE.........................................................................3
INTRON-A........................................................................... 3
INVIRASE............................................................................ 3
INVOKAMET........................................................................6
INVOKANA.......................................................................... 6
ipratropium/albuterol.......................................................10
ipratropium inhal soln.................................................... 10
ipratropium nasal............................................................ 10
irbesartan........................................................................... 8
irbesartan/hydrochlorothiazide........................................ 8
ISENTRESS........................................................................ 3
ISONIAZID syrup.................................................................2
isoniazid tabs.....................................................................2
ISOSORBIDE DINITRATE tabs, 30 mg.............................. 9
isosorbide dinitrate tabs, 5 mg, 10 mg, 20 mg............... 9
isosorbide mononitrate.....................................................9
isosorbide mononitrate ext-release.................................9
isotretinoin 10 mg, 20 mg, 40 mg – Amnesteem,
Claravis, Myorisan, Zenatane....................................... 19
Florida Blue January 2015 Closed Medication Drug Guide
2015
ISRADIPINE caps, 2.5 mg.................................................. 8
itraconazole........................................................................3
ivermectin...........................................................................4
J
JAKAFI.................................................................................5
JANUMET............................................................................6
JANUMET XR..................................................................... 6
JANUVIA..............................................................................6
K
KALETRA............................................................................ 3
KALYDECO....................................................................... 11
ketoconazole crm, shampoo.......................................... 19
ketoprofen........................................................................ 15
ketorolac eye soln...........................................................18
KOATE-DVI....................................................................... 17
KOGENATE FS.................................................................17
KOMBIGLYZE XR............................................................... 6
K-PHOS NO. 2.................................................................. 12
L
labetalol.............................................................................. 8
lactulose........................................................................... 11
lactulose........................................................................... 11
lamivudine.......................................................................... 3
lamivudine.......................................................................... 3
lamivudine/zidovudine...................................................... 3
lamotrigine....................................................................... 15
LANCET DEVICES – VARIOUS MANUFACTURERS...... 20
LANCETS – VARIOUS MANUFACTURERS.................... 20
lansoprazole delayed-release.........................................11
LANTUS inj..........................................................................7
latanoprost eye soln....................................................... 18
leflunomide.......................................................................15
LETAIRIS...........................................................................10
letrozole.............................................................................. 5
LEUCOVORIN CALCIUM tabs, 10 mg, 15 mg................... 5
leucovorin calcium tabs, 5 mg, 25 mg............................ 5
LEUKERAN......................................................................... 5
LEUKINE........................................................................... 17
leuprolide acetate..............................................................5
levalbuterol neb soln, NP = 1.25 mg/0.5 mL................. 10
LEVEMIR inj........................................................................ 7
levetiracetam....................................................................15
LEVITRA............................................................................10
levobunolol eye soln, 0.5%............................................ 18
levocarnitine.......................................................................7
levofloxacin oral................................................................ 2
levonorgestrel.................................................................... 6
levothyroxine..................................................................... 7
LEXIVA................................................................................ 3
LIALDA.............................................................................. 11
lidocaine/prilocaine crm................................................. 19
lidocaine jelly, 2%; oint, 5%; soln, 4%.......................... 19
lidocaine patches............................................................ 19
Florida Blue January 2015 Closed Medication Drug Guide
lidocaine viscous............................................................ 18
lindane.............................................................................. 19
liothyronine........................................................................ 7
lisinopril..............................................................................8
lisinopril/hydrochlorothiazide.......................................... 8
lithium carbonate............................................................ 13
LITHIUM CARBONATE caps, 600 mg..............................13
lithium carbonate ext-release 300 mg........................... 13
lithium carbonate ext-release 450 mg........................... 13
LITHIUM soln.................................................................... 13
LOMUSTINE........................................................................5
loperamide........................................................................11
loratadine..........................................................................10
loratadine/pseudoephedrine...........................................10
lorazepam conc............................................................... 12
lorazepam tabs................................................................ 12
losartan...............................................................................8
losartan/hydrochlorothiazide........................................... 8
lovastatin............................................................................ 9
loxapine............................................................................ 13
LYSODREN......................................................................... 5
M
malathion..........................................................................19
MATULANE......................................................................... 5
meclizine...........................................................................11
medroxyprogesterone acetate tabs.................................6
mefloquine..........................................................................4
megestrol............................................................................5
MEKINIST............................................................................5
MELOXICAM susp............................................................ 15
meloxicam tabs............................................................... 15
MENACTRA.........................................................................4
MENEST..............................................................................6
MENOMUNE-A/C/Y/W-135................................................. 4
MENVEO............................................................................. 4
MEPHYTON...................................................................... 16
mercaptopurine..................................................................5
mesalamine...................................................................... 11
MESNEX tabs..................................................................... 5
MESTINON syrup..............................................................16
MESTINON TIMESPAN.................................................... 16
metaxalone....................................................................... 16
metformin........................................................................... 6
metformin ext-release....................................................... 7
metformin ext-release OSM..............................................7
methadone conc, soln.................................................... 14
methadone tabs...............................................................14
methazolamide...................................................................9
methimazole....................................................................... 7
methocarbamol................................................................ 16
methotrexate...................................................................... 5
methscopolamine............................................................ 11
methyldopa.......................................................................10
methylergonovine..............................................................7
methylphenidate ext-release caps; tabs, 20 mg........... 14
25
2015
methylphenidate tabs......................................................13
methylprednisolone...........................................................6
metoclopramide............................................................... 11
metolazone......................................................................... 9
metoprolol succinate ext-release.................................... 8
metoprolol tartrate............................................................ 8
metronidazole oral............................................................ 4
metronidazole topical......................................................19
metronidazole vaginal gel.............................................. 12
mexiletine........................................................................... 9
midodrine......................................................................... 10
minocycline........................................................................ 2
minoxidil........................................................................... 10
mirtazapine.......................................................................13
misoprostol...................................................................... 11
modafinil...........................................................................14
moexipril.............................................................................8
moexipril/hydrochlorothiazide......................................... 8
mometasone.....................................................................19
MONOCLATE-P................................................................ 17
MONONINE....................................................................... 17
montelukast......................................................................10
morphine sulfate conc, soln.......................................... 14
morphine sulfate ext-release..........................................14
MORPHINE SULFATE tabs.............................................. 14
mupirocin......................................................................... 19
mycophenolate mofetil................................................... 20
mycophenolate sodium delayed-release...................... 20
MYLERAN........................................................................... 5
N
nabumetone..................................................................... 15
nadolol................................................................................ 8
naloxone inj, 0.4 mg/mL................................................. 20
naltrexone.........................................................................14
naproxen...........................................................................15
naproxen delayed-release.............................................. 15
naproxen sodium............................................................ 15
naratriptan........................................................................ 15
NATACYN..........................................................................17
nateglinide..........................................................................7
NEBUPENT......................................................................... 4
neomycin/polymyxin B/bacitracin/hydrocortisone eye
oint.................................................................................. 18
neomycin/polymyxin B/bacitracin eye oint...................17
neomycin/polymyxin B/dexamethasone eye oint,
susp.................................................................................18
neomycin/polymyxin B/gramicidin eye soln.................17
neomycin/polymyxin B/hydrocortisone ear soln,
susp.................................................................................18
neomycin sulfate............................................................... 2
NEULASTA........................................................................17
NEUPOGEN...................................................................... 17
nevirapine ext-release.......................................................3
NEVIRAPINE susp.............................................................. 3
nevirapine tabs.................................................................. 3
26
NEXAVAR............................................................................5
niacin ext-release.............................................................. 9
NICOTROL INHALER....................................................... 14
NICOTROL NS..................................................................14
nifedipine ext-release........................................................8
NILANDRON........................................................................5
NISOLDIPINE ext-release 25.5 mg.....................................8
NITRO-BID.......................................................................... 9
nitrofurantoin................................................................... 12
nitrofurantoin macrocrystalline..................................... 12
nitrofurantoin monohydrate/macrocrystalline..............12
nitroglycerin 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/
hr....................................................................................... 9
NITROSTAT........................................................................ 9
NORDITROPIN....................................................................7
norelgestromin/ethinyl estradiol......................................6
norethindrone acetate.......................................................6
nortriptyline caps............................................................ 13
NORVIR...............................................................................3
NOVOLIN 70/30 inj............................................................. 7
NOVOLIN N inj....................................................................7
NOVOLIN R inj....................................................................7
NOVOLOG inj......................................................................7
NOVOLOG MIX 70/30 inj....................................................7
NOVOSEVEN/RT.............................................................. 17
NOXAFIL............................................................................. 3
nystatin/triamcinolone.................................................... 19
nystatin oral....................................................................... 3
nystatin susp................................................................... 18
nystatin topical................................................................ 19
O
octreotide........................................................................... 7
ofloxacin 200 mg, 300 mg................................................ 2
ofloxacin ear soln............................................................18
ofloxacin eye soln........................................................... 17
olanzapine........................................................................ 13
OLYSIO............................................................................... 3
OMEPRAZOLE (Prilosec OTC).........................................11
omeprazole delayed-release...........................................11
ondansetron..................................................................... 11
ondansetron tabs, 24 mg............................................... 11
ONGLYZA............................................................................7
OPSUMIT.......................................................................... 10
oral contraceptives – all generics................................... 6
ORFADIN.............................................................................7
orphenadrine/aspirin/caffeine 25-385-30 mg................ 16
orphenadrine citrate ext-release....................................16
oxaprozin..........................................................................15
oxcarbazepine..................................................................15
oxybutynin........................................................................12
oxybutynin ext-release....................................................12
oxycodone........................................................................14
oxycodone/acetaminophen caps, 5-500 mg................. 14
oxycodone/acetaminophen tabs....................................14
oxycodone/aspirin........................................................... 14
Florida Blue January 2015 Closed Medication Drug Guide
2015
OXYCONTIN..................................................................... 14
P
pantoprazole delayed-release........................................ 11
paricalcitol..........................................................................7
paromomycin..................................................................... 2
paroxetine hcl.................................................................. 13
paroxetine hcl ext-release.............................................. 13
PAXIL susp........................................................................13
PEGASYS............................................................................3
PEG – electrolytes for soln............................................ 11
penicillin v potassium.......................................................2
PENTASA.......................................................................... 11
pentoxifylline ext-release................................................17
perindopril.......................................................................... 8
permethrin crm................................................................ 19
perphenazine....................................................................13
phenelzine........................................................................ 13
phenobarbital soln; tabs, 16.2 mg, 32.4 mg..................13
PHENOBARBITAL tabs, 15 mg, 30 mg, 60 mg, 64.8 mg,
100 mg; NP = 97.2 mg....................................................13
phenytoin..........................................................................15
phenytoin sodium ext-release........................................15
pilocarpine eye soln........................................................18
pilocarpine tabs...............................................................18
pindolol...............................................................................8
pioglitazone........................................................................7
pioglitazone/metformin..................................................... 7
piroxicam..........................................................................15
PLEGRIDY.........................................................................14
PNEUMOVAX 23................................................................ 4
podofilox...........................................................................19
polymyxin B/trimethoprim eye soln.............................. 17
POMALYST......................................................................... 5
potassium bicarbonate/chloride effervescent tabs, 25
mEq................................................................................. 16
potassium chloride ext-release, NP = 20 mEq..............16
potassium chloride packets; soln................................. 16
potassium citrate/citric acid...........................................12
potassium citrate ext-release.........................................12
potassium phosphate/sodium phosphates.................. 16
PRADAXA..........................................................................17
pramipexole......................................................................16
pravastatin..........................................................................9
prazosin............................................................................ 10
prednisolone acetate eye susp......................................18
prednisolone sodium phosphate oral soln, 15 mg/5
mL......................................................................................6
prednisolone sodium phosphate oral soln, 5 mg/5
mL......................................................................................6
prednisolone soln, 15 mg/5 mL....................................... 6
PREDNISONE soln, 5 mg/5 mL; tabs, 50 mg; NP = dose
packs..................................................................................6
prednisone tabs, 1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg...... 6
PREMARIN crm................................................................ 12
PREMARIN tabs..................................................................6
Florida Blue January 2015 Closed Medication Drug Guide
PREMPHASE...................................................................... 6
PREMPRO...........................................................................6
PRENATAL MULTIVITAMINS/FOLIC ACID......................16
PREVNAR 13...................................................................... 4
PREZISTA tabs................................................................... 3
PRIFTIN...............................................................................2
PRIMAQUINE...................................................................... 4
primidone......................................................................... 15
PRIMSOL.............................................................................4
PROAIR HFA.................................................................... 10
probenecid....................................................................... 15
probenecid/colchicine.....................................................15
prochlorperazine..............................................................13
PROCRIT...........................................................................17
PROCTOFOAM HC.......................................................... 18
PROFILNINE SD...............................................................17
progesterone micronized..................................................6
PROGLYCEM......................................................................7
promethazine................................................................... 10
propafenone....................................................................... 9
propafenone ext-release................................................... 9
PROPANTHELINE 15 mg................................................. 11
PROPRANOLOL/HYDROCHLOROTHIAZIDE 80-25
mg...................................................................................... 8
propranolol ext-release.....................................................8
PROPRANOLOL soln, 20 mg/5 mL.................................... 8
propranolol tabs................................................................ 8
propylthiouracil..................................................................7
PROSTIGMIN tabs............................................................ 16
PULMICORT FLEXHALER............................................... 10
PULMICORT RESPULES 1 mg/2 mL...............................10
PULMOZYME.................................................................... 11
PURIXAN.............................................................................5
pyrazinamide......................................................................2
pyridostigmine................................................................. 16
Q
quetiapine.........................................................................13
quinapril..............................................................................8
quinapril/hydrochlorothiazide.......................................... 8
quinidine gluconate ext-release.......................................9
QUINIDINE SULFATE 200 mg......................................... 10
quinidine sulfate 300 mg................................................ 10
QUINIDINE SULFATE ext-release......................................9
QVAR.................................................................................10
R
raloxifene............................................................................7
ramipril................................................................................8
ranitidine...........................................................................11
RAPAMUNE soln.............................................................. 20
REBIF................................................................................ 14
RECOMBINATE................................................................ 17
RELION R inj...................................................................... 7
RENVELA.......................................................................... 11
repaglinide..........................................................................7
27
2015
RESCRIPTOR..................................................................... 3
REVLIMID..........................................................................20
REYATAZ............................................................................ 3
RIBATAB............................................................................. 3
ribavirin...............................................................................3
rifabutin.............................................................................. 2
RIFAMATE...........................................................................3
rifampin...............................................................................3
riluzole.............................................................................. 16
risedronate......................................................................... 7
risperidone....................................................................... 13
rivastigmine......................................................................14
RIXUBIS............................................................................ 17
rizatriptan......................................................................... 15
ropinirole.......................................................................... 16
ROXICET soln...................................................................14
S
SABRIL.............................................................................. 16
salsalate............................................................................14
selegiline caps.................................................................16
selegiline tabs..................................................................16
selenium sulfide 2.5%.....................................................20
SELZENTRY........................................................................3
SENSIPAR...........................................................................7
SEROQUEL XR................................................................ 13
sertraline...........................................................................13
sildenafil........................................................................... 10
silver sulfadiazine........................................................... 19
SIMPONI............................................................................15
simvastatin......................................................................... 9
sirolimus...........................................................................20
SIVEXTRO tabs.................................................................. 4
sodium citrate/citric acid................................................ 12
sodium fluoride oral, NP = tabs, 1.1 mg........................16
SODIUM FLUORIDE tabs, 2.2 mg....................................16
sodium polystyrene sulfonate....................................... 20
SOMAVERT.........................................................................7
sotalol............................................................................... 10
SOVALDI............................................................................. 3
SPIRIVA HANDIHALER.................................................... 10
SPIRIVA RESPIMAT......................................................... 10
spironolactone................................................................... 9
spironolactone/hydrochlorothiazide................................9
SPORANOX soln................................................................ 3
SPRYCEL............................................................................ 5
stavudine............................................................................ 3
STELARA.......................................................................... 20
STIMATE............................................................................. 7
STIVARGA...........................................................................5
STRIBILD.............................................................................4
SUBOXONE film............................................................... 14
sucralfate..........................................................................11
sulfacetamide sodium/prednisolone eye soln..............18
sulfacetamide sodium/sulfur, NP = susp, 10-5%.......... 19
sulfacetamide sodium eye soln..................................... 17
28
sulfacetamide sodium lotn............................................. 19
SULFADIAZINE................................................................... 2
sulfamethoxazole/trimethoprim....................................... 4
sulfasalazine.................................................................... 11
sulfasalazine delayed-release........................................ 12
sulindac............................................................................ 15
sumatriptan auto-injector; cartridge; inj, 6 mg/0.5 mL;
tabs..................................................................................15
SUMATRIPTAN inj, 4 mg/0.5 mL......................................15
SUSTIVA............................................................................. 4
SUTENT.............................................................................. 5
SYLATRON......................................................................... 5
SYMAX DUOTAB..............................................................11
SYMBICORT..................................................................... 11
SYMLINPEN inj................................................................... 7
SYNAREL............................................................................ 7
SYNTHROID........................................................................7
SYRINGES/NEEDLES – VARIOUS MANUFACTURERS –
for self-injectable drug administration..............................20
T
TABLOID............................................................................. 5
tacrolimus.........................................................................20
TAFINLAR........................................................................... 5
TAMIFLU............................................................................. 4
tamoxifen............................................................................5
tamsulosin........................................................................12
TARCEVA............................................................................5
TARGRETIN caps............................................................... 5
TASIGNA............................................................................. 5
TAZORAC..........................................................................19
TECFIDERA...................................................................... 14
temazepam....................................................................... 13
temozolomide.....................................................................5
terazosin........................................................................... 10
terbinafine.......................................................................... 3
terbutaline........................................................................ 11
terconazole.......................................................................12
TEST DISCS – BAYER BREEZE 2.................................. 20
TEST STRIPS – BAYER...................................................20
TETRACYCLINE................................................................. 2
THALOMID........................................................................ 20
theophylline ext-release..................................................11
thiothixene........................................................................13
timolol maleate eye soln................................................ 18
TIMOLOL tabs.....................................................................8
TIVICAY...............................................................................4
tizanidine.......................................................................... 16
TOBI PODHALER............................................................... 2
TOBRADEX oint................................................................18
tobramycin/dexamethasone eye susp...........................18
tobramycin eye soln....................................................... 17
tobramycin inhal soln....................................................... 2
tolterodine........................................................................ 12
tolterodine ext-release.................................................... 12
topiramate........................................................................ 16
Florida Blue January 2015 Closed Medication Drug Guide
2015
torsemide............................................................................9
TRACLEER........................................................................10
tramadol............................................................................14
tramadol/acetaminophen................................................ 15
tramadol ext-release....................................................... 15
trandolapril......................................................................... 8
tranylcypromine...............................................................13
trazodone..........................................................................13
tretinoin caps.....................................................................5
tretinoin crm, gel............................................................. 19
tretinoin microsphere......................................................19
TRETTEN.......................................................................... 17
triamcinolone dental paste.............................................18
triamcinolone nasal.........................................................10
triamcinolone topical, NP = oint, 0.5%.......................... 19
triamterene/hydrochlorothiazide, NP = caps, 50-25
mg......................................................................................9
trifluoperazine.................................................................. 13
trifluridine eye soln......................................................... 17
trihexyphenidyl................................................................ 16
trimethobenzamide..........................................................11
trimethoprim.......................................................................4
tropicamide eye soln...................................................... 18
TRUVADA............................................................................4
TYKERB.............................................................................. 5
U
ursodiol.............................................................................12
V
VAGIFEM...........................................................................12
valacyclovir........................................................................ 3
VALCHLOR....................................................................... 20
VALCYTE............................................................................ 3
valproic acid.................................................................... 16
valsartan............................................................................. 8
valsartan/hydrochlorothiazide..........................................8
vancomycin........................................................................ 4
venlafaxine....................................................................... 13
venlafaxine ext-release caps..........................................13
VENLAFAXINE ext-release tabs, 225 mg......................... 13
venlafaxine ext-release tabs, 37.5 mg, 75 mg, 150
mg....................................................................................13
VENTAVIS......................................................................... 10
VENTOLIN HFA................................................................ 11
VERAPAMIL 40 mg.............................................................8
verapamil 80 mg, 120 mg................................................. 9
verapamil ext-release........................................................ 9
VESICARE.........................................................................12
VIDEX.................................................................................. 4
VIGAMOX.......................................................................... 17
VIRACEPT...........................................................................4
VIRAMUNE susp.................................................................4
VIRAMUNE XR 100 mg...................................................... 4
VIREAD............................................................................... 4
voriconazole.......................................................................3
Florida Blue January 2015 Closed Medication Drug Guide
VOTRIENT...........................................................................5
W
warfarin.............................................................................17
WELCHOL........................................................................... 9
WILATE............................................................................. 17
X
XALKORI............................................................................. 5
XARELTO.......................................................................... 17
XIFAXAN 550 mg................................................................4
XTANDI................................................................................5
XYNTHA/SOLOFUSE........................................................17
Y
YODOXIN............................................................................ 4
Z
zafirlukast......................................................................... 11
zaleplon............................................................................ 13
ZAVESCA.......................................................................... 17
ZELBORAF..........................................................................5
ZENPEP............................................................................ 11
ZIAGEN soln....................................................................... 4
zidovudine.......................................................................... 4
ziprasidone.......................................................................13
ZITHROMAX packets.......................................................... 2
ZOLINZA..............................................................................5
zolpidem........................................................................... 13
zolpidem ext-release....................................................... 13
zonisamide....................................................................... 16
ZORTRESS....................................................................... 20
ZOSTAVAX..........................................................................4
ZOVIRAX crm....................................................................19
ZYDELIG............................................................................. 5
ZYKADIA............................................................................. 5
ZYTIGA................................................................................5
ZYVOX.................................................................................4
29