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January 2015
Horizon Blue Cross Blue Shield of New Jersey Drug Guide
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide
Contents
Introduction ...................................................................... I
Drug selection .................................................................. I
Generic drugs .................................................................. I
Member Prescription Benefit ........................................... I
Affordable Care Act ........................................................ II
Utilization Management .................................................. II
Prior Authorization/Medical Necessity Review
and Determination .......................................................... II
Quantity Limits ................................................................ II
“Smart” Prior Authorization ............................................ III
Specialty ........................................................................ III
How to use this list ......................................................... IV
Abbreviation/acronym key .............................................. V
Anti-Infective Drugs ..................................................... 1
Biologicals.................................................................. 15
Antineoplastic Agents ................................................ 15
Endocrine And Metabolic Drugs ................................ 19
Cardiovascular Agents .............................................. 41
Respiratory Agents .................................................... 63
Gastrointestinal Agents ............................................. 74
Genitourinary Agents ................................................. 82
Central Nervous System Drugs ................................. 86
Analgesics and Anesthetics..................................... 106
Neuromuscular Drugs .............................................. 123
Nutritional Products ................................................. 133
Hematological Agents .............................................. 150
Topical Products ...................................................... 156
Miscellaneous Products........................................... 183
Index ....................................................................... 244
Please consider talking to your doctor about prescribing generic and preferred brand medicines, which may help
reduce your out-of-pocket costs. This Drug Guide may help you and your doctor to choose an appropriate medicine.
This guide is a draft version and is subject to change. Please check back on and after 1/1/2015 for the final version.
To search for a medicine 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.
A=$0 PREVENTIVE DRUGS
THIS FORMULARY (DRUG LIST) APPLIES TO HORIZON BCBSNJ’S HEALTH INSURANCE MARKETPLACE INDIVIDUAL AND SMALL
GROUP MEDICAL PRODUCTS. THE APPLICABLE PRODUCTS FOR THE INDIVIDUAL MARKET ARE: HORIZON ADVANCE EPO GOLD,
HORIZON ADVANTAGE EPO GOLD, HORIZON ADVANCE EPO SILVER, HORIZON ADVANCE EPO SILVER 40/70%, HORIZON
ADVANTAGE EPO SILVER, PATIENT CENTERED ADVANTAGE EPO SILVER 20/30/30%, HORIZON ADVANCE EPO BRONZE, HORIZON
ADVANTAGE EPO BRONZE, AND HORIZON ADVANTAGE EPO ESSENTIALS. THE APPLICABLE PRODUCTS FOR THE SMALL GROUP
MARKET ARE: DIRECT ACCESS GOLD 100/80/60 BLUECARD, ADVANTAGE EPO GOLD 100 $20/$40, PATIENT CENTERED ADVANTAGE
EPO GOLD 5/20/40, ADVANTAGE EPO GOLD 100/80, ADVANTAGE EPO SILVER 100/70, ADVANTAGE EPO HSA SILVER 100
COMPATIBLE $750 CONTRIB., PATIENT CENTERED ADVANTAGE EPO SILVER 20/30/70%, ADVANTAGE EPO HSA BRONZE 100
COMPATIBLE, AND PATIENT CENTERED ADVANTAGE EPO BRONZE 40/50%/50%.
5517-E NJ IVL © Prime Therapeutics LLC 01/15
Introduction
Horizon Blue Cross Blue Shield of New Jersey is pleased to present the Advantage Drug Guide for the Health
Insurance Marketplace. A formulary, or drug list, is a list of medicines that your prescription benefit plan covers. At
Horizon BCBSNJ, our goal is to give members access to safe and effective medicine.
The drug list in this guide applies to Horizon BCBSNJ’s Health Insurance Marketplace individual and small group
products. The applicable products for the individual market are: Horizon Advance EPO Gold, Horizon Advantage
EPO Gold, Horizon Advance EPO Silver, Horizon Advance EPO Silver 40/70%, Horizon Advantage EPO Silver,
Patient Centered Advantage EPO Silver 20/30/30%, Horizon Advance EPO Bronze, Horizon Advantage EPO
Bronze, and Horizon Advantage EPO Essentials. The applicable products for the small group market are: Direct
Access Gold 100/80/60 BlueCard, Advantage EPO Gold 100 $20/$40, Patient Centered Advantage EPO Gold
5/20/40, Advantage EPO Gold 100/80, Advantage EPO Silver 100/70, Advantage EPO HSA Silver 100 Compatible
$750 Contrib., Patient Centered Advantage EPO Silver 20/30/70%, Advantage EPO HSA Bronze 100 Compatible,
and Patient Centered Advantage EPO Bronze 40/50%/50%.
Drug selection
Each medicine chosen for the drug list was analyzed for its safety, efficacy and value by our Pharmacy and
Therapeutics (P&T) Committee. The P&T Committee is made up of local, independent practicing doctors and
pharmacists and meets at least quarterly. Decisions to add or remove medicines from the Advantage Drug List for the
Health Insurance Marketplace are based on safety, efficacy, uniqueness and cost. New medicines are considered NonPreferred (Tier 3) until reviewed and approved for inclusion on the drug list by the P&T Committee. Horizon BCBSNJ
encourages doctors to prescribe Generic (Tier 1) and Preferred (Tier 2) medicines. While coverage is provided for NonPreferred drugs (Tier 3), members pay more for them.
Generic drugs
We encourage the use of generics as a way to provide high-quality at a lower cost. Generics are as safe and
effective as their brand counterparts, but are usually less expensive. Generics are manufactured under the same
strict requirements of the Food and Drug Administration’s (FDA’s) current Good Manufacturing Practice regulations
required for brand drugs in manufacturing, strength, purity and quality.
An FDA-approved generic drug may be substituted for the brand equivalent when it:
•
Contains the same active ingredient(s) as the brand drug.
•
Is identical in strength, dosage form and route of administration.
•
Is therapeutically equivalent and can be expected to have the same clinical effect and safety profile.
To encourage use of generics, Tier 2 Preferred brand drugs typically move to Tier 3 after an equivalent generic drug
becomes available.
Member prescription benefit
The Horizon BCBSNJ prescription benefit is tiered, placing medicine into one of three copayment/cost share levels:
Generic drugs (Tier 1), Preferred brand drugs (Tier 2) and Non-Preferred brand drugs (Tier 3).
Tier 1 – Lowest copayment/cost share – Generic drugs. Tier 1 includes all generic medicines, although not all
generics are listed in the Drug Guide.
A=$0 PREVENTIVE DRUGS
THIS FORMULARY (DRUG LIST) APPLIES TO HORIZON BCBSNJ’S HEALTH INSURANCE MARKETPLACE INDIVIDUAL AND SMALL
GROUP MEDICAL PRODUCTS. THE APPLICABLE PRODUCTS FOR THE INDIVIDUAL MARKET ARE: HORIZON ADVANCE EPO GOLD,
HORIZON ADVANTAGE EPO GOLD, HORIZON ADVANCE EPO SILVER, HORIZON ADVANCE EPO SILVER 40/70%, HORIZON
ADVANTAGE EPO SILVER, PATIENT CENTERED ADVANTAGE EPO SILVER 20/30/30%, HORIZON ADVANCE EPO BRONZE, HORIZON
ADVANTAGE EPO BRONZE, AND HORIZON ADVANTAGE EPO ESSENTIALS. THE APPLICABLE PRODUCTS FOR THE SMALL GROUP
MARKET ARE: DIRECT ACCESS GOLD 100/80/60 BLUECARD, ADVANTAGE EPO GOLD 100 $20/$40, PATIENT CENTERED ADVANTAGE
EPO GOLD 5/20/40, ADVANTAGE EPO GOLD 100/80, ADVANTAGE EPO SILVER 100/70, ADVANTAGE EPO HSA SILVER 100
COMPATIBLE $750 CONTRIB., PATIENT CENTERED ADVANTAGE EPO SILVER 20/30/70%, ADVANTAGE EPO HSA BRONZE 100
COMPATIBLE, AND PATIENT CENTERED ADVANTAGE EPO BRONZE 40/50%/50%.
I
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Tier 2 – Middle copayment/cost share – Preferred brand drugs.
Tier 3 – Highest copayment/cost share – Non-Preferred brand drugs.
Investigational drugs and drugs indicated for cosmetic purposes (for example, Propecia for hair growth) typically are
excluded (not covered). Coverage, copayment, and additional restrictions and exclusions may vary depending on
the individual plan design. Please refer to the policy and benefit information you received from Horizon BCBSNJ.
Affordable Care Act
Please note, some medicines may have limited or $0 cost-sharing under the Affordable Care Act indicated on the
drug list with the letter A. Examples of categories that may be subject to limited or $0 cost share include aspirin,
breast cancer preventive, fluoride supplements, folic acid supplements, gonorrhea prophylaxis (newborn), iron
supplements, vaccines, vitamin D supplements, and some contraceptive (birth control) drugs and devices. If you do
not find the medicine you are searching for, contact Pharmacy Member Services to find out if the drug is available
over-the-counter, or is covered under your medical benefit.
Utilization management (UM)
In addition to the tier level, medicines that require Prior Authorization (PA), Medical Necessity Review and
Determination (MND), a “Smart” Prior Authorization process (“Smart” PA) or that are subject to a Quantity Limits
(QL) are noted on the drug list.
Prior Authorization/Medical Necessity Review and Determination
Some medicines require Prior Authorization (PA). This means that specific clinical criteria must be met to
demonstrate the medical necessity of the medicine before coverage can be approved. Only medicines that are
medically necessary are approved. This ensures safe and proper use of the medicine. If this drug list shows that
you need a PA for your medicine, your doctor must send a PA request to Horizon BCBSNJ for review. You will be
notified in writing of the decision. If the PA request is not approved, there is an appeals process available, or you
may choose to buy the medicine at your own expense. Also, some medicines may be reviewed for medical
necessity from time to time, even though they are not subject to our PA requirements. If so, your prescribing doctor
may be asked for clinical information to support your use of the medicine. In instances where the medical necessity
determination (MND) results in an unfavorable decision, please remember such determinations may also be eligible
for the appeals process or you may choose to buy the medicine at your own expense.
Quantity Limits
A Quantity Limit (QL) identifies gender or age restrictions and/or controls the maximum amount of medicine covered
per prescription. Quantity limits are placed on medicines in certain categories and are based upon FDA-approved
drug labeling. These limits help encourage safe and proper use. If the drug list shows that there is a QL, your doctor
must submit a PA request to Horizon BCBSNJ for review if he/she wants to exceed the QL for your medicine.
Clinical information will be required to be submitted with the PA request to explain why you need to exceed the
quantity limit. If the request is not approved, there is an appeals process available to you or you may choose to buy
the medicine at your own expense.
A=$0 PREVENTIVE DRUGS
THIS FORMULARY (DRUG LIST) APPLIES TO HORIZON BCBSNJ’S HEALTH INSURANCE MARKETPLACE INDIVIDUAL AND SMALL
GROUP MEDICAL PRODUCTS. THE APPLICABLE PRODUCTS FOR THE INDIVIDUAL MARKET ARE: HORIZON ADVANCE EPO GOLD,
HORIZON ADVANTAGE EPO GOLD, HORIZON ADVANCE EPO SILVER, HORIZON ADVANCE EPO SILVER 40/70%, HORIZON
ADVANTAGE EPO SILVER, PATIENT CENTERED ADVANTAGE EPO SILVER 20/30/30%, HORIZON ADVANCE EPO BRONZE, HORIZON
ADVANTAGE EPO BRONZE, AND HORIZON ADVANTAGE EPO ESSENTIALS. THE APPLICABLE PRODUCTS FOR THE SMALL GROUP
MARKET ARE: DIRECT ACCESS GOLD 100/80/60 BLUECARD, ADVANTAGE EPO GOLD 100 $20/$40, PATIENT CENTERED ADVANTAGE
EPO GOLD 5/20/40, ADVANTAGE EPO GOLD 100/80, ADVANTAGE EPO SILVER 100/70, ADVANTAGE EPO HSA SILVER 100
COMPATIBLE $750 CONTRIB., PATIENT CENTERED ADVANTAGE EPO SILVER 20/30/70%, ADVANTAGE EPO HSA BRONZE 100
COMPATIBLE, AND PATIENT CENTERED ADVANTAGE EPO BRONZE 40/50%/50%.
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
II
“Smart” Prior Authorization
The “Smart” Prior Authorization (“Smart” PA) process applies to certain therapeutic drug classes. If the drug list
shows that “Smart” PA is used for a certain medicine, it requires the previous use of one or more medicines (usually
a generic drug) before a different medicine (usually a brand name drug) is covered. The “Smart” PA process will
automatically search for the previous use of one or more of the required generic drugs before the brand named drug
will be covered. If that previous use history is present, the request for the brand name drug will be approved
automatically.
If the “Smart” PA process applies, you must first use a generic. Or your doctor must submit a PA request to Horizon
BCBSNJ stating the clinical reason(s) why you cannot use the generic and that the brand is medically necessary. If
the request is not approved, please remember that there is an appeals process available to you or you may choose
to buy the medicine at your own expense.
Specialty
Specialty pharmaceuticals are a class of prescription drugs that are typically produced through biotechnology
(sometimes known as biologicals). They require special patient monitoring and handling, and unique education prior
to use. These specialty medicines also require your doctor to submit a Prior Authorization request to Horizon
BCBSNJ for review.
Horizon BCBSNJ has contracted with select specialty pharmacies that specialize in these therapies. Members who
want to minimize their cost-sharing are required to obtain the specialty medicines from a participating specialty
pharmacy. To find out more information about our Specialty Rx Program and to see the list and phone numbers of
the participating specialty pharmacies, please refer to the following webpage:
http://www.horizonblue.com/members/services/specialty-rx-program/specialty-pharmaceutical-list
A=$0 PREVENTIVE DRUGS
THIS FORMULARY (DRUG LIST) APPLIES TO HORIZON BCBSNJ’S HEALTH INSURANCE MARKETPLACE INDIVIDUAL AND SMALL
GROUP MEDICAL PRODUCTS. THE APPLICABLE PRODUCTS FOR THE INDIVIDUAL MARKET ARE: HORIZON ADVANCE EPO GOLD,
HORIZON ADVANTAGE EPO GOLD, HORIZON ADVANCE EPO SILVER, HORIZON ADVANCE EPO SILVER 40/70%, HORIZON
ADVANTAGE EPO SILVER, PATIENT CENTERED ADVANTAGE EPO SILVER 20/30/30%, HORIZON ADVANCE EPO BRONZE, HORIZON
ADVANTAGE EPO BRONZE, AND HORIZON ADVANTAGE EPO ESSENTIALS. THE APPLICABLE PRODUCTS FOR THE SMALL GROUP
MARKET ARE: DIRECT ACCESS GOLD 100/80/60 BLUECARD, ADVANTAGE EPO GOLD 100 $20/$40, PATIENT CENTERED ADVANTAGE
EPO GOLD 5/20/40, ADVANTAGE EPO GOLD 100/80, ADVANTAGE EPO SILVER 100/70, ADVANTAGE EPO HSA SILVER 100
COMPATIBLE $750 CONTRIB., PATIENT CENTERED ADVANTAGE EPO SILVER 20/30/70%, ADVANTAGE EPO HSA BRONZE 100
COMPATIBLE, AND PATIENT CENTERED ADVANTAGE EPO BRONZE 40/50%/50%.
III
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
How to use this list
The drug list is organized into broad categories (e.g. ANTINEOPLASTIC AGENTS AND RELATED DRUGS).
The first column of the chart lists the drug name. Generic drugs are shown in lower-case boldface type. Most
generic drugs are followed by a reference brand drug in (parentheses). Some generic products have no
reference brand.
Brand prescription drugs are shown in capital letters followed by the generic name.
The second column indicates the drug tier.
These columns indicate the Utilization Management (UM) program(s) that apply to the prescription drug
(e.g., Prior Authorization/Medical Necessity Determination (PA/MND), “Smart” Prior Authorization (“Smart” PA)
and Quantity Limits. If an indicator is present in the column(s), then the UM program applies.
The last column indicates if the drug is a specialty drug.
A=$0 PREVENTIVE DRUGS
THIS FORMULARY (DRUG LIST) APPLIES TO HORIZON BCBSNJ’S HEALTH INSURANCE MARKETPLACE INDIVIDUAL AND SMALL
GROUP MEDICAL PRODUCTS. THE APPLICABLE PRODUCTS FOR THE INDIVIDUAL MARKET ARE: HORIZON ADVANCE EPO GOLD,
HORIZON ADVANTAGE EPO GOLD, HORIZON ADVANCE EPO SILVER, HORIZON ADVANCE EPO SILVER 40/70%, HORIZON
ADVANTAGE EPO SILVER, PATIENT CENTERED ADVANTAGE EPO SILVER 20/30/30%, HORIZON ADVANCE EPO BRONZE, HORIZON
ADVANTAGE EPO BRONZE, AND HORIZON ADVANTAGE EPO ESSENTIALS. THE APPLICABLE PRODUCTS FOR THE SMALL GROUP
MARKET ARE: DIRECT ACCESS GOLD 100/80/60 BLUECARD, ADVANTAGE EPO GOLD 100 $20/$40, PATIENT CENTERED ADVANTAGE
EPO GOLD 5/20/40, ADVANTAGE EPO GOLD 100/80, ADVANTAGE EPO SILVER 100/70, ADVANTAGE EPO HSA SILVER 100
COMPATIBLE $750 CONTRIB., PATIENT CENTERED ADVANTAGE EPO SILVER 20/30/70%, ADVANTAGE EPO HSA BRONZE 100
COMPATIBLE, AND PATIENT CENTERED ADVANTAGE EPO BRONZE 40/50%/50%.
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
IV
Abbreviation/acronym key
cap .............................................................. capsules
chew .......................................................... chewable
conc ........................................................concentrate
cr ................................................... controlled release
dr ...................................................... delayed release
ec ......................................................... enteric coated
effe ......................................................... effervescent
equiv ......................................................... equivalent
er ....................................................extended release
inhal ........................................................... inhalation
inj.................................................................. injection
liq....................................................................... liquid
lotn .................................................................... lotion
nebu ............................................................ nebulizer
odt ...................................... orally disintegrating tabs
oint ..............................................................ointment
ophth.......................................................... opthalmic
osm .................................................. osmotic release
powd ..............................................................powder
sa ..................................................... sustained action
sl ............................................................... sublingual
soln ............................................................... solution
sr ................................................... sustained release
suppose .............................................. suppositories
susp ....................................................... suspension
tab…................................................................ tablets
td… ......................................................... transdermal
A=$0 PREVENTIVE DRUGS
THIS FORMULARY (DRUG LIST) APPLIES TO HORIZON BCBSNJ’S HEALTH INSURANCE MARKETPLACE INDIVIDUAL AND SMALL
GROUP MEDICAL PRODUCTS. THE APPLICABLE PRODUCTS FOR THE INDIVIDUAL MARKET ARE: HORIZON ADVANCE EPO GOLD,
HORIZON ADVANTAGE EPO GOLD, HORIZON ADVANCE EPO SILVER, HORIZON ADVANCE EPO SILVER 40/70%, HORIZON
ADVANTAGE EPO SILVER, PATIENT CENTERED ADVANTAGE EPO SILVER 20/30/30%, HORIZON ADVANCE EPO BRONZE, HORIZON
ADVANTAGE EPO BRONZE, AND HORIZON ADVANTAGE EPO ESSENTIALS. THE APPLICABLE PRODUCTS FOR THE SMALL GROUP
MARKET ARE: DIRECT ACCESS GOLD 100/80/60 BLUECARD, ADVANTAGE EPO GOLD 100 $20/$40, PATIENT CENTERED ADVANTAGE
EPO GOLD 5/20/40, ADVANTAGE EPO GOLD 100/80, ADVANTAGE EPO SILVER 100/70, ADVANTAGE EPO HSA SILVER 100
COMPATIBLE $750 CONTRIB., PATIENT CENTERED ADVANTAGE EPO SILVER 20/30/70%, ADVANTAGE EPO HSA BRONZE 100
COMPATIBLE, AND PATIENT CENTERED ADVANTAGE EPO BRONZE 40/50%/50%.
V
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
ANTI-INFECTIVE AGENTS
PENICILLINS
amoxicillin & k clavulanate tab
250-125 mg
1
AMOXICILLIN - amoxicillin
(trihydrate) chew tab 125 mg
1
amoxicillin & k clavulanate tab
500-125 mg (Augmentin)
1
AMOXICILLIN - amoxicillin
(trihydrate) chew tab 250 mg
1
amoxicillin & k clavulanate tab
875-125 mg (Augmentin)
1
amoxicillin (trihydrate) cap
250 mg
1
AMOXICILLIN ER - amoxicillin
(trihydrate) tab sr 24hr 775 mg
1
amoxicillin (trihydrate) cap
500 mg
1
AMPICILLIN - ampicillin for susp
125 mg/5ml
1
amoxicillin (trihydrate) for susp
125 mg/5ml
1
AMPICILLIN - ampicillin for susp
250 mg/5ml
1
amoxicillin (trihydrate) for susp
200 mg/5ml
1
ampicillin cap 250 mg
1
ampicillin cap 500 mg
1
amoxicillin (trihydrate) for susp
250 mg/5ml
1
AUGMENTIN - amoxicillin & k
clavulanate tab 500-125 mg
3
amoxicillin (trihydrate) for susp
400 mg/5ml
1
AUGMENTIN - amoxicillin & k
clavulanate tab 875-125 mg
3
amoxicillin (trihydrate) tab
500 mg
1
3
amoxicillin (trihydrate) tab
875 mg
1
AUGMENTIN - amoxicillin & k
clavulanate chew tab 200-28.5
mg
3
amoxicillin & k clavulanate chew
tab 200-28.5 mg
1
AUGMENTIN - amoxicillin & k
clavulanate for susp 125-31.25
mg/5ml
amoxicillin & k clavulanate chew
tab 400-57 mg
1
3
amoxicillin & k clavulanate for
susp 200-28.5 mg/5ml
1
AUGMENTIN - amoxicillin & k
clavulanate for susp 250-62.5
mg/5ml
3
amoxicillin & k clavulanate
for susp 250-62.5 mg/5ml
(Augmentin)
1
AUGMENTIN ES-600 - amoxicillin
& k clavulanate for susp 600-42.9
mg/5ml
3
amoxicillin & k clavulanate for
susp 400-57 mg/5ml
1
AUGMENTIN XR - amoxicillin
& k clavulanate tab sr 12hr
1000-62.5 mg
1
dicloxacillin sodium cap 250 mg
1
amoxicillin & k clavulanate
for susp 600-42.9 mg/5ml
(Augmentin es-600)
dicloxacillin sodium cap 500 mg
1
amoxicillin & k clavulanate tab sr
12hr 1000-62.5 mg (Augmentin
xr)
1
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
MOXATAG - amoxicillin (trihydrate) 3
tab sr 24hr 775 mg
1
penicillin v potassium tab
250 mg
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
1
1
CEPHALOSPORINS
CEDAX - ceftibuten cap 400 mg
3
CEDAX - ceftibuten for susp 90
mg/5ml
3
CEDAX - ceftibuten for susp 180
mg/5ml
3
CEFACLOR - cefaclor for susp 125 1
mg/5ml
CEFACLOR - cefaclor for susp 250 1
mg/5ml
CEFACLOR - cefaclor for susp 375 1
mg/5ml
1
cefaclor cap 250 mg
1
cefprozil for susp 250 mg/5ml
1
cefprozil tab 250 mg
1
cefprozil tab 500 mg
1
CEFTIBUTEN - ceftibuten cap 400
mg
1
CEFTIBUTEN - ceftibuten for susp
180 mg/5ml
1
cefaclor cap 500 mg
1
CEFACLOR ER - cefaclor
monohydrate tab sr 12hr 500 mg
1
cefadroxil cap 500 mg
1
cefadroxil for susp 250 mg/5ml
1
cefadroxil for susp 500 mg/5ml
1
cefadroxil tab 1 gm
1
cefazolin sodium for inj 1 gm
1
cefazolin sodium for inj 500 mg
1
cefdinir cap 300 mg
1
cefdinir for susp 125 mg/5ml
1
cefdinir for susp 250 mg/5ml
1
CEFTIN - cefuroxime axetil tab 250 3
mg
CEFTIN - cefuroxime axetil tab 500 3
mg
3
CEFTIN - cefuroxime axetil for
susp 125 mg/5ml
3
CEFTIN - cefuroxime axetil for
susp 250 mg/5ml
1
cefuroxime axetil for susp
125 mg/5ml (Ceftin)
1
cefuroxime axetil tab 250 mg
(Ceftin)
1
cefuroxime axetil tab 500 mg
(Ceftin)
CEPHALEXIN - cephalexin tab 250 1
mg
CEPHALEXIN - cephalexin tab 500 1
mg
1
cephalexin cap 250 mg (Keflex)
CEFDITOREN PIVOXIL cefditoren pivoxil tab 200 mg
(base equivalent)
1
cephalexin cap 500 mg (Keflex)
1
cephalexin cap 750 mg (Keflex)
1
1
cephalexin for susp 125 mg/5ml
1
CEFDITOREN PIVOXIL cefditoren pivoxil tab 400 mg
(base equivalent)
cephalexin for susp 250 mg/5ml
1
KEFLEX - cephalexin cap 250 mg
3
cefpodoxime proxetil for susp
100 mg/5ml
1
KEFLEX - cephalexin cap 500 mg
3
KEFLEX - cephalexin cap 750 mg
3
cefpodoxime proxetil for susp
50 mg/5ml
1
SPECTRACEF - cefditoren pivoxil
tab 200 mg (base equivalent)
3
cefpodoxime proxetil tab 100 mg
1
2
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
cefprozil for susp 125 mg/5ml
Quantity Limits
1
"Smart" PA
cefpodoxime proxetil tab 200 mg
Prior Authorization
Specialty
Quantity Limits
Drug Name
Drug Tier
penicillin v potassium tab
500 mg
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
SPECTRACEF - cefditoren pivoxil
tab 400 mg (base equivalent)
3
clarithromycin tab sr 24hr
500 mg (Biaxin xl pac)
1
•
SUPRAX - cefixime cap 400 mg
3
1
•
SUPRAX - cefixime tab 400 mg
3
clarithromycin tab 250 mg
(Biaxin)
SUPRAX - cefixime chew tab 100
mg
3
clarithromycin tab 500 mg
(Biaxin)
1
•
SUPRAX - cefixime chew tab 200
mg
3
DIFICID - fidaxomicin tab 200 mg
3
•
3
SUPRAX - cefixime for susp 100
mg/5ml
3
E.E.S. GRANULES - erythromycin
ethylsuccinate for susp 200
mg/5ml
SUPRAX - cefixime for susp 200
mg/5ml
3
E.E.S. 400 - erythromycin
ethylsuccinate tab 400 mg
3
SUPRAX - cefixime for susp 500
mg/5ml
3
ERY-TAB - erythromycin tab
delayed release 250 mg
2
ERY-TAB - erythromycin tab
delayed release 333 mg
2
ERY-TAB - erythromycin tab
delayed release 500 mg
2
ERYPED 200 - erythromycin
ethylsuccinate for susp 200
mg/5ml
3
ERYPED 400 - erythromycin
ethylsuccinate for susp 400
mg/5ml
3
3
MACROLIDES
•
AZITHROMYCIN - azithromycin
powd pack for susp 1 gm
1
azithromycin for susp
100 mg/5ml (Zithromax)
1
azithromycin for susp
200 mg/5ml (Zithromax)
1
azithromycin tab 250 mg
(Zithromax)
1
•
azithromycin tab 500 mg
(Zithromax)
1
•
azithromycin tab 600 mg
(Zithromax)
1
•
ERYTHROCIN STEARATE erythromycin stearate tab 250
mg
•
•
ERYTHROMYCIN - erythromycin
w/ delayed release particles cap
250 mg
1
BIAXIN - clarithromycin tab 250 mg 3
BIAXIN - clarithromycin tab 500 mg 3
3
BIAXIN - clarithromycin for susp
250 mg/5ml
3
BIAXIN XL - clarithromycin tab sr
24hr 500 mg
3
BIAXIN XL PAC - clarithromycin
tab sr 24hr 500 mg
1
clarithromycin for susp
125 mg/5ml
1
clarithromycin for susp
250 mg/5ml (Biaxin)
ERYTHROMYCIN BASE erythromycin tab 250 mg
1
•
ERYTHROMYCIN BASE erythromycin tab 500 mg
1
•
ERYTHROMYCIN
ETHYLSUCCINA - erythromycin
ethylsuccinate tab 400 mg
1
ERYTHROMYCIN STEARATE erythromycin stearate tab 250
mg
1
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
3
3
ADOXA PAK 2/100 - doxycycline
monohydrate tab 100 mg
3
•
•
PCE - erythromycin w/ enteric
coated particles tab 500 mg
3
3
•
ZITHROMAX - azithromycin tab
250 mg
3
ALODOX CONVENIENCE KIT doxycycline hyclate tab 20 mg w/
eyelid cleansers kit
3
•
ZITHROMAX - azithromycin tab
500 mg
3
•
AVIDOXY DK - doxycycline tab
100 mg & suncreen & sal acid
wash 2% kit
ZITHROMAX - azithromycin tab
600 mg
3
•
demeclocycline hcl tab 150 mg
1
demeclocycline hcl tab 300 mg
1
ZITHROMAX - azithromycin for
susp 100 mg/5ml
3
DORYX - doxycycline hyclate tab
delayed release 150 mg
3
•
•
ZITHROMAX - azithromycin for
susp 200 mg/5ml
3
DORYX - doxycycline hyclate tab
delayed release 200 mg
3
•
•
ZITHROMAX - azithromycin powd
pack for susp 1 gm
3
•
doxycycline hyclate cap 100 mg
(Vibramycin)
1
ZITHROMAX TRI-PAK azithromycin tab 500 mg
3
•
doxycycline hyclate cap 50 mg
1
•
doxycycline hyclate tab delayed
release 100 mg
1
•
•
ZITHROMAX Z-PAK - azithromycin 3
tab 250 mg
3
ZMAX - azithromycin extended
release for oral susp 2 gm
1
•
doxycycline hyclate tab delayed
release 150 mg (Doryx)
•
•
doxycycline hyclate tab delayed
release 75 mg
1
•
•
doxycycline hyclate tab 100 mg
1
doxycycline hyclate tab 20 mg
1
doxycycline monohydrate cap
100 mg (Monodox)
1
doxycycline monohydrate cap
150 mg (Adoxa)
1
•
•
doxycycline monohydrate cap
50 mg
1
doxycycline monohydrate cap
75 mg (Monodox)
1
doxycycline monohydrate for
susp 25 mg/5ml (Vibramycin)
1
doxycycline monohydrate tab
100 mg (Adoxa pak 1/100)
1
•
•
•
TETRACYCLINES
ACTICLATE - doxycycline hyclate
tab 75 mg
3
•
ACTICLATE - doxycycline hyclate
tab 150 mg
3
•
ADOXA - doxycycline monohydrate 3
cap 150 mg
ADOXA - doxycycline monohydrate 3
tab 50 mg
ADOXA - doxycycline monohydrate 3
tab 75 mg
ADOXA - doxycycline monohydrate 3
tab 100 mg
3
ADOXA PAK 1/100 - doxycycline
monohydrate tab 100 mg
•
•
•
•
•
•
•
•
•
•
4
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
PCE - erythromycin w/ enteric
coated particles tab 333 mg
Quantity Limits
Prior Authorization
•
Drug Name
"Smart" PA
Drug Tier
•
Specialty
3
Quantity Limits
ADOXA PAK 1/150 - doxycycline
monohydrate tab 150 mg
"Smart" PA
1
Drug Tier
erythromycin w/ delayed release
particles cap 250 mg
Drug Name
Prior Authorization
2015
3
•
doxycycline monohydrate tab
50 mg (Adoxa)
1
•
•
3
•
•
doxycycline monohydrate tab
75 mg (Adoxa)
1
•
•
MORGIDOX 1X100MG doxycycline hyclate cap 1 x 100
mg w/ cleanser kit
3
•
•
DYNACIN - minocycline hcl tab 50
mg
3
•
MORGIDOX 2X100MG doxycycline hyclate cap 2 x 100
mg w/ cleanser kit
DYNACIN - minocycline hcl tab 75
mg
3
•
3
•
DYNACIN - minocycline hcl tab
100 mg
3
•
NICAZELDOXY 30 KIT doxycycline monohyd tab 100 mg
&multivit/minerals tab kit
3
•
MINOCIN - minocycline hcl cap 50
mg
3
•
NICAZELDOXY 60 KIT doxycycline monohyd tab 100 mg
&multivit/minerals tab kit
MINOCIN - minocycline hcl cap 75
mg
3
•
•
MINOCIN - minocycline hcl cap
100 mg
3
•
MINOCIN KIT - minocycline hcl cap 3
50 mg w/ acne care products kit
MINOCIN KIT - minocycline hcl cap 3
100 mg w/ acne care products kit
1
minocycline hcl cap 100 mg
(Minocin)
1
minocycline hcl cap 50 mg
(Minocin)
1
minocycline hcl cap 75 mg
(Minocin)
1
minocycline hcl tab sr 24hr
135 mg
1
minocycline hcl tab sr 24hr
45 mg
1
minocycline hcl tab sr 24hr
90 mg
1
minocycline hcl tab 100 mg
•
NUTRIDOX - doxycycline monohyd 3
cap 75 mg w/ omega 3-vit e cap
kit
3
OCUDOX - doxycycline hyclate
cap 50 mg & eyelid cleans &
spray kit
ORAXYL - doxycycline hyclate cap 3
20 mg
SOLODYN - minocycline hcl tab sr 3
24hr 55 mg
SOLODYN - minocycline hcl tab sr 3
24hr 65 mg
SOLODYN - minocycline hcl tab sr 3
24hr 80 mg
SOLODYN - minocycline hcl tab sr 3
24hr 105 mg
SOLODYN - minocycline hcl tab sr 3
24hr 115 mg
1
TETRACYCLINE HCL tetracycline hcl cap 250 mg
1
TETRACYCLINE HCL tetracycline hcl cap 500 mg
3
VIBRAMYCIN - doxycycline
monohydrate for susp 25 mg/5ml
VIBRAMYCIN - doxycycline hyclate 3
cap 100 mg
minocycline hcl tab 50 mg
1
minocycline hcl tab 75 mg
1
MONODOX - doxycycline
monohydrate cap 75 mg
3
•
•
•
•
•
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
MONODOX - doxycycline
monohydrate cap 100 mg
Quantity Limits
Prior Authorization
•
Drug Name
"Smart" PA
Drug Tier
•
Specialty
1
Quantity Limits
Prior Authorization
doxycycline monohydrate tab
150 mg (Adoxa pak 1/150)
Drug Name
"Smart" PA
Drug Tier
2015
•
•
•
•
•
•
•
•
•
•
•
•
•
•
5
VIBRAMYCIN - doxycycline
calcium syrup 50 mg/5ml
FLUOROQUINOLONES
ciprofloxacin-ciprofloxacin hcl
tab sr 24hr 500 mg (base eq)
(Cipro xr)
1
•
3
•
FACTIVE - gemifloxacin mesylate
tab 320 mg (base equiv)
3
•
AVELOX ABC PACK - moxifloxacin 3
hcl tab 400 mg (base equiv)
CIPRO - ciprofloxacin for oral susp 3
250 mg/5ml (5%) (5 gm/100ml)
3
CIPRO - ciprofloxacin for oral
susp 500 mg/5ml (10%) (10
gm/100ml)
3
CIPRO - ciprofloxacin hcl tab 250
mg (base equiv)
3
CIPRO - ciprofloxacin hcl tab 500
mg (base equiv)
3
CIPRO XR - ciprofloxacinciprofloxacin hcl tab sr 24hr 500
mg (base eq)
3
CIPRO XR - ciprofloxacinciprofloxacin hcl tab sr 24hr 1000
mg(base eq)
1
ciprofloxacin for oral susp
250 mg/5ml (5%) (5 gm/100ml)
(Cipro)
1
ciprofloxacin for oral
susp 500 mg/5ml (10%)
(10 gm/100ml) (Cipro)
1
ciprofloxacin hcl tab 100 mg
(base equiv)
1
ciprofloxacin hcl tab 250 mg
(base equiv) (Cipro)
1
ciprofloxacin hcl tab 500 mg
(base equiv) (Cipro)
1
ciprofloxacin hcl tab 750 mg
(base equiv)
1
ciprofloxacin-ciprofloxacin hcl
tab sr 24hr 1000 mg(base eq)
(Cipro xr)
•
LEVAQUIN - levofloxacin tab 250
mg
3
• •
LEVAQUIN - levofloxacin tab 500
mg
3
• •
LEVAQUIN - levofloxacin tab 750
mg
3
• •
LEVAQUIN - levofloxacin oral soln
25 mg/ml
3
•
levofloxacin oral soln 25 mg/ml
(Levaquin)
1
levofloxacin tab 250 mg
(Levaquin)
1
•
levofloxacin tab 500 mg
(Levaquin)
1
•
levofloxacin tab 750 mg
(Levaquin)
1
•
moxifloxacin hcl tab 400 mg
(base equiv) (Avelox)
1
AVELOX - moxifloxacin hcl tab 400
mg (base equiv)
6
•
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
•
Quantity Limits
3
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
NOROXIN - norfloxacin tab 400 mg 3
1
OFLOXACIN - ofloxacin tab 400
mg
1
ofloxacin tab 200 mg
ofloxacin tab 300 mg
1
ofloxacin tab 400 mg
1
AMINOGLYCOSIDES
•
amikacin sulfate inj 1 gm/4ml
(250 mg/ml)
1
amikacin sulfate inj 500 mg/2ml
(250 mg/ml)
1
BETHKIS - tobramycin nebu soln
300 mg/4ml
3
gentamicin sulfate inj 10 mg/ml
1
gentamicin sulfate inj 40 mg/ml
1
• • •
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
1
NEO-FRADIN - neomycin sulfate
soln 25 mg/ml
3
neomycin sulfate tab 500 mg
1
paromomycin sulfate cap
250 mg
1
STREPTOMYCIN SULFATE streptomycin sulfate for inj 1 gm
1
TOBI - tobramycin nebu soln 300
mg/5ml
3
TOBI PODHALER - tobramycin
inhal cap 28 mg
2
tobramycin nebu soln
300 mg/5ml (Tobi)
1
SULFONAMIDES
SULFADIAZINE - sulfadiazine tab
500 mg
1
rifabutin cap 150 mg (Mycobutin)
1
RIFADIN - rifampin cap 150 mg
3
RIFADIN - rifampin cap 300 mg
3
RIFAMATE - isoniazid & rifampin
cap 150-300 mg
3
rifampin cap 150 mg (Rifadin)
1
• • •
rifampin cap 300 mg (Rifadin)
1
3
• • •
RIFATER - isoniazid-rifampin w/
pyrazinamide tab 50-120-300 mg
2
• • •
SEROMYCIN - cycloserine cap
250 mg
SIRTURO - bedaquiline fumarate
tab 100 mg (base equiv)
3
TRECATOR - ethionamide tab 250
mg
3
Specialty
1
Quantity Limits
pyrazinamide tab 500 mg
"Smart" PA
3
Specialty
PRIFTIN - rifapentine tab 150 mg
Prior Authorization
Quantity Limits
"Smart" PA
Drug Name
Drug Tier
KANAMYCIN SULFATE kanamycin sulfate inj 333 mg/ml
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
ANTIFUNGALS
ANTIMYCOBACTERIAL AGENTS
CYCLOSERINE - cycloserine cap
250 mg
1
nystatin oral powder
1
3
ethambutol hcl tab 100 mg
(Myambutol)
1
ANCOBON - flucytosine cap 250
mg
3
ethambutol hcl tab 400 mg
(Myambutol)
1
ANCOBON - flucytosine cap 500
mg
3
ISONIAZID - isoniazid syrup 50
mg/5ml
1
BIO-STATIN - nystatin cap 500000
unit
3
isoniazid & rifampin cap
150-300 mg
1
BIO-STATIN - nystatin cap
1000000 unit
isoniazid tab 100 mg
1
isoniazid tab 300 mg
1
MYAMBUTOL - ethambutol hcl tab
100 mg
3
MYAMBUTOL - ethambutol hcl tab
400 mg
3
MYCOBUTIN - rifabutin cap 150
mg
3
PASER - aminosalicylic acid cr
granules packet 4 gm
3
DIFLUCAN - fluconazole tab 50 mg 3
3
DIFLUCAN - fluconazole tab 100
mg
3
DIFLUCAN - fluconazole tab 150
mg
3
DIFLUCAN - fluconazole tab 200
mg
3
DIFLUCAN - fluconazole for susp
10 mg/ml
3
DIFLUCAN - fluconazole for susp
40 mg/ml
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
7
3
SPORANOX - itraconazole cap
100 mg
3
SPORANOX - itraconazole oral
soln 10 mg/ml
3
SPORANOX PULSEPAK itraconazole cap 100 mg
3
fluconazole for susp 10 mg/ml
(Diflucan)
1
fluconazole for susp 40 mg/ml
(Diflucan)
1
fluconazole tab 100 mg (Diflucan)
1
fluconazole tab 150 mg (Diflucan)
1
fluconazole tab 200 mg (Diflucan)
1
fluconazole tab 50 mg (Diflucan)
1
flucytosine cap 250 mg
(Ancobon)
1
terbinafine hcl tab 250 mg
(Lamisil)
1
•
flucytosine cap 500 mg
(Ancobon)
1
3
•
GRIFULVIN V - griseofulvin
microsize tab 500 mg
3
TERBINEX - terbinafine oral tab
250 mg & hydrxyprop chitosan liq
1% kit
VFEND - voriconazole tab 50 mg
3
GRIS-PEG - griseofulvin
ultramicrosize tab 125 mg
3
VFEND - voriconazole tab 200 mg
3
3
GRIS-PEG - griseofulvin
ultramicrosize tab 250 mg
3
VFEND - voriconazole for susp 40
mg/ml
1
griseofulvin microsize susp
125 mg/5ml
1
voriconazole for susp 40 mg/ml
(Vfend)
voriconazole tab 200 mg (Vfend)
1
griseofulvin microsize tab
500 mg (Grifulvin v)
1
voriconazole tab 50 mg (Vfend)
1
griseofulvin ultramicrosize tab
125 mg (Gris-peg)
1
griseofulvin ultramicrosize tab
250 mg (Gris-peg)
1
itraconazole cap 100 mg
(Sporanox)
1
ketoconazole tab 200 mg
1
LAMISIL - terbinafine hcl tab 250
mg
3
LAMISIL - terbinafine hcl oral
granules packet 125 mg
3
•
LAMISIL - terbinafine hcl oral
granules packet 187.5 mg
3
NOXAFIL - posaconazole tab
delayed release 100 mg
3
NOXAFIL - posaconazole susp 40
mg/ml
2
8
•
•
ANTIVIRALS
abacavir sulfate tab 300 mg
(base equiv) (Ziagen)
1
•
abacavir sulfate-lamivudinezidovudine tab 300-150-300 mg
(Trizivir)
1
•
acyclovir cap 200 mg (Zovirax)
1
acyclovir susp 200 mg/5ml
(Zovirax)
1
acyclovir tab 400 mg (Zovirax)
1
acyclovir tab 800 mg (Zovirax)
1
•
adefovir dipivoxil tab 10 mg
(Hepsera)
1
•
APTIVUS - tipranavir cap 250 mg
2
APTIVUS - tipranavir oral soln 100
mg/ml
2
•
•
ATRIPLA - efavirenz-emtricitabinetenofovir df tab 600-200-300 mg
2
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
ONMEL - itraconazole tab 200 mg
Quantity Limits
1
"Smart" PA
nystatin tab 500000 unit
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
BARACLUDE - entecavir tab 0.5
mg
3
EPZICOM - abacavir sulfatelamivudine tab 600-300 mg
2
BARACLUDE - entecavir tab 1 mg
3
famciclovir tab 125 mg (Famvir)
1
BARACLUDE - entecavir oral soln
0.05 mg/ml
2
famciclovir tab 250 mg (Famvir)
1
famciclovir tab 500 mg (Famvir)
1
FAMVIR - famciclovir tab 125 mg
3
FAMVIR - famciclovir tab 250 mg
3
FAMVIR - famciclovir tab 500 mg
3
FLUMADINE - rimantadine
hydrochloride tab 100 mg
3
FUZEON - enfuvirtide for inj 90 mg
2
•
HARVONI - ledipasvir-sofosbuvir
tab 90-400 mg
3
3
•
HEPSERA - adefovir dipivoxil tab
10 mg
INCIVEK - telaprevir tab 375 mg
3
INFERGEN - interferon alfacon-1
inj 9 mcg/0.3ml
COMBIVIR - lamivudine-zidovudine 3
tab 150-300 mg
2
COMPLERA - emtricitabinerilpivirine-tenofovir df tab
200-25-300 mg
3
COPEGUS - ribavirin tab 200 mg
•
•
•
• •
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
•
•
• •
• •
3
•
•
• •
• •
INFERGEN - interferon alfacon-1
inj 15 mcg/0.5ml
3
•
• •
INTELENCE - etravirine tab 25 mg
2
•
INTELENCE - etravirine tab 100
mg
2
•
•
•
INTELENCE - etravirine tab 200
mg
2
•
2
•
•
2
INVIRASE - saquinavir mesylate
cap 200 mg
2
EMTRIVA - emtricitabine soln 10
mg/ml
•
entecavir tab 0.5 mg (Baraclude)
INVIRASE - saquinavir mesylate
tab 500 mg
2
1
entecavir tab 1 mg (Baraclude)
1
2
•
EPIVIR - lamivudine tab 150 mg
3
EPIVIR - lamivudine tab 300 mg
3
ISENTRESS - raltegravir
potassium tab 400 mg (base
equiv)
2
ISENTRESS - raltegravir
potassium chew tab 25 mg (base
equiv)
2
EPIVIR - lamivudine oral soln 10
mg/ml
•
EPIVIR HBV - lamivudine tab 100
mg
3
2
•
EPIVIR HBV - lamivudine oral soln
5 mg/ml
2
ISENTRESS - raltegravir
potassium chew tab 100 mg
(base equiv)
CRIXIVAN - indinavir sulfate cap
200 mg
2
CRIXIVAN - indinavir sulfate cap
400 mg
2
didanosine delayed release
capsule 125 mg (Videx ec)
1
didanosine delayed release
capsule 200 mg (Videx ec)
1
•
didanosine delayed release
capsule 250 mg (Videx ec)
1
•
didanosine delayed release
capsule 400 mg (Videx ec)
1
•
EDURANT - rilpivirine hcl tab 25
mg (base equivalent)
2
EMTRIVA - emtricitabine caps 200
mg
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
9
•
•
• •
KALETRA - lopinavir-ritonavir tab
200-50 mg
PEG-INTRON - peginterferon
alfa-2b for inj kit 150 mcg/0.5ml
3
2
•
•
• •
2
PEG-INTRON REDIPEN peginterferon alfa-2b for inj kit 50
mcg/0.5ml
3
KALETRA - lopinavir-ritonavir soln
400-100 mg/5ml (80-20 mg/ml)
lamivudine tab 100 mg (Epivir
hbv)
1
3
•
• •
lamivudine tab 150 mg (Epivir)
1
lamivudine tab 300 mg (Epivir)
1
•
• •
1
PEG-INTRON REDIPEN peginterferon alfa-2b for inj kit
120 mcg/0.5ml
3
lamivudine-zidovudine tab
150-300 mg (Combivir)
•
•
•
PEG-INTRON REDIPEN peginterferon alfa-2b for inj kit 80
mcg/0.5ml
2
•
•
• •
LEXIVA - fosamprenavir calcium
susp 50 mg/ml (base equiv)
2
•
PEG-INTRON REDIPEN peginterferon alfa-2b for inj kit
150 mcg/0.5ml
3
LEXIVA - fosamprenavir calcium
tab 700 mg (base equiv)
3
•
• •
MODERIBA - ribavirin tab 200 mg
& ribavirin tab 400 mg dose pack
3
PEG-INTRON REDIPEN PAK 4 peginterferon alfa-2b for inj kit 50
mcg/0.5ml
•
• •
•
• •
MODERIBA - ribavirin tab 400 mg
& ribavirin tab 600 mg dose pack
PEG-INTRON REDIPEN PAK 4 peginterferon alfa-2b for inj kit 80
mcg/0.5ml
3
3
MODERIBA 1200 DOSE PACK ribavirin tab 600 mg
3
•
• •
3
•
• •
MODERIBA 800 DOSE PACK ribavirin tab 400 mg
3
•
• •
PEG-INTRON REDIPEN PAK 4
- peginterferon alfa-2b for inj kit
120 mcg/0.5ml
3
•
• •
NEVIRAPINE - nevirapine susp 50
mg/5ml
1
•
PEG-INTRON REDIPEN PAK 4
- peginterferon alfa-2b for inj kit
150 mcg/0.5ml
nevirapine tab sr 24hr 400 mg
(Viramune xr)
1
•
PEGASYS - peginterferon alfa-2a
inj 180 mcg/ml
2
•
• •
nevirapine tab 200 mg (Viramune) 1
2
NORVIR - ritonavir cap 100 mg
•
•
•
•
PEGASYS - peginterferon alfa-2a
inj 180 mcg/0.5ml
2
•
• •
PEGASYS - peginterferon alfa-2a
inj kit 180 mcg/0.5ml
2
•
• •
PEGASYS PROCLICK peginterferon alfa-2a inj 135
mcg/0.5ml
2
•
• •
PEGASYS PROCLICK peginterferon alfa-2a inj 180
mcg/0.5ml
2
•
• •
KALETRA - lopinavir-ritonavir tab
100-25 mg
NORVIR - ritonavir tab 100 mg
2
NORVIR - ritonavir oral soln 80 mg/ 2
ml
2
OLYSIO - simeprevir sodium cap
150 mg (base equivalent)
3
PEG-INTRON - peginterferon
alfa-2b for inj kit 50 mcg/0.5ml
10
•
• •
•
• •
•
• •
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
• •
Quantity Limits
Prior Authorization
•
•
Drug Name
"Smart" PA
Drug Tier
3
•
PEG-INTRON - peginterferon
alfa-2b for inj kit 120 mcg/0.5ml
2
Specialty
• •
2
Quantity Limits
•
ISENTRESS - raltegravir
potassium packet for susp 100
mg (base equiv)
"Smart" PA
3
Drug Tier
PEG-INTRON - peginterferon
alfa-2b for inj kit 80 mcg/0.5ml
Drug Name
Prior Authorization
2015
PEGINTRON - peginterferon
alfa-2b for inj kit 80 mcg/0.5ml
3
•
• •
REYATAZ - atazanavir sulfate cap
300 mg (base equiv)
2
•
PEGINTRON - peginterferon
alfa-2b for inj kit 120 mcg/0.5ml
3
•
• •
RIBASPHERE - ribavirin tab 400
mg
3
•
• •
PEGINTRON - peginterferon
alfa-2b for inj kit 150 mcg/0.5ml
3
•
• •
RIBASPHERE - ribavirin tab 600
mg
3
•
• •
PREZISTA - darunavir ethanolate
tab 75 mg (base equiv)
2
•
RIBASPHERE RIBAPAK - ribavirin
tab 400 mg
3
•
• •
PREZISTA - darunavir ethanolate
tab 150 mg (base equiv)
2
•
RIBASPHERE RIBAPAK - ribavirin
tab 600 mg
3
•
• •
PREZISTA - darunavir ethanolate
tab 400 mg (base equiv)
2
•
3
•
• •
PREZISTA - darunavir ethanolate
tab 600 mg (base equiv)
2
•
RIBASPHERE RIBAPAK - ribavirin
tab 200 mg & ribavirin tab 400
mg dose pack
3
•
• •
PREZISTA - darunavir ethanolate
tab 800 mg (base equiv)
2
•
RIBASPHERE RIBAPAK - ribavirin
tab 400 mg & ribavirin tab 600
mg dose pack
PREZISTA - darunavir ethanolate
susp 100 mg/ml (base equiv)
2
•
RIBATAB - ribavirin tab 400 mg
3
RIBATAB - ribavirin tab 600 mg
3
REBETOL - ribavirin cap 200 mg
3
3
• •
• •
• •
REBETOL - ribavirin soln 40 mg/ml
3
RIBATAB - ribavirin tab 400 mg &
ribavirin tab 600 mg dose pack
•
•
•
ribavirin cap 200 mg (Rebetol)
1
ribavirin tab 200 mg (Copegus)
1
•
•
• •
• •
rimantadine hydrochloride tab
100 mg (Flumadine)
1
•
RIMANTALIST - rimantadine tab
100 mg & dietary management
cap pack
3
•
• •
SELZENTRY - maraviroc tab 150
mg
2
•
• •
SELZENTRY - maraviroc tab 300
mg
2
•
• •
SITAVIG - acyclovir buccal tab 50
mg
3
•
SOVALDI - sofosbuvir tab 400 mg
2
stavudine cap 15 mg (Zerit)
1
stavudine cap 20 mg (Zerit)
1
stavudine cap 30 mg (Zerit)
1
RELENZA DISKHALER - zanamivir 3
aero powder breath activated 5
mg/blister
2
RESCRIPTOR - delavirdine
mesylate tab 100 mg
2
RESCRIPTOR - delavirdine
mesylate tab 200 mg
3
RETROVIR - zidovudine cap 100
mg
3
RETROVIR - zidovudine tab 300
mg
3
RETROVIR - zidovudine syrup 10
mg/ml
REYATAZ - atazanavir sulfate cap 2
100 mg (base equiv)
REYATAZ - atazanavir sulfate cap 2
150 mg (base equiv)
• •
• •
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
•
Specialty
•
Quantity Limits
2
"Smart" PA
REYATAZ - atazanavir sulfate cap
200 mg (base equiv)
•
•
Prior Authorization
• •
Drug Name
Drug Tier
•
Specialty
3
Quantity Limits
Prior Authorization
PEGINTRON - peginterferon
alfa-2b for inj kit 50 mcg/0.5ml
Drug Name
"Smart" PA
Drug Tier
2015
• •
•
•
•
11
2
SUSTIVA - efavirenz cap 50 mg
2
SUSTIVA - efavirenz cap 200 mg
2
SUSTIVA - efavirenz tab 600 mg
2
TAMIFLU - oseltamivir phosphate
cap 30 mg (base equiv)
3
TAMIFLU - oseltamivir phosphate
cap 45 mg (base equiv)
3
TAMIFLU - oseltamivir phosphate
cap 75 mg (base equiv)
3
TAMIFLU - oseltamivir phosphate
for susp 6 mg/ml (base equiv)
3
TIVICAY - dolutegravir sodium tab
50 mg (base equiv)
2
TRIUMEQ - abacavir-dolutegravirlamivudine tab 600-50-300 mg
3
TRIZIVIR - abacavir sulfatelamivudine-zidovudine tab
300-150-300 mg
3
TRUVADA - emtricitabine-tenofovir
disoproxil fumarate tab 200-300
mg
2
•
TYBOST - cobicistat tab 150 mg
3
TYZEKA - telbivudine tab 600 mg
2
•
•
valacyclovir hcl tab 1 gm
(Valtrex)
•
•
VALTREX - valacyclovir hcl tab
500 mg
3
3
•
VALTREX - valacyclovir hcl tab 1
gm
VICTRELIS - boceprevir cap 200
mg
2
VIDEX - didanosine for soln 2 gm
2
VIDEX - didanosine for soln 4 gm
2
VIDEX EC - didanosine delayed
release capsule 125 mg
3
•
•
• •
3
• •
•
VIDEX EC - didanosine delayed
release capsule 200 mg
3
• •
•
VIDEX EC - didanosine delayed
release capsule 250 mg
3
• •
•
VIDEX EC - didanosine delayed
release capsule 400 mg
2
•
•
VIRACEPT - nelfinavir mesylate
tab 250 mg
2
•
•
VIRACEPT - nelfinavir mesylate
tab 625 mg
3
•
•
VIRAMUNE - nevirapine tab 200
mg
VIRAMUNE - nevirapine susp 50
mg/5ml
3
•
VIRAMUNE XR - nevirapine tab sr
24hr 100 mg
2
•
VIRAMUNE XR - nevirapine tab sr
24hr 400 mg
3
•
3
1
VIRAZOLE - ribavirin for inhal soln
6 gm
2
•
valacyclovir hcl tab 500 mg
(Valtrex)
1
VIREAD - tenofovir disoproxil
fumarate tab 150 mg
2
•
VALCYTE - valganciclovir hcl tab
450 mg
2
VIREAD - tenofovir disoproxil
fumarate tab 200 mg
2
•
VALCYTE - valganciclovir hcl for
soln 50 mg/ml (base equiv)
2
VIREAD - tenofovir disoproxil
fumarate tab 250 mg
2
•
valganciclovir hcl tab 450 mg
(Valcyte)
1
VIREAD - tenofovir disoproxil
fumarate tab 300 mg
VIREAD - tenofovir disoproxil
fumarate oral powder 40 mg/gm
2
•
12
•
•
•
•
•
Specialty
STRIBILD - elvitegrav-cobicisemtricitab-tenofov tab
150-150-200-300 mg
Quantity Limits
1
"Smart" PA
stavudine for oral soln 1 mg/ml
(Zerit)
Prior Authorization
1
Drug Name
Drug Tier
stavudine cap 40 mg (Zerit)
Specialty
Quantity Limits
"Smart" PA
Drug Name
Drug Tier
Prior Authorization
2015
• •
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
ZERIT - stavudine for oral soln 1
mg/ml
3
ZIAGEN - abacavir sulfate tab 300
mg (base equiv)
2
ZIAGEN - abacavir sulfate soln 20
mg/ml (base equiv)
1
PLAQUENIL - hydroxychloroquine
sulfate tab 200 mg
3
1
•
PRIMAQUINE PHOSPHATE primaquine phosphate tab 26.3
mg
2
•
QUALAQUIN - quinine sulfate cap
324 mg
3
1
quinine sulfate cap 324 mg
(Qualaquin)
zidovudine syrup 10 mg/ml
(Retrovir)
1
•
•
1
zidovudine cap 100 mg (Retrovir)
1
•
YODOXIN - iodoquinol tab 210 mg
3
zidovudine tab 300 mg
3
YODOXIN - iodoquinol tab 650 mg
3
ZOVIRAX - acyclovir cap 200 mg
ZOVIRAX - acyclovir tab 400 mg
3
ZOVIRAX - acyclovir tab 800 mg
3
ZOVIRAX - acyclovir susp 200
mg/5ml
3
ANTIMALARIALS
ARALEN - chloroquine phosphate
tab 500 mg
3
atovaquone-proguanil hcl tab
250-100 mg (Malarone)
1
atovaquone-proguanil hcl tab
62.5-25 mg (Malarone)
1
chloroquine phosphate tab
250 mg
1
chloroquine phosphate tab
500 mg (Aralen)
1
COARTEM - artemetherlumefantrine tab 20-120 mg
2
DARAPRIM - pyrimethamine tab
25 mg
•
•
•
•
Specialty
3
mefloquine hcl tab 250 mg
Quantity Limits
ZERIT - stavudine cap 40 mg
3
"Smart" PA
3
MALARONE - atovaquoneproguanil hcl tab 250-100 mg
Prior Authorization
ZERIT - stavudine cap 30 mg
•
•
•
•
•
Drug Name
Drug Tier
3
•
•
•
•
•
Specialty
ZERIT - stavudine cap 20 mg
Quantity Limits
3
"Smart" PA
ZERIT - stavudine cap 15 mg
Prior Authorization
Drug Name
Drug Tier
2015
•
AMEBICIDES
ANTHELMINTICS
ALBENZA - albendazole tab 200
mg
3
BILTRICIDE - praziquantel tab 600
mg
2
ivermectin tab 3 mg (Stromectol)
1
STROMECTOL - ivermectin tab 3
mg
3
•
ANTI-INFECTIVE AGENTS - MISC.
ALINIA - nitazoxanide tab 500 mg
2
ALINIA - nitazoxanide for susp 100
mg/5ml
2
atovaquone susp 750 mg/5ml
(Mepron)
1
•
•
AZACTAM - aztreonam for inj 1 gm 3
AZACTAM - aztreonam for inj 2 gm 3
aztreonam for inj 1 gm (Azactam)
1
2
aztreonam for inj 2 gm (Azactam)
1
hydroxychloroquine sulfate tab
200 mg (Plaquenil)
BACTRIM - sulfamethoxazoletrimethoprim tab 400-80 mg
3
1
MALARONE - atovaquoneproguanil hcl tab 62.5-25 mg
BACTRIM DS - sulfamethoxazoletrimethoprim tab 800-160 mg
3
3
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
13
• • •
3
MEPRON - atovaquone susp 750
mg/5ml
3
metronidazole cap 375 mg
(Flagyl)
1
metronidazole tab 250 mg
(Flagyl)
1
metronidazole tab 500 mg
(Flagyl)
1
NEBUPENT - pentamidine
isethionate for nebulization soln
300 mg
2
PRIMSOL - trimethoprim hcl oral
soln 50 mg/5ml (base equiv)
3
SIVEXTRO - tedizolid phosphate
tab 200 mg
3
sulfamethoxazole-trimethoprim
susp 200-40 mg/5ml
1
sulfamethoxazole-trimethoprim
tab 400-80 mg (Bactrim)
1
sulfamethoxazole-trimethoprim
tab 800-160 mg (Bactrim ds)
1
TINDAMAX - tinidazole tab 250 mg
3
TINDAMAX - tinidazole tab 500 mg
3
tinidazole tab 250 mg (Tindamax)
1
tinidazole tab 500 mg (Tindamax)
1
trimethoprim tab 100 mg
1
CLEOCIN - clindamycin hcl cap 75
mg
2
CLEOCIN - clindamycin hcl cap
150 mg
2
CLEOCIN - clindamycin hcl cap
300 mg
2
CLEOCIN PEDIATRIC GRANULE
- clindamycin palmitate hcl for
soln 75 mg/5ml (base equiv)
2
clindamycin hcl cap 150 mg
(Cleocin)
1
clindamycin hcl cap 300 mg
(Cleocin)
1
clindamycin hcl cap 75 mg
(Cleocin)
1
clindamycin palmitate hcl for
soln 75 mg/5ml (base equiv)
(Cleocin pediatric gr)
1
DAPSONE - dapsone tab 25 mg
1
DAPSONE - dapsone tab 100 mg
1
erythromycin-sulfisoxazole for
susp 200-600 mg/5ml
1
FIRST-VANCOMYCIN 25 vancomycin hcl oral soln 25 mg/
ml (compound kit)
3
FIRST-VANCOMYCIN 50 vancomycin hcl oral soln 50 mg/
ml (compound kit)
3
FLAGYL - metronidazole cap 375
mg
VANCOCIN HCL - vancomycin hcl
cap 125 mg
3
3
FLAGYL - metronidazole tab 250
mg
VANCOCIN HCL - vancomycin hcl
cap 250 mg
3
3
3
vancomycin hcl cap 125 mg
(Vancocin hcl)
1
FLAGYL - metronidazole tab 500
mg
3
vancomycin hcl cap 250 mg
(Vancocin hcl)
1
FLAGYL ER - metronidazole tab sr
24hr 750 mg
XIFAXAN - rifaximin tab 200 mg
3
KETEK - telithromycin tab 300 mg
3
XIFAXAN - rifaximin tab 550 mg
2
14
•
•
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
LINCOCIN - lincomycin hcl inj 300
mg/ml
Quantity Limits
3
2
"Smart" PA
KETEK - telithromycin tab 400 mg
CAYSTON - aztreonam lysine
for inhal soln 75 mg (base
equivalent)
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
Quantity Limits
Specialty
•
•
•
•
•
AFINITOR DISPERZ - everolimus
tab for oral susp 3 mg
2
•
• •
2
•
• •
2
3
AFINITOR - everolimus tab 5 mg
2
AFINITOR - everolimus tab 7.5 mg
2
AFINITOR - everolimus tab 10 mg
2
AFINITOR DISPERZ - everolimus
tab for oral susp 2 mg
Specialty
AFINITOR - everolimus tab 2.5 mg
VACCINES
BCG VACCINE - bcg vaccine inj
1
VIVOTIF BERNA - typhoid vaccine
cap delayed release
3
TOXOIDS
DAPTACEL - diph, acellular pert &
tet tox inj 15 lf-10 mcg-5 lf/0.5ml
3
AFINITOR DISPERZ - everolimus
tab for oral susp 5 mg
2
DIPHTHERIA/TETANUS TOXOID
- diphtheria-tetanus tox adsorbed
(dt) im inj 25-5 unit/0.5ml
1
ALFERON N - interferon alfa-n3 inj
5000000 unit/ml
ALKERAN - melphalan tab 2 mg
2
anastrozole tab 1 mg (Arimidex)
1
INFANRIX - diph, acellular pert &
tet tox inj 25 lf-58 mcg-10 lf/0.5ml
3
ARIMIDEX - anastrozole tab 1 mg
3
3
AROMASIN - exemestane tab 25
mg
3
KINRIX - diph-tetanus tox ad-acell
pert & polio virus, ipv vac inj
3
bicalutamide tab 50 mg
(Casodex)
1
PEDIARIX - diph-tetanus tox-acell
pert-hepatitis b-polio ipv vac inj
3
BOSULIF - bosutinib tab 100 mg
2
PENTACEL - diph-ac per-tet tox
ad-poliov-haemoph b poly vac for
im susp
BOSULIF - bosutinib tab 500 mg
2
TRIPEDIA - diph, acellular
pert & tet tox inj 6.7 lf-46.8
mcg-5lf/0.5ml
3
BIOLOGICALS MISC
GRASTEK - timothy grass pollen
allergen ext tab sl 2800 bau
3
•
•
ORALAIR - grass mixed pollen ext
tab sl 300 ir (index of reactivity)
3
•
•
RAGWITEK - short ragweed pollen
allergen extract tab sl 12 amb a
1-u
3
•
•
ANTINEOPLASTIC AGENTS
ANTINEOPLASTICS
ACTIMMUNE - interferon
gamma-1b inj 100 mcg/0.5ml
(2000000 unit/0.5ml)
2
•
• •
•
CAPRELSA - vandetanib tab 100
mg
2
•
•
•
•
•
CAPRELSA - vandetanib tab 300
mg
2
•
• •
CASODEX - bicalutamide tab 50
mg
3
CEENU - lomustine cap 10 mg
2
CEENU - lomustine cap 40 mg
2
CEENU - lomustine cap 100 mg
2
COMETRIQ - cabozantinib smalate cap 3 x 20 mg (60 mg
dose) kit
2
•
• •
COMETRIQ - cabozantinib s-mal
cap 1 x 80 mg & 1 x 20 mg (100
dose) kit
2
•
• •
capecitabine tab 150 mg (Xeloda) 1
capecitabine tab 500 mg (Xeloda) 1
PASSIVE IMMUNIZING AGENTS
"Smart" PA
•
•
•
•
•
3
BIOLOGICALS
Prior Authorization
2
•
•
•
•
•
Drug Name
Drug Tier
Quantity Limits
ZYVOX - linezolid for susp 100
mg/5ml
"Smart" PA
ZYVOX - linezolid tab 600 mg
Prior Authorization
Drug Name
Drug Tier
2015
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
•
•
•
•
•
•
•
•
•
•
15
•
• •
•
• •
CYCLOPHOSPHAMIDE cyclophosphamide cap 25 mg
GLEEVEC - imatinib mesylate tab
100 mg (base equivalent)
2
1
•
• •
CYCLOPHOSPHAMIDE cyclophosphamide cap 50 mg
GLEEVEC - imatinib mesylate tab
400 mg (base equivalent)
2
1
HEXALEN - altretamine cap 50 mg
2
CYCLOPHOSPHAMIDE cyclophosphamide tab 25 mg
1
HYCAMTIN - topotecan hcl cap
0.25 mg (base equiv)
2
•
•
•
•
CYCLOPHOSPHAMIDE cyclophosphamide tab 50 mg
1
HYCAMTIN - topotecan hcl cap 1
mg (base equiv)
2
•
•
DEPO-PROVERA medroxyprogesterone acetate im
susp 400 mg/ml
2
HYDREA - hydroxyurea cap 500
mg
3
3
• •
hydroxyurea cap 500 mg
(Hydrea)
1
ELIGARD - leuprolide acetate for
subcutaneous inj kit 7.5 mg
3
• •
ICLUSIG - ponatinib hcl tab 15 mg
(base equiv)
2
ELIGARD - leuprolide acetate (3
month) for subcutaneous inj kit
22.5mg
•
• •
2
•
• •
ELIGARD - leuprolide acetate (4
month) for subcutaneous inj kit
30 mg
3
ICLUSIG - ponatinib hcl tab 45 mg
(base equiv)
IMBRUVICA - ibrutinib cap 140 mg
2
INLYTA - axitinib tab 1 mg
2
ELIGARD - leuprolide acetate (6
month) for subcutaneous inj kit
45 mg
3
INLYTA - axitinib tab 5 mg
2
2
•
• •
• •
•
EMCYT - estramustine phosphate
sodium cap 140 mg
2
INTRON A - interferon alfa-2b for
inj 10000000 unit
•
•
•
•
2
•
•
ERIVEDGE - vismodegib cap 150
mg
2
•
• •
INTRON A - interferon alfa-2b for
inj 18000000 unit
2
•
•
ETOPOSIDE - etoposide cap 50
mg
1
•
•
INTRON A - interferon alfa-2b for
inj 50000000 unit
2
•
•
exemestane tab 25 mg
(Aromasin)
1
INTRON-A - interferon alfa-2b inj
6000000 unit/ml
INTRON-A - interferon alfa-2b inj
10000000 unit/ml
2
•
•
INTRON-A W/DILUENT - interferon 2
alfa-2b for inj 10000000 unit
INTRON-A W/DILUENT - interferon 2
alfa-2b for inj 18000000 unit
INTRON-A W/DILUENT - interferon 2
alfa-2b for inj 50000000 unit
JAKAFI - ruxolitinib phosphate tab 2
5 mg (base equivalent)
•
•
•
•
•
•
•
• •
• •
• •
FARESTON - toremifene citrate tab 2
60 mg (base equivalent)
3
FEMARA - letrozole tab 2.5 mg
•
flutamide cap 125 mg
1
GILOTRIF - afatinib dimaleate tab
20 mg (base equivalent)
2
•
• •
GILOTRIF - afatinib dimaleate tab
30 mg (base equivalent)
2
•
• •
16
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
2
Quantity Limits
Prior Authorization
GILOTRIF - afatinib dimaleate tab
40 mg (base equivalent)
• •
Drug Name
"Smart" PA
Drug Tier
•
Specialty
2
Quantity Limits
Prior Authorization
COMETRIQ - cabozantinib s-mal
cap 1 x 80 mg & 3 x 20 mg (140
dose) kit
Drug Name
"Smart" PA
Drug Tier
2015
• •
JAKAFI - ruxolitinib phosphate tab
20 mg (base equivalent)
•
• •
MEGACE ORAL - megestrol
acetate susp 40 mg/ml
3
2
2
•
• •
megestrol acetate susp 40 mg/ml
(Megace oral)
1
JAKAFI - ruxolitinib phosphate tab
25 mg (base equivalent)
megestrol acetate tab 20 mg
1
letrozole tab 2.5 mg (Femara)
1
megestrol acetate tab 40 mg
1
LEUCOVORIN CALCIUM leucovorin calcium tab 10 mg
1
LEUCOVORIN CALCIUM leucovorin calcium tab 15 mg
1
MEKINIST - trametinib dimethyl
sulfoxide tab 0.5 mg (base
equivalent)
leucovorin calcium tab 25 mg
1
leucovorin calcium tab 5 mg
1
LEUKERAN - chlorambucil tab 2
mg
2
leuprolide acetate inj kit 5 mg/ml
1
LOMUSTINE - lomustine cap 10
mg
Specialty
JAKAFI - ruxolitinib phosphate tab
15 mg (base equivalent)
•
MATULANE - procarbazine hcl cap
50 mg
2
2
Quantity Limits
2
"Smart" PA
LYSODREN - mitotane tab 500 mg
Prior Authorization
• •
Drug Name
Drug Tier
•
Specialty
2
Quantity Limits
Prior Authorization
JAKAFI - ruxolitinib phosphate tab
10 mg (base equivalent)
Drug Name
"Smart" PA
Drug Tier
2015
•
•
•
•
2
•
• •
MEKINIST - trametinib dimethyl
sulfoxide tab 2 mg (base
equivalent)
2
•
• •
mercaptopurine tab 50 mg
(Purinethol)
1
MESNEX - mesna tab 400 mg
2
1
methotrexate sodium tab 2.5 mg
(base equiv)
1
LOMUSTINE - lomustine cap 40
mg
1
MYLERAN - busulfan tab 2 mg
2
2
•
• •
LOMUSTINE - lomustine cap 100
mg
1
NEXAVAR - sorafenib tosylate tab
200 mg (base equivalent)
2
LUPRON DEPOT - leuprolide
acetate for inj kit 3.75 mg
2
• •
NILANDRON - nilutamide tab 150
mg
2
•
• •
LUPRON DEPOT - leuprolide
acetate for inj kit 7.5 mg
2
• •
POMALYST - pomalidomide cap 1
mg
2
•
•
LUPRON DEPOT - leuprolide
acetate (3 month) for inj kit 11.25
mg
2
• •
POMALYST - pomalidomide cap 2
mg
POMALYST - pomalidomide cap 3
mg
2
•
• •
LUPRON DEPOT - leuprolide
acetate (3 month) for inj kit 22.5
mg
2
• •
POMALYST - pomalidomide cap 4
mg
2
•
• •
2
• •
PURINETHOL - mercaptopurine
tab 50 mg
3
LUPRON DEPOT - leuprolide
acetate (4 month) for inj kit 30
mg
PURIXAN - mercaptopurine susp
2000 mg/100ml (20 mg/ml)
3
LUPRON DEPOT - leuprolide
acetate (6 month) for inj kit 45
mg
2
•
• •
• •
• •
SOLTAMOX - tamoxifen citrate oral A
soln 10 mg/5ml (base equivalent)
2
SPRYCEL - dasatinib tab 20 mg
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
17
SPRYCEL - dasatinib tab 140 mg
2
STIVARGA - regorafenib tab 40 mg 2
2
SUTENT - sunitinib malate cap
12.5 mg (base equivalent)
SUTENT - sunitinib malate cap 25 2
mg (base equivalent)
2
SUTENT - sunitinib malate cap
37.5 mg (base equivalent)
SUTENT - sunitinib malate cap 50 2
mg (base equivalent)
SYLATRON - peginterferon alfa-2b 2
for inj kit 296 mcg
SYLATRON - peginterferon alfa-2b 2
for inj kit 444 mcg
SYLATRON - peginterferon alfa-2b 2
for inj kit 888 mcg
SYLATRON - peginterferon alfa-2b 2
for inj kit 4 x 296 mcg
SYLATRON - peginterferon alfa-2b 2
for inj kit 4 x 444 mcg
SYLATRON - peginterferon alfa-2b 2
for inj kit 4 x 888 mcg
2
TABLOID - thioguanine tab 40 mg
•
• •
•
• •
•
• •
•
• •
•
• •
•
• •
•
• •
•
• •
•
• •
TAFINLAR - dabrafenib mesylate
cap 50 mg (base equivalent)
2
•
• •
TAFINLAR - dabrafenib mesylate
cap 75 mg (base equivalent)
2
•
• •
tamoxifen citrate tab 10 mg
(base equivalent)
A
tamoxifen citrate tab 20 mg
(base equivalent)
A
TARCEVA - erlotinib hcl tab 25 mg
(base equivalent)
2
•
•
TARCEVA - erlotinib hcl tab 100
mg (base equivalent)
2
•
•
18
2
•
TARGRETIN - bexarotene cap 75
mg
2
•
TASIGNA - nilotinib hcl cap 150 mg 2
(base equivalent)
TASIGNA - nilotinib hcl cap 200 mg 2
(base equivalent)
3
TEMODAR - temozolomide cap 5
mg
TEMODAR - temozolomide cap 20 3
mg
3
TEMODAR - temozolomide cap
100 mg
3
TEMODAR - temozolomide cap
140 mg
3
TEMODAR - temozolomide cap
180 mg
3
TEMODAR - temozolomide cap
250 mg
1
temozolomide cap 100 mg
(Temodar)
1
temozolomide cap 140 mg
(Temodar)
1
temozolomide cap 180 mg
(Temodar)
1
temozolomide cap 20 mg
(Temodar)
1
temozolomide cap 250 mg
(Temodar)
1
temozolomide cap 5 mg
(Temodar)
3
THERACYS - bcg live intravesical
for susp 81 mg/vial
TICE BCG - bcg live intravesical for 3
susp 50 mg
3
TRELSTAR DEPOT - triptorelin
pamoate for im susp 3.75 mg
•
•
•
•
•
• •
•
• •
•
• •
•
• •
•
• •
•
• •
•
• •
•
• •
•
• •
•
• •
•
• •
•
• •
Specialty
2
TARCEVA - erlotinib hcl tab 150
mg (base equivalent)
Quantity Limits
SPRYCEL - dasatinib tab 100 mg
•
•
•
•
•
•
•
Drug Name
"Smart" PA
2
•
•
•
•
•
•
•
Prior Authorization
SPRYCEL - dasatinib tab 80 mg
•
•
•
•
•
•
•
Drug Tier
2
Specialty
SPRYCEL - dasatinib tab 70 mg
Quantity Limits
2
"Smart" PA
SPRYCEL - dasatinib tab 50 mg
Prior Authorization
Drug Name
Drug Tier
2015
•
•
• •
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
• •
ZYDELIG - idelalisib tab 150 mg
2
ZYKADIA - ceritinib cap 150 mg
2
• •
ZYTIGA - abiraterone acetate tab
250 mg
2
TRELSTAR LA - triptorelin
pamoate for im susp 11.25 mg
3
TRELSTAR LA MIXJECT triptorelin pamoate for im susp
11.25 mg
3
TRELSTAR MIXJECT - triptorelin
pamoate for im susp 22.5 mg
3
tretinoin cap 10 mg
1
TREXALL - methotrexate sodium
tab 5 mg (base equiv)
3
TREXALL - methotrexate sodium
tab 7.5 mg (base equiv)
3
TREXALL - methotrexate sodium
tab 10 mg (base equiv)
3
TREXALL - methotrexate sodium
tab 15 mg (base equiv)
3
TYKERB - lapatinib ditosylate tab
250 mg (base equiv)
2
•
• •
VANDETANIB - vandetanib tab
100 mg
1
•
• •
VANDETANIB - vandetanib tab
300 mg
1
•
• •
VOTRIENT - pazopanib hcl tab 200 2
mg (base equiv)
2
XALKORI - crizotinib cap 200 mg
•
• •
• •
• •
• •
Specialty
2
•
•
•
•
•
Quantity Limits
ZYDELIG - idelalisib tab 100 mg
3
"Smart" PA
2
• •
TRELSTAR DEPOT MIXJECT triptorelin pamoate for im susp
3.75 mg
Prior Authorization
ZOLINZA - vorinostat cap 100 mg
Specialty
Drug Name
Drug Tier
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
• •
•
•
• •
• •
ENDOCRINE AND METABOLIC DRUGS
• •
CORTICOSTEROIDS
budesonide cap sr 24hr 3 mg
(Entocort ec)
•
1
CORTEF - hydrocortisone tab 5 mg 3
3
CORTEF - hydrocortisone tab 10
mg
3
CORTEF - hydrocortisone tab 20
mg
1
CORTISONE ACETATE cortisone acetate tab 25 mg
1
DEXAMETHASONE dexamethasone tab 1 mg
1
DEXAMETHASONE dexamethasone tab 2 mg
1
DEXAMETHASONE dexamethasone soln 0.5 mg/5ml
dexamethasone elixir 0.5 mg/5ml 1
DEXAMETHASONE INTENSOL dexamethasone conc 1 mg/ml
1
dexamethasone tab 0.5 mg
1
dexamethasone tab 0.75 mg
1
dexamethasone tab 1.5 mg
1
XALKORI - crizotinib cap 250 mg
2
XELODA - capecitabine tab 150
mg
3
•
•
•
3
•
• •
dexamethasone tab 4 mg
1
XELODA - capecitabine tab 500
mg
dexamethasone tab 6 mg
1
XTANDI - enzalutamide cap 40 mg
2
2
• •
• •
DEXPAK 10 DAY dexamethasone tab 1.5 mg taper
pack
3
ZELBORAF - vemurafenib tab 240
mg (base equivalent)
•
•
3
•
ZOLADEX - goserelin acetate
implant 10.8 mg
3
•
DEXPAK 13 DAY dexamethasone tab 1.5 mg taper
pack
3
ZOLADEX - goserelin acetate
implant 3.6 mg
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
19
DEXPAK 6 DAY - dexamethasone
tab 1.5 mg taper pack
3
ENTOCORT EC - budesonide cap
sr 24hr 3 mg
3
FLO-PRED - prednisolone acetate
oral susp 16.7 mg/5ml (15
mg/5ml base)
MILLIPRED - prednisolone sod
phosphate oral soln 10 mg/5ml
(base equiv)
3
3
3
MILLIPRED DP - prednisolone tab
5 mg dose pack
3
fludrocortisone acetate tab
0.1 mg
1
ORAPRED - prednisolone sod
phosphate oral soln 15 mg/5ml
(base equiv)
3
hydrocortisone tab 10 mg
(Cortef)
1
ORAPRED ODT - prednisolone
sod phos orally disintegr tab 10
mg (base eq)
hydrocortisone tab 20 mg
(Cortef)
1
3
hydrocortisone tab 5 mg (Cortef)
1
ORAPRED ODT - prednisolone
sod phos orally disintegr tab 15
mg (base eq)
3
ORAPRED ODT - prednisolone
sod phos orally disintegr tab 30
mg (base eq)
3
MEDROL - methylprednisolone tab
2 mg
MEDROL - methylprednisolone tab
4 mg
3
3
MEDROL - methylprednisolone tab
8 mg
3
PEDIAPRED - prednisolone sod
phosph oral soln 6.7 mg/5ml (5
mg/5ml base)
MEDROL - methylprednisolone tab
16 mg
prednisolone sod phos orally
disintegr tab 10 mg (base eq)
(Orapred odt)
1
3
MEDROL - methylprednisolone tab
32 mg
3
1
MEDROL DOSEPAK methylprednisolone tab 4 mg
dose pack
3
prednisolone sod phos orally
disintegr tab 15 mg (base eq)
(Orapred odt)
1
methylprednisolone tab 16 mg
(Medrol)
1
prednisolone sod phos orally
disintegr tab 30 mg (base eq)
(Orapred odt)
1
methylprednisolone tab 32 mg
(Medrol)
1
prednisolone sod phosph oral
soln 6.7 mg/5ml (5 mg/5ml
base) (Pediapred)
methylprednisolone tab 4 mg
(Medrol)
1
1
methylprednisolone tab 4 mg
dose pack (Medrol dosepak)
1
prednisolone sod phosphate
oral soln 15 mg/5ml (base
equiv)
1
methylprednisolone tab 8 mg
(Medrol)
1
PREDNISOLONE SODIUM
PHOSP - prednisolone sodium
phosphate oral soln 25 mg/5ml
(base eq)
MILLIPRED - prednisolone tab 5
mg
3
prednisolone syrup 15 mg/5ml
(usp solution equivalent)
(Prelone)
1
20
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
1
ANDROGEL - testosterone td gel
20.25 mg/1.25gm (1.62%)
3
•
•
PREDNISONE - prednisone tab 5
mg dose pack
1
ANDROGEL - testosterone td gel
40.5 mg/2.5gm (1.62%)
3
•
•
PREDNISONE - prednisone tab 10
mg dose pack
1
ANDROGEL PUMP - testosterone
td gel 12.5 mg/act (1%)
3
•
•
PREDNISONE INTENSOL prednisone conc 5 mg/ml
1
ANDROGEL PUMP - testosterone
td gel 20.25 mg/act (1.62%)
3
•
•
prednisone tab 1 mg
1
3
•
prednisone tab 10 mg
1
ANDROID - methyltestosterone
cap 10 mg
prednisone tab 10 mg dose pack
1
3
•
prednisone tab 2.5 mg
1
ANDROXY - fluoxymesterone tab
10 mg
1
AXIRON - testosterone td soln 30
mg/act
3
prednisone tab 20 mg
•
prednisone tab 5 mg
1
danazol cap 100 mg
1
prednisone tab 5 mg dose pack
1
danazol cap 200 mg
1
PRELONE - prednisolone syrup 15
mg/5ml (usp solution equivalent)
3
danazol cap 50 mg
1
3
DEPO-TESTOSTERONE testosterone cypionate im in oil
100 mg/ml
3
RAYOS - prednisone tab delayed
release 1 mg
•
•
•
•
RAYOS - prednisone tab delayed
release 2 mg
3
3
•
RAYOS - prednisone tab delayed
release 5 mg
3
DEPO-TESTOSTERONE testosterone cypionate im in oil
200 mg/ml
FIRST-TESTOSTERONE testosterone propionate td
ointment 2%
3
•
•
3
FIRST-TESTOSTERONE MC
COM - testosterone propionate td
cream 2%
3
FORTESTA - testosterone td gel
10mg/act (2%)
3
METHITEST - methyltestosterone
oral tab 10 mg
3
OXANDRIN - oxandrolone tab 2.5
mg
3
OXANDRIN - oxandrolone tab 10
mg
•
•
•
•
•
UCERIS - budesonide tab sr 24hr 9 3
mg
3
VERIPRED 20 - prednisolone sod
phosphate oral soln 20 mg/5ml
(base equiv)
ANDROGEN-ANABOLIC
ANADROL-50 - oxymetholone tab
50 mg
3
ANDRODERM - testosterone td
patch 24hr 2 mg/24hr
2
ANDRODERM - testosterone td
patch 24hr 4 mg/24hr
2
ANDROGEL - testosterone td gel
25 mg/2.5gm (1%)
3
•
•
•
•
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
PREDNISONE - prednisone oral
soln 5 mg/5ml
Quantity Limits
Prior Authorization
•
Drug Name
"Smart" PA
Drug Tier
•
Specialty
3
Quantity Limits
ANDROGEL - testosterone td gel
50 mg/5gm (1%)
"Smart" PA
1
Drug Tier
PREDNISONE - prednisone tab 50
mg
Drug Name
Prior Authorization
2015
•
•
•
•
21
1
•
ALORA - estradiol td patch
biweekly 0.1 mg/24hr
3
•
STRIANT - testosterone buccal
mucoadhesive system 30 mg
3
•
•
ANGELIQ - drospirenone-estradiol
tab 0.25-0.5 mg
3
TESTIM - testosterone td gel 50
mg/5gm (1%)
2
•
•
ANGELIQ - drospirenone-estradiol
tab 0.5-1 mg
3
TESTOSTERONE - testosterone td 1
gel 50 mg/5gm (1%)
TESTOSTERONE - testosterone td 1
gel 10mg/act (2%)
1
testosterone cypionate im
inj in oil 100 mg/ml (Depotestosterone)
1
testosterone cypionate im
inj in oil 200 mg/ml (Depotestosterone)
1
testosterone enanthate im inj in
oil 200 mg/ml
1
TESTOSTERONE PUMP testosterone td gel 12.5 mg/act
(1%)
3
TESTRED - methyltestosterone
cap 10 mg
VOGELXO - testosterone td gel 50 3
mg/5gm (1%)
VOGELXO PUMP - testosterone td 3
gel 12.5 mg/act (1%)
•
•
2
•
•
CENESTIN - estrogens,
conjugated synthetic a tab 0.3
mg
2
•
CENESTIN - estrogens,
conjugated synthetic a tab 0.45
mg
2
•
CENESTIN - estrogens,
conjugated synthetic a tab 0.625
mg
2
•
CENESTIN - estrogens,
conjugated synthetic a tab 0.9
mg
CENESTIN - estrogens,
conjugated synthetic a tab 1.25
mg
2
CLIMARA - estradiol td patch
weekly 0.025 mg/24hr
3
•
CLIMARA - estradiol td patch
weekly 0.0375 mg/24hr (37.5
mcg/24hr)
3
•
CLIMARA - estradiol td patch
weekly 0.05 mg/24hr
3
•
CLIMARA - estradiol td patch
weekly 0.06 mg/24hr
3
•
CLIMARA - estradiol td patch
weekly 0.075 mg/24hr
3
•
CLIMARA - estradiol td patch
weekly 0.1 mg/24hr
3
•
CLIMARA PRO - estradiollevonorgestrel td patch weekly
0.045-0.015 mg/day
2
•
•
•
•
•
•
•
ESTROGENS
ACTIVELLA - estradiol &
norethindrone acetate tab 0.5-0.1
mg
3
ACTIVELLA - estradiol &
norethindrone acetate tab 1-0.5
mg
3
ALORA - estradiol td patch
biweekly 0.025 mg/24hr
3
•
ALORA - estradiol td patch
biweekly 0.05 mg/24hr
3
•
22
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
oxandrolone tab 2.5 mg
(Oxandrin)
Quantity Limits
•
"Smart" PA
3
•
Prior Authorization
ALORA - estradiol td patch
biweekly 0.075 mg/24hr
Drug Name
Drug Tier
•
Specialty
1
Quantity Limits
Prior Authorization
oxandrolone tab 10 mg
(Oxandrin)
Drug Name
"Smart" PA
Drug Tier
2015
•
ESTRACE - estradiol tab 0.5 mg
3
ESTRACE - estradiol tab 1 mg
3
ESTRACE - estradiol tab 2 mg
3
estradiol & norethindrone
acetate tab 0.5-0.1 mg
(Activella)
1
estradiol & norethindrone
acetate tab 1-0.5 mg (Activella)
1
estradiol tab 0.5 mg (Estrace)
1
estradiol tab 1 mg (Estrace)
1
estradiol tab 2 mg (Estrace)
1
estradiol td patch weekly
0.025 mg/24hr (Climara)
1
•
1
•
•
•
•
COMBIPATCH - estradiolnorethindrone ace td pttw
0.05-0.14 mg/day
3
COMBIPATCH - estradiolnorethindrone ace td pttw
0.05-0.25 mg/day
3
DELESTROGEN - estradiol
valerate im in oil 10 mg/ml
3
DELESTROGEN - estradiol
valerate im in oil 20 mg/ml
3
DELESTROGEN - estradiol
valerate im in oil 40 mg/ml
3
DEPO-ESTRADIOL - estradiol
cypionate im in oil 5 mg/ml
3
DIVIGEL - estradiol td gel 0.25
mg/0.25gm (0.1%)
3
•
DIVIGEL - estradiol td gel 0.5
mg/0.5gm (0.1%)
3
•
estradiol td patch weekly
0.0375 mg/24hr (37.5 mcg/24hr)
(Climara)
1
•
DIVIGEL - estradiol td gel 1 mg/gm
(0.1%)
3
•
estradiol td patch weekly
0.05 mg/24hr (Climara)
1
•
DUAVEE - conjugated estrogensbazedoxifene tab 0.45-20 mg
3
estradiol td patch weekly
0.06 mg/24hr (Climara)
1
•
ELESTRIN - estradiol gel 0.06%
(0.52 mg/0.87 gm metered-dose
pump)
3
estradiol td patch weekly
0.075 mg/24hr (Climara)
estradiol td patch weekly
0.1 mg/24hr (Climara)
1
•
ENJUVIA - estrogens, conjugated
synthetic b tab 0.3 mg
2
estradiol valerate im in oil 10 mg/
ml
1
ENJUVIA - estrogens, conjugated
synthetic b tab 0.45 mg
2
estradiol valerate im in oil 20 mg/
ml (Delestrogen)
1
ENJUVIA - estrogens, conjugated
synthetic b tab 0.625 mg
2
estradiol valerate im in oil 40 mg/
ml (Delestrogen)
1
ENJUVIA - estrogens, conjugated
synthetic b tab 0.9 mg
2
3
•
ENJUVIA - estrogens, conjugated
synthetic b tab 1.25 mg
2
ESTRASORB - estradiol
transdermal emulsion 4.35
mg/1.74gm
3
•
esterified estrogens &
methyltestosterone tab
0.625-1.25 mg
1
ESTROGEL - estradiol gel 0.06%
(0.75 mg/1.25 gm metered-dose
pump)
1
esterified estrogens &
methyltestosterone tab
1.25-2.5 mg
1
ESTROPIPATE - estropipate tab 3
mg
estropipate tab 0.75 mg
1
estropipate tab 1.5 mg
1
•
•
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
23
EVAMIST - estradiol transdermal
spray 1.53 mg/spray
3
FEMHRT LOW DOSE norethindrone acetate-ethinyl
estradiol tab 0.5 mg-2.5 mcg
3
FEMHRT 1/5 - norethindrone
acetate-ethinyl estradiol tab 1
mg-5 mcg
3
FEMTRACE - estradiol acetate tab
0.45 mg
3
FEMTRACE - estradiol acetate tab
0.9 mg
3
JINTELI - norethindrone acetateethinyl estradiol tab 1 mg-5 mcg
3
MENEST - esterified estrogens tab
0.3 mg
3
MENEST - esterified estrogens tab
0.625 mg
3
MENEST - esterified estrogens tab
1.25 mg
3
MENEST - esterified estrogens tab
2.5 mg
3
MENOSTAR - estradiol td patch
weekly 14 mcg/24hr
3
MINIVELLE - estradiol td patch
twice weekly 0.025 mg/24hr
3
MINIVELLE - estradiol td patch
biweekly 0.0375 mg/24hr
3
MINIVELLE - estradiol td patch
biweekly 0.05 mg/24hr
3
MINIVELLE - estradiol td patch
biweekly 0.075 mg/24hr
3
MINIVELLE - estradiol td patch
biweekly 0.1 mg/24hr
3
norethindrone acetate-ethinyl
estradiol tab 1 mg-5 mcg
1
PREFEST - estradiol tab 1
mg(15)/estrad-norgestimate tab
1-0.09mg(15)
3
PREMARIN - estrogens,
conjugated tab 0.3 mg
2
24
•
•
•
•
•
•
•
PREMARIN - estrogens,
conjugated tab 0.45 mg
2
PREMARIN - estrogens,
conjugated tab 0.625 mg
2
PREMARIN - estrogens,
conjugated tab 0.9 mg
2
PREMARIN - estrogens,
conjugated tab 1.25 mg
2
PREMPHASE - conj est 0.625(14)/
conj est-medroxypro ac tab
0.625-5mg(14)
2
PREMPRO - conjugated estrogenmedroxyprogest acetate tab
0.3-1.5 mg
2
PREMPRO - conjugated estrogenmedroxyprogest acetate tab
0.45-1.5 mg
2
PREMPRO - conjugated estrogenmedroxyprogest acetate tab
0.625-2.5 mg
2
PREMPRO - conjugated estrogenmedroxyprogest acetate tab
0.625-5 mg
2
VIVELLE-DOT - estradiol td patch
biweekly 0.025 mg/24hr
3
•
VIVELLE-DOT - estradiol td patch
biweekly 0.0375 mg/24hr
3
•
VIVELLE-DOT - estradiol td patch
biweekly 0.05 mg/24hr
3
•
VIVELLE-DOT - estradiol td patch
biweekly 0.075 mg/24hr
3
•
VIVELLE-DOT - estradiol td patch
biweekly 0.1 mg/24hr
3
•
CONTRACEPTIVES
AMETHYST - levonorgestrelethinyl estradiol (continuous) tab
90-20 mcg
A
BEYAZ - drospirenone-ethinyl
estrad-levomefolate tab
3-0.02-0.451 mg
A
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
BREVICON-28 - norethindrone &
ethinyl estradiol tab 0.5 mg-35
mcg
3
3
CYCLESSA - desogestethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mgmg
3
DEPO-PROVERA
CONTRACEPTIV medroxyprogesterone acetate im
susp 150 mg/ml
A
DEPO-SUBQ PROVERA 104 medroxyprogesterone acetate
subcutaneous susp 104
mg/0.65ml
DESOGEN - desogestrel & ethinyl 3
estradiol tab 0.15 mg-30 mcg
desogest-eth estrad & eth estrad A
tab 0.15-0.02/0.01 mg(21/5)
(Mircette)
A
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mgmg (Cyclessa)
A
desogestrel & ethinyl estradiol
tab 0.15 mg-30 mcg (Desogen)
A
drospirenone-ethinyl estradiol
tab 3-0.02 mg (Yaz)
A
drospirenone-ethinyl estradiol
tab 3-0.03 mg (Yasmin 28)
ELLA - ulipristal acetate tab 30 mg A
•
ESTROSTEP FE - norethindrone
ac-ethinyl estrad-fe tab
1-20/1-30/1-35 mg-mcg
3
•
ethynodiol diacetate & ethinyl
estradiol tab 1 mg-35 mcg
A
FALESSA - levonorgest-eth estrad
tab 0.1 mg-20 mcg & fa tab 1 mg
kit
A
FEMCON FE - norethindrone &
ethinyl estradiol-fe chew tab 0.4
mg-35 mcg
3
•
GENERESS FE - norethindrone &
ethinyl estradiol-fe chew tab 0.8
mg-25 mcg
A
IMPLANON - etonogestrel
subdermal implant 68 mg
A
levonorg-eth est tab
0.1-0.02mg(84) & eth est tab
0.01mg(7) (Loseasonique)
A
levonorg-eth est tab
0.15-0.03mg(84) & eth est tab
0.01mg(7) (Seasonique)
A
levonorgestrel & ethinyl
estradiol (91-day) tab
0.15-0.03 mg
A
levonorgestrel & ethinyl
estradiol tab 0.1 mg-20 mcg
A
levonorgestrel & ethinyl
estradiol tab 0.15 mg-30 mcg
A
levonorgestrel tab 0.75 mg (Plan
b)
A
levonorgestrel tab 1.5 mg (Plan b A
one-step)
A
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mgmcg
A
LO LOESTRIN FE - norethin-eth
estradiol-fe tab 1 mg-10 mcg
(24)/10 mcg (2)
A
LO MINASTRIN FE - norethineth estrad-fe chew/tab 1 mg-10
mcg/10 mcg ther pack
3
LO/OVRAL - norgestrel & ethinyl
estradiol tab 0.3 mg-30 mcg
3
LO/OVRAL-28 - norgestrel &
ethinyl estradiol tab 0.3 mg-30
mcg
3
LOESTRIN FE 1.5/30 norethindrone ace & ethinyl
estradiol-fe tab 1.5 mg-30 mcg
3
LOESTRIN FE 1/20 norethindrone ace & ethinyl
estradiol-fe tab 1 mg-20 mcg
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
•
•
25
LOESTRIN 1.5/30-21 norethindrone ace & ethinyl
estradiol tab 1.5 mg-30 mcg
3
LOESTRIN 1/20-21 - norethindrone 3
ace & ethinyl estradiol tab 1
mg-20 mcg
A
LOESTRIN 24 FE - norethindrone
ace-ethinyl estradiol-fe tab 1
mg-20 mcg (24)
3
LOSEASONIQUE - levonorg-eth
est tab 0.1-0.02mg(84) & eth est
tab 0.01mg(7)
medroxyprogesterone acetate im A
susp 150 mg/ml (Depo-provera
contrac)
MINASTRIN 24 FE - norethindrone A
ace-eth estradiol-fe chew tab 1
mg-20 mcg (24)
3
MIRCETTE - desogest-eth estrad
& eth estrad tab 0.15-0.02/0.01
mg(21/5)
MIRENA - levonorgestrel releasing A
iud 20 mcg/24hr (52 mg total)
3
MODICON - norethindrone &
ethinyl estradiol tab 0.5 mg-35
mcg
A
NATAZIA - estradiol valeratedienogest tab 3 mg /2-2 mg/2-3
mg/1 mg
NECON 1/50-28 - norethindrone & A
mestranol tab 1 mg-50 mcg
NECON 10/11-28 - norethindrone- A
eth estradiol tab 0.5-35/1-35 mgmcg (10/11)
A
NEXPLANON - etonogestrel
subdermal implant 68 mg
3
NOR-QD - norethindrone tab 0.35
mg
3
NORDETTE-28 - levonorgestrel &
ethinyl estradiol tab 0.15 mg-30
mcg
26
•
A
norelgestromin-ethinyl estradiol
td ptwk 150-35 mcg/24hr (Ortho
evra)
norethindrone & ethinyl estradiol A
tab 0.4 mg-35 mcg (Ovcon-35)
A
norethindrone & ethinyl
estradiol tab 0.5 mg-35 mcg
(Brevicon-28)
norethindrone & ethinyl estradiol A
tab 1 mg-35 mcg (Norinyl 1+35)
A
norethindrone & ethinyl
estradiol-fe chew tab
0.4 mg-35 mcg (Femcon fe)
norethindrone ac-ethinyl estrad- A
fe tab 1-20/1-30/1-35 mg-mcg
(Estrostep fe)
A
norethindrone ace & ethinyl
estradiol tab 1 mg-20 mcg
(Loestrin 1/20-21)
A
norethindrone ace & ethinyl
estradiol tab 1.5 mg-30 mcg
(Loestrin 1.5/30-21)
A
norethindrone ace & ethinyl
estradiol-fe tab 1 mg-20 mcg
(Loestrin fe 1/20)
A
norethindrone ace & ethinyl
estradiol-fe tab 1.5 mg-30 mcg
(Loestrin fe 1.5/30)
A
norethindrone ace-ethinyl
estradiol-fe tab 1 mg-20 mcg
(24) (Lomedia 24 fe)
norethindrone tab 0.35 mg (Nor- A
qd)
A
norethindrone-eth estradiol tab
0.5-35/0.75-35/1-35 mg-mcg
(Ortho-novum 7/7/7)
A
norethindrone-eth estradiol tab
0.5-35/1-35/0.5-35 mg-mcg (Trinorinyl 28)
A
norgestimate & ethinyl estradiol
tab 0.25 mg-35 mcg (Orthocyclen)
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mgmcg (Ortho tri-cyclen)
A
OVCON-50 28 - norethindrone &
ethinyl estradiol tab 1 mg-50 mcg
A
norgestrel & ethinyl estradiol tab
0.3 mg-30 mcg
OVCON-50/28 - norethindrone &
ethinyl estradiol tab 1 mg-50 mcg
A
A
NORINYL 1+35 - norethindrone &
ethinyl estradiol tab 1 mg-35 mcg
PLAN B - levonorgestrel tab 0.75
mg
3
3
A
PLAN B ONE-STEP levonorgestrel tab 1.5 mg
3
NORINYL 1+50 - norethindrone &
mestranol tab 1 mg-50 mcg
NUVARING - etonogestrel-ethinyl
estradiol va ring 0.120-0.015
mg/24hr
QUARTETTE - levonor-eth est tab
0.15-0.02/0.025/0.03 mg &eth est
0.01 mg
A
A
OGESTREL - norgestrel & ethinyl
estradiol tab 0.5 mg-50 mcg
SAFYRAL - drospirenoneethinyl estrad-levomefolate tab
3-0.03-0.451 mg
A
A
ORTHO EVRA - norelgestrominethinyl estradiol td ptwk 150-35
mcg/24hr
3
SEASONALE - levonorgestrel &
ethinyl estradiol (91-day) tab
0.15-0.03 mg
3
ORTHO MICRONOR norethindrone tab 0.35 mg
3
3
ORTHO TRI-CYCLEN norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mgmcg
3
SEASONIQUE - levonorg-eth est
tab 0.15-0.03mg(84) & eth est
tab 0.01mg(7)
SKYLA - levonorgestrel releasing
iud 13.5 mg
A
ORTHO TRI-CYCLEN LO norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mgmcg
TRI-NORINYL 28 norethindrone-eth estradiol tab
0.5-35/1-35/0.5-35 mg-mcg
3
A
3
ORTHO-CEPT - desogestrel &
ethinyl estradiol tab 0.15 mg-30
mcg
3
•
YASMIN 28 - drospirenone-ethinyl
estradiol tab 3-0.03 mg
YAZ - drospirenone-ethinyl
estradiol tab 3-0.02 mg
3
ORTHO-CYCLEN - norgestimate & 3
ethinyl estradiol tab 0.25 mg-35
mcg
3
ORTHO-NOVUM 1/35 norethindrone & ethinyl estradiol
tab 1 mg-35 mcg
3
ORTHO-NOVUM 7/7/7 norethindrone-eth estradiol tab
0.5-35/0.75-35/1-35 mg-mcg
3
OVCON-35 - norethindrone &
ethinyl estradiol tab 0.4 mg-35
mcg
•
•
•
•
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
•
ZOVIA 1/50E - ethynodiol diacetate A
& ethinyl estradiol tab 1 mg-50
mcg
PROGESTINS
AYGESTIN - norethindrone acetate 3
tab 5 mg
1
medroxyprogesterone acetate
tab 10 mg (Provera)
1
medroxyprogesterone acetate
tab 2.5 mg (Provera)
1
medroxyprogesterone acetate
tab 5 mg (Provera)
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
27
2
norethindrone acetate tab 5 mg
(Aygestin)
1
progesterone im in oil 50 mg/ml
1
progesterone micronized cap
100 mg (Prometrium)
1
progesterone micronized cap
200 mg (Prometrium)
1
PROMETRIUM - progesterone
micronized cap 100 mg
3
PROMETRIUM - progesterone
micronized cap 200 mg
3
PROVERA - medroxyprogesterone
acetate tab 2.5 mg
3
PROVERA - medroxyprogesterone
acetate tab 5 mg
3
PROVERA - medroxyprogesterone
acetate tab 10 mg
3
AMARYL - glimepiride tab 2 mg
3
AMARYL - glimepiride tab 4 mg
3
APPFORMIN - metformin hcl tab
500 mg & dietary management
cap pack
3
APPFORMIN-D - metformin hcl tab
500 mg & dietary management
cap pack
3
AVANDAMET - rosiglitazone
maleate-metformin hcl tab 2-500
mg
3
• •
AVANDAMET - rosiglitazone
maleate-metformin hcl tab
2-1000 mg
3
• •
AVANDAMET - rosiglitazone
maleate-metformin hcl tab 4-500
mg
3
• •
AVANDAMET - rosiglitazone
maleate-metformin hcl tab
4-1000 mg
3
• •
AVANDARYL - rosiglitazone
maleate-glimepiride tab 4-1 mg
3
• •
AVANDARYL - rosiglitazone
maleate-glimepiride tab 4-2 mg
3
• •
AVANDARYL - rosiglitazone
maleate-glimepiride tab 4-4 mg
3
• •
• •
• •
acarbose tab 100 mg (Precose)
1
acarbose tab 25 mg (Precose)
1
acarbose tab 50 mg (Precose)
1
ACTOPLUS MET - pioglitazone
hcl-metformin hcl tab 15-500 mg
3
•
•
•
• •
ACTOPLUS MET - pioglitazone
hcl-metformin hcl tab 15-850 mg
3
• •
AVANDARYL - rosiglitazone
maleate-glimepiride tab 8-2 mg
3
• •
ACTOPLUS MET XR - pioglitazone 3
hcl-metformin hcl tab sr 24hr
15-1000 mg
ACTOPLUS MET XR - pioglitazone 3
hcl-metformin hcl tab sr 24hr
30-1000 mg
3
ACTOS - pioglitazone hcl tab 15
mg (base equiv)
3
ACTOS - pioglitazone hcl tab 30
mg (base equiv)
3
ACTOS - pioglitazone hcl tab 45
mg (base equiv)
3
AMARYL - glimepiride tab 1 mg
• •
AVANDARYL - rosiglitazone
maleate-glimepiride tab 8-4 mg
3
• •
AVANDIA - rosiglitazone maleate
tab 2 mg (base equiv)
3
• •
AVANDIA - rosiglitazone maleate
tab 4 mg (base equiv)
3
• •
• •
AVANDIA - rosiglitazone maleate
tab 8 mg (base equiv)
3
• •
• •
2
• •
• •
BYDUREON - exenatide extended
release for susp pen-injector 2
mg
2
• •
• •
BYDUREON - exenatide extended
release for inj susp 2 mg
28
• •
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Specialty
Quantity Limits
ANTIDIABETICS
Drug Name
Drug Tier
MEGACE ES - megestrol acetate
susp 625 mg/5ml
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
BYETTA - exenatide soln peninjector 5 mcg/0.02ml
2
• •
glipizide-metformin hcl tab
2.5-250 mg
1
•
BYETTA - exenatide soln peninjector 10 mcg/0.04ml
2
• •
glipizide-metformin hcl tab
2.5-500 mg
1
•
CHLORPROPAMIDE chlorpropamide tab 100 mg
1
•
glipizide-metformin hcl tab
5-500 mg
1
•
CHLORPROPAMIDE chlorpropamide tab 250 mg
1
•
GLUCAGEN - glucagon hcl (rdna)
for inj 1 mg (base equiv)
2
CYCLOSET - bromocriptine
mesylate tab 0.8 mg (base
equivalent)
3
•
GLUCAGEN HYPOKIT - glucagon
hcl (rdna) for inj 1 mg (base
equiv)
2
DIABETA - glyburide tab 1.25 mg
3
3
GLUCAGON EMERGENCY KIT glucagon (rdna) for inj kit 1 mg
DIABETA - glyburide tab 5 mg
3
DUETACT - pioglitazone hclglimepiride tab 30-2 mg
3
•
•
•
•
2
DIABETA - glyburide tab 2.5 mg
•
•
•
•
DUETACT - pioglitazone hclglimepiride tab 30-4 mg
3
• •
FARXIGA - dapagliflozin
propanediol tab 5 mg (base
equivalent)
3
• •
FARXIGA - dapagliflozin
propanediol tab 10 mg (base
equivalent)
3
• •
FORTAMET - metformin hcl tab sr
24hr osmotic 500 mg
3
• •
GLUCOTROL - glipizide tab 10 mg
3
3
GLUCOTROL XL - glipizide tab sr
24hr 2.5 mg
3
FORTAMET - metformin hcl tab sr
24hr osmotic 1000 mg
• •
• •
• •
• •
• •
glimepiride tab 1 mg (Amaryl)
glimepiride tab 2 mg (Amaryl)
1
• •
1
GLUCOTROL XL - glipizide tab sr
24hr 10 mg
3
glimepiride tab 4 mg (Amaryl)
glipizide tab sr 24hr 10 mg
(Glucotrol xl)
1
•
•
•
•
GLUCOTROL XL - glipizide tab sr
24hr 5 mg
3
1
GLUCOVANCE - glyburidemetformin tab 1.25-250 mg
3
• •
glipizide tab sr 24hr 2.5 mg
(Glucotrol xl)
1
•
GLUCOVANCE - glyburidemetformin tab 2.5-500 mg
3
• •
glipizide tab sr 24hr 5 mg
(Glucotrol xl)
1
•
GLUCOVANCE - glyburidemetformin tab 5-500 mg
3
• •
glipizide tab 10 mg (Glucotrol)
1
•
1
GLUMETZA - metformin hcl tab sr
24hr modified release 500 mg
3
glipizide tab 5 mg (Glucotrol)
•
•
GLUCOPHAGE - metformin hcl tab 3
500 mg
GLUCOPHAGE - metformin hcl tab 3
850 mg
GLUCOPHAGE - metformin hcl tab 3
1000 mg
GLUCOPHAGE XR - metformin hcl 3
tab sr 24hr 500 mg
GLUCOPHAGE XR - metformin hcl 3
tab sr 24hr 750 mg
3
GLUCOTROL - glipizide tab 5 mg
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
• •
• •
• •
• •
• •
29
GLUMETZA - metformin hcl tab sr
24hr modified release 1000 mg
3
•
INVOKANA - canagliflozin tab 100
mg
2
• •
GLYBURIDE - glyburide tab 1.25
mg
1
• •
INVOKANA - canagliflozin tab 300
mg
2
• •
GLYBURIDE - glyburide tab 2.5 mg 1
1
GLYBURIDE - glyburide tab 5 mg
JANUMET - sitagliptin-metformin
hcl tab 50-500 mg
2
• •
JANUMET - sitagliptin-metformin
hcl tab 50-1000 mg
2
• •
JANUMET XR - sitagliptinmetformin hcl tab sr 24hr 50-500
mg
2
• •
JANUMET XR - sitagliptinmetformin hcl tab sr 24hr
50-1000 mg
2
• •
JANUMET XR - sitagliptinmetformin hcl tab sr 24hr
100-1000 mg
2
• •
2
• •
•
JANUVIA - sitagliptin phosphate
tab 25 mg (base equiv)
2
• •
•
JANUVIA - sitagliptin phosphate
tab 50 mg (base equiv)
2
• •
• •
JANUVIA - sitagliptin phosphate
tab 100 mg (base equiv)
3
• •
• •
JARDIANCE - empagliflozin tab 10
mg
3
• •
• •
JARDIANCE - empagliflozin tab 25
mg
JENTADUETO - linagliptinmetformin hcl tab 2.5-500 mg
3
• •
JENTADUETO - linagliptinmetformin hcl tab 2.5-850 mg
3
• •
JENTADUETO - linagliptinmetformin hcl tab 2.5-1000 mg
3
• •
glyburide micronized tab 1.5 mg
(Glynase)
1
• •
• •
•
glyburide micronized tab 3 mg
(Glynase)
1
•
glyburide micronized tab 6 mg
(Glynase)
1
•
glyburide tab 1.25 mg
1
glyburide tab 2.5 mg
1
glyburide tab 5 mg
1
glyburide-metformin tab
1.25-250 mg (Glucovance)
1
glyburide-metformin tab
2.5-500 mg (Glucovance)
1
glyburide-metformin tab
5-500 mg (Glucovance)
1
GLYNASE - glyburide micronized
tab 1.5 mg
3
GLYNASE - glyburide micronized
tab 3 mg
3
GLYNASE - glyburide micronized
tab 6 mg
3
GLYSET - miglitol tab 25 mg
2
GLYSET - miglitol tab 50 mg
2
GLYSET - miglitol tab 100 mg
2
INVOKAMET - canagliflozinmetformin hcl tab 50-500 mg
3
•
•
•
• •
3
• •
JUVISYNC - sitagliptin-simvastatin
tab 50-10 mg
2
INVOKAMET - canagliflozinmetformin hcl tab 50-1000 mg
• •
3
• •
JUVISYNC - sitagliptin-simvastatin
tab 50-20 mg
2
INVOKAMET - canagliflozinmetformin hcl tab 150-500 mg
• •
3
• •
JUVISYNC - sitagliptin-simvastatin
tab 50-40 mg
2
INVOKAMET - canagliflozinmetformin hcl tab 150-1000 mg
• •
JUVISYNC - sitagliptin-simvastatin
tab 100-10 mg
2
• •
30
•
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
JUVISYNC - sitagliptin-simvastatin
tab 100-20 mg
2
• •
NESINA - alogliptin benzoate tab
25 mg (base equiv)
3
• •
JUVISYNC - sitagliptin-simvastatin
tab 100-40 mg
2
• •
ONGLYZA - saxagliptin hcl tab 2.5
mg (base equiv)
2
• •
KAZANO - alogliptin-metformin hcl
tab 12.5-500 mg
3
• •
ONGLYZA - saxagliptin hcl tab 5
mg (base equiv)
2
• •
KAZANO - alogliptin-metformin hcl
tab 12.5-1000 mg
3
• •
OSENI - alogliptin-pioglitazone tab
12.5-15 mg
3
• •
KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr 24hr
2.5-1000 mg
2
• •
OSENI - alogliptin-pioglitazone tab
12.5-30 mg
3
• •
• •
KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr 24hr 5-500
mg
• •
OSENI - alogliptin-pioglitazone tab
12.5-45 mg
3
2
OSENI - alogliptin-pioglitazone tab
25-15 mg
3
• •
KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr 24hr 5-1000
mg
2
OSENI - alogliptin-pioglitazone tab
25-30 mg
3
• •
2
• •
OSENI - alogliptin-pioglitazone tab
25-45 mg
3
KORLYM - mifepristone tab 300
mg
• •
1
•
pioglitazone hcl tab 15 mg (base
equiv) (Actos)
1
metformin hcl tab sr 24hr
osmotic 1000 mg (Fortamet)
• •
1
•
pioglitazone hcl tab 30 mg (base
equiv) (Actos)
1
metformin hcl tab sr 24hr
osmotic 500 mg (Fortamet)
• •
1
•
pioglitazone hcl tab 45 mg (base
equiv) (Actos)
1
metformin hcl tab sr 24hr 500 mg
(Glucophage xr)
• •
1
•
pioglitazone hcl-glimepiride tab
30-2 mg (Duetact)
1
metformin hcl tab sr 24hr 750 mg
(Glucophage xr)
•
1
•
pioglitazone hcl-glimepiride tab
30-4 mg (Duetact)
1
metformin hcl tab 1000 mg
(Glucophage)
•
1
•
pioglitazone hcl-metformin hcl
tab 15-500 mg (Actoplus met)
1
metformin hcl tab 500 mg
(Glucophage)
•
1
•
pioglitazone hcl-metformin hcl
tab 15-850 mg (Actoplus met)
1
metformin hcl tab 850 mg
(Glucophage)
•
1
PRANDIMET - repaglinidemetformin hcl tab 1-500 mg
•
nateglinide tab 60 mg (Starlix)
1
•
3
PRANDIMET - repaglinidemetformin hcl tab 2-500 mg
3
NESINA - alogliptin benzoate tab
6.25 mg (base equiv)
•
•
• •
3
nateglinide tab 120 mg (Starlix)
3
3
• •
PRANDIN - repaglinide tab 0.5 mg
NESINA - alogliptin benzoate tab
12.5 mg (base equiv)
PRANDIN - repaglinide tab 1 mg
3
PRANDIN - repaglinide tab 2 mg
3
PRECOSE - acarbose tab 25 mg
3
•
•
•
•
• •
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
31
repaglinide tab 1 mg (Prandin)
1
repaglinide tab 2 mg (Prandin)
1
RIOMET - metformin hcl oral soln
500 mg/5ml
3
STARLIX - nateglinide tab 60 mg
3
STARLIX - nateglinide tab 120 mg
3
SYMLINPEN 120 - pramlintide
acetate pen-inj 2700 mcg/2.7ml
(1000 mcg/ml)
2
SYMLINPEN 60 - pramlintide
acetate pen-inj 1500 mcg/1.5ml
(1000 mcg/ml)
2
TANZEUM - albiglutide for soln
pen-injector 30 mg
3
TANZEUM - albiglutide for soln
pen-injector 50 mg
3
TOLAZAMIDE - tolazamide tab 500 1
mg
1
tolazamide tab 250 mg
TOLBUTAMIDE - tolbutamide tab
500 mg
1
TRADJENTA - linagliptin tab 5 mg
3
TRULICITY - dulaglutide soln peninjector 0.75 mg/0.5ml
3
TRULICITY - dulaglutide soln peninjector 1.5 mg/0.5ml
3
VICTOZA - liraglutide soln peninjector 18 mg/3ml (6 mg/ml)
2
XIGDUO XR - dapagliflozinmetformin hcl tab sr 24hr 5-500
mg
3
XIGDUO XR - dapagliflozinmetformin hcl tab sr 24hr 5-1000
mg
3
•
•
•
•
XIGDUO XR - dapagliflozinmetformin hcl tab sr 24hr 10-500
mg
3
• •
XIGDUO XR - dapagliflozinmetformin hcl tab sr 24hr
10-1000 mg
3
• •
Rapid-Acting Insulins
APIDRA - insulin glulisine inj 100
unit/ml
3
APIDRA SOLOSTAR - insulin
glulisine soln pen-injector inj 100
unit/ml
3
HUMALOG - insulin lispro (human)
soln cartridge 100 unit/ml
3
HUMALOG - insulin lispro (human)
inj 100 unit/ml
3
3
• •
HUMALOG KWIKPEN - insulin
lispro (human) soln pen-injector
100 unit/ml
2
• •
NOVOLOG - insulin aspart inj 100
unit/ml
2
•
NOVOLOG FLEXPEN - insulin
aspart soln pen-injector 100 unit/
ml
•
•
NOVOLOG PENFILL - insulin
aspart soln cartridge 100 unit/ml
2
NOVOLOG PENFILL - insulin
aspart inj 100 unit/ml
2
•
•
•
•
• •
• •
Short-Acting Insulins
HUMULIN R - insulin regular
(human) inj 100 unit/ml
3
3
• •
HUMULIN R U-500 (CONCENTR
- insulin regular (human) inj 500
unit/ml
• •
NOVOLIN R - insulin regular
(human) inj 100 unit/ml
2
NOVOLIN R RELION - insulin
regular (human) inj 100 unit/ml
2
RELION R - insulin regular
(human) inj 100 unit/ml
2
• •
• •
Intermediate-Acting Insulins
32
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
1
Quantity Limits
repaglinide tab 0.5 mg (Prandin)
"Smart" PA
3
Prior Authorization
PROGLYCEM - diazoxide susp 50
mg/ml
Drug Name
Drug Tier
3
•
•
Specialty
PRECOSE - acarbose tab 100 mg
Quantity Limits
3
"Smart" PA
PRECOSE - acarbose tab 50 mg
Prior Authorization
Drug Name
Drug Tier
2015
HUMALOG MIX 50/50 - insulin
lispro prot & lispro (human) inj
100 unit/ml (50-50)
3
NOVOLOG MIX 70/30 - insulin
aspart prot & aspart (human) inj
100 unit/ml (70-30)
2
HUMALOG MIX 50/50 KWIKPEN
- insulin lispro prot & lispro sus
pen-inj 100 unit/ml (50-50)
3
NOVOLOG MIX 70/30 PREFILL insulin aspart prot & aspart sus
pen-inj 100 unit/ml (70-30)
2
HUMALOG MIX 75/25 - insulin
lispro prot & lispro (human) inj
100 unit/ml (75-25)
3
Basal Insulins
HUMALOG MIX 75/25 KWIKPEN
- insulin lispro prot & lispro sus
pen-inj 100 unit/ml (75-25)
3
HUMULIN N - insulin isophane
(human) inj 100 unit/ml
3
HUMULIN N KWIKPEN - insulin
isophane (human) susp peninjector 100 unit/ml
3
HUMULIN N U-100 PEN - insulin
isophane (human) susp peninjector 100 unit/ml
3
HUMULIN 70/30 - insulin isophane
& regular (human) inj 100 unit/ml
(70-30)
3
HUMULIN 70/30 KWIKPEN insulin isophane & regular susp
pen-inj 100 unit/ml (70-30)
3
HUMULIN 70/30 PEN - insulin
isophane & regular susp pen-inj
100 unit/ml (70-30)
3
NOVOLIN N - insulin isophane
(human) inj 100 unit/ml
LANTUS - insulin glargine inj 100
unit/ml
2
LANTUS SOLOSTAR - insulin
glargine soln pen-injector 100
unit/ml
2
LEVEMIR - insulin detemir inj 100
unit/ml
2
LEVEMIR FLEXPEN - insulin
detemir soln pen-injector 100
unit/ml
2
LEVEMIR FLEXTOUCH - insulin
detemir soln pen-injector 100
unit/ml
2
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
THYROID AGENTS
ARMOUR THYROID - thyroid tab
15 mg (1/4 grain)
2
ARMOUR THYROID - thyroid tab
30 mg (1/2 grain)
2
ARMOUR THYROID - thyroid tab
60 mg (1 grain)
2
2
2
ARMOUR THYROID - thyroid tab
90 mg (1 1/2 grain)
2
NOVOLIN N RELION - insulin
isophane (human) inj 100 unit/ml
2
ARMOUR THYROID - thyroid tab
120 mg (2 grain)
2
NOVOLIN N U-100 - insulin
isophane (human) inj 100 unit/ml
2
ARMOUR THYROID - thyroid tab
180 mg (3 grain)
2
NOVOLIN 70/30 - insulin isophane
& regular (human) inj 100 unit/ml
(70-30)
2
ARMOUR THYROID - thyroid tab
240 mg (4 grain)
ARMOUR THYROID - thyroid tab
300 mg (5 grain)
2
NOVOLIN 70/30 RELION - insulin
isophane & regular (human) inj
100 unit/ml (70-30)
2
CYTOMEL - liothyronine sodium
tab 5 mcg
2
CYTOMEL - liothyronine sodium
tab 25 mcg
2
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
33
CYTOMEL - liothyronine sodium
tab 50 mcg
2
NATURE-THROID - thyroid tab
48.75 mg (3/4 grain)
3
levothyroxine sodium tab
100 mcg (Synthroid)
1
NATURE-THROID - thyroid tab 65
mg
3
levothyroxine sodium tab
112 mcg (Synthroid)
1
NATURE-THROID - thyroid tab
81.25 mg
3
levothyroxine sodium tab
125 mcg (Synthroid)
1
NATURE-THROID - thyroid tab
97.5 mg
3
levothyroxine sodium tab
137 mcg (Synthroid)
1
NATURE-THROID - thyroid tab
113.75 mg
3
levothyroxine sodium tab
150 mcg (Synthroid)
1
NATURE-THROID - thyroid tab
130 mg
3
levothyroxine sodium tab
175 mcg (Synthroid)
1
NATURE-THROID - thyroid tab
195 mg
3
levothyroxine sodium tab
200 mcg (Synthroid)
1
NATURE-THROID - thyroid tab
260 mg
3
levothyroxine sodium tab
25 mcg (Synthroid)
1
NATURE-THROID - thyroid tab
325 mg (5 grain)
3
levothyroxine sodium tab
300 mcg (Synthroid)
1
NATURE-THROID - thyroid tab
146.25 mg
3
levothyroxine sodium tab
50 mcg (Synthroid)
1
NATURE-THROID NT-2.5 - thyroid
tab 162.5 mg (2 1/2 grain)
3
levothyroxine sodium tab
75 mcg (Synthroid)
1
propylthiouracil tab 50 mg
1
2
levothyroxine sodium tab
88 mcg (Synthroid)
1
SYNTHROID - levothyroxine
sodium tab 25 mcg
1
SYNTHROID - levothyroxine
sodium tab 50 mcg
2
liothyronine sodium tab 25 mcg
(Cytomel)
liothyronine sodium tab 5 mcg
(Cytomel)
SYNTHROID - levothyroxine
sodium tab 75 mcg
2
1
liothyronine sodium tab 50 mcg
(Cytomel)
SYNTHROID - levothyroxine
sodium tab 88 mcg
2
1
methimazole tab 10 mg
(Tapazole)
SYNTHROID - levothyroxine
sodium tab 100 mcg
2
1
2
methimazole tab 5 mg (Tapazole)
1
SYNTHROID - levothyroxine
sodium tab 112 mcg
NATURE-THROID - thyroid tab
16.25 mg
3
SYNTHROID - levothyroxine
sodium tab 125 mcg
2
NATURE-THROID - thyroid tab
32.5 mg
3
SYNTHROID - levothyroxine
sodium tab 137 mcg
2
34
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
SYNTHROID - levothyroxine
sodium tab 150 mcg
2
TIROSINT - levothyroxine sodium
cap 112 mcg
3
SYNTHROID - levothyroxine
sodium tab 175 mcg
2
TIROSINT - levothyroxine sodium
cap 125 mcg
3
SYNTHROID - levothyroxine
sodium tab 200 mcg
2
TIROSINT - levothyroxine sodium
cap 137 mcg
3
SYNTHROID - levothyroxine
sodium tab 300 mcg
2
TIROSINT - levothyroxine sodium
cap 150 mcg
3
TAPAZOLE - methimazole tab 5
mg
3
WESTHROID - thyroid tab 16.25
mg
3
TAPAZOLE - methimazole tab 10
mg
3
WESTHROID - thyroid tab 32.5 mg
3
thyroid tab 30 mg (1/2 grain)
(Armour thyroid)
WESTHROID - thyroid tab 48.75
mg (3/4 grain)
3
1
WESTHROID - thyroid tab 65 mg
3
thyroid tab 60 mg (1 grain)
(Armour thyroid)
1
WESTHROID - thyroid tab 81.25
mg
3
thyroid tab 90 mg (1 1/2 grain)
(Armour thyroid)
1
WESTHROID - thyroid tab 97.5 mg
3
2
WESTHROID - thyroid tab 113.75
mg
3
THYROLAR-1 - liotrix (t3-t4) tab 60
mg (12.5-50 mcg)
2
WESTHROID - thyroid tab 130 mg
3
THYROLAR-1/2 - liotrix (t3-t4) tab
30 mg (6.25-25 mcg)
3
THYROLAR-1/4 - liotrix (t3-t4) tab
15 mg (3.1-12.5 mcg)
2
WESTHROID - thyroid tab 162.5
mg (2 1/2 grain)
WESTHROID - thyroid tab 195 mg
3
THYROLAR-2 - liotrix (t3-t4) tab
120 mg (25-100 mcg)
2
WESTHROID - thyroid tab 260 mg
3
3
THYROLAR-3 - liotrix (t3-t4) tab
180 mg (37.5-150 mcg)
2
WESTHROID - thyroid tab 325 mg
(5 grain)
3
TIROSINT - levothyroxine sodium
cap 13 mcg
3
WESTHROID - thyroid tab 146.25
mg
3
TIROSINT - levothyroxine sodium
cap 25 mcg
3
WESTHROID-P - thyroid tab 16.25
mg
3
TIROSINT - levothyroxine sodium
cap 50 mcg
3
WESTHROID-P - thyroid tab 32.5
mg
3
TIROSINT - levothyroxine sodium
cap 75 mcg
3
WESTHROID-P - thyroid tab 48.75
mg (3/4 grain)
TIROSINT - levothyroxine sodium
cap 88 mcg
3
TIROSINT - levothyroxine sodium
cap 100 mcg
3
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
WESTHROID-P - thyroid tab 65 mg 3
3
WESTHROID-P - thyroid tab 97.5
mg
3
WESTHROID-P - thyroid tab 130
mg
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
35
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
ALENDRONATE SODIUM alendronate sodium oral soln 70
mg/75ml
1
• •
alendronate sodium tab 10 mg
1
alendronate sodium tab 35 mg
1
alendronate sodium tab 5 mg
1
1
3
alendronate sodium tab 70 mg
(Fosamax)
•
•
•
•
• •
WP THYROID - thyroid tab 97.5
mg
ATELVIA - risedronate sodium tab
delayed release 35 mg
3
3
• •
WP THYROID - thyroid tab 113.75
mg
BINOSTO - alendronate sodium
effervescent tab 70 mg
3
3
• •
WP THYROID - thyroid tab 130 mg
BONIVA - ibandronate sodium tab
150 mg (base equivalent)
3
3
2
•
• •
CERVIDIL - dinoprostone vaginal
inserts 10 mg
3
BRAVELLE - urofollitropin purified
for inj 75 unit
3
•
•
METHERGINE - methylergonovine
maleate tab 0.2 mg
2
BUPHENYL - sodium
phenylbutyrate tab 500 mg
3
•
•
METHERGINE - methylergonovine
maleate inj 0.2 mg/ml
3
BUPHENYL - sodium
phenylbutyrate oral powder 3 gm/
teaspoonful
methylergonovine maleate inj
0.2 mg/ml
1
cabergoline tab 0.5 mg
1
methylergonovine maleate tab
0.2 mg
1
calcitonin (salmon) nasal soln
200 unit/act (Miacalcin)
1
calcitriol cap 0.25 mcg (Rocaltrol)
1
PREPIDIL - dinoprostone cervical
gel 0.5 mg/3gm
3
calcitriol cap 0.5 mcg (Rocaltrol)
1
PROSTIN E2 - dinoprostone
vaginal suppos 20 mg
calcitriol oral soln 1 mcg/ml
(Rocaltrol)
1
3
CARBAGLU - carglumic acid tab
200 mg
3
•
CARNITOR - levocarnitine tab 330
mg
3
•
CARNITOR - levocarnitine oral
soln 1 gm/10ml (10%)
3
•
CARNITOR SF - levocarnitine oral
soln 1 gm/10ml (10%)
3
•
CETROTIDE - cetrorelix acetate for 3
inj kit 0.25 mg
CETROTIDE - cetrorelix acetate for 3
inj kit 3 mg
WP THYROID - thyroid tab 16.25
mg
3
WP THYROID - thyroid tab 32.5
mg
3
WP THYROID - thyroid tab 48.75
mg (3/4 grain)
3
WP THYROID - thyroid tab 65 mg
3
WP THYROID - thyroid tab 81.25
mg
OXYTOCICS
ENDOCRINE and METABOLIC AGENTS - MISC.
2
ACTONEL - risedronate sodium
tab 5 mg
2
ACTONEL - risedronate sodium
tab 30 mg
2
ACTONEL - risedronate sodium
tab 35 mg
2
ACTONEL - risedronate sodium
tab 150 mg
1
•
ALENDRONATE SODIUM alendronate sodium tab 40 mg
36
•
•
•
•
•
• •
•
• •
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
• •
CLOMID - clomiphene citrate tab
50 mg
2
•
• •
FOLLISTIM AQ - follitropin beta inj
150 unit/0.5ml
2
•
• •
3
FOLLISTIM AQ - follitropin beta inj
300 unit/0.36ml
2
•
• •
DDAVP - desmopressin acetate
nasal soln 0.01% (refrigerated)
3
FOLLISTIM AQ - follitropin beta inj
600 unit/0.72ml
2
•
• •
DDAVP - desmopressin acetate
nasal spray soln 0.01%
3
FOLLISTIM AQ - follitropin beta inj
900 unit/1.08ml
2
•
• •
desmopressin acetate inj 4 mcg/
ml (Ddavp)
1
FORTEO - teriparatide
(recombinant) inj 600 mcg/2.4ml
2
•
• •
desmopressin acetate nasal soln
0.01% (refrigerated) (Ddavp)
1
FORTICAL - calcitonin (salmon)
nasal soln 200 unit/act
2
desmopressin acetate nasal
spray soln 0.01% (Ddavp)
1
FOSAMAX - alendronate sodium
tab 70 mg
3
• •
desmopressin acetate nasal
spray soln 0.01% (refrigerated)
1
3
• •
desmopressin acetate tab 0.1 mg
(Ddavp)
1
FOSAMAX PLUS D - alendronate
sodium-cholecalciferol tab
70-2800 mg-unit
3
• •
desmopressin acetate tab 0.2 mg
(Ddavp)
1
FOSAMAX PLUS D - alendronate
sodium-cholecalciferol tab
70-5600 mg-unit
DIDRONEL - etidronate disodium
tab 400 mg
3
GANIRELIX ACETATE - ganirelix
acetate inj 250 mcg/0.5ml
1
•
• •
doxercalciferol cap 0.5 mcg
(Hectorol)
1
GENOTROPIN - somatropin for
subcutaneous inj 5 mg
3
•
•
doxercalciferol cap 1 mcg
(Hectorol)
1
GENOTROPIN - somatropin for inj
12 mg (13.8 mg overfill)
3
•
•
doxercalciferol cap 2.5 mcg
(Hectorol)
1
GENOTROPIN MINIQUICK somatropin for inj 0.2 mg
3
•
•
EGRIFTA - tesamorelin acetate for
inj 1 mg (base equiv)
2
GENOTROPIN MINIQUICK somatropin for inj 0.4 mg
3
•
•
EGRIFTA - tesamorelin acetate for
inj 2 mg (base equiv)
3
• •
ETIDRONATE DISODIUM etidronate disodium tab 200 mg
1
clomiphene citrate tab 50 mg
1
• •
1
CYSTADANE - betaine powder for
oral solution
3
ETIDRONATE DISODIUM etidronate disodium tab 400 mg
EVISTA - raloxifene hcl tab 60 mg
A
DDAVP - desmopressin acetate
tab 0.1 mg
3
FOLLISTIM AQ - follitropin beta inj
75 unit/0.5ml
DDAVP - desmopressin acetate
tab 0.2 mg
3
DDAVP - desmopressin acetate inj
4 mcg/ml
•
• •
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
•
• •
Quantity Limits
Prior Authorization
2
Drug Name
"Smart" PA
Drug Tier
•
Specialty
1
Quantity Limits
Prior Authorization
chorionic gonadotropin for inj
10000 unit
Drug Name
"Smart" PA
Drug Tier
2015
37
3
•
•
GENOTROPIN MINIQUICK somatropin for inj 0.8 mg
3
•
•
HUMATROPE - somatropin for inj
6 mg (18 unit)
3
•
•
GENOTROPIN MINIQUICK somatropin for inj 1 mg
3
•
•
HUMATROPE - somatropin for inj
12 mg (36 unit)
3
•
•
GENOTROPIN MINIQUICK somatropin for inj 1.2 mg
3
•
•
HUMATROPE - somatropin for inj
24 mg
3
•
•
GENOTROPIN MINIQUICK somatropin for inj 1.4 mg
3
•
•
HUMATROPE COMBO PACK somatropin for inj 5 mg
3
•
•
GENOTROPIN MINIQUICK somatropin for inj 1.6 mg
3
•
•
ibandronate sodium tab 150 mg
(base equivalent) (Boniva)
1
GENOTROPIN MINIQUICK somatropin for inj 1.8 mg
3
•
•
INCRELEX - mecasermin inj 40
mg/4ml (10 mg/ml)
3
•
•
GENOTROPIN MINIQUICK somatropin for inj 2 mg
3
•
•
2
•
• •
GONAL-F - follitropin alfa for inj
450 unit
3
•
• •
KUVAN - sapropterin
dihydrochloride powder packet
100 mg
2
•
• •
GONAL-F - follitropin alfa for inj
1050 unit
3
•
• •
KUVAN - sapropterin
dihydrochloride soluble tab 100
mg
GONAL-F RFF - follitropin alfa for
inj 75 unit
3
•
• •
levocarnitine oral soln
1 gm/10ml (10%) (Carnitor)
1
GONAL-F RFF PEN - follitropin
alfa inj 300 unit/0.5ml
3
•
• •
levocarnitine tab 330 mg
(Carnitor)
1
GONAL-F RFF PEN - follitropin
alfa inj 450 unit/0.75ml
3
•
• •
3
• •
GONAL-F RFF PEN - follitropin
alfa inj 900 unit/1.5ml
3
•
• •
LUPANETA PACK - leuprolide (1
mon) inj 3.75 mg & norethindrone
tab 5 mg kit
3
• •
GONAL-F RFF REDIJECT follitropin alfa inj 300 unit/0.5ml
3
•
• •
LUPANETA PACK - leuprolide
(3 mon) inj 11.25 mg &
norethindrone tab 5 mg kit
3
•
• •
LUPRON DEPOT-PED - leuprolide
acetate for inj pediatric kit 7.5 mg
2
GONAL-F RFF REDIJECT follitropin alfa inj 450 unit/0.75ml
• •
3
•
• •
LUPRON DEPOT-PED - leuprolide
acetate for inj pediatric kit 11.25
mg
2
GONAL-F RFF REDIJECT follitropin alfa inj 900 unit/1.5ml
• •
HECTOROL - doxercalciferol cap
0.5 mcg
3
LUPRON DEPOT-PED - leuprolide
acetate for inj pediatric kit 15 mg
2
• •
LUPRON DEPOT-PED - leuprolide
acetate (3 month) for inj pediatric
kit 11.25 mg
2
• •
HECTOROL - doxercalciferol cap 1 3
mcg
3
HECTOROL - doxercalciferol cap
2.5 mcg
38
Specialty
HUMATROPE - somatropin for inj
5 mg
Quantity Limits
Prior Authorization
•
Drug Name
"Smart" PA
Drug Tier
•
Specialty
3
Quantity Limits
Prior Authorization
GENOTROPIN MINIQUICK somatropin for inj 0.6 mg
Drug Name
"Smart" PA
Drug Tier
2015
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
octreotide acetate inj 1000 mcg/
ml (1 mg/ml) (Sandostatin)
1
• •
octreotide acetate inj 200 mcg/ml
(0.2 mg/ml) (Sandostatin)
1
• •
octreotide acetate inj 50 mcg/ml
(0.05 mg/ml) (Sandostatin)
1
• •
octreotide acetate inj 500 mcg/ml
(0.5 mg/ml) (Sandostatin)
1
• •
3
•
•
MIACALCIN - calcitonin (salmon)
nasal soln 200 unit/act
OMNITROPE - somatropin inj 5
mg/1.5ml
3
3
•
•
MYALEPT - metreleptin for
subcutaneous inj 11.3 mg
• •
OMNITROPE - somatropin inj 10
mg/1.5ml
3
3
•
•
•
NORDITROPIN CARTRIDGE somatropin inj 5 mg/1.5ml
OMNITROPE - somatropin for inj
5.8 mg
3
2
3
NORDITROPIN FLEXPRO somatropin inj 5 mg/1.5ml
2
•
•
ORFADIN - nitisinone cap 2 mg
ORFADIN - nitisinone cap 5 mg
3
2
•
•
ORFADIN - nitisinone cap 10 mg
3
NORDITROPIN FLEXPRO somatropin inj 10 mg/1.5ml
•
•
•
•
•
•
NORDITROPIN FLEXPRO somatropin inj 15 mg/1.5ml
2
•
•
•
• •
NORDITROPIN NORDIFLEX PEN
- somatropin inj 30 mg/3ml
2
•
•
NUTROPIN - somatropin for inj 10
mg
3
•
•
NUTROPIN AQ - somatropin inj 10
mg/2ml
3
•
•
NUTROPIN AQ NUSPIN 10 somatropin inj 10 mg/2ml
3
•
•
NUTROPIN AQ NUSPIN 20 somatropin inj 20 mg/2ml
3
•
•
NUTROPIN AQ NUSPIN 5 somatropin inj 5 mg/2ml
3
•
•
NUTROPIN AQ PEN - somatropin
inj 10 mg/2ml
3
•
•
NUTROPIN AQ PEN - somatropin
inj 20 mg/2ml
3
•
•
octreotide acetate inj 100 mcg/ml
(0.1 mg/ml) (Sandostatin)
1
LUPRON DEPOT-PED - leuprolide
acetate (3 month) for inj pediatric
kit 30 mg
2
LUVERIS - lutropin alfa for
subcutaneous inj 75 unit
3
MENOPUR - menotropins for
subcutaneous inj 75 unit
2
MIACALCIN - calcitonin (salmon)
inj 200 unit/ml
• •
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
• •
• •
OSPHENA - ospemifene tab 60 mg 3
OVIDREL - choriogonadotropin alfa 3
inj 250 mcg/0.5ml
1
paricalcitol cap 1 mcg (Zemplar)
•
•
•
paricalcitol cap 2 mcg (Zemplar)
1
paricalcitol cap 4 mcg (Zemplar)
1
raloxifene hcl tab 60 mg (Evista)
1
RAVICTI - glycerol phenylbutyrate
liquid 1.1 gm/ml
3
•
REPRONEX - menotropins for inj
75 unit
2
•
risedronate sodium tab 150 mg
(Actonel)
1
ROCALTROL - calcitriol cap 0.25
mcg
3
ROCALTROL - calcitriol cap 0.5
mcg
3
ROCALTROL - calcitriol oral soln 1
mcg/ml
3
SAIZEN - somatropin (nonrefrigerated) for inj 5 mg
3
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
• •
•
•
•
39
• •
SIGNIFOR - pasireotide
diaspartate inj 0.9 mg/ml (base
equiv)
3
•
• •
SKELID - tiludronate disodium
tab 200 mg (tiludronic acid
equivalent)
3
•
•
Specialty
•
SAMSCA - tolvaptan tab 30 mg
2
SANDOSTATIN - octreotide
acetate inj 50 mcg/ml (0.05 mg/
ml)
3
• •
• •
• •
3
• •
sodium phenylbutyrate oral
powder 3 gm/teaspoonful
(Buphenyl)
1
SANDOSTATIN - octreotide
acetate inj 100 mcg/ml (0.1 mg/
ml)
3
• •
SOMATULINE DEPOT - lanreotide
acetate extended release inj 60
mg/0.2ml
2
SANDOSTATIN - octreotide
acetate inj 200 mcg/ml (0.2 mg/
ml)
• •
3
• •
SOMATULINE DEPOT - lanreotide
acetate extended release inj 90
mg/0.3ml
2
SANDOSTATIN - octreotide
acetate inj 500 mcg/ml (0.5 mg/
ml)
• •
3
• •
SOMATULINE DEPOT - lanreotide
acetate extended release inj 120
mg/0.5ml
2
SANDOSTATIN - octreotide
acetate inj 1000 mcg/ml (1 mg/
ml)
• •
2
SOMAVERT - pegvisomant for inj
10 mg (as protein)
2
SENSIPAR - cinacalcet hcl tab 30
mg (base equiv)
• •
2
SOMAVERT - pegvisomant for inj
15 mg (as protein)
2
SENSIPAR - cinacalcet hcl tab 60
mg (base equiv)
• •
2
SOMAVERT - pegvisomant for inj
20 mg (as protein)
2
SENSIPAR - cinacalcet hcl tab 90
mg (base equiv)
• •
2
SOMAVERT - pegvisomant for inj
25 mg (as protein)
2
SEROSTIM - somatropin (nonrefrigerated) for subcutaneous inj
4 mg
2
SEROSTIM - somatropin (nonrefrigerated) for subcutaneous inj
5 mg
2
SOMAVERT - pegvisomant for inj
30 mg (as protein)
STIMATE - desmopressin acetate
nasal soln 1.5 mg/ml
3
SEROSTIM - somatropin (nonrefrigerated) for subcutaneous inj
6 mg
2
SIGNIFOR - pasireotide
diaspartate inj 0.3 mg/ml (base
equiv)
3
40
•
•
3
Quantity Limits
•
SIGNIFOR - pasireotide
diaspartate inj 0.6 mg/ml (base
equiv)
Drug Name
"Smart" PA
•
Prior Authorization
SAIZEN CLICK.EASY - somatropin 3
(non-refrigerated) for inj 8.8 mg
2
SAMSCA - tolvaptan tab 15 mg
Drug Tier
•
Specialty
•
SAIZEN - somatropin (nonrefrigerated) for inj 8.8 mg
Quantity Limits
Prior Authorization
3
Drug Name
"Smart" PA
Drug Tier
2015
•
• •
•
• •
•
• •
•
• •
SYNAREL - nafarelin acetate nasal 2
soln 2 mg/ml
3
TEV-TROPIN - somatropin for
subcutaneous inj 5 mg
ZEMPLAR - paricalcitol cap 1 mcg 3
ZEMPLAR - paricalcitol cap 2 mcg
3
ZEMPLAR - paricalcitol cap 4 mcg
3
•
•
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
CARDIOVASCULAR AGENTS
CARDIOTONICS
• •
1
isosorbide mononitrate tab sr
24hr 120 mg (Imdur)
1
DIGOXIN - digoxin oral soln 0.05
mg/ml
1
isosorbide mononitrate tab sr
24hr 30 mg (Imdur)
1
digoxin tab 125 mcg (0.125 mg)
(Lanoxin)
1
isosorbide mononitrate tab sr
24hr 60 mg (Imdur)
1
digoxin tab 250 mcg (0.25 mg)
(Lanoxin)
1
isosorbide mononitrate tab
10 mg
1
LANOXIN - digoxin tab 62.5 mcg
(0.0625 mg)
2
isosorbide mononitrate tab
20 mg
1
LANOXIN - digoxin tab 125 mcg
(0.125 mg)
2
MONOKET - isosorbide
mononitrate tab 10 mg
3
LANOXIN - digoxin tab 187.5 mcg
(0.1875 mg)
2
MONOKET - isosorbide
mononitrate tab 20 mg
3
LANOXIN - digoxin tab 250 mcg
(0.25 mg)
2
NITRO-BID - nitroglycerin oint 2%
3
ANTIANGINAL AGENTS
DILATRATE SR - isosorbide
dinitrate cap cr 40 mg
3
IMDUR - isosorbide mononitrate
tab sr 24hr 30 mg
3
IMDUR - isosorbide mononitrate
tab sr 24hr 60 mg
3
IMDUR - isosorbide mononitrate
tab sr 24hr 120 mg
3
ISORDIL TITRADOSE - isosorbide
dinitrate tab 5 mg
3
ISORDIL TITRADOSE - isosorbide
dinitrate tab 40 mg
3
ISOSORBIDE DINITRATE isosorbide dinitrate tab 30 mg
1
ISOSORBIDE DINITRATE isosorbide dinitrate sl tab 2.5 mg
1
isosorbide dinitrate tab cr 40 mg
1
isosorbide dinitrate tab 10 mg
1
isosorbide dinitrate tab 20 mg
1
Specialty
isosorbide dinitrate tab 5 mg
(Isordil titradose)
Quantity Limits
1
"Smart" PA
isosorbide dinitrate tab 30 mg
Prior Authorization
Specialty
Quantity Limits
•
"Smart" PA
2
Drug Name
Drug Tier
ZORBTIVE - somatropin (nonrefrigerated) for subcutaneous inj
8.8 mg
Prior Authorization
Drug Name
Drug Tier
2015
NITRO-DUR - nitroglycerin td patch 3
24hr 0.1 mg/hr
NITRO-DUR - nitroglycerin td patch 3
24hr 0.2 mg/hr
NITRO-DUR - nitroglycerin td patch 3
24hr 0.3 mg/hr
NITRO-DUR - nitroglycerin td patch 3
24hr 0.4 mg/hr
NITRO-DUR - nitroglycerin td patch 3
24hr 0.6 mg/hr
NITRO-DUR - nitroglycerin td patch 3
24hr 0.8 mg/hr
1
nitroglycerin cap cr 2.5 mg
nitroglycerin cap cr 6.5 mg
1
nitroglycerin cap cr 9 mg
1
NITROGLYCERIN LINGUAL nitroglycerin lingual aerosol 400
mcg/spray
1
nitroglycerin td patch 24hr
0.1 mg/hr (Nitro-dur)
1
nitroglycerin td patch 24hr
0.2 mg/hr (Nitro-dur)
1
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
41
•
nitroglycerin td patch 24hr
0.4 mg/hr (Nitro-dur)
1
BETAPACE AF - sotalol hcl (afib/
afl) tab 160 mg
3
nitroglycerin td patch 24hr
0.6 mg/hr (Nitro-dur)
1
betaxolol hcl tab 10 mg (Kerlone)
1
betaxolol hcl tab 20 mg (Kerlone)
1
nitroglycerin tl soln 0.4 mg/spray
(400 mcg/spray) (Nitrolingual
pumpspr)
1
bisoprolol fumarate tab 10 mg
(Zebeta)
1
3
bisoprolol fumarate tab 5 mg
(Zebeta)
1
NITROLINGUAL PUMPSPRAY nitroglycerin tl soln 0.4 mg/spray
(400 mcg/spray)
3
•
NITROMIST - nitroglycerin lingual
aerosol 400 mcg/spray
3
BYSTOLIC - nebivolol hcl tab 2.5
mg (base equivalent)
3
•
NITROSTAT - nitroglycerin sl tab
0.3 mg
2
BYSTOLIC - nebivolol hcl tab 5 mg
(base equivalent)
3
•
NITROSTAT - nitroglycerin sl tab
0.4 mg
2
BYSTOLIC - nebivolol hcl tab 10
mg (base equivalent)
3
•
NITROSTAT - nitroglycerin sl tab
0.6 mg
2
BYSTOLIC - nebivolol hcl tab 20
mg (base equivalent)
carvedilol tab 12.5 mg (Coreg)
1
RANEXA - ranolazine tab sr 12hr
500 mg
3
carvedilol tab 25 mg (Coreg)
1
carvedilol tab 3.125 mg (Coreg)
1
RANEXA - ranolazine tab sr 12hr
1000 mg
3
carvedilol tab 6.25 mg (Coreg)
1
COREG - carvedilol tab 3.125 mg
3
COREG - carvedilol tab 6.25 mg
3
COREG - carvedilol tab 12.5 mg
3
•
•
BETA BLOCKERS
acebutolol hcl cap 200 mg
(Sectral)
1
1
COREG - carvedilol tab 25 mg
3
acebutolol hcl cap 400 mg
(Sectral)
3
atenolol tab 100 mg (Tenormin)
1
COREG CR - carvedilol phosphate
cap sr 24hr 10 mg
1
atenolol tab 50 mg (Tenormin)
1
COREG CR - carvedilol phosphate
cap sr 24hr 20 mg
3
atenolol tab 25 mg (Tenormin)
BETAPACE - sotalol hcl tab 80 mg
BETAPACE - sotalol hcl tab 120
mg
3
•
•
COREG CR - carvedilol phosphate
cap sr 24hr 40 mg
3
3
COREG CR - carvedilol phosphate
cap sr 24hr 80 mg
3
BETAPACE - sotalol hcl tab 160
mg
3
•
CORGARD - nadolol tab 20 mg
3
3
3
•
CORGARD - nadolol tab 40 mg
BETAPACE AF - sotalol hcl (afib/
afl) tab 80 mg
CORGARD - nadolol tab 80 mg
3
3
•
HEMANGEOL - propranolol hcl
oral soln 4.28 mg/ml
3
BETAPACE AF - sotalol hcl (afib/
afl) tab 120 mg
42
•
•
•
•
•
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
HYPERTENEVIDE-12.5 carvedilol tab 12.5 mg & dietary
management cap pack
3
INDERAL LA - propranolol hcl cap
sr 24hr 60 mg
3
metoprolol succinate tab sr 24hr
200 mg (Toprol xl)
1
1
•
metoprolol succinate tab sr 24hr
25 mg (Toprol xl)
INDERAL LA - propranolol hcl cap
sr 24hr 80 mg
•
metoprolol succinate tab sr 24hr
50 mg (Toprol xl)
1
3
3
•
metoprolol tartrate tab 100 mg
(Lopressor)
1
INDERAL LA - propranolol hcl cap
sr 24hr 120 mg
1
INDERAL LA - propranolol hcl cap
sr 24hr 160 mg
•
metoprolol tartrate tab 25 mg
3
metoprolol tartrate tab 50 mg
(Lopressor)
1
INDERAL XL - propranolol hcl
sustained-release beads cap sr
24hr 80 mg
3
nadolol tab 20 mg (Corgard)
1
nadolol tab 40 mg (Corgard)
1
INDERAL XL - propranolol hcl
sustained-release beads cap sr
24hr 120 mg
3
nadolol tab 80 mg (Corgard)
1
pindolol tab 10 mg
1
1
3
pindolol tab 5 mg
INNOPRAN XL - propranolol hcl
sustained-release beads cap sr
24hr 80 mg
1
INNOPRAN XL - propranolol hcl
sustained-release beads cap sr
24hr 120 mg
3
PROPRANOLOL HCL propranolol hcl oral soln 20
mg/5ml
1
KERLONE - betaxolol hcl tab 10
mg
3
•
PROPRANOLOL HCL propranolol hcl oral soln 40
mg/5ml
1
KERLONE - betaxolol hcl tab 20
mg
3
•
propranolol hcl cap sr 24hr
120 mg (Inderal la)
1
labetalol hcl tab 100 mg
(Trandate)
1
propranolol hcl cap sr 24hr
160 mg (Inderal la)
1
labetalol hcl tab 200 mg
(Trandate)
1
propranolol hcl cap sr 24hr
60 mg (Inderal la)
1
labetalol hcl tab 300 mg
(Trandate)
1
propranolol hcl cap sr 24hr
80 mg (Inderal la)
propranolol hcl tab 10 mg
1
3
propranolol hcl tab 20 mg
1
LEVATOL - penbutolol sulfate tab
20 mg
propranolol hcl tab 40 mg
1
LOPRESSOR - metoprolol tartrate
tab 50 mg
3
propranolol hcl tab 60 mg
1
propranolol hcl tab 80 mg
1
LOPRESSOR - metoprolol tartrate
tab 100 mg
3
SECTRAL - acebutolol hcl cap 200
mg
3
•
metoprolol succinate tab sr 24hr
100 mg (Toprol xl)
1
SECTRAL - acebutolol hcl cap 400
mg
3
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
43
sotalol hcl (afib/afl) tab 120 mg
(Betapace af)
1
ADALAT CC - nifedipine tab sr
24hr 30 mg
3
•
sotalol hcl (afib/afl) tab 160 mg
(Betapace af)
1
ADALAT CC - nifedipine tab sr
24hr 60 mg
3
•
sotalol hcl (afib/afl) tab 80 mg
(Betapace af)
1
ADALAT CC - nifedipine tab sr
24hr 90 mg
3
•
sotalol hcl tab 120 mg (Betapace) 1
sotalol hcl tab 160 mg (Betapace) 1
amlodipine besylate tab 10 mg
(Norvasc)
1
sotalol hcl tab 240 mg
1
1
sotalol hcl tab 80 mg (Betapace)
1
amlodipine besylate tab 2.5 mg
(Norvasc)
3
amlodipine besylate tab 5 mg
(Norvasc)
1
TENORMIN - atenolol tab 25 mg
TENORMIN - atenolol tab 50 mg
3
CALAN - verapamil hcl tab 80 mg
3
TENORMIN - atenolol tab 100 mg
3
CALAN - verapamil hcl tab 120 mg
3
TIMOLOL MALEATE - timolol
maleate tab 5 mg
1
CALAN SR - verapamil hcl tab cr
120 mg
3
•
•
•
TIMOLOL MALEATE - timolol
maleate tab 10 mg
1
CALAN SR - verapamil hcl tab cr
180 mg
3
•
TIMOLOL MALEATE - timolol
maleate tab 20 mg
1
CALAN SR - verapamil hcl tab cr
240 mg
3
•
TOPROL XL - metoprolol succinate 3
tab sr 24hr 25 mg
TOPROL XL - metoprolol succinate 3
tab sr 24hr 50 mg
TOPROL XL - metoprolol succinate 3
tab sr 24hr 100 mg
TOPROL XL - metoprolol succinate 3
tab sr 24hr 200 mg
TRANDATE - labetalol hcl tab 100 3
mg
TRANDATE - labetalol hcl tab 200 3
mg
TRANDATE - labetalol hcl tab 300 3
mg
3
ZEBETA - bisoprolol fumarate tab
5 mg
3
ZEBETA - bisoprolol fumarate tab
10 mg
CALCIUM CHANNEL BLOCKERS
44
•
•
•
•
•
•
•
•
•
•
•
•
CARDENE SR - nicardipine hcl cap 3
sr 12hr 30 mg
CARDENE SR - nicardipine hcl cap 3
sr 12hr 45 mg
CARDENE SR - nicardipine hcl cap 3
sr 12hr 60 mg
3
CARDIZEM - diltiazem hcl tab 30
mg
3
CARDIZEM - diltiazem hcl tab 60
mg
3
CARDIZEM - diltiazem hcl tab 90
mg
CARDIZEM - diltiazem hcl tab 120 3
mg
3
CARDIZEM CD - diltiazem hcl
coated beads cap sr 24hr 120
mg
3
CARDIZEM CD - diltiazem hcl
coated beads cap sr 24hr 180
mg
•
•
•
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
CARDIZEM CD - diltiazem hcl
coated beads cap sr 24hr 240
mg
3
CARDIZEM CD - diltiazem hcl
coated beads cap sr 24hr 300
mg
3
CARDIZEM CD - diltiazem hcl
coated beads cap sr 24hr 360
mg
3
CARDIZEM LA - diltiazem hcl
coated beads tab sr 24hr 120 mg
•
diltiazem hcl coated beads cap
sr 24hr 300 mg (Cardizem cd)
1
diltiazem hcl coated beads cap
sr 24hr 360 mg (Cardizem cd)
1
diltiazem hcl coated beads tab sr
24hr 180 mg (Cardizem la)
1
diltiazem hcl coated beads tab sr
24hr 240 mg (Cardizem la)
1
3
diltiazem hcl coated beads tab sr
24hr 300 mg (Cardizem la)
1
3
diltiazem hcl coated beads tab sr
24hr 360 mg (Cardizem la)
1
CARDIZEM LA - diltiazem hcl
coated beads tab sr 24hr 180 mg
3
diltiazem hcl coated beads tab sr
24hr 420 mg (Cardizem la)
1
CARDIZEM LA - diltiazem hcl
coated beads tab sr 24hr 240 mg
3
diltiazem hcl extended release
beads cap sr 24hr 120 mg
(Tiazac)
1
CARDIZEM LA - diltiazem hcl
coated beads tab sr 24hr 300 mg
CARDIZEM LA - diltiazem hcl
coated beads tab sr 24hr 360 mg
3
1
CARDIZEM LA - diltiazem hcl
coated beads tab sr 24hr 420 mg
3
diltiazem hcl extended release
beads cap sr 24hr 180 mg
(Tiazac)
COVERA-HS - verapamil hcl tab sr
24hr (controlled onset) 180 mg
diltiazem hcl extended release
beads cap sr 24hr 240 mg
(Tiazac)
1
3
COVERA-HS - verapamil hcl tab sr
24hr (controlled onset) 240 mg
3
1
DILACOR XR - diltiazem hcl cap sr
24hr 240 mg
3
diltiazem hcl extended release
beads cap sr 24hr 300 mg
(Tiazac)
1
diltiazem hcl cap sr 12hr 120 mg
1
diltiazem hcl cap sr 12hr 60 mg
1
diltiazem hcl extended release
beads cap sr 24hr 360 mg
(Tiazac)
1
diltiazem hcl cap sr 24hr 120 mg
1
diltiazem hcl extended release
beads cap sr 24hr 420 mg
(Tiazac)
1
diltiazem hcl cap sr 12hr 90 mg
diltiazem hcl cap sr 24hr 180 mg
1
1
diltiazem hcl cap sr 24hr 240 mg
1
diltiazem hcl tab 120 mg
(Cardizem)
diltiazem hcl coated beads cap
sr 24hr 120 mg (Cardizem cd)
1
diltiazem hcl tab 30 mg
(Cardizem)
1
diltiazem hcl coated beads cap
sr 24hr 180 mg (Cardizem cd)
1
diltiazem hcl tab 60 mg
(Cardizem)
1
diltiazem hcl coated beads cap
sr 24hr 240 mg (Cardizem cd)
1
diltiazem hcl tab 90 mg
1
DYNACIRC CR - isradipine tab sr
24hr 5 mg
3
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
45
DYNACIRC CR - isradipine tab sr
24hr 10 mg
3
NISOLDIPINE - nisoldipine tab sr
24hr 40 mg
1
felodipine tab sr 24hr 10 mg
1
1
felodipine tab sr 24hr 2.5 mg
1
NISOLDIPINE ER - nisoldipine tab
sr 24hr 25.5 mg
felodipine tab sr 24hr 5 mg
1
1
HYPERTENIPINE-2.5 amlodipine tab 2.5 mg & dietary
management cap pack
3
nisoldipine tab sr 24hr 17 mg
(Sular)
nisoldipine tab sr 24hr 34 mg
(Sular)
1
ISOPTIN SR - verapamil hcl tab cr
120 mg
3
•
nisoldipine tab sr 24hr 8.5 mg
(Sular)
1
ISOPTIN SR - verapamil hcl tab cr
180 mg
3
•
NORVASC - amlodipine besylate
tab 2.5 mg
3
•
ISOPTIN SR - verapamil hcl tab cr
240 mg
3
•
NORVASC - amlodipine besylate
tab 5 mg
3
•
ISRADIPINE - isradipine cap 2.5
mg
1
NORVASC - amlodipine besylate
tab 10 mg
3
•
ISRADIPINE - isradipine cap 5 mg
1
3
nicardipine hcl cap 20 mg
1
NYMALIZE - nimodipine oral soln
60 mg/20ml
1
PROCARDIA - nifedipine cap 10
mg
3
nicardipine hcl cap 30 mg
•
PROCARDIA XL - nifedipine tab sr
24hr osmotic 30 mg
3
•
3
•
3
•
NIFEDIPINE - nifedipine cap 20 mg 1
nifedipine cap 10 mg (Procardia) 1
nifedipine cap 20 mg
1
nifedipine tab sr 24hr osmotic
30 mg (Procardia xl)
1
PROCARDIA XL - nifedipine tab sr
24hr osmotic 60 mg
nifedipine tab sr 24hr osmotic
60 mg (Procardia xl)
1
PROCARDIA XL - nifedipine tab sr
24hr osmotic 90 mg
nifedipine tab sr 24hr osmotic
90 mg (Procardia xl)
1
nifedipine tab sr 24hr 30 mg
(Adalat cc)
1
nifedipine tab sr 24hr 60 mg
(Adalat cc)
1
nifedipine tab sr 24hr 90 mg
(Adalat cc)
1
nimodipine cap 30 mg
1
NISOLDIPINE - nisoldipine tab sr
24hr 20 mg
1
NISOLDIPINE - nisoldipine tab sr
24hr 30 mg
1
46
SULAR - nisoldipine tab sr 24hr 8.5 3
mg
SULAR - nisoldipine tab sr 24hr 17 3
mg
SULAR - nisoldipine tab sr 24hr 34 3
mg
3
TIAZAC - diltiazem hcl extended
release beads cap sr 24hr 120
mg
3
TIAZAC - diltiazem hcl extended
release beads cap sr 24hr 180
mg
3
TIAZAC - diltiazem hcl extended
release beads cap sr 24hr 240
mg
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
TIAZAC - diltiazem hcl extended
release beads cap sr 24hr 300
mg
3
TIAZAC - diltiazem hcl extended
release beads cap sr 24hr 360
mg
3
TIAZAC - diltiazem hcl extended
release beads cap sr 24hr 420
mg
3
VERAPAMIL HCL - verapamil hcl
tab 40 mg
1
verapamil hcl cap sr 24hr
100 mg (Verelan pm)
•
•
•
VERELAN - verapamil hcl cap sr
24hr 360 mg
3
•
VERELAN PM - verapamil hcl cap
sr 24hr 100 mg
3
•
VERELAN PM - verapamil hcl cap
sr 24hr 200 mg
3
•
VERELAN PM - verapamil hcl cap
sr 24hr 300 mg
3
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
ANTIARRHYTHMICS
amiodarone hcl tab 100 mg
1
1
amiodarone hcl tab 200 mg
(Cordarone)
1
verapamil hcl cap sr 24hr
120 mg (Verelan)
1
amiodarone hcl tab 400 mg
1
3
verapamil hcl cap sr 24hr
180 mg (Verelan)
1
CORDARONE - amiodarone hcl
tab 200 mg
1
verapamil hcl cap sr 24hr
200 mg (Verelan pm)
1
disopyramide phosphate cap
100 mg (Norpace)
1
verapamil hcl cap sr 24hr
240 mg (Verelan)
1
disopyramide phosphate cap
150 mg (Norpace)
flecainide acetate tab 100 mg
1
verapamil hcl cap sr 24hr
300 mg (Verelan pm)
1
flecainide acetate tab 150 mg
1
flecainide acetate tab 50 mg
1
verapamil hcl cap sr 24hr
360 mg (Verelan)
1
1
verapamil hcl tab cr 120 mg
(Calan sr)
1
MEXILETINE HCL - mexiletine hcl
cap 150 mg
mexiletine hcl cap 150 mg
1
1
mexiletine hcl cap 200 mg
1
verapamil hcl tab cr 180 mg
(Calan sr)
mexiletine hcl cap 250 mg
1
verapamil hcl tab cr 240 mg
(Calan sr)
1
MULTAQ - dronedarone hcl tab
400 mg (base equivalent)
2
verapamil hcl tab 120 mg (Calan)
1
3
verapamil hcl tab 80 mg (Calan)
1
NORPACE - disopyramide
phosphate cap 100 mg
3
•
NORPACE - disopyramide
phosphate cap 150 mg
3
VERELAN - verapamil hcl cap sr
24hr 120 mg
3
•
NORPACE CR - disopyramide
phosphate cap sr 12hr 100 mg
3
VERELAN - verapamil hcl cap sr
24hr 180 mg
3
•
NORPACE CR - disopyramide
phosphate cap sr 12hr 150 mg
3
VERELAN - verapamil hcl cap sr
24hr 240 mg
propafenone hcl cap sr 12hr
225 mg (Rythmol sr)
1
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
•
47
propafenone hcl cap sr 12hr
325 mg (Rythmol sr)
1
ACCUPRIL - quinapril hcl tab 5 mg
3
3
propafenone hcl cap sr 12hr
425 mg (Rythmol sr)
1
ACCUPRIL - quinapril hcl tab 10
mg
•
•
•
propafenone hcl tab 150 mg
(Rythmol)
ACCUPRIL - quinapril hcl tab 20
mg
3
1
•
1
ACCUPRIL - quinapril hcl tab 40
mg
3
propafenone hcl tab 225 mg
(Rythmol)
•
1
quinidine gluconate tab cr
324 mg
1
ACCURETIC - quinaprilhydrochlorothiazide tab 10-12.5
mg
3
propafenone hcl tab 300 mg
3
•
QUINIDINE SULFATE - quinidine
sulfate tab 200 mg
1
ACCURETIC - quinaprilhydrochlorothiazide tab 20-12.5
mg
QUINIDINE SULFATE ER quinidine sulfate tab cr 300 mg
1
ACCURETIC - quinaprilhydrochlorothiazide tab 20-25 mg
3
•
quinidine sulfate tab 200 mg
1
3
•
quinidine sulfate tab 300 mg
1
ACEON - perindopril erbumine tab
4 mg
3
ACEON - perindopril erbumine tab
8 mg
3
RYTHMOL - propafenone hcl tab
150 mg
•
3
ALTACE - ramipril cap 1.25 mg
3
RYTHMOL - propafenone hcl tab
225 mg
ALTACE - ramipril cap 2.5 mg
3
RYTHMOL SR - propafenone hcl
cap sr 12hr 225 mg
3
ALTACE - ramipril cap 5 mg
3
ALTACE - ramipril cap 10 mg
3
•
•
•
•
RYTHMOL SR - propafenone hcl
cap sr 12hr 325 mg
3
amlodipine besylate-benazepril
hcl cap 10-20 mg (Lotrel)
1
RYTHMOL SR - propafenone hcl
cap sr 12hr 425 mg
3
amlodipine besylate-benazepril
hcl cap 10-40 mg (Lotrel)
1
TAMBOCOR - flecainide acetate
tab 50 mg
3
amlodipine besylate-benazepril
hcl cap 2.5-10 mg (Lotrel)
1
TAMBOCOR - flecainide acetate
tab 100 mg
3
amlodipine besylate-benazepril
hcl cap 5-10 mg (Lotrel)
1
TAMBOCOR - flecainide acetate
tab 150 mg
3
amlodipine besylate-benazepril
hcl cap 5-20 mg (Lotrel)
1
TIKOSYN - dofetilide cap 125 mcg
(0.125 mg)
3
amlodipine besylate-benazepril
hcl cap 5-40 mg (Lotrel)
1
TIKOSYN - dofetilide cap 250 mcg
(0.25 mg)
3
amlodipine besylate-valsartan
tab 10-160 mg (Exforge)
1
TIKOSYN - dofetilide cap 500 mcg
(0.5 mg)
3
amlodipine besylate-valsartan
tab 10-320 mg (Exforge)
1
ANTIHYPERTENSIVES
48
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
amlodipine besylate-valsartan
tab 5-160 mg (Exforge)
1
amlodipine besylate-valsartan
tab 5-320 mg (Exforge)
1
amlodipine-valsartanhydrochlorothiazide tab
10-160-12.5 mg (Exforge hct)
ATACAND HCT - candesartan
cilexetil-hydrochlorothiazide tab
16-12.5 mg
3
3
1
ATACAND HCT - candesartan
cilexetil-hydrochlorothiazide tab
32-12.5 mg
3
amlodipine-valsartanhydrochlorothiazide tab
10-160-25 mg (Exforge hct)
1
ATACAND HCT - candesartan
cilexetil-hydrochlorothiazide tab
32-25 mg
1
amlodipine-valsartanhydrochlorothiazide tab
10-320-25 mg (Exforge hct)
1
atenolol & chlorthalidone tab
100-25 mg (Tenoretic 100)
atenolol & chlorthalidone tab
50-25 mg (Tenoretic 50)
1
amlodipine-valsartanhydrochlorothiazide tab
5-160-12.5 mg (Exforge hct)
1
AVALIDE - irbesartanhydrochlorothiazide tab 150-12.5
mg
3
•
amlodipine-valsartanhydrochlorothiazide tab
5-160-25 mg (Exforge hct)
1
AVALIDE - irbesartanhydrochlorothiazide tab 300-12.5
mg
3
•
AMTURNIDE - aliskirenamlodipine-hydrochlorothiazide
tab 150-5-12.5 mg
3
AVAPRO - irbesartan tab 75 mg
3
AVAPRO - irbesartan tab 150 mg
3
3
AVAPRO - irbesartan tab 300 mg
3
AMTURNIDE - aliskirenamlodipine-hydrochlorothiazide
tab 300-5-12.5 mg
•
•
•
3
AMTURNIDE - aliskirenamlodipine-hydrochlorothiazide
tab 300-5-25 mg
3
AZOR - amlodipine besylateolmesartan medoxomil tab 5-20
mg
3
AMTURNIDE - aliskirenamlodipine-hydrochlorothiazide
tab 300-10-12.5 mg
3
AZOR - amlodipine besylateolmesartan medoxomil tab 5-40
mg
3
AMTURNIDE - aliskirenamlodipine-hydrochlorothiazide
tab 300-10-25 mg
3
AZOR - amlodipine besylateolmesartan medoxomil tab 10-20
mg
3
ATACAND - candesartan cilexetil
tab 4 mg
3
AZOR - amlodipine besylateolmesartan medoxomil tab 10-40
mg
1
ATACAND - candesartan cilexetil
tab 8 mg
3
benazepril &
hydrochlorothiazide tab
10-12.5 mg (Lotensin hct)
3
benazepril &
hydrochlorothiazide tab
20-12.5 mg (Lotensin hct)
1
ATACAND - candesartan cilexetil
tab 16 mg
ATACAND - candesartan cilexetil
tab 32 mg
3
•
•
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
49
benazepril &
hydrochlorothiazide tab
20-25 mg (Lotensin hct)
1
candesartan cilexetil tab 8 mg
(Atacand)
1
benazepril &
hydrochlorothiazide tab
5-6.25 mg
candesartan cilexetilhydrochlorothiazide tab
16-12.5 mg (Atacand hct)
1
1
1
benazepril hcl tab 10 mg
(Lotensin)
1
candesartan cilexetilhydrochlorothiazide tab
32-12.5 mg (Atacand hct)
benazepril hcl tab 20 mg
(Lotensin)
1
1
benazepril hcl tab 40 mg
(Lotensin)
1
candesartan cilexetilhydrochlorothiazide tab
32-25 mg (Atacand hct)
captopril tab 100 mg
1
benazepril hcl tab 5 mg
1
captopril tab 12.5 mg
1
BENICAR - olmesartan medoxomil
tab 5 mg
3
captopril tab 25 mg
1
captopril tab 50 mg
1
BENICAR - olmesartan medoxomil
tab 20 mg
3
BENICAR - olmesartan medoxomil
tab 40 mg
3
BENICAR HCT - olmesartan
medoxomil-hydrochlorothiazide
tab 20-12.5 mg
3
BENICAR HCT - olmesartan
medoxomil-hydrochlorothiazide
tab 40-12.5 mg
3
BENICAR HCT - olmesartan
medoxomil-hydrochlorothiazide
tab 40-25 mg
3
bisoprolol & hydrochlorothiazide
tab 10-6.25 mg (Ziac)
1
bisoprolol & hydrochlorothiazide
tab 2.5-6.25 mg (Ziac)
1
bisoprolol & hydrochlorothiazide
tab 5-6.25 mg (Ziac)
1
candesartan cilexetil tab 16 mg
(Atacand)
1
candesartan cilexetil tab 32 mg
(Atacand)
1
candesartan cilexetil tab 4 mg
(Atacand)
1
50
1
CAPTOPRIL/
HYDROCHLOROTHIA - captopril
& hydrochlorothiazide tab 25-15
mg
1
CAPTOPRIL/
HYDROCHLOROTHIA - captopril
& hydrochlorothiazide tab 25-25
mg
1
CAPTOPRIL/
HYDROCHLOROTHIA - captopril
& hydrochlorothiazide tab 50-15
mg
1
CAPTOPRIL/
HYDROCHLOROTHIA - captopril
& hydrochlorothiazide tab 50-25
mg
3
CARDURA - doxazosin mesylate
tab 1 mg
3
CARDURA - doxazosin mesylate
tab 2 mg
3
CARDURA - doxazosin mesylate
tab 4 mg
3
CARDURA - doxazosin mesylate
tab 8 mg
CATAPRES - clonidine hcl tab 0.1 3
mg
•
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
CATAPRES - clonidine hcl tab 0.2
mg
3
CATAPRES - clonidine hcl tab 0.3
mg
3
CATAPRES-TTS-1 - clonidine hcl
td patch weekly 0.1 mg/24hr
2
•
CATAPRES-TTS-2 - clonidine hcl
td patch weekly 0.2 mg/24hr
2
•
CATAPRES-TTS-3 - clonidine hcl
td patch weekly 0.3 mg/24hr
2
•
clonidine hcl tab 0.1 mg
(Catapres)
1
clonidine hcl tab 0.2 mg
(Catapres)
1
clonidine hcl tab 0.3 mg
(Catapres)
1
clonidine hcl td patch weekly
0.1 mg/24hr (Catapres-tts-1)
1
•
clonidine hcl td patch weekly
0.2 mg/24hr (Catapres-tts-2)
1
•
clonidine hcl td patch weekly
0.3 mg/24hr (Catapres-tts-3)
1
CLORPRES - clonidine &
chlorthalidone tab 0.1-15 mg
DIBENZYLINE phenoxybenzamine hcl cap 10
mg
2
DIOVAN - valsartan tab 40 mg
3
DIOVAN - valsartan tab 80 mg
3
DIOVAN - valsartan tab 160 mg
3
DIOVAN - valsartan tab 320 mg
3
DIOVAN HCT - valsartanhydrochlorothiazide tab 80-12.5
mg
3
DIOVAN HCT - valsartanhydrochlorothiazide tab 160-12.5
mg
3
DIOVAN HCT - valsartanhydrochlorothiazide tab 160-25
mg
3
DIOVAN HCT - valsartanhydrochlorothiazide tab 320-12.5
mg
3
DIOVAN HCT - valsartanhydrochlorothiazide tab 320-25
mg
3
3
doxazosin mesylate tab 1 mg
(Cardura)
1
CLORPRES - clonidine &
chlorthalidone tab 0.2-15 mg
3
doxazosin mesylate tab 2 mg
(Cardura)
1
CLORPRES - clonidine &
chlorthalidone tab 0.3-15 mg
3
doxazosin mesylate tab 4 mg
(Cardura)
1
CORZIDE - nadolol &
bendroflumethiazide tab 40-5 mg
3
•
doxazosin mesylate tab 8 mg
(Cardura)
1
CORZIDE - nadolol &
bendroflumethiazide tab 80-5 mg
3
•
2
COZAAR - losartan potassium tab
25 mg
3
•
DUTOPROL - metoprolol &
hydrochlorothiazide tab sr 24hr
25-12.5 mg
2
COZAAR - losartan potassium tab
50 mg
3
•
DUTOPROL - metoprolol &
hydrochlorothiazide tab sr 24hr
50-12.5 mg
3
•
DUTOPROL - metoprolol &
hydrochlorothiazide tab sr 24hr
100-12.5 mg
2
COZAAR - losartan potassium tab
100 mg
DEMSER - metyrosine cap 250 mg
2
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
EDARBI - azilsartan medoxomil tab 3
40 mg
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
51
EDARBI - azilsartan medoxomil tab 3
80 mg
3
EDARBYCLOR - azilsartan
medoxomil-chlorthalidone tab
40-12.5 mg
3
EDARBYCLOR - azilsartan
medoxomil-chlorthalidone tab
40-25 mg
1
enalapril maleate &
hydrochlorothiazide tab
10-25 mg (Vaseretic)
1
enalapril maleate &
hydrochlorothiazide tab
5-12.5 mg
1
enalapril maleate tab 10 mg
(Vasotec)
1
enalapril maleate tab 2.5 mg
(Vasotec)
1
enalapril maleate tab 20 mg
(Vasotec)
1
enalapril maleate tab 5 mg
(Vasotec)
3
EPANED - enalapril maleate for
oral soln 1 mg/ml
1
eplerenone tab 25 mg (Inspra)
eplerenone tab 50 mg (Inspra)
1
eprosartan mesylate tab 600 mg
(Teveten)
1
EXFORGE - amlodipine besylatevalsartan tab 5-160 mg
3
EXFORGE - amlodipine besylatevalsartan tab 5-320 mg
3
EXFORGE - amlodipine besylatevalsartan tab 10-160 mg
3
EXFORGE - amlodipine besylatevalsartan tab 10-320 mg
3
EXFORGE HCT - amlodipinevalsartan-hydrochlorothiazide tab
5-160-12.5 mg
2
52
EXFORGE HCT - amlodipinevalsartan-hydrochlorothiazide tab
5-160-25 mg
2
EXFORGE HCT - amlodipinevalsartan-hydrochlorothiazide tab
10-160-12.5 mg
2
EXFORGE HCT - amlodipinevalsartan-hydrochlorothiazide tab
10-160-25 mg
2
EXFORGE HCT - amlodipinevalsartan-hydrochlorothiazide tab
10-320-25 mg
2
fosinopril sodium &
hydrochlorothiazide tab
10-12.5 mg
1
fosinopril sodium &
hydrochlorothiazide tab
20-12.5 mg
1
fosinopril sodium tab 10 mg
1
fosinopril sodium tab 20 mg
1
fosinopril sodium tab 40 mg
1
guanfacine hcl tab 1 mg (Tenex)
1
guanfacine hcl tab 2 mg (Tenex)
1
hydralazine hcl tab 10 mg
1
hydralazine hcl tab 100 mg
1
hydralazine hcl tab 25 mg
1
hydralazine hcl tab 50 mg
1
HYPERTENSOLOL - metoprolol
tab 50 mg & dietary management
cap pack
3
HYZAAR - losartan potassium &
hydrochlorothiazide tab 50-12.5
mg
3
•
HYZAAR - losartan potassium &
hydrochlorothiazide tab 100-12.5
mg
3
•
HYZAAR - losartan potassium &
hydrochlorothiazide tab 100-25
mg
3
•
INSPRA - eplerenone tab 25 mg
3
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
irbesartan-hydrochlorothiazide
tab 150-12.5 mg (Avalide)
1
LOTENSIN - benazepril hcl tab 10
mg
3
•
1
LOTENSIN - benazepril hcl tab 20
mg
3
•
1
LOTENSIN - benazepril hcl tab 40
mg
3
irbesartan-hydrochlorothiazide
tab 300-12.5 mg (Avalide)
•
1
LOTENSIN HCT - benazepril &
hydrochlorothiazide tab 10-12.5
mg
3
lisinopril & hydrochlorothiazide
tab 10-12.5 mg (Zestoretic)
•
lisinopril & hydrochlorothiazide
tab 20-12.5 mg (Zestoretic)
1
3
•
lisinopril & hydrochlorothiazide
tab 20-25 mg (Zestoretic)
1
LOTENSIN HCT - benazepril &
hydrochlorothiazide tab 20-12.5
mg
3
•
lisinopril tab 10 mg (Prinivil)
1
LOTENSIN HCT - benazepril &
hydrochlorothiazide tab 20-25 mg
lisinopril tab 2.5 mg (Zestril)
1
3
•
lisinopril tab 20 mg (Prinivil)
1
LOTREL - amlodipine besylatebenazepril hcl cap 2.5-10 mg
lisinopril tab 30 mg (Zestril)
1
3
•
lisinopril tab 40 mg (Zestril)
1
LOTREL - amlodipine besylatebenazepril hcl cap 5-10 mg
1
•
LOPRESSOR HCT - metoprolol &
hydrochlorothiazide tab 50-25 mg
3
•
LOTREL - amlodipine besylatebenazepril hcl cap 5-20 mg
3
lisinopril tab 5 mg (Prinivil)
3
•
LOPRESSOR HCT - metoprolol &
hydrochlorothiazide tab 100-25
mg
3
•
LOTREL - amlodipine besylatebenazepril hcl cap 5-40 mg
LOTREL - amlodipine besylatebenazepril hcl cap 10-20 mg
3
•
1
LOTREL - amlodipine besylatebenazepril hcl cap 10-40 mg
3
losartan potassium &
hydrochlorothiazide tab
100-12.5 mg (Hyzaar)
•
3
losartan potassium &
hydrochlorothiazide tab
100-25 mg (Hyzaar)
1
LYTENSOPRIL KIT - lisinopril tab
20 mg & dietary management
cap pack
3
losartan potassium &
hydrochlorothiazide tab
50-12.5 mg (Hyzaar)
1
LYTENSOPRIL-90 - lisinopril tab
20 mg & dietary management
cap pack
3
losartan potassium tab 100 mg
(Cozaar)
1
LYTENSOPRIL-90 KIT - lisinopril
tab 20 mg & dietary management
cap pack
1
MAVIK - trandolapril tab 1 mg
3
losartan potassium tab 25 mg
(Cozaar)
MAVIK - trandolapril tab 2 mg
3
MAVIK - trandolapril tab 4 mg
3
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
1
losartan potassium tab 50 mg
(Cozaar)
Quantity Limits
irbesartan tab 75 mg (Avapro)
"Smart" PA
1
Prior Authorization
irbesartan tab 300 mg (Avapro)
Drug Name
Drug Tier
1
Specialty
irbesartan tab 150 mg (Avapro)
Quantity Limits
3
"Smart" PA
INSPRA - eplerenone tab 50 mg
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
53
metoprolol &
hydrochlorothiazide tab
100-25 mg (Lopressor hct)
1
metoprolol &
hydrochlorothiazide tab
100-50 mg
1
metoprolol &
hydrochlorothiazide tab
50-25 mg (Lopressor hct)
1
MICARDIS - telmisartan tab 20 mg
3
MICARDIS - telmisartan tab 40 mg
3
MICARDIS - telmisartan tab 80 mg
3
MICARDIS HCT - telmisartanhydrochlorothiazide tab 40-12.5
mg
3
MICARDIS HCT - telmisartanhydrochlorothiazide tab 80-12.5
mg
3
MICARDIS HCT - telmisartanhydrochlorothiazide tab 80-25 mg
moexipril hcl tab 7.5 mg
(Univasc)
1
moexipril-hydrochlorothiazide
tab 15-12.5 mg (Uniretic)
1
moexipril-hydrochlorothiazide
tab 15-25 mg
1
moexipril-hydrochlorothiazide
tab 7.5-12.5 mg
1
nadolol & bendroflumethiazide
tab 40-5 mg (Corzide)
1
nadolol & bendroflumethiazide
tab 80-5 mg (Corzide)
1
NEXICLON XR - clonidine hcl
extended release susp 0.09 mg/
ml (base equiv)
3
•
NEXICLON XR - clonidine hcl
tab sr 24hr 0.17 mg (base
equivalent)
3
•
perindopril erbumine tab 2 mg
1
perindopril erbumine tab 4 mg
(Aceon)
1
perindopril erbumine tab 8 mg
(Aceon)
1
prazosin hcl cap 1 mg (Minipress) 1
prazosin hcl cap 2 mg (Minipress) 1
prazosin hcl cap 5 mg (Minipress) 1
3
PRINIVIL - lisinopril tab 5 mg
PRINIVIL - lisinopril tab 10 mg
3
3
PRINIVIL - lisinopril tab 20 mg
3
3
MINIPRESS - prazosin hcl cap 1
mg
3
•
PRINZIDE - lisinopril &
hydrochlorothiazide tab 10-12.5
mg
•
•
•
•
3
•
•
MINIPRESS - prazosin hcl cap 5
mg
3
•
PRINZIDE - lisinopril &
hydrochlorothiazide tab 20-12.5
mg
3
MINIPRESS - prazosin hcl cap 2
mg
1
minoxidil tab 10 mg
1
minoxidil tab 2.5 mg
1
PROPRANOLOL/
HYDROCHLOROTH
- propranolol &
hydrochlorothiazide tab 40-25 mg
moexipril hcl tab 15 mg (Univasc) 1
54
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
1
Quantity Limits
METHYLDOPA/
HYDROCHLOROTHI
- methyldopa &
hydrochlorothiazide tab 250-25
mg
"Smart" PA
1
Prior Authorization
METHYLDOPA/
HYDROCHLOROTHI
- methyldopa &
hydrochlorothiazide tab 250-15
mg
Drug Name
Drug Tier
1
Specialty
methyldopa tab 500 mg
Quantity Limits
1
"Smart" PA
methyldopa tab 250 mg
Prior Authorization
Drug Name
Drug Tier
2015
TEKTURNA - aliskiren fumarate
tab 150 mg (base equivalent)
3
•
TEKTURNA - aliskiren fumarate
tab 300 mg (base equivalent)
3
•
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 150-12.5
mg
3
•
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 150-25
mg
3
•
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 300-12.5
mg
3
•
3
•
1
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 300-25
mg
ramipril cap 10 mg (Altace)
1
telmisartan tab 20 mg (Micardis)
1
ramipril cap 2.5 mg (Altace)
1
telmisartan tab 40 mg (Micardis)
1
ramipril cap 5 mg (Altace)
1
telmisartan tab 80 mg (Micardis)
1
RESERPINE - reserpine tab 0.1
mg
1
telmisartan-amlodipine tab
40-10 mg (Twynsta)
1
RESERPINE - reserpine tab 0.25
mg
1
telmisartan-amlodipine tab
40-5 mg (Twynsta)
1
TARKA - trandolapril-verapamil hcl
tab cr 1-240 mg
3
telmisartan-amlodipine tab
80-10 mg (Twynsta)
1
TARKA - trandolapril-verapamil hcl
tab cr 2-180 mg
3
telmisartan-amlodipine tab
80-5 mg (Twynsta)
1
TARKA - trandolapril-verapamil hcl
tab cr 2-240 mg
3
telmisartan-hydrochlorothiazide
tab 40-12.5 mg (Micardis hct)
1
TARKA - trandolapril-verapamil hcl
tab cr 4-240 mg
3
telmisartan-hydrochlorothiazide
tab 80-12.5 mg (Micardis hct)
1
TEKAMLO - aliskiren-amlodipine
tab 150-5 mg
3
•
telmisartan-hydrochlorothiazide
tab 80-25 mg (Micardis hct)
1
TEKAMLO - aliskiren-amlodipine
tab 150-10 mg
3
•
TENEX - guanfacine hcl tab 1 mg
3
3
3
•
TENEX - guanfacine hcl tab 2 mg
TEKAMLO - aliskiren-amlodipine
tab 300-5 mg
3
•
TEKAMLO - aliskiren-amlodipine
tab 300-10 mg
3
•
TENORETIC 100 - atenolol &
chlorthalidone tab 100-25 mg
TENORETIC 50 - atenolol &
chlorthalidone tab 50-25 mg
3
•
terazosin hcl cap 1 mg
1
PROPRANOLOL/
HYDROCHLOROTH
- propranolol &
hydrochlorothiazide tab 80-25 mg
1
quinapril hcl tab 10 mg (Accupril)
1
quinapril hcl tab 20 mg (Accupril)
1
quinapril hcl tab 40 mg (Accupril)
1
quinapril hcl tab 5 mg (Accupril)
1
quinapril-hydrochlorothiazide
tab 10-12.5 mg (Accuretic)
1
quinapril-hydrochlorothiazide
tab 20-12.5 mg (Accuretic)
1
quinapril-hydrochlorothiazide
tab 20-25 mg (Accuretic)
1
ramipril cap 1.25 mg (Altace)
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
55
TEVETEN - eprosartan mesylate
tab 600 mg
3
TEVETEN HCT - eprosartan
mesylate-hydrochlorothiazide tab
600-12.5 mg
3
TEVETEN HCT - eprosartan
mesylate-hydrochlorothiazide tab
600-25 mg
3
trandolapril tab 1 mg (Mavik)
•
3
•
UNIRETIC - moexiprilhydrochlorothiazide tab 15-12.5
mg
3
•
UNIRETIC - moexiprilhydrochlorothiazide tab 15-25 mg
3
•
UNIVASC - moexipril hcl tab 7.5
mg
3
•
UNIVASC - moexipril hcl tab 15 mg 3
1
valsartan tab 160 mg (Diovan)
•
valsartan tab 320 mg (Diovan)
1
1
valsartan tab 40 mg (Diovan)
1
trandolapril tab 2 mg (Mavik)
1
valsartan tab 80 mg (Diovan)
1
trandolapril tab 4 mg (Mavik)
1
1
TRIBENZOR - olmesartanamlodipine-hydrochlorothiazide
tab 20-5-12.5 mg
3
valsartan-hydrochlorothiazide
tab 160-12.5 mg (Diovan hct)
valsartan-hydrochlorothiazide
tab 160-25 mg (Diovan hct)
1
TRIBENZOR - olmesartanamlodipine-hydrochlorothiazide
tab 40-5-12.5 mg
3
valsartan-hydrochlorothiazide
tab 320-12.5 mg (Diovan hct)
1
TRIBENZOR - olmesartanamlodipine-hydrochlorothiazide
tab 40-5-25 mg
valsartan-hydrochlorothiazide
tab 320-25 mg (Diovan hct)
1
3
valsartan-hydrochlorothiazide
tab 80-12.5 mg (Diovan hct)
1
TRIBENZOR - olmesartanamlodipine-hydrochlorothiazide
tab 40-10-12.5 mg
3
VASERETIC - enalapril maleate &
hydrochlorothiazide tab 10-25 mg
3
•
3
VASOTEC - enalapril maleate tab
2.5 mg
3
TRIBENZOR - olmesartanamlodipine-hydrochlorothiazide
tab 40-10-25 mg
•
3
•
TWYNSTA - telmisartanamlodipine tab 40-5 mg
3
VASOTEC - enalapril maleate tab
5 mg
3
•
TWYNSTA - telmisartanamlodipine tab 40-10 mg
3
VASOTEC - enalapril maleate tab
10 mg
3
•
TWYNSTA - telmisartanamlodipine tab 80-5 mg
3
VASOTEC - enalapril maleate tab
20 mg
TWYNSTA - telmisartanamlodipine tab 80-10 mg
3
VECAMYL - mecamylamine hcl tab 3
2.5 mg
3
ZESTORETIC - lisinopril &
hydrochlorothiazide tab 10-12.5
mg
•
56
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
3
UNIRETIC - moexiprilhydrochlorothiazide tab 7.5-12.5
mg
Quantity Limits
TEVETEN - eprosartan mesylate
tab 400 mg
"Smart" PA
1
Prior Authorization
terazosin hcl cap 5 mg
Drug Name
Drug Tier
1
Specialty
terazosin hcl cap 2 mg
Quantity Limits
1
"Smart" PA
terazosin hcl cap 10 mg
Prior Authorization
Drug Name
Drug Tier
2015
3
ZESTORETIC - lisinopril &
hydrochlorothiazide tab 20-25 mg
3
ZESTRIL - lisinopril tab 2.5 mg
3
ZESTRIL - lisinopril tab 5 mg
3
ZESTRIL - lisinopril tab 10 mg
3
ZESTRIL - lisinopril tab 20 mg
3
ZESTRIL - lisinopril tab 30 mg
3
ZESTRIL - lisinopril tab 40 mg
3
ZIAC - bisoprolol &
hydrochlorothiazide tab 2.5-6.25
mg
3
ZIAC - bisoprolol &
hydrochlorothiazide tab 5-6.25
mg
3
ZIAC - bisoprolol &
hydrochlorothiazide tab 10-6.25
mg
3
DIURETICS
•
bumetanide tab 1 mg
1
bumetanide tab 2 mg
1
•
•
•
•
•
•
•
CHLOROTHIAZIDE chlorothiazide tab 250 mg
1
chlorothiazide tab 250 mg
1
chlorothiazide tab 500 mg
1
CHLORTHALIDONE chlorthalidone tab 25 mg
1
CHLORTHALIDONE chlorthalidone tab 50 mg
1
CHLORTHALIDONE chlorthalidone tab 100 mg
1
DEMADEX - torsemide tab 5 mg
3
DEMADEX - torsemide tab 10 mg
3
DEMADEX - torsemide tab 20 mg
3
DEMADEX - torsemide tab 100 mg
3
DIAMOX - acetazolamide cap sr
12hr 500 mg
3
•
•
ACETAZOLAMIDE acetazolamide tab 125 mg
1
DIURIL - chlorothiazide susp 250
mg/5ml
3
acetazolamide cap sr 12hr
500 mg (Diamox)
1
3
acetazolamide sodium for inj
500 mg
1
DYAZIDE - triamterene &
hydrochlorothiazide cap 37.5-25
mg
3
acetazolamide tab 250 mg
1
DYRENIUM - triamterene cap 50
mg
ALDACTAZIDE - spironolactone &
hydrochlorothiazide tab 25-25 mg
3
DYRENIUM - triamterene cap 100
mg
3
ALDACTAZIDE - spironolactone &
hydrochlorothiazide tab 50-50 mg
3
EDECRIN - ethacrynic acid tab 25
mg
3
ALDACTONE - spironolactone tab
25 mg
3
FUROSEMIDE - furosemide oral
soln 8 mg/ml
1
ALDACTONE - spironolactone tab
50 mg
3
furosemide oral soln 10 mg/ml
1
furosemide tab 20 mg (Lasix)
1
ALDACTONE - spironolactone tab
100 mg
3
furosemide tab 40 mg (Lasix)
1
furosemide tab 80 mg (Lasix)
1
amiloride & hydrochlorothiazide
tab 5-50 mg
1
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
1
Quantity Limits
bumetanide tab 0.5 mg
"Smart" PA
1
Specialty
amiloride hcl tab 5 mg
•
Prior Authorization
Quantity Limits
"Smart" PA
Drug Name
Drug Tier
ZESTORETIC - lisinopril &
hydrochlorothiazide tab 20-12.5
mg
Prior Authorization
Drug Name
Drug Tier
2015
57
hydrochlorothiazide cap 12.5 mg
(Microzide)
1
spironolactone tab 50 mg
(Aldactone)
1
hydrochlorothiazide tab 12.5 mg
1
torsemide tab 10 mg (Demadex)
1
hydrochlorothiazide tab 25 mg
1
torsemide tab 100 mg (Demadex)
1
hydrochlorothiazide tab 50 mg
1
torsemide tab 20 mg (Demadex)
1
indapamide tab 1.25 mg
1
torsemide tab 5 mg (Demadex)
1
indapamide tab 2.5 mg
1
1
INTROL - glycerin soln 75%
3
LASIX - furosemide tab 20 mg
3
triamterene &
hydrochlorothiazide cap
37.5-25 mg (Dyazide)
3
LASIX - furosemide tab 80 mg
3
triamterene &
hydrochlorothiazide tab
37.5-25 mg (Maxzide-25)
1
LASIX - furosemide tab 40 mg
MAXZIDE - triamterene &
hydrochlorothiazide tab 75-50 mg
3
1
MAXZIDE-25 - triamterene &
hydrochlorothiazide tab 37.5-25
mg
3
triamterene &
hydrochlorothiazide tab
75-50 mg (Maxzide)
1
methazolamide tab 25 mg
(Neptazane)
1
methazolamide tab 50 mg
(Neptazane)
1
TRIAMTERENE/
HYDROCHLOROTH
- triamterene &
hydrochlorothiazide cap 50-25
mg
3
METHYCLOTHIAZIDE methyclothiazide tab 5 mg
1
ZAROXOLYN - metolazone tab 2.5
mg
3
metolazone tab 10 mg
1
ZAROXOLYN - metolazone tab 5
mg
metolazone tab 2.5 mg
(Zaroxolyn)
1
metolazone tab 5 mg (Zaroxolyn)
1
MICROZIDE - hydrochlorothiazide
cap 12.5 mg
3
NEPTAZANE - methazolamide tab
25 mg
3
NEPTAZANE - methazolamide tab
50 mg
3
spironolactone &
hydrochlorothiazide tab
25-25 mg (Aldactazide)
VASOPRESSORS
ADRENACLICK - epinephrine
solution auto-injector 0.15
mg/0.15ml (1:1000)
3
•
ADRENACLICK - epinephrine
solution auto-injector 0.3
mg/0.3ml (1:1000)
3
•
AUVI-Q - epinephrine solution
auto-injector 0.15 mg/0.15ml
(1:1000)
2
•
1
AUVI-Q - epinephrine solution
auto-injector 0.3 mg/0.3ml
(1:1000)
2
•
spironolactone tab 100 mg
(Aldactone)
1
1
•
spironolactone tab 25 mg
(Aldactone)
1
EPINEPHRINE - epinephrine
solution auto-injector 0.15
mg/0.15ml (1:1000)
58
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
•
EPINEPHRINE - epinephrine
solution auto-injector 0.3
mg/0.3ml (1:1000)
1
EPIPEN 2-PAK - epinephrine
solution auto-injector 0.3
mg/0.3ml (1:1000)
2
EPIPEN-JR 2-PAK - epinephrine
solution auto-injector 0.15
mg/0.3ml (1:2000)
2
midodrine hcl tab 10 mg
1
midodrine hcl tab 2.5 mg
1
midodrine hcl tab 5 mg
1
NORTHERA - droxidopa cap 100
mg
3
•
NORTHERA - droxidopa cap 200
mg
3
NORTHERA - droxidopa cap 300
mg
3
ANTARA - fenofibrate micronized
cap 130 mg
3
atorvastatin calcium tab 10 mg
(base equivalent) (Lipitor)
1
atorvastatin calcium tab 20 mg
(base equivalent) (Lipitor)
1
atorvastatin calcium tab 40 mg
(base equivalent) (Lipitor)
1
atorvastatin calcium tab 80 mg
(base equivalent) (Lipitor)
1
cholestyramine light powder
packets 4 gm
1
•
cholestyramine light powder
4 gm/dose (Questran light)
1
•
•
cholestyramine powder packets
4 gm (Questran)
1
•
•
cholestyramine powder 4 gm/
dose (Questran)
1
1
•
•
ANTIHYPERLIPIDEMICS
ADVICOR - niacin-lovastatin tab sr
24hr 500-20 mg
3
•
choline fenofibrate cap dr
135 mg (fenofibric acid equiv)
(Trilipix)
ADVICOR - niacin-lovastatin tab sr
24hr 750-20 mg
3
•
choline fenofibrate cap dr 45 mg
(fenofibric acid equiv) (Trilipix)
1
ADVICOR - niacin-lovastatin tab sr
24hr 1000-20 mg
3
•
COLESTID - colestipol hcl tab 1
gm
3
ADVICOR - niacin-lovastatin tab sr
24hr 1000-40 mg
3
•
ALTOPREV - lovastatin tab sr 24hr
20 mg
3
•
ALTOPREV - lovastatin tab sr 24hr
40 mg
3
•
ALTOPREV - lovastatin tab sr 24hr
60 mg
3
•
ANTARA - fenofibrate micronized
cap 30 mg
3
•
ANTARA - fenofibrate micronized
cap 43 mg
3
•
ANTARA - fenofibrate micronized
cap 90 mg
3
•
COLESTID - colestipol hcl granules 3
5 gm
COLESTID - colestipol hcl granule 3
packets 5 gm
COLESTID FLAVORED - colestipol 3
hcl granules 5 gm
COLESTID FLAVORED - colestipol 3
hcl granule packets 5 gm
1
colestipol hcl granule packets
5 gm (Colestid flavored)
1
colestipol hcl granules 5 gm
(Colestid flavored)
colestipol hcl tab 1 gm (Colestid) 1
CRESTOR - rosuvastatin calcium
tab 5 mg
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
3
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
•
•
59
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
CRESTOR - rosuvastatin calcium
tab 10 mg
3
•
gemfibrozil tab 600 mg (Lopid)
1
•
• •
CRESTOR - rosuvastatin calcium
tab 20 mg
•
JUXTAPID - lomitapide mesylate
cap 5 mg (base equiv)
2
3
•
•
• •
CRESTOR - rosuvastatin calcium
tab 40 mg
JUXTAPID - lomitapide mesylate
cap 10 mg (base equiv)
2
3
•
•
• •
1
JUXTAPID - lomitapide mesylate
cap 20 mg (base equiv)
2
FENOFIBRATE - fenofibrate cap
50 mg
•
•
•
1
KYNAMRO - mipomersen sodium
soln prefilled syringe 200 mg/ml
3
FENOFIBRATE - fenofibrate cap
150 mg
•
fenofibrate micronized cap
130 mg
LESCOL - fluvastatin sodium cap
20 mg
3
1
•
fenofibrate micronized cap
134 mg (Lofibra)
LESCOL - fluvastatin sodium cap
40 mg
3
1
•
fenofibrate micronized cap
200 mg (Lofibra)
LESCOL XL - fluvastatin sodium
tab sr 24 hr 80 mg
3
1
•
1
LIPITOR - atorvastatin calcium tab
10 mg (base equivalent)
3
fenofibrate micronized cap
43 mg
•
1
LIPITOR - atorvastatin calcium tab
20 mg (base equivalent)
3
fenofibrate micronized cap
67 mg (Lofibra)
•
fenofibrate tab 145 mg (Tricor)
LIPITOR - atorvastatin calcium tab
40 mg (base equivalent)
3
1
fenofibrate tab 160 mg (Lofibra)
1
3
•
fenofibrate tab 48 mg (Tricor)
1
LIPITOR - atorvastatin calcium tab
80 mg (base equivalent)
fenofibrate tab 54 mg (Lofibra)
1
LIPOFEN - fenofibrate cap 50 mg
3
FENOFIBRIC ACID - fenofibric
acid tab 35 mg
1
•
LIPOFEN - fenofibrate cap 150 mg
3
3
FENOFIBRIC ACID - fenofibric
acid tab 105 mg
1
•
LIPTRUZET - ezetimibeatorvastatin tab 10-10 mg
•
•
•
3
•
FENOGLIDE - fenofibrate tab 40
mg
3
•
LIPTRUZET - ezetimibeatorvastatin tab 10-20 mg
3
•
FENOGLIDE - fenofibrate tab 120
mg
3
•
LIPTRUZET - ezetimibeatorvastatin tab 10-40 mg
3
•
FIBRICOR - fenofibric acid tab 35
mg
3
•
LIPTRUZET - ezetimibeatorvastatin tab 10-80 mg
•
FIBRICOR - fenofibric acid tab 105
mg
3
fluvastatin sodium cap 20 mg
(Lescol)
1
fluvastatin sodium cap 40 mg
(Lescol)
1
LIVALO - pitavastatin calcium tab 1 3
mg (base equiv)
LIVALO - pitavastatin calcium tab 2 3
mg (base equiv)
LIVALO - pitavastatin calcium tab 4 3
mg (base equiv)
3
LOFIBRA - fenofibrate tab 54 mg
60
•
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
LOPID - gemfibrozil tab 600 mg
3
lovastatin tab 10 mg
1
lovastatin tab 20 mg (Mevacor)
1
lovastatin tab 40 mg (Mevacor)
1
LOVAZA - omega-3-acid ethyl
esters cap 1 gm
3
MEVACOR - lovastatin tab 20 mg
3
MEVACOR - lovastatin tab 40 mg
3
niacin tab cr 1000 mg
(antihyperlipidemic) (Niaspan)
1
niacin tab cr 500 mg
(antihyperlipidemic) (Niaspan)
1
niacin tab cr 750 mg
(antihyperlipidemic) (Niaspan)
1
NIACOR - niacin
(antihyperlipidemic) tab 500 mg
3
NIASPAN - niacin tab cr 500 mg
(antihyperlipidemic)
3
NIASPAN - niacin tab cr 750 mg
(antihyperlipidemic)
3
NIASPAN - niacin tab cr 1000 mg
(antihyperlipidemic)
3
omega-3-acid ethyl esters cap
1 gm (Lovaza)
1
PRAVACHOL - pravastatin sodium
tab 20 mg
3
PRAVACHOL - pravastatin sodium
tab 40 mg
3
PRAVACHOL - pravastatin sodium
tab 80 mg
3
pravastatin sodium tab 10 mg
1
1
•
pravastatin sodium tab 40 mg
(Pravachol)
1
•
pravastatin sodium tab 80 mg
(Pravachol)
QUESTRAN - cholestyramine
powder 4 gm/dose
3
QUESTRAN - cholestyramine
powder packets 4 gm
3
QUESTRAN LIGHT cholestyramine light powder 4
gm/dose
3
QUESTRAN LIGHT cholestyramine light powder
packets 4 gm
3
•
•
•
•
SIMCOR - niacin-simvastatin tab sr 3
24hr 500-20 mg
SIMCOR - niacin-simvastatin tab sr 3
24hr 500-40 mg
SIMCOR - niacin-simvastatin tab sr 3
24hr 750-20 mg
SIMCOR - niacin-simvastatin tab sr 3
24hr 1000-20 mg
SIMCOR - niacin-simvastatin tab sr 3
24hr 1000-40 mg
1
simvastatin tab 10 mg (Zocor)
•
•
•
•
•
simvastatin tab 20 mg (Zocor)
1
simvastatin tab 40 mg (Zocor)
1
simvastatin tab 5 mg (Zocor)
1
simvastatin tab 80 mg (Zocor)
1
•
TRICOR - fenofibrate tab 48 mg
3
TRICOR - fenofibrate tab 145 mg
3
•
TRIGLIDE - fenofibrate tab 50 mg
3
TRIGLIDE - fenofibrate tab 160 mg
3
TRILIPIX - choline fenofibrate cap
dr 45 mg (fenofibric acid equiv)
3
•
•
•
•
•
TRILIPIX - choline fenofibrate cap
dr 135 mg (fenofibric acid equiv)
3
•
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
3
1
Quantity Limits
LOFIBRA - fenofibrate micronized
cap 200 mg
pravastatin sodium tab 20 mg
(Pravachol)
"Smart" PA
3
•
•
Prior Authorization
LOFIBRA - fenofibrate micronized
cap 134 mg
Drug Name
Drug Tier
3
Specialty
LOFIBRA - fenofibrate micronized
cap 67 mg
Quantity Limits
3
"Smart" PA
LOFIBRA - fenofibrate tab 160 mg
Prior Authorization
Drug Name
Drug Tier
2015
61
•
amlodipine besylate-atorvastatin
calcium tab 2.5-40 mg (Caduet)
1
3
•
amlodipine besylate-atorvastatin
calcium tab 5-10 mg (Caduet)
1
VYTORIN - ezetimibe-simvastatin
tab 10-40 mg
3
•
amlodipine besylate-atorvastatin
calcium tab 5-20 mg (Caduet)
1
VYTORIN - ezetimibe-simvastatin
tab 10-80 mg
3
•
amlodipine besylate-atorvastatin
calcium tab 5-40 mg (Caduet)
1
WELCHOL - colesevelam hcl tab
625 mg
2
amlodipine besylate-atorvastatin
calcium tab 5-80 mg (Caduet)
1
WELCHOL - colesevelam hcl
packet for susp 3.75 gm
2
BIDIL - isosorbide dinitratehydralazine hcl tab 20-37.5 mg
2
ZETIA - ezetimibe tab 10 mg
3
3
ZOCOR - simvastatin tab 5 mg
3
ZOCOR - simvastatin tab 10 mg
3
CADUET - amlodipine besylateatorvastatin calcium tab 2.5-10
mg
3
ZOCOR - simvastatin tab 40 mg
3
CADUET - amlodipine besylateatorvastatin calcium tab 2.5-20
mg
3
ZOCOR - simvastatin tab 20 mg
ZOCOR - simvastatin tab 80 mg
3
CADUET - amlodipine besylateatorvastatin calcium tab 2.5-40
mg
3
CADUET - amlodipine besylateatorvastatin calcium tab 5-10 mg
3
CADUET - amlodipine besylateatorvastatin calcium tab 5-20 mg
3
CADUET - amlodipine besylateatorvastatin calcium tab 5-40 mg
3
CADUET - amlodipine besylateatorvastatin calcium tab 5-80 mg
3
CADUET - amlodipine besylateatorvastatin calcium tab 10-10
mg
3
CADUET - amlodipine besylateatorvastatin calcium tab 10-20
mg
3
CADUET - amlodipine besylateatorvastatin calcium tab 10-40
mg
3
CARDIOVASCULAR AGENTS - MISC.
2
ADCIRCA - tadalafil tab 20 mg
(pah)
3
ADEMPAS - riociguat tab 0.5 mg
ADEMPAS - riociguat tab 1 mg
3
ADEMPAS - riociguat tab 1.5 mg
3
ADEMPAS - riociguat tab 2 mg
3
ADEMPAS - riociguat tab 2.5 mg
3
amlodipine besylate-atorvastatin
calcium tab 10-10 mg (Caduet)
1
amlodipine besylate-atorvastatin
calcium tab 10-20 mg (Caduet)
1
amlodipine besylate-atorvastatin
calcium tab 10-40 mg (Caduet)
1
amlodipine besylate-atorvastatin
calcium tab 10-80 mg (Caduet)
1
amlodipine besylate-atorvastatin
calcium tab 2.5-10 mg (Caduet)
1
62
•
•
•
•
•
•
• •
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
VYTORIN - ezetimibe-simvastatin
tab 10-20 mg
1
"Smart" PA
3
amlodipine besylate-atorvastatin
calcium tab 2.5-20 mg (Caduet)
Prior Authorization
VYTORIN - ezetimibe-simvastatin
tab 10-10 mg
•
Drug Name
Drug Tier
•
Specialty
3
Quantity Limits
Prior Authorization
VASCEPA - icosapent ethyl cap 1
gm
Drug Name
"Smart" PA
Drug Tier
2015
CADUET - amlodipine besylateatorvastatin calcium tab 10-80
mg
3
CIALIS - tadalafil tab 5 mg
3
ISOXSUPRINE HCL - isoxsuprine
hcl tab 20 mg
1
isoxsuprine hcl tab 10 mg
1
LETAIRIS - ambrisentan tab 5 mg
2
LETAIRIS - ambrisentan tab 10 mg
2
OPSUMIT - macitentan tab 10 mg
2
ORENITRAM - treprostinil
diolamine tab cr 0.125 mg (base
equiv)
3
ORENITRAM - treprostinil
diolamine tab cr 0.25 mg (base
equiv)
3
ORENITRAM - treprostinil
diolamine tab cr 1 mg (base
equiv)
3
ORENITRAM - treprostinil
diolamine tab cr 2.5 mg (base
equiv)
3
REVATIO - sildenafil citrate tab 20
mg
3
•
REVATIO - sildenafil citrate for
suspension 10 mg/ml
3
•
sildenafil citrate tab 20 mg
(Revatio)
1
TRACLEER - bosentan tab 62.5
mg
BROMPHENIRAMINE TANNATE
- brompheniramine tannate chew
tab 12 mg
1
carbinoxamine maleate soln
4 mg/5ml
1
carbinoxamine maleate tab 4 mg
1
cetirizine hcl oral soln 1 mg/ml
(5 mg/5ml)
1
•
CLARINEX - desloratadine tab 5
mg
3
• •
CLARINEX - desloratadine syrup
0.5 mg/ml
3
• •
3
• •
• •
CLARINEX REDITABS desloratadine tab orally
disintegrating 2.5 mg
3
• •
• •
CLARINEX REDITABS desloratadine tab orally
disintegrating 5 mg
1
• •
CLEMASTINE FUMARATE clemastine fumarate syrup 0.67
mg/5ml (0.5 mg/5ml base eq)
clemastine fumarate tab 2.68 mg
1
• •
cyproheptadine hcl syrup
2 mg/5ml
1
• •
cyproheptadine hcl tab 4 mg
1
1
•
•
• •
desloratadine tab orally
disintegrating 2.5 mg (Clarinex
reditabs)
2
•
• •
1
•
TRACLEER - bosentan tab 125 mg 2
•
• •
desloratadine tab orally
disintegrating 5 mg (Clarinex
reditabs)
desloratadine tab 5 mg (Clarinex)
1
•
1
RESPIRATORY AGENTS
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
AEROHIST - chlorpheniraminemethscopolamine tab sr 12hr
8-2.5 mg
3
DEXCHLORPHENIRAMINE
MALEA - dexchlorpheniramine
maleate syrup 2 mg/5ml
3
brompheniramine maleate tab sr
12hr 6 mg
1
DICOPANOL FUSEPAQ diphenhydramine hcl for oral
susp 5 mg/ml (compound kit)
diphenhydramine hcl cap 25 mg
1
diphenhydramine hcl cap 50 mg
1
ANTIHISTAMINES
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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Quantity Limits
"Smart" PA
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Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
63
diphenhydramine hcl elixir
12.5 mg/5ml
1
diphenhydramine hcl inj 50 mg/
ml
1
DOXYTEX - doxylamine succinate
liquid 2.5 mg/2.5ml
3
ED CHLORPED chlorpheniramine tannate susp 2
mg/ml
3
ED-CHLOR-TAN chlorpheniramine tannate tab 8
mg
3
fexofenadine hcl tab 60 mg
1
KARBINAL ER - carbinoxamine
maleate er susp 4 mg/5ml
3
levocetirizine dihydrochloride
soln 2.5 mg/5ml (0.5 mg/ml)
(Xyzal)
1
•
levocetirizine dihydrochloride
tab 5 mg (Xyzal)
1
•
PALGIC - carbinoxamine maleate
tab 4 mg
3
PALGIC - carbinoxamine maleate
soln 4 mg/5ml
3
1
promethazine hcl syrup
6.25 mg/5ml
1
promethazine hcl tab 12.5 mg
1
promethazine hcl tab 25 mg
1
promethazine hcl tab 50 mg
1
RESPA-BR - brompheniramine
maleate tab sr 12hr 11 mg
3
XYZAL - levocetirizine
dihydrochloride tab 5 mg
3
64
•
• •
3
• •
NASAL AGENTS - SYSTEMIC and TOPICAL
3
ASTELIN - azelastine hcl nasal
spray 137 mcg/spray (1 mg/ml)
3
ASTEPRO - azelastine hcl nasal
spray 0.15% (205.5 mcg/spray)
ATROVENT - ipratropium bromide 3
nasal soln 0.03% (21 mcg/spray)
ATROVENT - ipratropium bromide 3
nasal soln 0.06% (42 mcg/spray)
azelastine hcl nasal spray 0.15% 1
(205.5 mcg/spray) (Astepro)
1
azelastine hcl nasal spray
137 mcg/spray (1 mg/ml)
3
BACTROBAN NASAL - mupirocin
calcium nasal oint 2%
•
BECONASE AQ - beclomethasone 3
dipropionate monohyd nasal
susp 42 mcg/spray
1
budesonide nasal susp 32 mcg/
act (Rhinocort aqua)
3
•
DYMISTA - azelastine hclfluticasone prop nasal spray
137-50 mcg/act
•
FLONASE - fluticasone propionate 3
nasal susp 50 mcg/act
1
FLUNISOLIDE - flunisolide nasal
soln 25 mcg/act (0.025%)
1
FLUNISOLIDE - flunisolide nasal
soln 29 mcg/act (0.025%)
flunisolide nasal soln 25 mcg/act 1
(0.025%) (Flunisolide)
1
fluticasone propionate nasal
susp 50 mcg/act (Flonase)
1
ipratropium bromide nasal soln
0.03% (21 mcg/spray) (Atrovent)
1
ipratropium bromide nasal soln
0.06% (42 mcg/spray) (Atrovent)
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Tier
Drug Name
XYZAL - levocetirizine
dihydrochloride soln 2.5 mg/5ml
(0.5 mg/ml)
PBZ - tripelennamine hcl tab 50 mg 3
1
promethazine hcl suppos
12.5 mg
1
promethazine hcl suppos 25 mg
promethazine hcl suppos 50 mg
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
NASONEX - mometasone furoate
nasal susp 50 mcg/act
2
•
ALLFEN CDX - guaifenesincodeine tab 400-20 mg
3
olopatadine hcl nasal soln 0.6%
(Patanase)
1
•
ALLFEN CDX - guaifenesincodeine liquid 200-20 mg/5ml
3
OMNARIS - ciclesonide nasal susp
50 mcg/act
3
• •
AMBIFED CD - pseudoephedrine
w/ cod-gg tab 30-10-400 mg
3
PATANASE - olopatadine hcl nasal 3
soln 0.6%
1
pseudoephedrine hcl tab 30 mg
•
AMBIFED CDX - pseudoephedrine
w/ cod-gg tab 30-20-400 mg
3
AMBIFED-G CD pseudoephedrine w/ cod-gg tab
20-10-400 mg
3
AMBIFED-G CDX pseudoephedrine w/ cod-gg tab
20-20-400 mg
3
benzonatate cap 100 mg
(Tessalon perles)
1
benzonatate cap 200 mg
1
brompheniramine &
pseudoephedrine tab sr 12hr
6-45 mg
1
BRONCOPECTOL - phenylephchlorphen w/ dm-gg syrup
5-2-5-75 mg/5ml
3
CAPCOF - phenylephrinechlorphen w/ codeine syrup
5-2-10 mg/5ml
3
CARBAPHEN 12 - phenylephchlorphen-carbetapentane liqd
10-4-27.5 mg/5ml
3
CARBAPHEN 12 PED phenyleph-chlorphencarbetapentane susp
2.5-1.25-7.5 mg/ml
3
pseudoephedrine hcl tab 60 mg
1
QNASL - beclomethasone
dipropionate nasal aerosol 80
mcg/act
3
RHINOCORT AQUA - budesonide
nasal susp 32 mcg/act
3
TYZINE - tetrahydrozoline hcl
nasal soln 0.1%
3
TYZINE PEDIATRIC NASAL DR
- tetrahydrozoline hcl nasal soln
0.05%
3
VERAMYST - fluticasone furoate
nasal susp 27.5 mcg/spray
3
• •
ZETONNA - ciclesonide nasal
aerosol soln 37 mcg/act (50 mcg/
valve)
3
• •
COUGH/COLD/ALLERGY
• •
• •
acetylcysteine inhal soln 10%
1
acetylcysteine inhal soln 20%
1
ALAHIST AC - phenylephrine w/
codeine liqd 7.5-10 mg/5ml
3
ALAHIST DHC - phenylephrinedihydrocodeine liqd 7.5-3 mg/5ml
3
ALBATUSSIN - phenylephrinecarbetapentane-gg cap
10-25-400 mg
3
chlorpheniramine w/ codeine
liquid 2-10 mg/5ml
1
3
• •
ALBATUSSIN NN - phenylephdm-pyril-pot guai-sod cit-cit acid
liquid
3
CLARINEX-D 12 HOUR
- desloratadine &
pseudoephedrine tab sr 12hr
2.5-120 mg
ALLFEN CD - guaifenesin-codeine
tab 400-10 mg
3
CLARINEX-D 24 HOUR
- desloratadine &
3
• •
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
65
GILTUSS - phenylephrine w/ dmgg liqd 10-28-388 mg/5ml
3
3
CODAR AR - chlorpheniramine w/
codeine liquid 2-8 mg/5ml
3
CODAR D - pseudoephedrine w/
codeine liquid 30-8 mg/5ml
3
GILTUSS PED-C - phenylephrine
w/ codeine-gg liquid 2.5-3-50 mg/
ml
3
COTAB A - chlorpheniramine w/
codeine tab 4-10 mg
3
GILTUSS TR - phenylephrine w/
dm-gg cap 7-14-288 mg
3
GILTUSS TR - phenylephrine w/
dm-gg tab 10-28-388 mg
3
COTAB AX - chlorpheniramine w/
codeine tab 4-20 mg
COTABFLU - codeinechlorpheniramine-acetaminophen
tab 20-4-500 mg
GILTUSS TR - phenylephrine w/
dm-gg tab sr 12hr 20-30-600 mg
3
3
guaifenesin-codeine liquid
200-8 mg/5ml
1
CPB WC - pseudoephedrinebromphen-codeine liq 10-1.3-6.3
mg/5ml
3
guaifenesin-codeine liquid
225-7.5 mg/5ml
1
3
guaifenesin-codeine soln
100-10 mg/5ml
1
DECON-A - brompheniramine &
phenylephrine elixir 2-5 mg/5ml
3
guaifenesin-codeine soln
100-6.3 mg/5ml
1
DECON-G - phenylephrinebrompheniramine-guaifenesin
liqd 2-1-40 mg/ml
DESPEC-EXP - pseudoephedrinedihydrocodeine-gg syrup
15-7.5-100 mg/5ml
3
DESPEC-PDC - phenylephrinechlorphen-dihydrocodeine liqd
7.5-2.5-3 mg/5ml
3
DEX-TUSS - guaifenesin-codeine
liquid 300-10 mg/5ml
3
DEXTROMETHORPHAN
HBR/CHLO - phenylephrinechlorphen-dm liquid
1.75-0.75-2.75 mg/ml
1
DONATUSS DC - phenylephrinedihydrocodeine-gg syrup
7.5-7.5-50 mg/5ml
3
ENDACOF-DC - pseudoephedrine
w/ codeine liquid 30-10 mg/5ml
3
EXACTUSS - phenylephrine w/
dm-gg liqd 10-28-388 mg/5ml
3
GILPHEX TR - phenylephrineguaifenesin tab 10-388 mg
3
66
1
hydrocod polst-chlorphen polst
cr susp 10-8 mg/5ml (Tussionex
pennkineti)
1
hydrocodone w/ homatropine
syrup 5-1.5 mg/5ml
1
hydrocodone w/ homatropine
tab 5-1.5 mg
HYPER-SAL - sodium chloride soln 3
nebu 7%
HYPERSAL - sodium chloride soln 3
nebu 3.5%
HYPERSAL - sodium chloride soln 3
nebu 7%
3
J-COF DHC - pseudoephedbromphen-dihydrocodeine liqd
15-3-7.5 mg/5ml
3
J-MAX DHC - dihydrocodeineguaifenesin liquid 7.5-100
mg/5ml
LARTUS - phenyleph-chlorphen w/ 3
dm-gg liquid 5-2-15-150 mg/5ml
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
pseudoephedrine tab sr 24hr
5-240 mg
Drug Tier
2015
LORTUSS EX - pseudoephedrine
w/ cod-gg liqd 22.5-10-100
mg/5ml
3
MUCINEX D - pseudoephedrineguaifenesin tab sr 12hr 60-600
mg
3
LORTUSS EX - pseudoephedrine
w/ cod-gg liquid 30-10-100
mg/5ml
3
MUCINEX DM dextromethorphan-guaifenesin
tab sr 12hr 30-600 mg
3
M-CLEAR - guaifenesin-codeine
cap 200-9 mg
3
NEBUSAL - sodium chloride soln
nebu 6%
3
NEO AC - pseudoephedrinepyrilamine-codeine syrup
30-15-10 mg/5ml
3
NEOTUSS PLUS - phenylephrinechlorphen-dm liquid 7.5-4-30
mg/5ml
3
NEOTUSS-D - pseudoephedchlorphen w/ dm-gg liqd
30-2-30-200 mg/5ml
3
NORTUSS-EX dextromethorphan-guaifenesin
liquid 20-200 mg/5ml
3
NOTUSS-NX - codeinechlorcyclizine liquid 10-9.375
mg/5ml
3
NOTUSS-NXD - codeinepseudoephedrine-chlorcyclizine
liq 10-30-9.375mg/5ml
3
PANATUSS DXP - phenylephrinedexbromphen-dm-gg liquid
5-1-15-100 mg/5ml
3
PEDIATEX TD - triprolidine &
pseudoephedrine liquid 0.938-10
mg/ml
3
PEDIATEX TDM - pseudoephedtriprolidine-dm susp 10-0.938-4
mg/ml
3
PHENFLU CD - phenylephrinecodeine-guaifenesin-apap tab
10-10-400-500 mg
3
PHENFLU CDX - phenylephrinecodeine-guaifenesin-apap tab
10-20-400-500 mg
3
M-END MAX D - pseudoephedrine- 3
dexbromphen-codeine liqd
20-0.667-6 mg/5ml
3
M-END PE - phenylephrinebromphen w/ codeine liqd
3.33-1.33-6.33 mg/5ml
MAR-COF BP - pseudoephedrine- 3
bromphen-codeine liqd 30-2-7.5
mg/5ml
3
MAR-COF CG EXPECTORANT
- guaifenesin-codeine liquid
225-7.5 mg/5ml
3
MAXIFED CD - pseudoephedrine
w/ cod-gg tab 60-10-400 mg
MAXIFED CDX - pseudoephedrine 3
w/ cod-gg tab 60-20-400 mg
3
MAXIFED-G - pseudoephedrineguaifenesin tab 40-400 mg
3
MAXIFED-G CD pseudoephedrine w/ cod-gg tab
40-10-400 mg
3
MAXIFED-G CDX pseudoephedrine w/ cod-gg tab
40-20-400 mg
3
MAXIFLU CD - pseudoephedcodeine-guaifenesin-apap tab
40-10-400-500 mg
3
MAXIFLU CDX - pseudoephedcodeine-guaifenesin-apap tab
60-20-400-500 mg
MAXIPHEN CD - phenylephrine w/ 3
codeine-gg tab 10-10-400 mg
3
MAXIPHEN CDX - phenylephrine
w/ codeine-gg tab 10-20-400 mg
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
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Drug Name
Drug Tier
2015
67
phenylephrine w/ dm-gg liqd
10-15-300 mg/5ml
1
phenylephrine w/ dm-gg liqd
10-30-200 mg/5ml
1
phenylephrine w/ dm-gg liqd
2.5-5-50 mg/ml
1
phenylephrine w/ dm-gg liqd
2.5-7.5-88 mg/ml
1
phenylephrinebrompheniramine-dm liquid
7.5-4-15 mg/5ml
1
phenylephrine-chlorphen-dm
liquid 10-4-15 mg/5ml
1
phenylephrine-chlorphen-dm
liquid 3.5-1-3 mg/ml
1
phenylephrine-guaifenesin liqd
7.5-100 mg/5ml (1.5-20 mg/ml)
1
phenylephrine-promethazine
w/ codeine syrup
5-6.25-10 mg/5ml
1
PHENYLHISTINE DH pseudoephedrine-chlorphen w/
codeine liq 30-2-10 mg/5ml
3
POLY HIST DHC - phenylephrinepyrilamine-dihydrocod liqd
5-7.5-7.5 mg/5ml
3
POLY HIST NC pseudoephedrine-triprolidine w/
cod liquid 15-1.25-10 mg/5ml
3
POLY-TUSSIN - codeinechlorcyclizine liquid 10-9.375
mg/5ml
3
POLY-TUSSIN AC phenylephrine-bromphen w/
codeine liqd 7.5-4-10 mg/5ml
3
POLY-TUSSIN AC phenylephrine-bromphen w/
codeine liquid 10-4-10 mg/5ml
3
POLY-TUSSIN D - codeinepseudoephedrine-chlorcyclizine
liq 10-30-9.375mg/5ml
3
68
POLY-TUSSIN DHC phenylephrine-bromphendihydrocodeine liqd 7.5-4-3
mg/5ml
3
POLY-TUSSIN EX phenylephrine-dihydrocodeine-gg
syrup 5-7.5-50 mg/5ml
3
PRO-CLEAR AC - codeinepyrilamine syrup 9-8.33 mg/5ml
3
PRO-RED AC - phenylephrinepyrilamine w/ codeine syrup
5-8.33-9 mg/5ml
3
PRO-RED AC - phenylephrinedexchlorphenir-codeine syrup
5-1-9 mg/5ml
3
promethazine & phenylephrine
syrup 6.25-5 mg/5ml
1
PROMETHAZINE VC promethazine & phenylephrine
syrup 6.25-5 mg/5ml
1
PROMETHAZINE VC PLAIN promethazine & phenylephrine
syrup 6.25-5 mg/5ml
1
PROMETHAZINE VC/CODEINE phenylephrine-promethazine w/
codeine syrup 5-6.25-10 mg/5ml
1
promethazine w/ codeine syrup
6.25-10 mg/5ml
1
promethazine-dm syrup
6.25-15 mg/5ml
1
1
PROMETHAZINE/
PHENYLEPHRIN - promethazine
& phenylephrine syrup 6.25-5
mg/5ml
1
pseudoeph-chlorphen
w/ hydrocodone soln
60-4-5 mg/5ml (Zutripro)
1
pseudoephed-bromphen-dm
syrup 30-2-10 mg/5ml
pseudoephedrine w/ cod-gg soln 1
30-10-100 mg/5ml
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
pseudoephedrine w/ cod-gg
syrup 30-10-100 mg/5ml
(Suttar-sf)
1
TESSALON - benzonatate cap 200
mg
3
pseudoephedrinebromphen-codeine liq
10-1.33-6.33 mg/5ml
TESSALON PERLES benzonatate cap 100 mg
3
1
3
pseudoephedrine-guaifenesin
tab 60-400 mg
1
TGQ 15DM/5PEH/2CPM phenylephrine-chlorphen-dm
syrup 5-2-15 mg/5ml
3
TGQ 30PSE/150GFN/15DM pseudoephedrine w/ dm-gg syrup
30-15-150 mg/5ml
3
RELHIST - bromphen tanphenyleph tan chew tab 6-15 mg
RESCON-JR - chlorpheniramine &
phenylephrine tab sr 12hr 4-20
mg
3
TGQ 30PSE/3BRM/15DM pseudoephed-bromphen-dm
syrup 30-3-15 mg/5ml
3
RESCON-JR dexchlorpheniraminephenylephrine tab sr 12hr 3-20
mg
3
TGQ 50PSE/3BRM/30DM pseudoephed-bromphen-dm
syrup 50-3-30 mg/5ml
1
3
TRICODE AR - pseudoephedrinechlorphen w/ codeine liq 30-2-8
mg/5ml
3
RESCON-MX dexchlorpheniraminephenylephrine tab sr 12hr 6-40
mg
TRICODE GF - pseudoephedrine
w/ cod-gg liquid 30-8-200 mg/5ml
3
REZIRA - pseudoephedrine w/
hydrocodone soln 60-5 mg/5ml
3
TUSNEL - brompheniramine w/
dm-gg cap 2-15-200 mg
3
RYDEX - pseudoephedrinebromphen-codeine liq
10-1.33-6.33 mg/5ml
3
TUSSICAPS - hydrocod polstchlorphen polst cap sr 12hr 5-4
mg
3
SEMPREX-D - acrivastine &
pseudoephedrine cap 8-60 mg
3
3
sodium chloride soln nebu 0.9%
1
TUSSICAPS - hydrocod polstchlorphen polst cap sr 12hr 10-8
mg
sodium chloride soln nebu 10%
1
sodium chloride soln nebu 3%
1
sodium chloride soln nebu 7%
(Hyper-sal)
1
STATUSS GREEN - codeinepseudoephedrine-chlorcyclizine
liq 9-30-12.5 mg/5ml
3
SUTTAR-SF - pseudoephedrine w/
cod-gg syrup 30-10-100 mg/5ml
3
SUTTAR-2 - pseudoephedrine w/
cod-gg syrup 30-10-100 mg/5ml
3
•
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
TUSSIONEX PENNKINETIC EXT - 3
hydrocod polst-chlorphen polst cr
susp 10-8 mg/5ml
3
VANACOF CD - phenylephrinedexchlorphenir-codeine liquid
5-1-10 mg/5ml
3
VITUZ - hydrocodonechlorpheniramine soln 5-4
mg/5ml
Z-TUSS AC - chlorpheniramine w/ 3
codeine liquid 2-9 mg/5ml
3
Z-TUSS E - pseudoephedrine w/
cod-gg liquid 30-9-200 mg/5ml
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
69
ANTIASTHMATIC and BRONCHODILATOR AGENTS
• •
ACCOLATE - zafirlukast tab 10 mg 3
70
ACCOLATE - zafirlukast tab 20 mg
3
ACCUNEB - albuterol sulfate soln
nebu 0.63 mg/3ml (base equiv)
3
ACCUNEB - albuterol sulfate soln
nebu 1.25 mg/3ml (base equiv)
3
ADVAIR DISKUS - fluticasonesalmeterol aer powder ba 100-50
mcg/dose
2
•
ADVAIR DISKUS - fluticasonesalmeterol aer powder ba 250-50
mcg/dose
2
•
ADVAIR DISKUS - fluticasonesalmeterol aer powder ba 500-50
mcg/dose
2
•
ADVAIR HFA - fluticasonesalmeterol inhal aerosol 45-21
mcg/act
2
•
ADVAIR HFA - fluticasonesalmeterol inhal aerosol 115-21
mcg/act
2
•
ADVAIR HFA - fluticasonesalmeterol inhal aerosol 230-21
mcg/act
2
•
AEROSPAN - flunisolide hfa inhal
aerosol 80 mcg/act
3
•
albuterol sulfate soln nebu
0.083% (2.5 mg/3ml)
1
albuterol sulfate soln nebu 0.5%
(5 mg/ml)
1
albuterol sulfate soln nebu
0.63 mg/3ml (base equiv)
1
albuterol sulfate soln nebu
1.25 mg/3ml (base equiv)
1
albuterol sulfate syrup 2 mg/5ml
1
albuterol sulfate tab sr 12hr 4 mg
(Vospire er)
1
albuterol sulfate tab sr 12hr 8 mg
(Vospire er)
1
albuterol sulfate tab 2 mg
1
albuterol sulfate tab 4 mg
1
• •
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Specialty
Quantity Limits
"Smart" PA
•
Drug Name
Drug Tier
ZODRYL AC 25 - chlorpheniramine 3
w/ codeine susp 0.333-1 mg/ml
ZODRYL AC 30 - chlorpheniramine 3
w/ codeine susp 0.286-1 mg/ml
ZODRYL AC 35 - chlorpheniramine 3
w/ codeine susp 0.25-1 mg/ml
ZODRYL AC 40 - chlorpheniramine 3
w/ codeine susp 0.222-1 mg/ml
3
ZODRYL DAC 25 pseudoephedrine-chlorphen w/
codeine susp 5-0.333-1 mg/ml
3
ZODRYL DAC 30 pseudoephedrine-chlorphen w/
codeine susp 4.286-0.286-1 mg/
ml
3
ZODRYL DAC 35 pseudoephedrine-chlorphen w/
codeine susp 3.75-0.25-1 mg/ml
3
ZODRYL DAC 40 pseudoephedrine-chlorphen w/
codeine susp 3.333-0.222-1 mg/
ml
3
ZODRYL DEC 25 pseudoephedrine w/ cod-gg susp
5-1-20 mg/ml
3
ZODRYL DEC 30 pseudoephedrine w/ cod-gg susp
4.286-1-20 mg/ml
3
ZODRYL DEC 35 pseudoephedrine w/ cod-gg susp
3.75-1-20 mg/ml
3
ZODRYL DEC 40 pseudoephedrine w/ cod-gg susp
3.333-1-20 mg/ml
ZONATUSS - benzonatate cap 150 3
mg
ZUTRIPRO - pseudoeph-chlorphen 3
w/ hydrocodone soln 60-4-5
mg/5ml
Prior Authorization
Drug Name
Drug Tier
2015
ALVESCO - ciclesonide inhal
aerosol 80 mcg/act
3
•
ALVESCO - ciclesonide inhal
aerosol 160 mcg/act
3
•
ANORO ELLIPTA - umeclidiniumvilanterol aero powd ba 62.5-25
mcg/inh
2
ARCAPTA NEOHALER indacaterol maleate inhal powder
cap 75 mcg (base equiv)
3
ASMANEX HFA - mometasone
furoate inhal aerosol suspension
100 mcg/act
ATROVENT HFA - ipratropium
bromide hfa inhal aerosol 17
mcg/act
2
•
2
•
•
BREO ELLIPTA - fluticasone
furoate-vilanterol aero powd ba
100-25 mcg/inh
3
•
BRONCOMAR-1 - theophyllinepse-gg elixir 150-30-150
mg/15ml
3
3
BRONDIL - dyphylline-guaifenesin
liqd 100-100 mg/15ml
3
•
ASMANEX HFA - mometasone
furoate inhal aerosol suspension
200 mcg/act
3
BROVANA - arformoterol tartrate
soln nebu 15 mcg/2ml (base
equiv)
budesonide inhalation susp
0.25 mg/2ml (Pulmicort)
1
•
ASMANEX TWISTHALER 120 ME
- mometasone furoate inhal powd
220 mcg/inh (breath activated)
2
•
budesonide inhalation susp
0.5 mg/2ml (Pulmicort)
1
•
•
•
2
COMBIVENT - ipratropiumalbuterol aerosol 18-103 mcg/act
(20-120mcg/act)
2
ASMANEX TWISTHALER 14 MET
- mometasone furoate inhal powd
220 mcg/inh (breath activated)
•
ASMANEX TWISTHALER 30 ME mometasone furoate inhal powd
220 mcg/inh (breath activated)
•
COMBIVENT RESPIMAT ipratropium-albuterol inhal
aerosol soln 20-100 mcg/act
2
2
ASMANEX TWISTHALER 30 MET
- mometasone furoate inhal powd
110 mcg/inh (breath activated)
•
CROMOLYN SODIUM - cromolyn
sodium soln nebu 20 mg/2ml
1
2
1
•
ASMANEX TWISTHALER 60 MET
- mometasone furoate inhal powd
220 mcg/inh (breath activated)
2
•
cromolyn sodium soln nebu
20 mg/2ml
DALIRESP - roflumilast tab 500
mcg
3
•
3
•
DULERA - mometasone furoateformoterol fumarate aerosol
100-5 mcg/act
2
ASMANEX TWISTHALER 7 METE
- mometasone furoate inhal powd
110 mcg/inh (breath activated)
•
2
•
DULERA - mometasone furoateformoterol fumarate aerosol
200-5 mcg/act
2
ASMANEX 14 METERED DOSES
- mometasone furoate inhal powd
220 mcg/inh (breath activated)
•
2
•
DUONEB - ipratropium-albuterol
nebu soln 0.5-2.5(3) mg/3ml
3
ASMANEX 60 METERED DOSES
- mometasone furoate inhal powd
220 mcg/inh (breath activated)
dyphylline-guaifenesin liqd
100-100 mg/5ml
1
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
71
MAXAIR AUTOHALER - pirbuterol
acetate breath activated inhal
aerosol 200mcg/inh
3
METAPROTERENOL SULFATE metaproterenol sulfate tab 10 mg
1
METAPROTERENOL SULFATE metaproterenol sulfate tab 20 mg
1
•
1
•
METAPROTERENOL SULFATE metaproterenol sulfate syrup 10
mg/5ml
montelukast sodium chew tab
4 mg (base equiv) (Singulair)
1
•
montelukast sodium chew tab
5 mg (base equiv) (Singulair)
1
•
•
montelukast sodium
oral granules packet 4 mg
(base equiv) (Singulair)
1
•
•
montelukast sodium tab 10 mg
(base equiv) (Singulair)
1
•
PERFOROMIST - formoterol
fumarate soln nebu 20 mcg/2ml
3
•
PROAIR HFA - albuterol sulfate
inhal aero 108 mcg/act (90mcg
base equiv)
2
•
PROVENTIL HFA - albuterol
sulfate inhal aero 108 mcg/act
(90mcg base equiv)
3
•
PULMICORT - budesonide
inhalation susp 0.25 mg/2ml
3
•
PULMICORT - budesonide
inhalation susp 0.5 mg/2ml
3
•
PULMICORT - budesonide
inhalation susp 1 mg/2ml
2
•
PULMICORT FLEXHALER budesonide inhal aero powd 90
mcg/act (breath activated)
3
•
PULMICORT FLEXHALER budesonide inhal aero powd 180
mcg/act (breath activated)
3
•
•
•
•
•
Specialty
3
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Quantity Limits
LUFYLLIN - dyphylline tab 400 mg
1
ELIXOPHYLLIN - theophylline elixir 3
80 mg/15ml
2
FLOVENT DISKUS - fluticasone
propionate aer pow ba 50 mcg/
blister
2
FLOVENT DISKUS - fluticasone
propionate aer pow ba 100 mcg/
blister
2
FLOVENT DISKUS - fluticasone
propionate aer pow ba 250 mcg/
blister
2
FLOVENT HFA - fluticasone
propionate hfa inhal aero 44
mcg/act (50/valve)
2
FLOVENT HFA - fluticasone
propionate hfa inhal aer 110
mcg/act (125/valve)
2
FLOVENT HFA - fluticasone
propionate hfa inhal aer 220
mcg/act (250/valve)
FORADIL AEROLIZER - formoterol 2
fumarate inhal cap 12 mcg
1
ipratropium bromide inhal soln
0.02%
1
ipratropium-albuterol nebu soln
0.5-2.5(3) mg/3ml
LEVALBUTEROL - levalbuterol hcl 1
soln nebu conc 1.25 mg/0.5ml
(base equiv)
1
levalbuterol hcl soln nebu
0.31 mg/3ml (base equiv)
(Xopenex)
1
levalbuterol hcl soln nebu
0.63 mg/3ml (base equiv)
(Xopenex)
1
levalbuterol hcl soln nebu
1.25 mg/3ml (base equiv)
(Xopenex)
LUFYLLIN - dyphylline tab 200 mg 3
72
Drug Name
Drug Tier
dyphylline-guaifenesin tab
200-400 mg
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
PULMOPHYLLINE - theophylline
tab 50 mg & dietary management
cap pack
3
QVAR - beclomethasone
dipropionate inhal aero soln 40
mcg/act
2
•
QVAR - beclomethasone
dipropionate inhal aero soln 80
mcg/act
2
•
SENOPHYLLINE - theophylline tab
200 mg & dietary management
cap pack
3
SEREVENT DISKUS - salmeterol
xinafoate aer pow ba 50 mcg/
dose (base equiv)
2
SINGULAIR - montelukast sodium
tab 10 mg (base equiv)
3
•
SINGULAIR - montelukast sodium
chew tab 4 mg (base equiv)
3
SINGULAIR - montelukast sodium
chew tab 5 mg (base equiv)
THEO-24 - theophylline cap sr 24hr 2
100 mg
THEO-24 - theophylline cap sr 24hr 2
200 mg
THEO-24 - theophylline cap sr 24hr 2
300 mg
THEO-24 - theophylline cap sr 24hr 2
400 mg
1
THEOPHYLLINE - theophylline
elixir 80 mg/15ml
1
theophylline soln 80 mg/15ml
theophylline tab sr 12hr 100 mg
1
theophylline tab sr 12hr 200 mg
1
theophylline tab sr 12hr 300 mg
1
theophylline tab sr 12hr 450 mg
1
•
theophylline tab sr 24hr 400 mg
1
theophylline tab sr 24hr 600 mg
1
3
•
3
•
SINGULAIR - montelukast sodium
oral granules packet 4 mg (base
equiv)
3
•
TUDORZA PRESSAIR - aclidinium
bromide aerosol powd breath
activated 400 mcg/act
2
•
SPIRIVA HANDIHALER tiotropium bromide monohydrate
inhal cap 18 mcg (base equiv)
2
•
VENTOLIN HFA - albuterol sulfate
inhal aero 108 mcg/act (90mcg
base equiv)
SPIRIVA RESPIMAT - tiotropium
bromide monohydrate inhal
aerosol 2.5 mcg/act
2
•
STRIVERDI RESPIMAT olodaterol hcl inhal aerosol soln
2.5 mcg/act (base equiv)
3
•
SYMBICORT - budesonideformoterol fumarate dihyd
aerosol 80-4.5 mcg/act
2
•
SYMBICORT - budesonideformoterol fumarate dihyd
aerosol 160-4.5 mcg/act
2
•
terbutaline sulfate tab 2.5 mg
1
terbutaline sulfate tab 5 mg
1
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
VOSPIRE ER - albuterol sulfate tab 3
sr 12hr 4 mg
VOSPIRE ER - albuterol sulfate tab 3
sr 12hr 8 mg
3
XOPENEX - levalbuterol hcl soln
nebu 0.31 mg/3ml (base equiv)
3
XOPENEX - levalbuterol hcl soln
nebu 0.63 mg/3ml (base equiv)
3
XOPENEX - levalbuterol hcl soln
nebu 1.25 mg/3ml (base equiv)
3
XOPENEX CONCENTRATE levalbuterol hcl soln nebu conc
1.25 mg/0.5ml (base equiv)
3
XOPENEX HFA - levalbuterol
tartrate inhal aerosol 45 mcg/act
(base equiv)
1
zafirlukast tab 10 mg (Accolate)
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
•
•
73
RESPIRATORY AGENTS - MISC.
OFEV - nintedanib esylate cap 100
mg (base equivalent)
3
•
•
•
OFEV - nintedanib esylate cap 150
mg (base equivalent)
3
•
PULMOZYME - dornase alfa inhal
soln 1 mg/ml
2
ESBRIET - pirfenidone cap 267 mg 3
KALYDECO - ivacaftor tab 150 mg 2
GASTROINTESTINAL AGENTS
LAXATIVES
CASCARA SAGRADA - cascara
sagrada fl ext 1 gm/ml
1
COLYTE-FLAVOR PACKS - peg
3350-kcl-na bicarb-nacl-na
sulfate for soln 227.1 gm
3
COLYTE-FLAVOR PACKS - peg
3350-kcl-na bicarb-nacl-na
sulfate for soln 240 gm
3
GOLYTELY - peg 3350-kcl-na
bicarb-nacl-na sulfate for soln
236 gm
3
GOLYTELY - peg 3350-kcl-na
bicarb-nacl-na sulfate packet
227.1 gm
3
HALFLYTELY BOWEL PREP/FLA
- bisacodyl tab & peg 3350-kclsod bicarb-nacl for soln kit
2
KRISTALOSE - lactulose oral
crystal packet 10 gm
3
KRISTALOSE - lactulose oral
crystal packet 20 gm
3
lactulose solution 10 gm/15ml
1
MOVIPREP - peg 3350-kcl-naclna sulfate-na acorbate-c for soln
100 gm
2
74
•
• •
•
•
• •
NULYTELY/FLAVOR PACKS - peg 3
3350-kcl-sod bicarb-nacl for soln
420 gm
2
OSMOPREP - sod phos monosod phos di tabs 1.102-0.398
gm(1.5gm na phos)
1
peg 3350-kcl-na bicarb-naclna sulfate for soln 236 gm
(Golytely)
1
peg 3350-kcl-na bicarb-nacl-na
sulfate for soln 240 gm (Colyteflavor packs)
1
peg 3350-kcl-sod bicarb-nacl
for soln 420 gm (Nulytely/flavor
pack)
1
polyethylene glycol 3350 oral
packet
1
polyethylene glycol 3350 oral
powder
3
PREPOPIK - sod picosulfate-mg
oxide-citric acid pack 10 mg-3.5
gm-12 gm
SUCLEAR - na sulf-k sulf-mg sulf & 3
peg 3350-nacl-na bicarb-kcl kit
SUPREP BOWEL PREP - sodium 2
sulfate-potassium sulfatemagnesium sulfate oral soln
3
VISICOL - sod phos monobasicsod phos dibasic-mcc tabs
1.102-0.398 gm
ANTIDIARRHEALS
diphenoxylate w/ atropine tab
2.5-0.025 mg (Lomotil)
1
DIPHENOXYLATE/ATROPINE
- diphenoxylate w/ atropine liq
2.5-0.025 mg/5ml
1
FULYZAQ - crofelemer tab delayed 3
release 125 mg
3
LOMOTIL - diphenoxylate w/
atropine tab 2.5-0.025 mg
1
loperamide hcl cap 2 mg
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
3
Prior Authorization
ZYFLO CR - zileuton tab sr 12hr
600 mg
•
•
•
Drug Name
Drug Tier
3
Specialty
ZYFLO - zileuton tab 600 mg
Quantity Limits
1
"Smart" PA
zafirlukast tab 20 mg (Accolate)
Prior Authorization
Drug Name
Drug Tier
2015
REZYST IM - probiotic product chew tab
3
REZYST SB - saccharomyces
boulardii chew tab 250 mg
3
VSL#3 DS - probiotic product packet
3
ANTACIDS
SODIUM BICARBONATE - sodium
bicarbonate powder
1
ULCER DRUGS
ACIPHEX - rabeprazole sodium ec
tab 20 mg
3
• •
ACIPHEX SPRINKLE rabeprazole sodium capsule
sprinkle dr 5 mg
3
• •
ACIPHEX SPRINKLE rabeprazole sodium capsule
sprinkle dr 10 mg
3
amoxicillin cap-clarithro tablansopraz cap dr therapy pack
(Prevpac)
1
ANASPAZ - hyoscyamine sulfate
tab disp 0.125 mg
3
ATROPEN - atropine sulfate im inj
device 0.25 mg/0.3ml
3
BELLADONNA & OPIUM belladonna alkaloids & opium
suppos 16.2-30 mg
1
BELLADONNA ALKALOIDS & OP
- belladonna alkaloids & opium
suppos 16.2-60 mg
1
belladonna alkaloidsphenobarbital elixir
16.2 mg/5ml (Donnatal)
1
BENTYL - dicyclomine hcl cap 10
mg
3
•
BENTYL - dicyclomine hcl tab 20
mg
3
•
BENTYL - dicyclomine hcl inj 10
mg/ml
3
BENTYL - dicyclomine hcl oral soln 3
10 mg/5ml
CANTIL - mepenzolate bromide tab 3
25 mg
3
CARAFATE - sucralfate tab 1 gm
•
CARAFATE - sucralfate susp 1
gm/10ml
2
cimetidine hcl soln 300 mg/5ml
1
cimetidine tab 200 mg
1
cimetidine tab 300 mg
1
cimetidine tab 400 mg
1
cimetidine tab 800 mg
1
3
clidinium & chlordiazepoxide
cap 2.5-5 mg (Librax)
1
3
CUVPOSA - glycopyrrolate oral
soln 1 mg/5ml
2
ATROPEN - atropine sulfate im inj
device 0.5 mg/0.7ml
•
3
CYTOTEC - misoprostol tab 100
mcg
3
ATROPEN - atropine sulfate im inj
device 1 mg/0.7ml
•
3
CYTOTEC - misoprostol tab 200
mcg
3
ATROPEN - atropine sulfate im inj
device 2 mg/0.7ml
•
3
AXID - nizatidine cap 300 mg
3
DEPRIZINE FUSEPAQ - ranitidine
hcl for oral susp 22.4 mg/ml
(compound kit)
3
AXID - nizatidine cap 150 mg
• •
•
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
3
AXID - nizatidine oral soln 15 mg/
ml
Quantity Limits
RESTORA RX - lactobacillus
casei-folic acid cap 60-1.25 mg
"Smart" PA
1
Prior Authorization
opium tincture 1% (10 mg/ml)
(morphine equiv)
Drug Name
Drug Tier
3
Specialty
MOTOFEN - difenoxin w/ atropine
tab 1-0.025 mg
Quantity Limits
1
"Smart" PA
loperamide hcl tab 2 mg
Prior Authorization
Drug Name
Drug Tier
2015
75
DEXILANT - dexlansoprazole cap
delayed release 30 mg
3
• •
DEXILANT - dexlansoprazole cap
delayed release 60 mg
3
• •
GABITIDINE - ranitidine hcl tab
150 mg & dietary management
cap pack
3
1
DICYCLOMINE HCL - dicyclomine
hcl oral soln 10 mg/5ml
1
GASTRINEX NF - hyoscyaminephenyltoloxamine cap 0.0625-15
mg
dicyclomine hcl cap 10 mg
(Bentyl)
1
GLYCATE - glycopyrrolate tab 1.5
mg
3
dicyclomine hcl tab 20 mg
(Bentyl)
1
glycopyrrolate inj 0.2 mg/ml
(Robinul)
1
DIGEX NF - hyoscyaminephenyltoloxamine cap 0.0625-15
mg
3
glycopyrrolate inj 0.4 mg/2ml
(0.2 mg/ml) (Robinul)
1
1
DONNATAL - pb-hyoscyatrop-scopol tab
16.2-0.1037-0.0194-0.0065 mg
3
glycopyrrolate inj 1 mg/5ml
(0.2 mg/ml) (Robinul)
glycopyrrolate inj 4 mg/20ml
(0.2 mg/ml) (Robinul)
1
DONNATAL - pb-hyoscyatrop-scopol elix
16.2-0.1037-0.0194-0.0065
mg/5ml
3
DONNATAL EXTENTABS - pbhyoscy-atrop-scopol tab cr
48.6-0.3111-0.0582-0.0195 mg
3
ESOMEPRAZOLE STRONTIUM
- esomeprazole strontium cap
delayed release 24.65 mg
3
• •
ESOMEPRAZOLE STRONTIUM
- esomeprazole strontium cap
delayed release 49.3 mg
3
• •
famotidine for susp 40 mg/5ml
(Pepcid)
1
famotidine tab 20 mg (Pepcid)
1
famotidine tab 40 mg (Pepcid)
1
FIRST-LANSOPRAZOLE lansoprazole susp 3 mg/ml
(compound kit)
3
• •
FIRST-OMEPRAZOLE omeprazole susp 2 mg/ml
(compound kit)
3
• •
76
•
glycopyrrolate tab 1 mg (Robinul) 1
glycopyrrolate tab 2 mg (Robinul 1
forte)
HELIDAC - metronidaz tab-tetracyc 3
cap-bis subsal chew tab therapy
pack
1
hyoscyamine sulfate elixir
0.125 mg/5ml
1
hyoscyamine sulfate soln
0.125 mg/ml
1
hyoscyamine sulfate tab disp
0.125 mg (Anaspaz)
1
hyoscyamine sulfate tab sl
0.125 mg (Levsin/sl)
1
hyoscyamine sulfate tab sr 12hr
0.375 mg (Levbid)
1
hyoscyamine sulfate tab
0.125 mg (Levsin)
1
lansoprazole cap delayed
release 15 mg (Prevacid)
1
lansoprazole cap delayed
release 30 mg (Prevacid)
LEVBID - hyoscyamine sulfate tab 3
sr 12hr 0.375 mg
•
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
LEVSIN - hyoscyamine sulfate tab
0.125 mg
3
•
LEVSIN/SL - hyoscyamine sulfate
tab sl 0.125 mg
3
LIBRAX - clidinium &
chlordiazepoxide cap 2.5-5 mg
3
methscopolamine bromide tab
2.5 mg (Pamine)
3
• •
•
OMEPRAZOLE + SYRSPEND
SF - omeprazole susp 2 mg/ml
(compound kit)
1
•
•
omeprazole cap delayed release
10 mg (Prilosec)
1
1
omeprazole cap delayed release
20 mg (Prilosec)
1
•
methscopolamine bromide tab
5 mg (Pamine forte)
1
omeprazole cap delayed release
40 mg (Prilosec)
1
•
misoprostol tab 100 mcg
(Cytotec)
1
omeprazole-sodium bicarbonate
cap 20-1100 mg (Zegerid)
1
•
misoprostol tab 200 mcg
(Cytotec)
1
omeprazole-sodium bicarbonate
cap 40-1100 mg (Zegerid)
3
•
NEXIUM - esomeprazole
magnesium for delayed release
susp pack 2.5 mg
3
• •
PAMINE - methscopolamine
bromide tab 2.5 mg
3
•
NEXIUM - esomeprazole
magnesium for delayed release
susp packet 5 mg
3
• •
PAMINE FORTE methscopolamine bromide tab 5
mg
3
NEXIUM - esomeprazole
magnesium for delayed release
susp packet 10 mg
3
• •
PAMINE FQ - methscopolamine
tab 5 mg & misc intestinal flora
reg cap
pantoprazole sodium ec tab
20 mg (base equiv) (Protonix)
1
•
NEXIUM - esomeprazole
magnesium for delayed release
susp packet 20 mg
3
• •
pantoprazole sodium ec tab
40 mg (base equiv) (Protonix)
1
•
NEXIUM - esomeprazole
magnesium for delayed release
susp packet 40 mg
3
• •
NEXIUM - esomeprazole
magnesium cap delayed release
40 mg
3
• •
nizatidine cap 150 mg
1
nizatidine cap 300 mg (Axid)
1
nizatidine oral soln 15 mg/ml
(Axid)
1
OMECLAMOX-PAK - amoxicillin
cap-clarithro tab w/ omepraz cap
dr therapy pack
3
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
1
pb-hyoscy-atrop-scopol elix
16.2-0.1037-0.0194-0.0065 mg/5ml
1
pb-hyoscy-atrop-scopol tab
16.2-0.1037-0.0194-0.0065 mg
(Donnatal)
3
PEPCID - famotidine tab 20 mg
•
PEPCID - famotidine tab 40 mg
3
PEPCID - famotidine for susp 40
mg/5ml
3
PREVACID - lansoprazole cap
delayed release 15 mg
3
PREVACID - lansoprazole cap
delayed release 30 mg
3
• •
PREVACID SOLUTAB lansoprazole tab delayed release
orally disintegrating 15 mg
3
• •
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
77
• •
ROBINUL - glycopyrrolate inj 0.4
mg/2ml (0.2 mg/ml)
3
•
ROBINUL - glycopyrrolate inj 1
mg/5ml (0.2 mg/ml)
3
•
ROBINUL - glycopyrrolate inj 4
mg/20ml (0.2 mg/ml)
3
•
ROBINUL FORTE - glycopyrrolate
tab 2 mg
3
•
SENTRADINE - ranitidine hcl tab
150 mg & dietary management
cap pack
3
SUCRALFATE - sucralfate susp 1
gm/10ml
1
sucralfate tab 1 gm (Carafate)
1
SYMAX DUOTAB - hyoscyamine
sulfate tab cr 0.375 mg (0.125
mg ir/0.25 mg cr)
3
• •
ZANTAC - ranitidine hcl tab 150
mg
3
3
• •
ZANTAC - ranitidine hcl tab 300
mg
3
3
• •
ZANTAC - ranitidine hcl effer tab
25 mg
3
PROTONIX - pantoprazole sodium
for delayed release susp packet
40 mg
3
•
PYLERA - bismuth subcitmetronidazole-tetracycline cap
140-125-125 mg
3
ZANTAC - ranitidine hcl syrup 15
mg/ml (75 mg/5ml)
ZEGERID - omeprazole-sodium
bicarbonate cap 20-1100 mg
3
• •
rabeprazole sodium ec tab
20 mg (Aciphex)
1
ZEGERID - omeprazole-sodium
bicarbonate cap 40-1100 mg
3
• •
ranitidine hcl cap 150 mg
1
3
• •
ranitidine hcl cap 300 mg
1
ZEGERID - omeprazole-sodium
bicarbonate powd pack for susp
20-1680 mg
ranitidine hcl syrup 15 mg/ml
(75 mg/5ml)
1
ZEGERID - omeprazole-sodium
bicarbonate powd pack for susp
40-1680 mg
3
• •
PREVACID SOLUTAB lansoprazole tab delayed release
orally disintegrating 30 mg
3
PREVPAC - amoxicillin capclarithro tab-lansopraz cap dr
therapy pack
3
PRILOSEC - omeprazole cap
delayed release 10 mg
3
• •
PRILOSEC - omeprazole cap
delayed release 40 mg
3
• •
PRILOSEC - omeprazole
magnesium for delayed release
susp packet 2.5 mg
3
• •
PRILOSEC - omeprazole
magnesium for delayed release
susp packet 10 mg
3
PROPANTHELINE BROMIDE propantheline bromide tab 15 mg
1
PROTONIX - pantoprazole sodium
ec tab 20 mg (base equiv)
3
PROTONIX - pantoprazole sodium
ec tab 40 mg (base equiv)
•
• •
•
•
ranitidine hcl tab 150 mg (Zantac) 1
ranitidine hcl tab 300 mg (Zantac) 1
ROBINUL - glycopyrrolate tab 1 mg 3
3
ROBINUL - glycopyrrolate inj 0.2
mg/ml
78
•
ANTIEMETICS
•
•
AKYNZEO - netupitantpalonosetron cap 300-0.5 mg
3
ANTIVERT - meclizine hcl tab 12.5
mg
3
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
ANTIVERT - meclizine hcl tab 25
mg
3
ondansetron hcl tab 8 mg
1
1
ANTIVERT - meclizine hcl tab 50
mg
3
ondansetron hcl tab 8 mg
(Zofran)
•
•
•
•
ANZEMET - dolasetron mesylate
tab 50 mg
ondansetron orally
disintegrating tab 4 mg (Zofran
odt)
1
3
ANZEMET - dolasetron mesylate
tab 100 mg
3
•
1
•
CESAMET - nabilone cap 1 mg
3
•
ondansetron orally
disintegrating tab 8 mg (Zofran
odt)
COCA COLA SYRUP phosphorated carbohydrate w/
caffeine syrup
3
SANCUSO - granisetron td patch
3.1 mg/24hr (contains 34.3 mg)
2
•
3
DICLEGIS - doxylamine-pyridoxine
tab delayed release 10-10 mg
3
TIGAN - trimethobenzamide hcl
cap 300 mg
2
dimenhydrinate tab 50 mg
1
dronabinol cap 10 mg (Marinol)
1
TRANSDERM-SCOP scopolamine td patch 72hr 1.5
mg
1
trimethobenzamide hcl cap
300 mg (Tigan)
1
dronabinol cap 2.5 mg (Marinol)
dronabinol cap 5 mg (Marinol)
1
ZOFRAN - ondansetron hcl tab 4
mg
3
•
ZOFRAN - ondansetron hcl tab 8
mg
3
•
ZOFRAN - ondansetron hcl oral
soln 4 mg/5ml
3
•
ZOFRAN ODT - ondansetron orally 3
disintegrating tab 4 mg
ZOFRAN ODT - ondansetron orally 3
disintegrating tab 8 mg
3
ZUPLENZ - ondansetron oral
soluble film 4 mg
3
ZUPLENZ - ondansetron oral
soluble film 8 mg
•
EMEND - aprepitant capsule 40 mg 2
EMEND - aprepitant capsule 80 mg 2
2
EMEND - aprepitant capsule 125
mg
2
EMEND - aprepitant capsule
therapy pack 80 & 125 mg
1
granisetron hcl tab 1 mg
GRANISOL - granisetron hcl oral
soln 2 mg/10ml (base equivalent)
3
MARINOL - dronabinol cap 2.5 mg
3
MARINOL - dronabinol cap 5 mg
3
MARINOL - dronabinol cap 10 mg
3
meclizine hcl tab 12.5 mg
1
meclizine hcl tab 25 mg
1
meclizine hcl tab 32 mg
1
ondansetron hcl oral soln
4 mg/5ml (Zofran)
1
ondansetron hcl tab 24 mg
1
ondansetron hcl tab 4 mg
(Zofran)
1
•
•
•
•
•
•
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
DIGESTIVE AIDS
•
•
•
CREON - pancrelipase (lip-protamyl) dr cap 3000-9500-15000
unit
2
CREON - pancrelipase (lip-protamyl) dr cap 6000-19000-30000
unit
2
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
79
CREON - pancrelipase (lip-protamyl) dr cap 12000-38000-60000
unit
2
VIOKACE - pancrelipase (lip-protamyl) tab 10440-39150-39150
unit
3
CREON - pancrelipase
(lip-prot-amyl) dr cap
24000-76000-120000 unit
2
VIOKACE - pancrelipase (lip-protamyl) tab 20880-78300-78300
unit
3
CREON - pancrelipase
(lip-prot-amyl) dr cap
36000-114000-180000 unit
2
ZENPEP - pancrelipase (lip-protamyl) dr cap 3000-10000-16000
unit
2
PANCREAZE - pancrelipase
(lip-prot-amyl) dr cap
4200-10000-17500 unit
3
ZENPEP - pancrelipase (lip-protamyl) dr cap 5000-17000-27000
unit
2
PANCREAZE - pancrelipase
(lip-prot-amyl) dr cap
10500-25000-43750 unit
3
ZENPEP - pancrelipase (lip-protamyl) dr cap 10000-34000-55000
unit
2
PANCREAZE - pancrelipase
(lip-prot-amyl) dr cap
16800-40000-70000 unit
3
ZENPEP - pancrelipase (lip-protamyl) dr cap 15000-51000-82000
unit
2
PANCREAZE - pancrelipase
(lip-prot-amyl) dr cap
21000-37000-61000 unit
3
ZENPEP - pancrelipase
(lip-prot-amyl) dr cap
20000-68000-109000 unit
2
PANCRELIPASE - pancrelipase
(lip-prot-amyl) dr cap
5000-17000-27000 unit
3
ZENPEP - pancrelipase
(lip-prot-amyl) dr cap
25000-85000-136000 unit
2
PERTZYE - pancrelipase (lip-protamyl) dr cap 8000-28750-30250
unit
3
ZENPEP - pancrelipase
(lip-prot-amyl) dr cap
40000-136000-218000 unit
2
PERTZYE - pancrelipase (lip-protamyl) dr cap 16000-57500-60500
unit
3
SUCRAID - sacrosidase soln 8500
unit/ml
3
GASTROINTESTINAL AGENTS- MISC.
mesalamine rectal enema 4 gm & 1
cleanser wipe kit (Rowasa)
3
ACTIGALL - ursodiol cap 300 mg
ULTRESA - pancrelipase (lip-protamyl) dr cap 13800-27600-27600
unit
3
ULTRESA - pancrelipase (lip-protamyl) dr cap 20700-41400-41400
unit
3
ULTRESA - pancrelipase (lip-protamyl) dr cap 23000-46000-46000
unit
3
80
•
AMITIZA - lubiprostone cap 8 mcg
3
AMITIZA - lubiprostone cap 24 mcg 3
APRISO - mesalamine cap sr 24hr 3
0.375 gm
2
ASACOL - mesalamine tab
delayed release 400 mg
2
ASACOL HD - mesalamine tab
delayed release 800 mg
3
AURYXIA - ferric citrate tab 1 gm
(210 mg ferric iron)
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
AZULFIDINE - sulfasalazine tab
500 mg
3
FOSRENOL - lanthanum
carbonate chew tab 1000 mg
AZULFIDINE EN-TABS sulfasalazine tab delayed release
500 mg
3
balsalazide disodium cap
750 mg (Colazal)
1
calcium acetate (phosphate
binder) cap 667 mg (169 mg
ca) (Phoslo)
1
calcium acetate (phosphate
binder) tab 667 mg (Eliphos)
1
CANASA - mesalamine suppos
1000 mg
2
GASTROCROM - cromolyn sodium 3
oral conc 100 mg/5ml
GATTEX - teduglutide (rdna) for inj 3
kit 5 mg
3
GIAZO - balsalazide disodium tab
1.1 gm
1
lactulose (encephalopathy)
solution 10 gm/15ml
LIALDA - mesalamine tab delayed 2
release 1.2 gm
LINZESS - linaclotide cap 145 mcg 2
CHENODAL - chenodiol tab 250
mg
3
CIMZIA - certolizumab pegol for inj
kit 2 x 200 mg
3
CIMZIA - certolizumab pegol inj kit
2 x 200 mg/ml
3
CIMZIA STARTER KIT certolizumab pegol inj kit 6 x 200
mg/ml
3
COLAZAL - balsalazide disodium
cap 750 mg
LINZESS - linaclotide cap 290 mcg
LOTRONEX - alosetron hcl tab 0.5
mg (base equiv)
3
LOTRONEX - alosetron hcl tab 1
mg (base equiv)
3
mesalamine enema 4 gm
1
metoclopramide hcl soln
5 mg/5ml (10 mg/10ml)
1
1
3
metoclopramide hcl tab 10 mg
(Reglan)
1
cromolyn sodium oral conc
100 mg/5ml (Gastrocrom)
1
metoclopramide hcl tab 5 mg
(Reglan)
3
DELZICOL - mesalamine cap dr
400 mg
2
METOZOLV ODT metoclopramide hcl orally
disintegrating tab 5 mg
DEXPANTHENOL - dexpanthenol
inj 250 mg/ml
1
3
DIPENTUM - olsalazine sodium
cap 250 mg
3
METOZOLV ODT metoclopramide hcl orally
disintegrating tab 10 mg
2
ELIPHOS - calcium acetate
(phosphate binder) tab 667 mg
3
PENTASA - mesalamine cap cr
250 mg
2
ENTEREG - alvimopan cap 12 mg
3
PENTASA - mesalamine cap cr
500 mg
2
PHOSLO - calcium acetate
(phosphate binder) cap 667 mg
(169 mg ca)
3
FOSRENOL - lanthanum
carbonate chew tab 500 mg
FOSRENOL - lanthanum
carbonate chew tab 750 mg
2
•
•
• •
•
• •
•
• •
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
2
2
•
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
81
1
VELPHORO - sucroferric
oxyhydroxide chew tab 500 mg
3
REGLAN - metoclopramide hcl tab
5 mg
3
REGLAN - metoclopramide hcl tab
10 mg
3
RELISTOR - methylnaltrexone
bromide inj 8 mg/0.4ml (20 mg/
ml)
2
methenamine-hyos-meth bluesod phos-phen sal tab 81.6 mg
1
1
RELISTOR - methylnaltrexone
bromide inj 12 mg/0.6ml (20 mg/
ml)
2
methenamine-hyosamine-meth
blue-sod phos tab 81.6 mg
(Urogesic-blue)
1
RELISTOR - methylnaltrexone
bromide inj kit 12 mg/0.6ml
2
methenamine-hyosc-meth bluesod phos-phen sal cap 120 mg
3
RENAGEL - sevelamer hcl tab 400
mg
3
FURADANTIN - nitrofurantoin susp
25 mg/5ml
3
RENAGEL - sevelamer hcl tab 800
mg
3
HIPREX - methenamine hippurate
tab 1 gm
3
RENVELA - sevelamer carbonate
tab 800 mg
2
MACROBID - nitrofurantoin
monohydrate macrocrystalline
cap 100 mg
RENVELA - sevelamer carbonate
packet 0.8 gm
2
MACRODANTIN - nitrofurantoin
macrocrystalline cap 25 mg
3
RENVELA - sevelamer carbonate
packet 2.4 gm
2
MACRODANTIN - nitrofurantoin
macrocrystalline cap 50 mg
3
ROWASA - mesalamine rectal
enema 4 gm & cleanser wipe kit
3
MACRODANTIN - nitrofurantoin
macrocrystalline cap 100 mg
3
SEVELAMER CARBONATE sevelamer carbonate tab 800 mg
1
methenamine hippurate tab 1 gm
(Hiprex)
1
SFROWASA - mesalamine sulfitefree (sf) enema 4 gm/60ml
3
1
sulfasalazine tab delayed
release 500 mg (Azulfidine entabs)
1
METHENAMINE MANDELATE methenamine mandelate tab 0.5
gm
methenamine mandelate tab
1 gm
1
sulfasalazine tab 500 mg
(Azulfidine)
1
1
URSO FORTE - ursodiol tab 500
mg
3
methenamine-hyosc-meth bluebenz acid-phenyl sal tab
81.6mg (Prosed/ds)
3
URSO 250 - ursodiol tab 250 mg
3
MONUROL - fosfomycin
tromethamine powd pack 3 gm
(base equivalent)
ursodiol cap 300 mg (Actigall)
1
82
GENITOURINARY AGENTS
URINARY ANTI-INFECTIVES
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
ursodiol tab 500 mg (Urso forte)
Quantity Limits
1
2
"Smart" PA
ursodiol tab 250 mg (Urso 250)
PHOSLYRA - calcium acetate
(phosphate binder) oral soln 667
mg/5ml
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
nitrofurantoin macrocrystalline
cap 100 mg (Macrodantin)
1
bethanechol chloride tab 50 mg
(Urecholine)
1
nitrofurantoin macrocrystalline
cap 50 mg (Macrodantin)
1
DETROL - tolterodine tartrate tab 1
mg
3
• •
nitrofurantoin monohydrate
macrocrystalline cap 100 mg
(Macrobid)
1
DETROL - tolterodine tartrate tab 2
mg
3
• •
•
1
DETROL LA - tolterodine tartrate
cap sr 24hr 2 mg
3
nitrofurantoin susp 25 mg/5ml
(Furadantin)
•
PROSED/DS - methenaminehyosc-meth blue-benz acidphenyl sal tab 81.6mg
DETROL LA - tolterodine tartrate
cap sr 24hr 4 mg
3
3
DITROPAN XL - oxybutynin
chloride tab sr 24hr 5 mg
3
• •
URELLE - methenamine-hyoscmeth blue-sod phos-phen sal tab
81 mg
1
DITROPAN XL - oxybutynin
chloride tab sr 24hr 10 mg
3
• •
3
DITROPAN XL - oxybutynin
chloride tab sr 24hr 15 mg
3
URETRON D/S - methenaminehyosc-meth blue-sod phos-phen
sal tab 120 mg
• •
3
• •
UREX - methenamine hippurate
tab 1 gm
3
ENABLEX - darifenacin
hydrobromide tab sr 24hr 7.5 mg
(base equiv)
1
ENABLEX - darifenacin
hydrobromide tab sr 24hr 15 mg
(base equiv)
3
URIBEL - methenamine-hyoscmeth blue-sod phos-phen sal cap
118 mg
• •
3
flavoxate hcl tab 100 mg
1
URIMAR-T - methenamine-hyoscmeth blue-sod phos-phen sal tab
120 mg
GELNIQUE - oxybutynin td gel 3%
(28 mg/act metered-dose pump)
3
•
• •
UROGESIC-BLUE - methenaminehyosamine-meth blue-sod phos
tab 81.6 mg
3
UROQID #2 - methenamine
mandelate-sod phosphate
monobasic tab 500-500 mg
3
UTA - methenamine-hyoscyaminemeth blue-sod phos cap 120 mg
3
URINARY ANTISPASMODICS
bethanechol chloride tab 10 mg
(Urecholine)
1
bethanechol chloride tab 25 mg
(Urecholine)
1
bethanechol chloride tab 5 mg
(Urecholine)
1
GELNIQUE - oxybutynin chloride td 3
gel 10%
3
MYRBETRIQ - mirabegron tab sr
24 hr 25 mg
3
MYRBETRIQ - mirabegron tab sr
24 hr 50 mg
1
oxybutynin chloride syrup
5 mg/5ml
1
oxybutynin chloride tab sr 24hr
10 mg (Ditropan xl)
1
oxybutynin chloride tab sr 24hr
15 mg (Ditropan xl)
1
oxybutynin chloride tab sr 24hr
5 mg (Ditropan xl)
1
oxybutynin chloride tab 5 mg
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
• •
• •
• •
•
•
•
•
•
83
SANCTURA - trospium chloride tab 3
20 mg
SANCTURA XR - trospium chloride 3
cap sr 24hr 60 mg
1
tolterodine tartrate cap sr 24hr
2 mg (Detrol la)
1
tolterodine tartrate cap sr 24hr
4 mg (Detrol la)
1
tolterodine tartrate tab 1 mg
(Detrol)
1
tolterodine tartrate tab 2 mg
(Detrol)
3
TOVIAZ - fesoterodine fumarate
tab sr 24hr 4 mg
3
TOVIAZ - fesoterodine fumarate
tab sr 24hr 8 mg
1
trospium chloride cap sr 24hr
60 mg
1
trospium chloride tab 20 mg
• •
3
•
CRINONE - progesterone vaginal
gel 4%
3
•
CRINONE - progesterone vaginal
gel 8%
A
•
ENCARE - nonoxynol-9 vaginal
suppos 100 mg
2
•
ENDOMETRIN - progesterone
vaginal insert 100 mg
3
• •
ESTRACE - estradiol vaginal
cream 0.1 mg/gm
2
•
ESTRING - estradiol vaginal ring 2
mg (7.5 mcg/24hrs)
3
•
FEM PH - acetic acid-oxyquinoline
vaginal gel 0.9-0.025%
3
•
•
FEMRING - estradiol acetate
vaginal ring 0.05 mg/24hr
•
• •
FEMRING - estradiol acetate
vaginal ring 0.1 mg/24hr
3
URECHOLINE - bethanechol
chloride tab 10 mg
3
3
URECHOLINE - bethanechol
chloride tab 25 mg
3
FIRST-PROGESTERONE VGS
10 - progesterone vaginal
suppository 100 mg
3
URECHOLINE - bethanechol
chloride tab 50 mg
3
FIRST-PROGESTERONE VGS
20 - progesterone vaginal
suppository 200 mg
3
• •
VESICARE - solifenacin succinate
tab 10 mg
3
• •
FIRST-PROGESTERONE VGS
25 - progesterone vaginal
suppository 25 mg
3
VESICARE - solifenacin succinate
tab 5 mg
FIRST-PROGESTERONE VGS
40 - progesterone vaginal
suppository 400 mg
3
FIRST-PROGESTERONE VGS
50 - progesterone vaginal
suppository 50 mg
3
3
3
AVC - sulfanilamide vaginal cream
15%
2
CLEOCIN - clindamycin phosphate
vaginal cream 2%
3
CLEOCIN - clindamycin phosphate
vaginal suppos 100 mg
3
GYNAZOLE-1 - butoconazole
nitrate (one dose) vaginal cream
2%
clindamycin phosphate vaginal
cream 2% (Cleocin)
1
METROGEL-VAGINAL metronidazole vaginal gel 0.75%
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
3
3
84
"Smart" PA
CLINDESSE - clindamycin
phosphate (one dose) vaginal
cream 2%
URECHOLINE - bethanechol
chloride tab 5 mg
VAGINAL PRODUCTS
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
metronidazole vaginal gel 0.75%
(Metrogel-vaginal)
1
acetic acid irrigation soln 0.25%
1
miconazole nitrate vaginal supp
200 mg & 2% cream 9 gm kit
alfuzosin hcl tab sr 24hr 10 mg
(Uroxatral)
1
1
• •
MICONAZOLE 3 - miconazole
nitrate vaginal suppos 200 mg
AVODART - dutasteride cap 0.5
mg
3
3
•
1
CARDURA XL - doxazosin
mesylate tab sr 24 hr 4 mg (base
equiv)
3
NYSTATIN VAGINAL - nystatin
vaginal tab 100000 unit
OPTIONS CONCEPTROL
VAGINA - nonoxynol-9 gel 4%
A
3
•
OPTIONS GYNOL II VAGINAL nonoxynol-9 gel 3%
A
CARDURA XL - doxazosin
mesylate tab sr 24 hr 8 mg (base
equiv)
3
PREMARIN - estrogens,
conjugated vaginal cream 0.625
mg/gm
2
CITROLITH - potassium & sodium
citrates tab 50-950 mg
CYSTAGON - cysteamine
bitartrate cap 50 mg
3
•
RELAGARD - acetic acidoxyquinoline vaginal gel
0.9-0.025%
3
CYSTAGON - cysteamine
bitartrate cap 150 mg
3
•
A
CYTRA-3 - pot & sod citrates w/ cit
ac syrup 550-500-334 mg/5ml
3
SHUR-SEAL - nonoxynol-9 gel 2%
TERAZOL 3 - terconazole vaginal
cream 0.8%
3
ELMIRON - pentosan polysulfate
sodium caps 100 mg
2
TERAZOL 3 - terconazole vaginal
suppos 80 mg
3
finasteride tab 5 mg (Proscar)
1
TERAZOL 7 - terconazole vaginal
cream 0.4%
FLOMAX - tamsulosin hcl cap 0.4
mg
3
3
glycine irrigation soln 1.5%
1
terconazole vaginal cream 0.4%
(Terazol 7)
1
terconazole vaginal cream 0.8%
(Terazol 3)
1
terconazole vaginal suppos
80 mg
1
TODAY SPONGE - nonoxynol-9
vaginal sponge 1000 mg
A
VAGIFEM - estradiol vaginal tab 10 2
mcg
VCF VAGINAL CONTRACEPTIVE A
- nonoxynol-9 foam 12.5%
VCF VAGINAL CONTRACEPTIVE A
- nonoxynol-9 film 28%
GENITOURINARY AGENTS - MISC.
JALYN - dutasteride-tamsulosin hcl 3
cap 0.5-0.4 mg
3
K-PHOS NO 2 - potassium &
sodium acid phosphates tab
305-700 mg
3
LITHOSTAT - acetohydroxamic
acid tab 250 mg
1
neomycin-polymyxin b gu
irrigation soln (Neosporin gu
irrigan)
3
NEOSPORIN GU IRRIGANT
- neomycin-polymyxin b gu
irrigation soln
3
ORACIT - sodium citrate & citric
acid soln 490-640 mg/5ml
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
•
•
• •
85
phenazopyridine hcl tab 100 mg
(Pyridium)
1
phenazopyridine hcl tab 200 mg
(Pyridium)
1
pot & sod citrates w/ cit ac soln
550-500-334 mg/5ml
1
potassium citrate & citric acid
powder pack 3300-1002 mg
1
potassium citrate & citric acid
soln 1100-334 mg/5ml
1
potassium citrate tab cr 10 meq
(1080 mg) (Urocit-k 10)
1
potassium citrate tab cr 15 meq
(1620 mg) (Urocit-k 15)
1
1
sodium citrate & citric acid soln
500-334 mg/5ml (Shohls solution
modi)
SORBITOL - sorbitol irrigation soln 1
3%
SORBITOL - sorbitol irrigation soln 1
3.3%
1
SORBITOL-MANNITOL - sorbitolmannitol irrigation soln 2.7-0.54
gm/100ml
1
tamsulosin hcl cap 0.4 mg
(Flomax)
3
THIOLA - tiopronin tab 100 mg
3
potassium citrate tab cr 5 meq
(540 mg) (Urocit-k 5)
1
UROCIT-K 10 - potassium citrate
tab cr 10 meq (1080 mg)
3
PROCYSBI - cysteamine bitartrate
cap delayed release 25 mg (base
equiv)
3
UROCIT-K 15 - potassium citrate
tab cr 15 meq (1620 mg)
UROCIT-K 5 - potassium citrate
tab cr 5 meq (540 mg)
3
PROCYSBI - cysteamine bitartrate
cap delayed release 75 mg (base
equiv)
3
UROXATRAL - alfuzosin hcl tab sr
24hr 10 mg
3
PROSCAR - finasteride tab 5 mg
3
PYRIDIUM - phenazopyridine hcl
tab 100 mg
3
PYRIDIUM - phenazopyridine hcl
tab 200 mg
3
RAPAFLO - silodosin cap 4 mg
3
RAPAFLO - silodosin cap 8 mg
3
RENACIDIN - citric acid & dgluconic acid soln
•
•
• •
alprazolam orally disintegrating
tab 0.25 mg (Niravam)
1
alprazolam orally disintegrating
tab 0.5 mg
1
3
alprazolam orally disintegrating
tab 1 mg
1
RIMSO-50 - dimethyl sulfoxide soln 3
50%
3
SHOHLS SOLUTION MODIFIED
- sodium citrate & citric acid soln
500-334 mg/5ml
SODIUM CITRATE - sodium citrate 1
granules
alprazolam orally disintegrating
tab 2 mg
1
alprazolam tab sr 24hr 0.5 mg
(Xanax xr)
1
alprazolam tab sr 24hr 1 mg
(Xanax xr)
1
alprazolam tab sr 24hr 2 mg
(Xanax xr)
1
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
ANTIANXIETY AGENTS
1
86
•
CENTRAL NERVOUS SYSTEM DRUGS
ALPRAZOLAM INTENSOL alprazolam conc 1 mg/ml
• •
• •
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
alprazolam tab sr 24hr 3 mg
(Xanax xr)
1
alprazolam tab 0.25 mg (Xanax)
1
alprazolam tab 0.5 mg (Xanax)
1
alprazolam tab 1 mg (Xanax)
1
alprazolam tab 2 mg (Xanax)
1
ATIVAN - lorazepam tab 0.5 mg
3
ATIVAN - lorazepam tab 1 mg
3
ATIVAN - lorazepam tab 2 mg
3
BUSPIRONE HCL - buspirone hcl
tab 7.5 mg
1
buspirone hcl tab 10 mg
1
buspirone hcl tab 15 mg
1
buspirone hcl tab 30 mg
1
buspirone hcl tab 5 mg
1
buspirone hcl tab 7.5 mg
1
chlordiazepoxide hcl cap 10 mg
1
chlordiazepoxide hcl cap 25 mg
1
chlordiazepoxide hcl cap 5 mg
1
clorazepate dipotassium tab
15 mg (Tranxene t)
•
•
•
GABAZOLAMINE - alprazolam tab
0.25 mg & dietary management
cap pack
3
GABAZOLAMINE-0.5 alprazolam tab 0.5 mg & dietary
management cap pack
3
1
hydroxyzine hcl tab 25 mg
1
hydroxyzine hcl tab 50 mg
1
HYDROXYZINE PAMOATE hydroxyzine pamoate cap 100
mg
1
hydroxyzine pamoate cap 25 mg
(Vistaril)
1
hydroxyzine pamoate cap 50 mg
(Vistaril)
1
lorazepam conc 2 mg/ml
(Lorazepam intensol)
1
1
LORAZEPAM INTENSOL lorazepam conc 2 mg/ml
1
clorazepate dipotassium tab
3.75 mg (Tranxene t)
1
lorazepam tab 0.5 mg (Ativan)
1
lorazepam tab 1 mg (Ativan)
1
clorazepate dipotassium tab
7.5 mg (Tranxene t)
1
lorazepam tab 2 mg (Ativan)
1
1
meprobamate tab 200 mg
1
DIAZEPAM - diazepam soln 1 mg/
ml
meprobamate tab 400 mg
1
DIAZEPAM - diazepam inj 5 mg/ml
1
3
•
DIAZEPAM - diazepam im inj
device 10 mg/2ml
1
NIRAVAM - alprazolam orally
disintegrating tab 0.25 mg
NIRAVAM - alprazolam orally
disintegrating tab 0.5 mg
3
•
NIRAVAM - alprazolam orally
disintegrating tab 1 mg
3
•
NIRAVAM - alprazolam orally
disintegrating tab 2 mg
3
•
oxazepam cap 10 mg
1
oxazepam cap 15 mg
1
oxazepam cap 30 mg
1
diazepam tab 2 mg (Valium)
1
diazepam tab 5 mg (Valium)
1
GABAVALE-5 - diazepam tab 5 mg 3
& dietary management cap pack
Specialty
HYDROXYZINE HCL - hydroxyzine 1
hcl im soln 25 mg/ml
hydroxyzine hcl syrup 10 mg/5ml 1
hydroxyzine hcl tab 10 mg
DIAZEPAM INTENSOL - diazepam 1
conc 5 mg/ml
1
diazepam tab 10 mg (Valium)
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
87
SENTRAZOLAM AM 0.25 alprazolam tab 0.25 mg & dietary
management cap pack
3
TRANXENE T - clorazepate
dipotassium tab 3.75 mg
3
AMOXAPINE - amoxapine tab 50
mg
1
1
•
AMOXAPINE - amoxapine tab 100
mg
TRANXENE T - clorazepate
dipotassium tab 7.5 mg
•
AMOXAPINE - amoxapine tab 150
mg
1
3
•
•
3
ANAFRANIL - clomipramine hcl
cap 25 mg
3
TRANXENE T - clorazepate
dipotassium tab 15 mg
•
VALIUM - diazepam tab 2 mg
VALIUM - diazepam tab 5 mg
3
•
3
ANAFRANIL - clomipramine hcl
cap 75 mg
3
VALIUM - diazepam tab 10 mg
VISTARIL - hydroxyzine pamoate
cap 25 mg
3
•
•
•
•
ANAFRANIL - clomipramine hcl
cap 50 mg
3
3
APLENZIN - bupropion hbr tab sr
24hr 174 mg
3
•
VISTARIL - hydroxyzine pamoate
cap 50 mg
3
•
APLENZIN - bupropion hbr tab sr
24hr 348 mg
3
•
XANAX - alprazolam tab 0.25 mg
3
•
3
APLENZIN - bupropion hbr tab sr
24hr 522 mg
3
XANAX - alprazolam tab 0.5 mg
3
XANAX - alprazolam tab 2 mg
3
APPBUTAMONE - bupropion hcl
tab 75 mg & dietary management
cap pack
3
XANAX - alprazolam tab 1 mg
XANAX XR - alprazolam tab sr
24hr 0.5 mg
3
•
•
•
•
•
XANAX XR - alprazolam tab sr
24hr 1 mg
3
•
XANAX XR - alprazolam tab sr
24hr 2 mg
3
XANAX XR - alprazolam tab sr
24hr 3 mg
3
ANTIDEPRESSANTS
amitriptyline hcl tab 10 mg
1
amitriptyline hcl tab 100 mg
1
amitriptyline hcl tab 150 mg
1
amitriptyline hcl tab 25 mg
1
amitriptyline hcl tab 50 mg
1
amitriptyline hcl tab 75 mg
1
AMOXAPINE - amoxapine tab 25
mg
1
88
•
•
APPBUTAMONE-D - bupropion hcl 3
tab 75 mg & dietary management
cap pack
BRINTELLIX - vortioxetine hbr tab 3
5 mg (base equiv)
BRINTELLIX - vortioxetine hbr tab 3
10 mg (base equiv)
BRINTELLIX - vortioxetine hbr tab 3
20 mg (base equiv)
1
bupropion hcl tab sr 12hr
100 mg (Wellbutrin sr)
1
bupropion hcl tab sr 12hr
150 mg (Wellbutrin sr)
1
bupropion hcl tab sr 12hr
200 mg (Wellbutrin sr)
1
bupropion hcl tab sr 24hr
150 mg (Wellbutrin xl)
1
bupropion hcl tab sr 24hr
300 mg (Wellbutrin xl)
• •
• •
• •
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
bupropion hcl tab 100 mg
(Wellbutrin)
1
desipramine hcl tab 50 mg
(Norpramin)
1
bupropion hcl tab 75 mg
(Wellbutrin)
1
desipramine hcl tab 75 mg
(Norpramin)
1
CELEXA - citalopram
hydrobromide tab 10 mg (base
equiv)
3
•
DESVENLAFAXINE ER desvenlafaxine tab sr 24hr 50 mg
1
• •
•
• •
3
DESVENLAFAXINE ER desvenlafaxine tab sr 24hr 100
mg
1
CELEXA - citalopram
hydrobromide tab 20 mg (base
equiv)
• •
CELEXA - citalopram
hydrobromide tab 40 mg (base
equiv)
•
DESVENLAFAXINE ER desvenlafaxine fumarate tab sr
24hr 50 mg (base equiv)
1
3
• •
citalopram hydrobromide oral
soln 10 mg/5ml
DESVENLAFAXINE ER desvenlafaxine fumarate tab sr
24hr 100 mg (base equiv)
1
1
citalopram hydrobromide tab
10 mg (base equiv) (Celexa)
1
DOXEPIN HCL - doxepin hcl cap
75 mg
1
citalopram hydrobromide tab
20 mg (base equiv) (Celexa)
1
doxepin hcl cap 10 mg
1
doxepin hcl cap 100 mg
1
citalopram hydrobromide tab
40 mg (base equiv) (Celexa)
1
doxepin hcl cap 150 mg
1
1
doxepin hcl cap 25 mg
1
clomipramine hcl cap 25 mg
(Anafranil)
doxepin hcl cap 50 mg
1
clomipramine hcl cap 50 mg
(Anafranil)
1
doxepin hcl conc 10 mg/ml
1
1
clomipramine hcl cap 75 mg
(Anafranil)
1
duloxetine hcl enteric coated
pellets cap 20 mg (Cymbalta)
1
• •
duloxetine hcl enteric coated
pellets cap 30 mg (Cymbalta)
1
• •
duloxetine hcl enteric coated
pellets cap 60 mg (Cymbalta)
EFFEXOR XR - venlafaxine hcl
cap sr 24hr 37.5 mg (base
equivalent)
3
•
EFFEXOR XR - venlafaxine
hcl cap sr 24hr 75 mg (base
equivalent)
3
•
EFFEXOR XR - venlafaxine
hcl cap sr 24hr 150 mg (base
equivalent)
3
•
EMSAM - selegiline td patch 24hr 6 3
mg/24hr
•
CYMBALTA - duloxetine hcl enteric 3
coated pellets cap 20 mg
CYMBALTA - duloxetine hcl enteric 3
coated pellets cap 30 mg
CYMBALTA - duloxetine hcl enteric 3
coated pellets cap 60 mg
1
desipramine hcl tab 10 mg
(Norpramin)
1
desipramine hcl tab 100 mg
(Norpramin)
1
desipramine hcl tab 150 mg
(Norpramin)
1
desipramine hcl tab 25 mg
(Norpramin)
• •
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
89
fluoxetine hcl cap 20 mg (Prozac) 1
fluoxetine hcl cap 40 mg (Prozac) 1
fluoxetine hcl solution
20 mg/5ml
1
fluoxetine hcl tab 10 mg
1
fluoxetine hcl tab 20 mg
1
fluvoxamine maleate cap sr 24hr
100 mg (Luvox cr)
1
fluvoxamine maleate cap sr 24hr
150 mg (Luvox cr)
1
fluvoxamine maleate tab 100 mg
1
90
•
• •
• •
• •
• •
• •
•
•
1
FORFIVO XL - bupropion hcl tab sr 3
24hr 450 mg
GABOXETINE - fluoxetine hcl cap 3
10 mg & dietary management
cap pack
1
imipramine hcl tab 10 mg
(Tofranil)
1
imipramine hcl tab 25 mg
(Tofranil)
1
imipramine hcl tab 50 mg
(Tofranil)
imipramine pamoate cap 100 mg 1
(Tofranil-pm)
imipramine pamoate cap 125 mg 1
(Tofranil-pm)
imipramine pamoate cap 150 mg 1
(Tofranil-pm)
1
imipramine pamoate cap 75 mg
(Tofranil-pm)
KHEDEZLA - desvenlafaxine tab sr 3
24hr 50 mg
KHEDEZLA - desvenlafaxine tab sr 3
24hr 100 mg
3
LEXAPRO - escitalopram oxalate
tab 5 mg (base equiv)
3
LEXAPRO - escitalopram oxalate
tab 10 mg (base equiv)
3
LEXAPRO - escitalopram oxalate
tab 20 mg (base equiv)
3
LEXAPRO - escitalopram oxalate
soln 5 mg/5ml (base equiv)
LUVOX CR - fluvoxamine maleate 3
cap sr 24hr 100 mg
LUVOX CR - fluvoxamine maleate 3
cap sr 24hr 150 mg
1
MAPROTILINE HCL - maprotiline
hcl tab 25 mg
•
• •
• •
•
•
•
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
fluvoxamine maleate tab 50 mg
Quantity Limits
1
"Smart" PA
fluvoxamine maleate tab 25 mg
Prior Authorization
Specialty
Quantity Limits
•
Drug Name
Drug Tier
EMSAM - selegiline td patch 24hr 9 3
mg/24hr
3
EMSAM - selegiline td patch 24hr
12 mg/24hr
1
escitalopram oxalate soln
5 mg/5ml (base equiv)
(Lexapro)
1
escitalopram oxalate tab 10 mg
(base equiv) (Lexapro)
1
escitalopram oxalate tab 20 mg
(base equiv) (Lexapro)
1
escitalopram oxalate tab 5 mg
(base equiv) (Lexapro)
FETZIMA - levomilnacipran hcl cap 3
sr 24hr 20 mg (base equivalent)
FETZIMA - levomilnacipran hcl cap 3
sr 24hr 40 mg (base equivalent)
FETZIMA - levomilnacipran hcl cap 3
sr 24hr 80 mg (base equivalent)
FETZIMA - levomilnacipran hcl cap 3
sr 24hr 120 mg (base equivalent)
3
FETZIMA TITRATION PACK levomilnacipran hcl cap sr 24hr
20 & 40 mg therapy pack
FLUOXETINE HCL - fluoxetine hcl 1
tab 60 mg
1
fluoxetine hcl cap delayed
release 90 mg (Prozac weekly)
fluoxetine hcl cap 10 mg (Prozac) 1
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
MAPROTILINE HCL - maprotiline
hcl tab 50 mg
1
•
NORTRIPTYLINE HCL nortriptyline hcl soln 10 mg/5ml
1
MAPROTILINE HCL - maprotiline
hcl tab 75 mg
1
•
nortriptyline hcl cap 10 mg
(Pamelor)
1
MARPLAN - isocarboxazid tab 10
mg
3
nortriptyline hcl cap 25 mg
(Pamelor)
1
mirtazapine orally disintegrating
tab 15 mg (Remeron soltab)
1
nortriptyline hcl cap 50 mg
(Pamelor)
1
mirtazapine orally disintegrating
tab 30 mg (Remeron soltab)
1
nortriptyline hcl cap 75 mg
(Pamelor)
1
mirtazapine orally disintegrating
tab 45 mg (Remeron soltab)
1
OLEPTRO - trazodone hcl tab sr
24hr 150 mg
3
• •
mirtazapine tab 15 mg (Remeron)
1
3
• •
mirtazapine tab 30 mg (Remeron)
1
OLEPTRO - trazodone hcl tab sr
24hr 300 mg
mirtazapine tab 45 mg (Remeron)
1
3
•
mirtazapine tab 7.5 mg
1
PAMELOR - nortriptyline hcl cap
10 mg
PAMELOR - nortriptyline hcl cap
25 mg
3
•
PAMELOR - nortriptyline hcl cap
50 mg
3
•
PAMELOR - nortriptyline hcl cap
75 mg
3
•
PARNATE - tranylcypromine
sulfate tab 10 mg
3
•
paroxetine hcl tab sr 24hr
12.5 mg (Paxil cr)
1
paroxetine hcl tab sr 24hr 25 mg
(Paxil cr)
1
paroxetine hcl tab sr 24hr
37.5 mg (Paxil cr)
1
paroxetine hcl tab 10 mg (Paxil)
1
•
paroxetine hcl tab 20 mg (Paxil)
1
paroxetine hcl tab 30 mg (Paxil)
1
•
paroxetine hcl tab 40 mg (Paxil)
1
PAXIL - paroxetine hcl tab 10 mg
3
PAXIL - paroxetine hcl tab 20 mg
3
PAXIL - paroxetine hcl tab 30 mg
3
PAXIL - paroxetine hcl tab 40 mg
3
NARDIL - phenelzine sulfate tab 15 2
mg
NEFAZODONE HCL - nefazodone 1
hcl tab 50 mg
NEFAZODONE HCL - nefazodone 1
hcl tab 100 mg
NEFAZODONE HCL - nefazodone 1
hcl tab 150 mg
NEFAZODONE HCL - nefazodone 1
hcl tab 200 mg
1
nefazodone hcl tab 250 mg
NORPRAMIN - desipramine hcl tab 3
10 mg
NORPRAMIN - desipramine hcl tab 3
25 mg
NORPRAMIN - desipramine hcl tab 3
50 mg
NORPRAMIN - desipramine hcl tab 3
75 mg
NORPRAMIN - desipramine hcl tab 3
100 mg
NORPRAMIN - desipramine hcl tab 3
150 mg
•
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
91
PAXIL - paroxetine hcl oral susp 10 3
mg/5ml (base equiv)
3
PAXIL CR - paroxetine hcl tab sr
24hr 12.5 mg
3
PAXIL CR - paroxetine hcl tab sr
24hr 25 mg
3
PAXIL CR - paroxetine hcl tab sr
24hr 37.5 mg
PEXEVA - paroxetine mesylate tab 3
10 mg (base equiv)
PEXEVA - paroxetine mesylate tab 3
20 mg (base equiv)
PEXEVA - paroxetine mesylate tab 3
30 mg (base equiv)
PEXEVA - paroxetine mesylate tab 3
40 mg (base equiv)
1
phenelzine sulfate tab 15 mg
(Nardil)
3
PRISTIQ - desvenlafaxine
succinate tab sr 24hr 50 mg
(base equiv)
3
PRISTIQ - desvenlafaxine
succinate tab sr 24hr 100 mg
(base equiv)
1
protriptyline hcl tab 10 mg
(Vivactil)
1
protriptyline hcl tab 5 mg
(Vivactil)
3
PROZAC - fluoxetine hcl cap 10
mg
3
PROZAC - fluoxetine hcl cap 20
mg
3
PROZAC - fluoxetine hcl cap 40
mg
PROZAC WEEKLY - fluoxetine hcl 3
cap delayed release 90 mg
3
REMERON - mirtazapine tab 15
mg
3
REMERON - mirtazapine tab 30
mg
92
•
REMERON - mirtazapine tab 45
mg
3
•
•
REMERON SOLTAB - mirtazapine
orally disintegrating tab 15 mg
3
•
•
REMERON SOLTAB - mirtazapine
orally disintegrating tab 30 mg
3
•
•
REMERON SOLTAB - mirtazapine
orally disintegrating tab 45 mg
3
•
•
SENTRAFLOX AM-10 - fluoxetine
hcl cap 10 mg & dietary
management cap pack
3
SENTRALOPRAM AM-10 citalopram tab 10 mg & dietary
management cap pack
3
SENTRAVIL PM-25 - amitriptyline
hcl tab 25 mg & diet manage
prod cap pack
3
SENTROXATINE - fluoxetine
hcl cap 10 mg & dietary
management cap pack
3
sertraline hcl oral conc 20 mg/ml
(Zoloft)
1
sertraline hcl tab 100 mg (Zoloft)
1
sertraline hcl tab 25 mg (Zoloft)
1
sertraline hcl tab 50 mg (Zoloft)
1
SURMONTIL - trimipramine
maleate cap 25 mg
3
•
SURMONTIL - trimipramine
maleate cap 50 mg
3
•
•
SURMONTIL - trimipramine
maleate cap 100 mg
3
•
•
3
•
TOFRANIL - imipramine hcl tab 10
mg
•
TOFRANIL - imipramine hcl tab 25
mg
3
•
TOFRANIL - imipramine hcl tab 50
mg
3
•
•
TOFRANIL-PM - imipramine
pamoate cap 75 mg
3
•
•
•
•
•
• •
• •
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
TOFRANIL-PM - imipramine
pamoate cap 100 mg
3
•
TOFRANIL-PM - imipramine
pamoate cap 125 mg
3
•
TOFRANIL-PM - imipramine
pamoate cap 150 mg
3
tranylcypromine sulfate tab
10 mg (Parnate)
1
•
TRAZAMINE - trazodone hcl tab 50 3
mg & dietary management cap
pack
1
trazodone hcl tab 100 mg
venlafaxine hcl tab sr 24hr
150 mg (base equivalent)
(Venlafaxine hcl er)
1
•
venlafaxine hcl tab sr 24hr
37.5 mg (base equivalent)
(Venlafaxine hcl er)
1
•
venlafaxine hcl tab sr 24hr 75 mg
(base equivalent) (Venlafaxine
hcl er)
1
•
venlafaxine hcl tab 100 mg
1
venlafaxine hcl tab 25 mg
1
venlafaxine hcl tab 37.5 mg
1
•
•
•
•
•
trazodone hcl tab 150 mg
1
venlafaxine hcl tab 50 mg
1
trazodone hcl tab 300 mg
1
venlafaxine hcl tab 75 mg
1
trazodone hcl tab 50 mg
1
3
•
trimipramine maleate cap
100 mg
1
VIIBRYD - vilazodone hcl tab 10
mg
3
•
trimipramine maleate cap 25 mg
1
VIIBRYD - vilazodone hcl tab 20
mg
trimipramine maleate cap 50 mg
1
3
•
venlafaxine hcl cap sr 24hr
150 mg (base equivalent)
(Effexor xr)
1
VIIBRYD - vilazodone hcl tab 40
mg
3
•
venlafaxine hcl cap sr 24hr
37.5 mg (base equivalent)
(Effexor xr)
1
VIIBRYD - vilazodone hcl tab
starter kit 10 (7) & 20 (7) & 40
(16) mg
VIVACTIL - protriptyline hcl tab 5
mg
3
•
venlafaxine hcl cap sr 24hr
75 mg (base equivalent)
(Effexor xr)
1
VIVACTIL - protriptyline hcl tab 10
mg
3
•
3
•
VENLAFAXINE HCL ER venlafaxine hcl tab sr 24hr 37.5
mg (base equivalent)
1
WELLBUTRIN - bupropion hcl tab
75 mg
WELLBUTRIN - bupropion hcl tab
100 mg
3
•
VENLAFAXINE HCL ER venlafaxine hcl tab sr 24hr 75 mg
(base equivalent)
1
WELLBUTRIN SR - bupropion hcl
tab sr 12hr 100 mg
3
•
3
•
VENLAFAXINE HCL ER venlafaxine hcl tab sr 24hr 150
mg (base equivalent)
1
WELLBUTRIN SR - bupropion hcl
tab sr 12hr 150 mg
WELLBUTRIN SR - bupropion hcl
tab sr 12hr 200 mg
3
•
VENLAFAXINE HCL ER venlafaxine hcl tab sr 24hr 225
mg (base equivalent)
1
WELLBUTRIN XL - bupropion hcl
tab sr 24hr 150 mg
3
•
•
•
•
•
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
93
WELLBUTRIN XL - bupropion hcl
tab sr 24hr 300 mg
3
•
CLOZAPINE ODT - clozapine
orally disintegrating tab 100 mg
1
ZOLOFT - sertraline hcl tab 25 mg
3
clozapine tab 100 mg (Clozaril)
1
ZOLOFT - sertraline hcl tab 50 mg
3
clozapine tab 200 mg
1
ZOLOFT - sertraline hcl tab 100
mg
3
•
•
•
clozapine tab 25 mg (Clozaril)
1
1
3
•
clozapine tab 50 mg
ZOLOFT - sertraline hcl oral conc
20 mg/ml
CLOZARIL - clozapine tab 25 mg
3
CLOZARIL - clozapine tab 100 mg
3
COMPAZINE - prochlorperazine
maleate tab 5 mg
3
COMPAZINE - prochlorperazine
maleate tab 10 mg
3
EQUETRO - carbamazepine
(antipsychotic) cap sr 12hr 100
mg
3
EQUETRO - carbamazepine
(antipsychotic) cap sr 12hr 200
mg
3
EQUETRO - carbamazepine
(antipsychotic) cap sr 12hr 300
mg
3
FANAPT - iloperidone tab 1 mg
3
FANAPT - iloperidone tab 2 mg
3
FANAPT - iloperidone tab 4 mg
3
FANAPT - iloperidone tab 6 mg
3
FANAPT - iloperidone tab 8 mg
3
FANAPT - iloperidone tab 10 mg
3
FANAPT - iloperidone tab 12 mg
3
FANAPT TITRATION PACK iloperidone tab 1 mg & 2 mg & 4
mg & 6 mg titration pak
3
FAZACLO - clozapine orally
disintegrating tab 12.5 mg
3
FAZACLO - clozapine orally
disintegrating tab 25 mg
3
FAZACLO - clozapine orally
disintegrating tab 100 mg
3
FAZACLO - clozapine orally
disintegrating tab 150 mg
3
ANTIPSYCHOTICS
ABILIFY - aripiprazole tab 2 mg
2
ABILIFY - aripiprazole tab 5 mg
2
ABILIFY - aripiprazole tab 10 mg
2
ABILIFY - aripiprazole tab 15 mg
2
ABILIFY - aripiprazole tab 20 mg
2
ABILIFY - aripiprazole tab 30 mg
2
ABILIFY - aripiprazole oral solution
1 mg/ml
2
ABILIFY - aripiprazole im inj 9.75
mg/1.3ml (7.5 mg/ml)
2
ABILIFY DISCMELT - aripiprazole
orally disintegrating tab 10 mg
2
ABILIFY DISCMELT - aripiprazole
orally disintegrating tab 15 mg
2
ABILIFY MAINTENA - aripiprazole
im for extended release susp 300
mg
3
ABILIFY MAINTENA - aripiprazole
im for extended release susp 400
mg
3
chlorpromazine hcl tab 10 mg
1
chlorpromazine hcl tab 100 mg
1
chlorpromazine hcl tab 200 mg
1
chlorpromazine hcl tab 25 mg
1
chlorpromazine hcl tab 50 mg
1
CLOZAPINE ODT - clozapine
orally disintegrating tab 12.5 mg
1
CLOZAPINE ODT - clozapine
orally disintegrating tab 25 mg
1
94
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
FAZACLO - clozapine orally
disintegrating tab 200 mg
3
INVEGA - paliperidone tab sr 24hr
9 mg
fluphenazine decanoate inj
25 mg/ml
1
LATUDA - lurasidone hcl tab 20 mg 3
LATUDA - lurasidone hcl tab 40 mg 3
FLUPHENAZINE HCL fluphenazine hcl elixir 2.5 mg/5ml
1
FLUPHENAZINE HCL fluphenazine hcl oral conc 5 mg/
ml
1
LATUDA - lurasidone hcl tab 60 mg 3
LATUDA - lurasidone hcl tab 80 mg 3
FLUPHENAZINE HCL fluphenazine hcl inj 2.5 mg/ml
Specialty
Quantity Limits
"Smart" PA
3
LATUDA - lurasidone hcl tab 120
mg
3
1
LITHIUM - lithium oral solution 8
meq/5ml
1
fluphenazine hcl tab 1 mg
1
1
fluphenazine hcl tab 10 mg
1
LITHIUM CARBONATE - lithium
carbonate cap 150 mg
1
LITHIUM CARBONATE - lithium
carbonate cap 600 mg
1
fluphenazine hcl tab 2.5 mg
fluphenazine hcl tab 5 mg
1
3
•
lithium carbonate cap 150 mg
(Lithium carbonate)
1
GEODON - ziprasidone hcl cap 20
mg
1
3
•
lithium carbonate cap 300 mg
GEODON - ziprasidone hcl cap 40
mg
1
GEODON - ziprasidone hcl cap 60
mg
3
•
lithium carbonate cap 600 mg
(Lithium carbonate)
1
GEODON - ziprasidone hcl cap 80
mg
3
•
lithium carbonate tab cr 300 mg
(Lithobid)
lithium carbonate tab cr 450 mg
1
3
lithium carbonate tab 300 mg
1
GEODON - ziprasidone mesylate
for inj 20 mg (base equivalent)
3
haloperidol lactate oral conc
2 mg/ml
1
LITHOBID - lithium carbonate tab
cr 300 mg
loxapine succinate cap 10 mg
1
haloperidol tab 0.5 mg
1
loxapine succinate cap 25 mg
1
haloperidol tab 1 mg
1
loxapine succinate cap 5 mg
1
haloperidol tab 10 mg
1
loxapine succinate cap 50 mg
1
haloperidol tab 2 mg
1
3
haloperidol tab 20 mg
1
LOXITANE - loxapine succinate
cap 5 mg
1
LOXITANE - loxapine succinate
cap 10 mg
3
haloperidol tab 5 mg
INVEGA - paliperidone tab sr 24hr
1.5 mg
3
LOXITANE - loxapine succinate
cap 25 mg
3
INVEGA - paliperidone tab sr 24hr
3 mg
3
LOXITANE - loxapine succinate
cap 50 mg
3
INVEGA - paliperidone tab sr 24hr
6 mg
3
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
95
olanzapine for im inj 10 mg
(Zyprexa)
1
RISPERDAL - risperidone tab 0.25
mg
3
olanzapine orally disintegrating
tab 10 mg (Zyprexa zydis)
1
RISPERDAL - risperidone tab 0.5
mg
3
olanzapine orally disintegrating
tab 15 mg (Zyprexa zydis)
1
RISPERDAL - risperidone tab 1 mg 3
RISPERDAL - risperidone tab 2 mg 3
olanzapine orally disintegrating
tab 20 mg (Zyprexa zydis)
1
olanzapine orally disintegrating
tab 5 mg (Zyprexa zydis)
1
RISPERDAL - risperidone tab 3 mg 3
RISPERDAL - risperidone tab 4 mg 3
olanzapine tab 10 mg (Zyprexa)
1
olanzapine tab 15 mg (Zyprexa)
1
olanzapine tab 2.5 mg (Zyprexa)
1
olanzapine tab 20 mg (Zyprexa)
1
olanzapine tab 5 mg (Zyprexa)
1
olanzapine tab 7.5 mg (Zyprexa)
1
perphenazine tab 16 mg
1
perphenazine tab 2 mg
1
perphenazine tab 4 mg
1
perphenazine tab 8 mg
1
RISPERDAL - risperidone soln 1
mg/ml
3
RISPERDAL M-TAB - risperidone
orally disintegrating tab 0.5 mg
3
RISPERDAL M-TAB - risperidone
orally disintegrating tab 1 mg
3
RISPERDAL M-TAB - risperidone
orally disintegrating tab 2 mg
3
RISPERDAL M-TAB - risperidone
orally disintegrating tab 3 mg
3
RISPERDAL M-TAB - risperidone
orally disintegrating tab 4 mg
3
prochlorperazine maleate tab
10 mg (Compazine)
risperidone orally disintegrating
tab 0.25 mg
1
1
1
prochlorperazine maleate tab
5 mg (Compazine)
1
risperidone orally disintegrating
tab 0.5 mg (Risperdal m-tab)
1
risperidone orally disintegrating
tab 1 mg (Risperdal m-tab)
1
prochlorperazine suppos 25 mg
quetiapine fumarate tab 100 mg
(Seroquel)
1
risperidone orally disintegrating
tab 2 mg (Risperdal m-tab)
1
quetiapine fumarate tab 200 mg
(Seroquel)
1
risperidone orally disintegrating
tab 3 mg (Risperdal m-tab)
1
quetiapine fumarate tab 25 mg
(Seroquel)
1
risperidone orally disintegrating
tab 4 mg (Risperdal m-tab)
1
quetiapine fumarate tab 300 mg
(Seroquel)
1
risperidone soln 1 mg/ml
(Risperdal)
1
quetiapine fumarate tab 400 mg
(Seroquel)
1
risperidone tab 0.25 mg
(Risperdal)
1
quetiapine fumarate tab 50 mg
(Seroquel)
1
risperidone tab 0.5 mg
(Risperdal)
1
risperidone tab 1 mg (Risperdal)
1
96
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
1
risperidone tab 3 mg (Risperdal)
1
trifluoperazine hcl tab 2 mg
1
risperidone tab 4 mg (Risperdal)
1
trifluoperazine hcl tab 5 mg
1
SAPHRIS - asenapine maleate sl
tab 5 mg (base equiv)
3
VERSACLOZ - clozapine susp 50
mg/ml
3
SAPHRIS - asenapine maleate sl
tab 10 mg (base equiv)
3
ziprasidone hcl cap 20 mg
(Geodon)
1
SEROQUEL - quetiapine fumarate
tab 25 mg
3
ziprasidone hcl cap 40 mg
(Geodon)
1
SEROQUEL - quetiapine fumarate
tab 50 mg
3
ziprasidone hcl cap 60 mg
(Geodon)
1
SEROQUEL - quetiapine fumarate
tab 100 mg
3
ziprasidone hcl cap 80 mg
(Geodon)
1
SEROQUEL - quetiapine fumarate
tab 200 mg
3
ZYPREXA - olanzapine tab 2.5 mg
3
ZYPREXA - olanzapine tab 5 mg
3
SEROQUEL - quetiapine fumarate
tab 300 mg
3
ZYPREXA - olanzapine tab 7.5 mg
3
3
ZYPREXA - olanzapine tab 10 mg
3
SEROQUEL - quetiapine fumarate
tab 400 mg
ZYPREXA - olanzapine tab 15 mg
3
SEROQUEL XR - quetiapine
fumarate tab sr 24hr 50 mg
2
ZYPREXA - olanzapine tab 20 mg
3
3
SEROQUEL XR - quetiapine
fumarate tab sr 24hr 150 mg
2
ZYPREXA - olanzapine for im inj
10 mg
3
SEROQUEL XR - quetiapine
fumarate tab sr 24hr 200 mg
2
ZYPREXA RELPREVV olanzapine pamoate for extended
rel im susp 210 mg (base eq)
SEROQUEL XR - quetiapine
fumarate tab sr 24hr 300 mg
2
3
SEROQUEL XR - quetiapine
fumarate tab sr 24hr 400 mg
2
ZYPREXA RELPREVV olanzapine pamoate for extended
rel im susp 300 mg (base eq)
3
thioridazine hcl tab 10 mg
1
ZYPREXA RELPREVV olanzapine pamoate for extended
rel im susp 405 mg (base eq)
thioridazine hcl tab 100 mg
1
•
thioridazine hcl tab 25 mg
ZYPREXA ZYDIS - olanzapine
orally disintegrating tab 5 mg
3
1
thioridazine hcl tab 50 mg
1
3
•
thiothixene cap 1 mg
1
ZYPREXA ZYDIS - olanzapine
orally disintegrating tab 10 mg
thiothixene cap 10 mg
1
3
•
thiothixene cap 2 mg
1
ZYPREXA ZYDIS - olanzapine
orally disintegrating tab 15 mg
1
ZYPREXA ZYDIS - olanzapine
orally disintegrating tab 20 mg
3
thiothixene cap 5 mg
•
trifluoperazine hcl tab 1 mg
1
Specialty
trifluoperazine hcl tab 10 mg
Quantity Limits
"Smart" PA
Prior Authorization
1
Specialty
Drug Name
Drug Tier
Quantity Limits
"Smart" PA
risperidone tab 2 mg (Risperdal)
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
•
•
HYPNOTICS
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
97
AMBIEN - zolpidem tartrate tab 5
mg
3
• •
AMBIEN - zolpidem tartrate tab 10
mg
3
• •
AMBIEN CR - zolpidem tartrate tab
cr 6.25 mg
3
AMBIEN CR - zolpidem tartrate tab
cr 12.5 mg
3
BELSOMRA - suvorexant tab 5 mg
3
BELSOMRA - suvorexant tab 10
mg
3
BELSOMRA - suvorexant tab 15
mg
3
BELSOMRA - suvorexant tab 20
mg
3
BUTISOL SODIUM - butabarbital
sodium tab 30 mg
3
BUTISOL SODIUM - butabarbital
sodium tab 50 mg
3
BUTISOL SODIUM - butabarbital
sodium elixir 30 mg/5ml
3
DORAL - quazepam tab 15 mg
3
EDLUAR - zolpidem tartrate sl tab
5 mg
3
• •
EDLUAR - zolpidem tartrate sl tab
10 mg
3
• •
estazolam tab 1 mg
GABAZOLPIDEM-5 - zolpidem tab
5 mg & dietary management cap
pack
3
HALCION - triazolam tab 0.25 mg
3
• •
HETLIOZ - tasimelteon capsule 20
mg
3
• •
INTERMEZZO - zolpidem tartrate
sl tab 1.75 mg
3
• •
INTERMEZZO - zolpidem tartrate
sl tab 3.5 mg
3
• •
LUNESTA - eszopiclone tab 1 mg
3
LUNESTA - eszopiclone tab 2 mg
3
LUNESTA - eszopiclone tab 3 mg
3
• •
• •
• •
PHENOBARBITAL - phenobarbital
tab 15 mg
1
PHENOBARBITAL - phenobarbital
tab 30 mg
1
PHENOBARBITAL - phenobarbital
tab 60 mg
1
PHENOBARBITAL - phenobarbital
tab 100 mg
1
phenobarbital elixir 20 mg/5ml
1
phenobarbital tab 16.2 mg
1
phenobarbital tab 32.4 mg
1
phenobarbital tab 64.8 mg
1
1
phenobarbital tab 97.2 mg
1
estazolam tab 2 mg
1
1
eszopiclone tab 1 mg (Lunesta)
1
QUAZEPAM - quazepam tab 15
mg
1
RESTORIL - temazepam cap 7.5
mg
3
eszopiclone tab 2 mg (Lunesta)
eszopiclone tab 3 mg (Lunesta)
1
FLURAZEPAM HCL - flurazepam
hcl cap 15 mg
RESTORIL - temazepam cap 15
mg
3
1
1
RESTORIL - temazepam cap 22.5
mg
3
FLURAZEPAM HCL - flurazepam
hcl cap 30 mg
flurazepam hcl cap 15 mg
RESTORIL - temazepam cap 30
mg
3
1
flurazepam hcl cap 30 mg
1
ROZEREM - ramelteon tab 8 mg
3
SECONAL - secobarbital sodium
cap 100 mg
3
98
•
•
•
•
•
• •
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
3
• •
ADDERALL - amphetaminedextroamphetamine tab 15 mg
•
•
ADDERALL - amphetaminedextroamphetamine tab 20 mg
3
•
•
ADDERALL - amphetaminedextroamphetamine tab 30 mg
3
•
•
3
•
•
3
ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr
5 mg
3
•
•
temazepam cap 15 mg (Restoril)
1
temazepam cap 22.5 mg
(Restoril)
1
ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr
10 mg
3
•
•
temazepam cap 30 mg (Restoril)
1
ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr
15 mg
temazepam cap 7.5 mg (Restoril)
1
•
•
triazolam tab 0.125 mg
triazolam tab 0.25 mg (Halcion)
1
ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr
20 mg
3
1
zaleplon cap 10 mg (Sonata)
1
•
•
1
ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr
25 mg
3
zaleplon cap 5 mg (Sonata)
zolpidem tartrate tab cr 12.5 mg
(Ambien cr)
1
•
•
•
3
•
•
zolpidem tartrate tab cr 6.25 mg
(Ambien cr)
1
•
ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr
30 mg
•
zolpidem tartrate tab 10 mg
(Ambien)
•
amphetaminedextroamphetamine cap sr
24hr 10 mg (Adderall xr)
1
1
zolpidem tartrate tab 5 mg
(Ambien)
1
•
1
•
ZOLPIMIST - zolpidem tartrate oral
spray 5 mg/act
3
• •
amphetaminedextroamphetamine cap sr
24hr 15 mg (Adderall xr)
amphetaminedextroamphetamine cap sr
24hr 20 mg (Adderall xr)
1
•
amphetaminedextroamphetamine cap sr
24hr 25 mg (Adderall xr)
1
•
SILENOR - doxepin hcl (sleep) tab
3 mg (base equiv)
SILENOR - doxepin hcl (sleep) tab
6 mg (base equiv)
3
SOMNOTE - chloral hydrate cap
500 mg
3
SONATA - zaleplon cap 5 mg
3
SONATA - zaleplon cap 10 mg
3
STRAZEPAM - temazepam cap
15mg & dietary management cap
pack
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/
ANOREXIANTS
3 •
ADDERALL - amphetaminedextroamphetamine tab 5 mg
3 •
ADDERALL - amphetaminedextroamphetamine tab 7.5 mg
• •
• •
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
•
Quantity Limits
Prior Authorization
•
Drug Name
"Smart" PA
Drug Tier
3
• •
ADDERALL - amphetaminedextroamphetamine tab 12.5 mg
3
Specialty
•
3
Quantity Limits
•
SENTRAZOLPIDEM PM-5 zolpidem tab 5 mg & dietary
management cap pack
"Smart" PA
3
Drug Tier
ADDERALL - amphetaminedextroamphetamine tab 10 mg
Drug Name
Prior Authorization
2015
99
amphetaminedextroamphetamine cap sr
24hr 5 mg (Adderall xr)
1
amphetaminedextroamphetamine tab 10 mg
(Adderall)
1
•
amphetaminedextroamphetamine tab
12.5 mg (Adderall)
1
•
amphetaminedextroamphetamine tab 15 mg
(Adderall)
1
•
amphetaminedextroamphetamine tab 20 mg
(Adderall)
1
•
amphetaminedextroamphetamine tab 30 mg
(Adderall)
1
amphetaminedextroamphetamine tab 5 mg
(Adderall)
1
•
amphetaminedextroamphetamine tab 7.5 mg
(Adderall)
1
•
CAFCIT - caffeine citrate oral soln
60 mg/3ml (10 mg/ml base equiv)
3
caffeine citrate oral soln
60 mg/3ml (10 mg/ml base
equiv) (Cafcit)
1
clonidine hcl tab sr 12hr 0.1 mg
(Kapvay)
1
CONCERTA - methylphenidate hcl
tab sa osm 18 mg
3
•
•
CONCERTA - methylphenidate hcl
tab sa osm 27 mg
3
•
•
CONCERTA - methylphenidate hcl
tab sa osm 36 mg
3
•
•
CONCERTA - methylphenidate hcl
tab sa osm 54 mg
3
•
•
100
•
•
•
•
•
DAYTRANA - methylphenidate td
patch 15 mg/9hr
3
•
•
DAYTRANA - methylphenidate td
patch 20 mg/9hr
3
•
•
DAYTRANA - methylphenidate td
patch 30 mg/9hr
3
•
•
DESOXYN - methamphetamine hcl 3
tab 5 mg
DEXEDRINE - dextroamphetamine 3
sulfate cap sr 24hr 5 mg
DEXEDRINE - dextroamphetamine 3
sulfate cap sr 24hr 10 mg
DEXEDRINE - dextroamphetamine 3
sulfate cap sr 24hr 15 mg
1
dexmethylphenidate hcl cap sr
24 hr 15 mg (Focalin xr)
1
dexmethylphenidate hcl cap sr
24 hr 30 mg (Focalin xr)
1
dexmethylphenidate hcl cap sr
24 hr 40 mg (Focalin xr)
1
dexmethylphenidate hcl cap sr
24 hr 5 mg (Focalin xr)
1
dexmethylphenidate hcl tab
10 mg (Focalin)
1
dexmethylphenidate hcl tab
2.5 mg (Focalin)
1
dexmethylphenidate hcl tab
5 mg (Focalin)
1
dextroamphetamine sulfate cap
sr 24hr 10 mg (Dexedrine)
1
dextroamphetamine sulfate cap
sr 24hr 15 mg (Dexedrine)
1
dextroamphetamine sulfate cap
sr 24hr 5 mg (Dexedrine)
1
dextroamphetamine sulfate oral
solution 5 mg/5ml (Procentra)
1
dextroamphetamine sulfate tab
10 mg
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
3
Quantity Limits
DAYTRANA - methylphenidate td
patch 10 mg/9hr
Drug Name
"Smart" PA
Prior Authorization
1
Drug Tier
•
amphetaminedextroamphetamine cap sr
24hr 30 mg (Adderall xr)
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
FOCALIN - dexmethylphenidate hcl 3
tab 2.5 mg
FOCALIN - dexmethylphenidate hcl 3
tab 5 mg
FOCALIN - dexmethylphenidate hcl 3
tab 10 mg
3
FOCALIN XR dexmethylphenidate hcl cap sr
24 hr 5 mg
3
FOCALIN XR dexmethylphenidate hcl cap sr
24 hr 10 mg
3
FOCALIN XR dexmethylphenidate hcl cap sr
24 hr 15 mg
3
FOCALIN XR dexmethylphenidate hcl cap sr
24 hr 20 mg
3
FOCALIN XR dexmethylphenidate hcl cap sr
24 hr 25 mg
3
FOCALIN XR dexmethylphenidate hcl cap sr
24 hr 30 mg
3
FOCALIN XR dexmethylphenidate hcl cap sr
24 hr 35 mg
3
FOCALIN XR dexmethylphenidate hcl cap sr
24 hr 40 mg
1
guanfacine hcl tab sr 24hr 1 mg
(base equiv) (Intuniv)
1
guanfacine hcl tab sr 24hr 2 mg
(base equiv) (Intuniv)
1
guanfacine hcl tab sr 24hr 3 mg
(base equiv) (Intuniv)
1
guanfacine hcl tab sr 24hr 4 mg
(base equiv) (Intuniv)
•
•
INTUNIV - guanfacine hcl tab sr
24hr 2 mg (base equiv)
3
•
•
•
•
INTUNIV - guanfacine hcl tab sr
24hr 3 mg (base equiv)
3
•
•
•
•
INTUNIV - guanfacine hcl tab sr
24hr 4 mg (base equiv)
3
•
•
•
•
KAPVAY - clonidine hcl tab sr 12hr
0.1 mg
3
•
•
•
KAPVAY DOSE PACK - clonidine
hcl tab sr 12hr therapy pack 0.1
& 0.2 mg
3
•
•
•
3
•
METADATE CD - methylphenidate
hcl cap cr 10 mg
•
•
METADATE CD - methylphenidate
hcl cap cr 20 mg
3
•
•
METADATE CD - methylphenidate
hcl cap cr 30 mg
3
•
•
METADATE CD - methylphenidate
hcl cap cr 40 mg
3
•
•
METADATE CD - methylphenidate
hcl cap cr 50 mg
3
•
•
METADATE CD - methylphenidate
hcl cap cr 60 mg
3
•
•
methamphetamine hcl tab 5 mg
(Desoxyn)
1
METHYLIN - methylphenidate hcl
chew tab 2.5 mg
3
•
•
METHYLIN - methylphenidate hcl
chew tab 5 mg
3
•
•
METHYLIN - methylphenidate hcl
chew tab 10 mg
3
•
•
METHYLIN - methylphenidate hcl
soln 5 mg/5ml
3
•
•
METHYLIN - methylphenidate hcl
soln 10 mg/5ml
3
•
•
methylphenidate hcl cap cr
10 mg (Metadate cd)
1
•
•
•
•
•
•
•
•
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
•
Quantity Limits
•
Drug Name
"Smart" PA
Prior Authorization
3
Specialty
INTUNIV - guanfacine hcl tab sr
24hr 1 mg (base equiv)
Quantity Limits
•
1
"Smart" PA
Drug Tier
dextroamphetamine sulfate tab
5 mg
Prior Authorization
Drug Name
Drug Tier
2015
•
•
101
methylphenidate hcl cap cr
20 mg (Metadate cd)
1
•
methylphenidate hcl tab 5 mg
(Ritalin)
1
methylphenidate hcl cap cr
30 mg (Metadate cd)
1
•
modafinil tab 100 mg (Provigil)
1
1
methylphenidate hcl cap cr
40 mg (Metadate cd)
•
modafinil tab 200 mg (Provigil)
1
NUVIGIL - armodafinil tab 50 mg
3
1
•
NUVIGIL - armodafinil tab 150 mg
3
methylphenidate hcl cap cr
50 mg (Metadate cd)
NUVIGIL - armodafinil tab 200 mg
3
methylphenidate hcl cap cr
60 mg (Metadate cd)
1
•
NUVIGIL - armodafinil tab 250 mg
3
3
methylphenidate hcl cap sr 24hr
20 mg (Ritalin la)
1
•
PROCENTRA dextroamphetamine sulfate oral
solution 5 mg/5ml
methylphenidate hcl cap sr 24hr
30 mg (Ritalin la)
1
•
PROVIGIL - modafinil tab 100 mg
3
PROVIGIL - modafinil tab 200 mg
3
methylphenidate hcl cap sr 24hr
40 mg (Ritalin la)
1
METHYLPHENIDATE HCL ER methylphenidate hcl tab cr 10 mg
1
METHYLPHENIDATE HCL ER methylphenidate hcl tab sa osm
18 mg
1
METHYLPHENIDATE HCL ER methylphenidate hcl tab sa osm
27 mg
•
•
•
•
•
1
•
•
METHYLPHENIDATE HCL ER methylphenidate hcl tab sa osm
36 mg
1
•
•
METHYLPHENIDATE HCL ER methylphenidate hcl tab sa osm
54 mg
1
methylphenidate hcl soln
10 mg/5ml (Methylin)
1
•
methylphenidate hcl soln
5 mg/5ml (Methylin)
1
•
methylphenidate hcl tab cr
20 mg (Ritalin sr)
1
•
methylphenidate hcl tab 10 mg
(Ritalin)
1
•
methylphenidate hcl tab 20 mg
(Ritalin)
1
•
102
•
•
QUILLIVANT XR - methylphenidate 3
hcl for er susp 25 mg/5ml (5 mg/
ml)
RITALIN - methylphenidate hcl tab 3
5 mg
RITALIN - methylphenidate hcl tab 3
10 mg
RITALIN - methylphenidate hcl tab 3
20 mg
RITALIN LA - methylphenidate hcl 3
cap sr 24hr 10 mg
RITALIN LA - methylphenidate hcl 3
cap sr 24hr 20 mg
RITALIN LA - methylphenidate hcl 3
cap sr 24hr 30 mg
RITALIN LA - methylphenidate hcl 3
cap sr 24hr 40 mg
RITALIN SR - methylphenidate hcl 3
tab cr 20 mg
3
SENTRAMODAFIN AM-100 modafinil tab 100 mg & dietary
management cap pack
STRATTERA - atomoxetine hcl cap 3
10 mg (base equiv)
STRATTERA - atomoxetine hcl cap 3
18 mg (base equiv)
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
•
•
ANTABUSE - disulfiram tab 250
mg
3
•
•
ANTABUSE - disulfiram tab 500
mg
3
•
•
ARICEPT - donepezil
hydrochloride tab 5 mg
3
• •
•
•
ARICEPT - donepezil
hydrochloride tab 10 mg
3
• •
•
•
ARICEPT - donepezil
hydrochloride tab 23 mg
3
• •
•
•
3
• •
•
•
ARICEPT ODT - donepezil
hydrochloride orally
disintegrating tab 5 mg
3
• •
Specialty
•
Quantity Limits
3
Drug Name
"Smart" PA
Prior Authorization
AMPYRA - dalfampridine tab sr
12hr 10 mg
Specialty
•
Quantity Limits
•
"Smart" PA
Drug Tier
STRATTERA - atomoxetine hcl cap 3
25 mg (base equiv)
STRATTERA - atomoxetine hcl cap 3
40 mg (base equiv)
STRATTERA - atomoxetine hcl cap 3
60 mg (base equiv)
STRATTERA - atomoxetine hcl cap 3
80 mg (base equiv)
STRATTERA - atomoxetine hcl cap 3
100 mg (base equiv)
3
VYVANSE - lisdexamfetamine
dimesylate cap 20 mg
3
VYVANSE - lisdexamfetamine
dimesylate cap 30 mg
3
VYVANSE - lisdexamfetamine
dimesylate cap 40 mg
3
VYVANSE - lisdexamfetamine
dimesylate cap 50 mg
3
VYVANSE - lisdexamfetamine
dimesylate cap 60 mg
3
VYVANSE - lisdexamfetamine
dimesylate cap 70 mg
3
ZENZEDI - dextroamphetamine
sulfate tab 2.5 mg
3
ZENZEDI - dextroamphetamine
sulfate tab 7.5 mg
3
ZENZEDI - dextroamphetamine
sulfate tab 15 mg
3
ZENZEDI - dextroamphetamine
sulfate tab 20 mg
3
ZENZEDI - dextroamphetamine
sulfate tab 30 mg
Prior Authorization
Drug Name
Drug Tier
2015
• •
•
•
ARICEPT ODT - donepezil
hydrochloride orally
disintegrating tab 10 mg
•
•
AUBAGIO - teriflunomide tab 7 mg
3
3
•
AUBAGIO - teriflunomide tab 14
mg
2
• •
•
•
•
• •
• •
•
•
AVONEX - interferon beta-1a for
im inj kit 30mcg (33mcg(6.6 mu)/
vial)
•
•
AVONEX - interferon beta-1a im inj
kit 30 mcg/0.5ml
2
• •
•
•
AVONEX PEN - interferon beta-1a
im inj kit 30 mcg/0.5ml
2
• •
•
•
BETASERON - interferon beta-1b
for inj kit 0.3 mg
3
• •
•
•
BRISDELLE - paroxetine mesylate
cap 7.5 mg (base equiv)
3
bupropion hcl (smoking
deterrent) tab sr 12hr 150 mg
(Zyban)
A
CAMPRAL - acamprosate calcium
tab delayed release 333 mg
3
CHANTIX - varenicline tartrate tab
0.5 mg (base equiv)
A
•
CHANTIX - varenicline tartrate tab
1 mg (base equiv)
A
•
PSYCHOTHERAPEUTIC and NEUROLOGICAL
AGENTS - MISC.
1
acamprosate calcium tab
delayed release 333 mg
(Campral)
3
ACTIVE-PAC/GABAPENTIN gabapentin oral cap 300 mg &
lidocaine-menthol gel ther pk
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
103
•
CHANTIX - varenicline tartrate
tab 0.5 mg x 11 & tab 1 mg x 42
pack
A
CHANTIX CONTINUING MONTH
- varenicline tartrate tab 1 mg
(base equiv)
A
CHANTIX STARTING MONTH PA
- varenicline tartrate tab 0.5 mg x
11 & tab 1 mg x 42 pack
A
CHLORDIAZEPOXIDE/AMITRIPT
- chlordiazepoxide-amitriptyline
tab 5-12.5 mg
1
CHLORDIAZEPOXIDE/AMITRIPT
- chlordiazepoxide-amitriptyline
tab 10-25 mg
1
COPAXONE - glatiramer acetate
soln prefilled syringe 40 mg/ml
2
• •
COPAXONE - glatiramer acetate
inj kit 20 mg/ml
2
• •
disulfiram tab 250 mg (Antabuse)
1
disulfiram tab 500 mg (Antabuse)
1
donepezil hydrochloride orally
disintegrating tab 10 mg
(Aricept odt)
1
donepezil hydrochloride orally
disintegrating tab 5 mg
1
donepezil hydrochloride tab
10 mg (Aricept)
1
donepezil hydrochloride tab
23 mg (Aricept)
1
donepezil hydrochloride tab
5 mg (Aricept)
1
ergoloid mesylates tab 1 mg
1
EXELON - rivastigmine td patch
24hr 4.6 mg/24hr
3
• •
EXELON - rivastigmine td patch
24hr 9.5 mg/24hr
3
• •
EXELON - rivastigmine td patch
24hr 13.3 mg/24hr
3
EXELON - rivastigmine tartrate cap 3
1.5 mg
104
•
•
• •
EXELON - rivastigmine tartrate cap 3
3 mg
EXELON - rivastigmine tartrate cap 3
4.5 mg
EXELON - rivastigmine tartrate cap 3
6 mg
3
EXELON - rivastigmine tartrate
soln 2 mg/ml
EXTAVIA - interferon beta-1b for inj 3
kit 0.3 mg
1
fluoxetine hcl (pmdd) cap 10 mg
• •
• •
• •
• •
fluoxetine hcl (pmdd) cap 20 mg
1
galantamine hydrobromide cap
sr 24hr 16 mg (Razadyne er)
1
•
galantamine hydrobromide cap
sr 24hr 24 mg (Razadyne er)
1
•
galantamine hydrobromide cap
sr 24hr 8 mg (Razadyne er)
1
•
galantamine hydrobromide oral
soln 4 mg/ml (Razadyne)
1
galantamine hydrobromide tab
12 mg (Razadyne)
1
•
1
•
•
galantamine hydrobromide tab
4 mg (Razadyne)
1
•
•
galantamine hydrobromide tab
8 mg (Razadyne)
3
•
GILENYA - fingolimod hcl cap 0.5
mg (base equiv)
3
•
•
GRALISE - gabapentin (phn) tab
300 mg
GRALISE - gabapentin (phn) tab
600 mg
3
•
GRALISE STARTER - gabapentin
(phn) tab starter pack 300 mg (9)
& 600 mg (69)
3
•
HORIZANT - gabapentin enacarbil
tab cr 300 mg
3
•
HORIZANT - gabapentin enacarbil
tab cr 600 mg
3
•
•
• •
• •
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
•
• •
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
NAMENDA - memantine hcl tab 5
mg
2
•
olanzapine-fluoxetine hcl cap
6-25 mg (Symbyax)
1
NAMENDA - memantine hcl tab 10
mg
2
•
olanzapine-fluoxetine hcl cap
6-50 mg (Symbyax)
1
NAMENDA - memantine hcl oral
solution 2 mg/ml
2
•
ORAP - pimozide tab 1 mg
3
3
2
•
ORAP - pimozide tab 2 mg
NAMENDA TITRATION PAK memantine hcl tab 5 mg (28) &
10 mg (21) titration pak
1
NAMENDA XR - memantine hcl
cap sr 24hr 7 mg
2
•
PERPHENAZINE/AMITRIPTYLIN
- perphenazine-amitriptyline tab
2-10 mg
1
NAMENDA XR - memantine hcl
cap sr 24hr 14 mg
2
•
PERPHENAZINE/AMITRIPTYLIN
- perphenazine-amitriptyline tab
2-25 mg
NAMENDA XR - memantine hcl
cap sr 24hr 21 mg
•
PERPHENAZINE/AMITRIPTYLIN
- perphenazine-amitriptyline tab
4-10 mg
1
2
NAMENDA XR - memantine hcl
cap sr 24hr 28 mg
2
•
1
NAMENDA XR TITRATION PACK
- memantine hcl cap sr 24hr 7
mg & 14 mg & 21 mg & 28 mg
pack
2
•
PERPHENAZINE/AMITRIPTYLIN
- perphenazine-amitriptyline tab
4-25 mg
PERPHENAZINE/AMITRIPTYLIN
- perphenazine-amitriptyline tab
4-50 mg
1
nicotine td patch 24hr
14 mg/24hr
A
PLEGRIDY - peginterferon beta-1a
soln pen-injector 125 mcg/0.5ml
3
• •
nicotine td patch 24hr
21 mg/24hr
A
3
• •
nicotine td patch 24hr 7 mg/24hr
A
PLEGRIDY - peginterferon beta-1a
soln prefilled syringe 125
mcg/0.5ml
NICOTROL INHALER - nicotine
inhaler system 10 mg (4 mg
delivered)
A
PLEGRIDY STARTER PACK peginterferon beta-1a soln peninj 63 & 94 mcg/0.5ml pack
3
• •
NICOTROL NS - nicotine nasal
spray 10 mg/ml (0.5 mg/spray)
A
3
• •
NUEDEXTA - dextromethorphan
hbr-quinidine sulfate cap 20-10
mg
2
PLEGRIDY STARTER PACK peginterferon beta-1a soln pref
syr 63 & 94 mcg/0.5ml pack
RAZADYNE - galantamine
hydrobromide tab 4 mg
3
• •
olanzapine-fluoxetine hcl cap
12-25 mg (Symbyax)
1
RAZADYNE - galantamine
hydrobromide tab 8 mg
3
• •
olanzapine-fluoxetine hcl cap
12-50 mg (Symbyax)
1
RAZADYNE - galantamine
hydrobromide tab 12 mg
3
• •
olanzapine-fluoxetine hcl cap
3-25 mg (Symbyax)
1
RAZADYNE - galantamine
hydrobromide oral soln 4 mg/ml
3
• •
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
105
RAZADYNE ER - galantamine
hydrobromide cap sr 24hr 8 mg
3
• •
SAVELLA - milnacipran hcl tab 50
mg
3
•
RAZADYNE ER - galantamine
hydrobromide cap sr 24hr 16 mg
3
• •
•
RAZADYNE ER - galantamine
hydrobromide cap sr 24hr 24 mg
3
• •
REBIF - interferon beta-1a inj 22
mcg/0.5ml (12mu/ml) (44 mcg/
ml)
2
• •
REBIF - interferon beta-1a inj 44
mcg/0.5ml (24mu/ml) (88 mcg/
ml)
2
• •
REBIF REBIDOSE - interferon
beta-1a inj 22 mcg/0.5ml (12mu/
ml) (44 mcg/ml)
2
• •
REBIF REBIDOSE - interferon
beta-1a inj 44 mcg/0.5ml (24mu/
ml) (88 mcg/ml)
2
• •
REBIF REBIDOSE TITRATION
- interferon beta-1a inj 6 x 8.8
mcg/0.2ml & 6 x 22 mcg/0.5ml
2
• •
REBIF TITRATION PACK interferon beta-1a inj 6 x 8.8
mcg/0.2ml & 6 x 22 mcg/0.5ml
2
• •
rivastigmine tartrate cap 1.5 mg
(Exelon)
1
•
rivastigmine tartrate cap 3 mg
(Exelon)
1
•
rivastigmine tartrate cap 4.5 mg
(Exelon)
1
•
rivastigmine tartrate cap 6 mg
(Exelon)
1
•
SARAFEM - fluoxetine hcl (pmdd)
tab 10 mg
3
SAVELLA - milnacipran hcl tab 100 3
mg
3
SAVELLA TITRATION PACK milnacipran hcl tab 12.5 mg (5) &
25 mg (8) & 50 mg (42) pak
SYMBYAX - olanzapine-fluoxetine 3
hcl cap 3-25 mg
SYMBYAX - olanzapine-fluoxetine 3
hcl cap 6-25 mg
SYMBYAX - olanzapine-fluoxetine 3
hcl cap 6-50 mg
SYMBYAX - olanzapine-fluoxetine 3
hcl cap 12-25 mg
SYMBYAX - olanzapine-fluoxetine 3
hcl cap 12-50 mg
2
TECFIDERA - dimethyl fumarate
capsule delayed release 120 mg
2
TECFIDERA - dimethyl fumarate
capsule delayed release 240 mg
2
TECFIDERA STARTER PACK dimethyl fumarate capsule dr
starter pack 120 mg & 240 mg
2
XENAZINE - tetrabenazine tab
12.5 mg
2
XENAZINE - tetrabenazine tab 25
mg
3
XYREM - sodium oxybate oral
solution 500 mg/ml
A
ZYBAN - bupropion hcl (smoking
deterrent) tab sr 12hr 150 mg
SARAFEM - fluoxetine hcl (pmdd)
tab 20 mg
3
ANALGESICS - NON-NARCOTIC
1
SAVELLA - milnacipran hcl tab
12.5 mg
3
•
acetaminophen-salicylamidephenyltoloxamine cap
300-200-20mg
SAVELLA - milnacipran hcl tab 25
mg
3
•
ADULT ASPIRIN LOW STRENGT
- aspirin dispersible tab 81 mg
A
106
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
•
•
• •
•
• •
•
• •
•
• •
•
• •
•
• •
ANALGESICS AND ANESTHETICS
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
1
•
BUTALBITAL/ASPIRIN/CAFFEI
- butalbital-aspirin-caffeine tab
50-325-40 mg
1
•
choline & magnesium salicylates
liq 500 mg/5ml
1
A
choline & magnesium salicylates
tab 1000 mg
1
aspirin tab delayed release
81 mg
A
choline & magnesium salicylates
tab 500 mg
1
aspirin tab 81 mg
A
1
BIOREGESIC - phenyltoloxamineacetaminophen tab 50-650 mg
3
choline & magnesium salicylates
tab 750 mg
1
BUPAP - butalbital-acetaminophen
tab 50-300 mg
3
•
CHOLINE MAGNESIUM TRISALI choline & magnesium salicylates
tab 1000 mg
3
•
diflunisal tab 500 mg
1
BUPAP - butalbital-acetaminophen
tab 50-650 mg
DISALCID - salsalate tab 500 mg
3
BUTAL/ASA/CAFF - butalbitalaspirin-caffeine tab 50-325-40
mg
1
•
DISALCID - salsalate tab 750 mg
3
3
butalbital-acetaminophen tab
50-325 mg
1
•
DOLGIC PLUS - butalbitalacetaminophen-caffeine tab
50-750-40 mg
3
butalbital-acetaminophen tab
50-650 mg
1
•
DOLOGESIC - phenyltoloxamineacetaminophen liquid 30-500
mg/15ml
butalbital-acetaminophencaffeine cap 50-300-40 mg
(Fioricet)
1
•
EQUAGESIC - meprobamateaspirin tab 200-325 mg
3
3
• •
butalbital-acetaminophencaffeine cap 50-325-40 mg
1
•
ESGIC - butalbital-acetaminophencaffeine cap 50-325-40 mg
3
• •
butalbital-acetaminophencaffeine cap 50-500-40 mg
1
•
ESGIC - butalbital-acetaminophencaffeine tab 50-325-40 mg
3
•
butalbital-acetaminophencaffeine tab 50-325-40 mg
(Esgic)
1
•
ESGIC-PLUS - butalbitalacetaminophen-caffeine cap
50-500-40 mg
3
•
butalbital-acetaminophencaffeine tab 50-500-40 mg
1
•
ESGIC-PLUS - butalbitalacetaminophen-caffeine tab
50-500-40 mg
butalbital-aspirin-caffeine cap
50-325-40 mg (Fiorinal)
1
•
FIORICET - butalbitalacetaminophen-caffeine cap
50-300-40 mg
3
•
3
ALPAIN - phenyltoloxamineacetaminophen tab 60-500 mg
3
ASPIRIN - aspirin tab 81 mg
A
aspirin chew tab 81 mg
A
ASPIRIN LOW DOSE - aspirin tab
81 mg
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Tier
Drug Name
butalbital-aspirin-caffeine tab
50-325-40 mg
ALAGESIC LQ - butalbitalacetaminophen-caffeine soln
50-325-40 mg/15ml
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
•
107
•
ABSTRAL - fentanyl citrate sl tab
400 mcg (base equiv)
3
•
•
ABSTRAL - fentanyl citrate sl tab
600 mcg (base equiv)
3
•
•
ABSTRAL - fentanyl citrate sl tab
800 mcg (base equiv)
3
•
•
acetaminophen w/ codeine soln
120-12 mg/5ml
1
acetaminophen w/ codeine tab
300-15 mg (Tylenol/codeine)
1
•
1
acetaminophen w/ codeine tab
300-30 mg (Tylenol/codeine #3)
1
•
1
acetaminophen w/ codeine tab
300-60 mg (Tylenol/codeine #4)
1
phenyltoloxamineacetaminophen tab 50-500 mg
•
1
•
PHRENILIN FORTE - butalbitalacetaminophen cap 50-650 mg
3
ACETAMINOPHEN/CAFFEINE/
DI - acetaminophen-caffeinedihydrocodeine tab 712.8-60-32
mg
1
phenyltoloxamineacetaminophen tab 55-500 mg
•
•
RELAGESIC - phenyltoloxamineacetaminophen tab 50-650 mg
ACTIQ - fentanyl citrate lollipop
200 mcg
3
3
3
•
•
RHINOFLEX-650 phenyltoloxamineacetaminophen tab 50-650 mg
3
ACTIQ - fentanyl citrate lollipop
400 mcg
ACTIQ - fentanyl citrate lollipop
600 mcg
3
•
•
salsalate tab 500 mg
1
•
•
salsalate tab 750 mg
ACTIQ - fentanyl citrate lollipop
800 mcg
3
1
STAFLEX - phenyltoloxamineacetaminophen tab 55-500 mg
3
ACTIQ - fentanyl citrate lollipop
1200 mcg
3
•
•
TENCON - butalbitalacetaminophen tab 50-650 mg
3
ACTIQ - fentanyl citrate lollipop
1600 mcg
3
•
•
ZGESIC - phenyltoloxamineacetaminophen tab cr 66-600 mg
3
ASPIRIN-CAFFEINE-DIHYDROC
- aspirin-caffeine-dihydrocodeine
cap 356.4-30-16 mg
1
•
AVINZA - morphine sulfate beads
cap sr 24hr 30 mg
3
•
AVINZA - morphine sulfate beads
cap sr 24hr 45 mg
3
•
FIORINAL - butalbital-aspirincaffeine cap 50-325-40 mg
LEVACET - aspirin-apapsalicylamide-caffeine tab
500-250-150-32.5 mg
3
MST 600 - magnesium salicylate
tab 600 mg
3
ORBIVAN - butalbitalacetaminophen-caffeine cap
50-300-40 mg
3
•
ORBIVAN CF - butalbitalacetaminophen tab 50-300 mg
3
•
phenyltoloxamineacetaminophen tab 30-500 mg
• •
•
•
ANALGESICS - NARCOTIC
ABSTRAL - fentanyl citrate sl tab
100 mcg (base equiv)
108
3
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
•
3
Quantity Limits
Prior Authorization
3
3
Drug Name
"Smart" PA
Drug Tier
ABSTRAL - fentanyl citrate sl tab
300 mcg (base equiv)
• •
FIORICET - butalbitalacetaminophen-caffeine tab
50-325-40 mg
Specialty
•
Quantity Limits
•
"Smart" PA
3
Drug Tier
ABSTRAL - fentanyl citrate sl tab
200 mcg (base equiv)
Drug Name
Prior Authorization
2015
AVINZA - morphine sulfate beads
cap sr 24hr 60 mg
3
•
BUTRANS - buprenorphine td
patch weekly 10 mcg/hr
3
•
AVINZA - morphine sulfate beads
cap sr 24hr 75 mg
3
•
BUTRANS - buprenorphine td
patch weekly 15 mcg/hr
3
•
AVINZA - morphine sulfate beads
cap sr 24hr 90 mg
3
•
BUTRANS - buprenorphine td
patch weekly 20 mcg/hr
3
•
AVINZA - morphine sulfate beads
cap sr 24hr 120 mg
3
•
3
•
BUNAVAIL - buprenorphinenaloxone buccal film 2.1-0.3 mg
(base equiv)
3
•
CAPITAL/CODEINE acetaminophen w/ codeine susp
120-12 mg/5ml
CODEINE SULFATE - codeine
sulfate tab 15 mg
1
•
BUNAVAIL - buprenorphinenaloxone buccal film 4.2-0.7 mg
(base equiv)
3
CODEINE SULFATE - codeine
sulfate oral soln 30 mg/5ml
1
codeine sulfate tab 30 mg
1
BUNAVAIL - buprenorphinenaloxone buccal film 6.3-1 mg
(base equiv)
3
codeine sulfate tab 60 mg
1
3
buprenorphine hcl sl tab 2 mg
(base equiv)
1
CONZIP - tramadol hcl cap sr 24hr
biphasic release 100 mg
•
•
•
3
•
buprenorphine hcl sl tab 8 mg
(base equiv)
1
CONZIP - tramadol hcl cap sr 24hr
biphasic release 200 mg
3
•
buprenorphine hcl-naloxone hcl
sl tab 2-0.5 mg (base equiv)
1
CONZIP - tramadol hcl cap sr 24hr
biphasic release 300 mg
3
•
buprenorphine hcl-naloxone hcl
sl tab 8-2 mg (base equiv)
1
DEMEROL - meperidine hcl tab 50
mg
3
•
butalbital-acetaminophen-caff
w/ cod cap 50-300-40-30 mg
(Fioricet/codeine)
1
DEMEROL - meperidine hcl tab
100 mg
DILAUDID - hydromorphone hcl
tab 2 mg
3
• •
butalbital-acetaminophen-caff w/
cod cap 50-325-40-30 mg
1
•
DILAUDID - hydromorphone hcl
tab 4 mg
3
• •
butalbital-aspirin-caff w/ codeine
cap 50-325-40-30 mg (Fiorinal/
codeine #3)
1
•
DILAUDID - hydromorphone hcl
tab 8 mg
3
• •
3
•
butorphanol tartrate inj 1 mg/ml
1
DILAUDID - hydromorphone hcl
liqd 1 mg/ml
butorphanol tartrate inj 2 mg/ml
1
3
• •
butorphanol tartrate nasal soln
10 mg/ml
1
•
DOLOPHINE - methadone hcl tab
10 mg
• •
BUTRANS - buprenorphine td
patch weekly 5 mcg/hr
3
•
BUTRANS - buprenorphine td
patch weekly 7.5 mcg/hr
3
•
DOLOPHINE HCL - methadone hcl 3
tab 5 mg
3
DURAGESIC - fentanyl td patch
72hr 12 mcg/hr
•
•
•
•
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
•
109
DURAGESIC - fentanyl td patch
72hr 50 mcg/hr
3
• •
FENTORA - fentanyl citrate buccal
tab 400 mcg (base equiv)
3
•
•
DURAGESIC - fentanyl td patch
72hr 75 mcg/hr
3
• •
FENTORA - fentanyl citrate buccal
tab 600 mcg (base equiv)
3
•
•
DURAGESIC - fentanyl td patch
72hr 100 mcg/hr
3
• •
FENTORA - fentanyl citrate buccal
tab 800 mcg (base equiv)
3
•
•
EXALGO - hydromorphone hcl tab
er 24hr deter 8 mg
3
•
3
•
EXALGO - hydromorphone hcl tab
er 24hr deter 12 mg
3
•
FIORICET/CODEINE - butalbitalacetaminophen-caff w/ cod cap
50-300-40-30 mg
3
•
EXALGO - hydromorphone hcl tab
er 24hr deter 16 mg
3
•
FIORICET/CODEINE - butalbitalacetaminophen-caff w/ cod cap
50-325-40-30 mg
EXALGO - hydromorphone hcl tab
er 24hr deter 32 mg
3
•
3
• •
fentanyl citrate lollipop
1200 mcg (Actiq)
1
FIORINAL/CODEINE #3 butalbital-aspirin-caff w/ codeine
cap 50-325-40-30 mg
3
• •
fentanyl citrate lollipop
1600 mcg (Actiq)
HYCET - hydrocodoneacetaminophen soln 7.5-325
mg/15ml
HYDROCODONE BITARTRATE/
AC - hydrocodoneacetaminophen tab 2.5-325 mg
1
•
1
•
•
•
1
•
•
fentanyl citrate lollipop 200 mcg
(Actiq)
1
•
•
fentanyl citrate lollipop 400 mcg
(Actiq)
1
•
•
fentanyl citrate lollipop 600 mcg
(Actiq)
1
•
•
HYDROCODONE BITARTRATE/
AC - hydrocodoneacetaminophen tab 10-750 mg
•
•
•
1
hydrocodone-acetaminophen
cap 5-500 mg
1
fentanyl citrate lollipop 800 mcg
(Actiq)
•
fentanyl td patch 72hr 100 mcg/
hr (Duragesic)
•
hydrocodone-acetaminophen
soln 10-325 mg/15ml
1
1
•
fentanyl td patch 72hr 12 mcg/hr
(Duragesic)
•
hydrocodone-acetaminophen
soln 7.5-325 mg/15ml (Hycet)
1
1
•
•
fentanyl td patch 72hr 25 mcg/hr
(Duragesic)
hydrocodone-acetaminophen
soln 7.5-500 mg/15ml
1
1
1
1
•
•
fentanyl td patch 72hr 50 mcg/hr
(Duragesic)
hydrocodone-acetaminophen
tab 10-300 mg (Xodol)
•
•
1
hydrocodone-acetaminophen
tab 10-325 mg (Norco)
1
fentanyl td patch 72hr 75 mcg/hr
(Duragesic)
•
FENTORA - fentanyl citrate buccal
tab 100 mcg (base equiv)
•
hydrocodone-acetaminophen
tab 10-500 mg
1
3
110
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
•
Quantity Limits
Prior Authorization
•
Drug Name
"Smart" PA
Drug Tier
3
Specialty
FENTORA - fentanyl citrate buccal
tab 200 mcg (base equiv)
Quantity Limits
• •
"Smart" PA
3
Drug Tier
DURAGESIC - fentanyl td patch
72hr 25 mcg/hr
Drug Name
Prior Authorization
2015
hydrocodone-acetaminophen
tab 10-650 mg
1
•
hydrocodone-acetaminophen
tab 10-660 mg
1
•
hydrocodone-acetaminophen
tab 10-750 mg
1
•
hydrocodone-acetaminophen
tab 2.5-325 mg
1
•
hydrocodone-acetaminophen
tab 2.5-500 mg
1
hydrocodone-acetaminophen
tab 5-300 mg (Xodol)
1
HYDROCODONE/
ACETAMINOPHEN hydrocodone-acetaminophen tab
7.5-750 mg
1
•
1
•
•
HYDROCODONE/
ACETAMINOPHEN hydrocodone-acetaminophen
soln 10-325 mg/15ml
HYDROMORPHONE HCL hydromorphone hcl suppos 3 mg
1
•
•
•
hydrocodone-acetaminophen
tab 5-325 mg (Norco)
HYDROMORPHONE HCL ER hydromorphone hcl tab er 24hr
deter 32 mg
1
1
hydrocodone-acetaminophen
tab 5-500 mg
1
•
hydromorphone hcl liqd 1 mg/ml
(Dilaudid)
1
•
hydrocodone-acetaminophen
tab 7.5-300 mg (Xodol)
1
•
hydromorphone hcl tab er 24hr
deter 12 mg (Exalgo)
1
•
hydrocodone-acetaminophen
tab 7.5-325 mg (Norco)
1
•
hydromorphone hcl tab er 24hr
deter 16 mg (Exalgo)
1
•
hydrocodone-acetaminophen
tab 7.5-500 mg
1
•
hydromorphone hcl tab er 24hr
deter 8 mg (Exalgo)
1
•
hydrocodone-acetaminophen
tab 7.5-650 mg
1
•
hydromorphone hcl tab 2 mg
(Dilaudid)
1
•
hydrocodone-acetaminophen
tab 7.5-750 mg
1
•
hydromorphone hcl tab 4 mg
(Dilaudid)
1
•
hydrocodone-ibuprofen tab
10-200 mg (Ibudone)
1
•
hydromorphone hcl tab 8 mg
(Dilaudid)
1
•
hydrocodone-ibuprofen tab
2.5-200 mg (Reprexain)
1
•
HYSINGLA ER - hydrocodone
bitartrate tab er 24hr deter 20 mg
3
hydrocodone-ibuprofen tab
5-200 mg (Reprexain)
1
•
HYSINGLA ER - hydrocodone
bitartrate tab er 24hr deter 30 mg
3
hydrocodone-ibuprofen tab
7.5-200 mg (Vicoprofen)
1
•
HYSINGLA ER - hydrocodone
bitartrate tab er 24hr deter 40 mg
3
HYDROCODONE/
ACETAMINOPHEN hydrocodone-acetaminophen tab
7.5-500 mg
1
•
HYSINGLA ER - hydrocodone
bitartrate tab er 24hr deter 60 mg
3
HYSINGLA ER - hydrocodone
bitartrate tab er 24hr deter 80 mg
3
HYDROCODONE/
ACETAMINOPHEN -
1
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
hydrocodone-acetaminophen tab
7.5-650 mg
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
111
HYSINGLA ER - hydrocodone
bitartrate tab er 24hr deter 100
mg
3
HYSINGLA ER - hydrocodone
bitartrate tab er 24hr deter 120
mg
3
IBUDONE - hydrocodone-ibuprofen 3
tab 10-200 mg
3
KADIAN - morphine sulfate cap sr
24hr 10 mg
3
KADIAN - morphine sulfate cap sr
24hr 20 mg
3
KADIAN - morphine sulfate cap sr
24hr 30 mg
3
KADIAN - morphine sulfate cap sr
24hr 40 mg
3
KADIAN - morphine sulfate cap sr
24hr 50 mg
3
KADIAN - morphine sulfate cap sr
24hr 60 mg
3
KADIAN - morphine sulfate cap sr
24hr 70 mg
3
KADIAN - morphine sulfate cap sr
24hr 80 mg
3
KADIAN - morphine sulfate cap sr
24hr 100 mg
3
KADIAN - morphine sulfate cap sr
24hr 130 mg
3
KADIAN - morphine sulfate cap sr
24hr 150 mg
3
KADIAN - morphine sulfate cap sr
24hr 200 mg
3
LAZANDA - fentanyl citrate nasal
spray 100 mcg/act (base equiv)
3
LAZANDA - fentanyl citrate nasal
spray 400 mcg/act (base equiv)
1
LEVORPHANOL TARTRATE levorphanol tartrate tab 2 mg
3
LIQUICET - hydrocodoneacetaminophen soln 10-500
mg/15ml
112
•
LORCET 10/650 - hydrocodoneacetaminophen tab 10-650 mg
3
•
LORTAB - hydrocodoneacetaminophen tab 5-500 mg
3
•
LORTAB - hydrocodoneacetaminophen tab 7.5-500 mg
3
•
LORTAB - hydrocodoneacetaminophen tab 10-500 mg
3
•
LORTAB - hydrocodoneacetaminophen soln 7.5-500
mg/15ml
3
•
LORTAB - hydrocodoneacetaminophen soln 10-300
mg/15ml
3
•
•
MAGNACET - oxycodone w/
acetaminophen tab 5-400 mg
3
•
•
MAGNACET - oxycodone w/
acetaminophen tab 7.5-400 mg
3
•
•
MAGNACET - oxycodone w/
acetaminophen tab 10-400 mg
3
•
•
MAXIDONE - hydrocodoneacetaminophen tab 10-750 mg
3
•
•
MEPERIDINE HCL - meperidine
hcl oral soln 50 mg/5ml
3
•
•
meperidine hcl tab 100 mg
(Demerol)
1
•
•
meperidine hcl tab 50 mg
(Demerol)
1
•
•
1
•
•
MEPERIDINE HCL/PROMETHAZI
- meperidine w/ promethazine
cap 50-25 mg
1
•
METHADONE HCL - methadone
hcl inj 10 mg/ml
1
•
•
METHADONE HCL - methadone
hcl soln 5 mg/5ml
1
•
•
METHADONE HCL - methadone
hcl soln 10 mg/5ml
methadone hcl conc 10 mg/ml
(Methadose)
1
•
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Tier
3
•
•
Drug Name
LORCET PLUS - hydrocodoneacetaminophen tab 7.5-650 mg
•
•
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
methadone hcl soln 10 mg/5ml
(Methadone hcl)
1
•
morphine sulfate cap sr 24hr
10 mg (Kadian)
1
•
methadone hcl soln 5 mg/5ml
(Methadone hcl)
1
•
morphine sulfate cap sr 24hr
100 mg (Kadian)
1
•
methadone hcl tab for oral susp
40 mg
1
•
morphine sulfate cap sr 24hr
20 mg (Kadian)
1
•
methadone hcl tab 10 mg
(Dolophine)
1
•
morphine sulfate cap sr 24hr
30 mg (Kadian)
1
•
methadone hcl tab 5 mg
(Dolophine hcl)
1
•
morphine sulfate cap sr 24hr
50 mg (Kadian)
1
•
METHADOSE - methadone hcl
conc 10 mg/ml
3
•
morphine sulfate cap sr 24hr
60 mg (Kadian)
1
•
METHADOSE SUGAR-FREE methadone hcl conc 10 mg/ml
3
•
morphine sulfate cap sr 24hr
80 mg (Kadian)
1
•
MORPHINE SULFATE - morphine
sulfate tab 15 mg
1
•
morphine sulfate oral soln
10 mg/5ml
1
•
MORPHINE SULFATE - morphine
sulfate tab 30 mg
1
•
morphine sulfate oral soln
20 mg/5ml
1
•
MORPHINE SULFATE - morphine
sulfate suppos 5 mg
1
morphine sulfate tab cr 100 mg
(Ms contin)
1
•
MORPHINE SULFATE - morphine
sulfate suppos 10 mg
1
morphine sulfate tab cr 15 mg
(Ms contin)
1
•
MORPHINE SULFATE - morphine
sulfate suppos 20 mg
1
morphine sulfate tab cr 200 mg
(Ms contin)
1
•
MORPHINE SULFATE - morphine
sulfate suppos 30 mg
1
morphine sulfate tab cr 30 mg
(Ms contin)
1
•
morphine sulfate (concentrate)
oral soln 20 mg/ml
1
•
morphine sulfate tab cr 60 mg
(Ms contin)
1
•
morphine sulfate beads cap sr
24hr 120 mg (Avinza)
1
•
MS CONTIN - morphine sulfate tab
cr 15 mg
3
• •
morphine sulfate beads cap sr
24hr 30 mg (Avinza)
1
•
MS CONTIN - morphine sulfate tab
cr 30 mg
3
• •
morphine sulfate beads cap sr
24hr 45 mg (Avinza)
1
•
MS CONTIN - morphine sulfate tab
cr 60 mg
3
• •
morphine sulfate beads cap sr
24hr 60 mg (Avinza)
1
•
MS CONTIN - morphine sulfate tab
cr 100 mg
3
• •
morphine sulfate beads cap sr
24hr 75 mg (Avinza)
1
•
MS CONTIN - morphine sulfate tab
cr 200 mg
3
• •
morphine sulfate beads cap sr
24hr 90 mg (Avinza)
1
•
NORCO - hydrocodoneacetaminophen tab 10-325 mg
3
• •
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
113
NORCO - hydrocodoneacetaminophen tab 5-325 mg
3
• •
NORCO - hydrocodoneacetaminophen tab 7.5-325 mg
3
• •
NUCYNTA - tapentadol hcl tab 50
mg
3
NUCYNTA - tapentadol hcl tab 75
mg
OPANA ER (CRUSH RESISTANT
- oxymorphone hcl tab er 12hr
deter 30 mg
2
•
2
•
•
OPANA ER (CRUSH RESISTANT
- oxymorphone hcl tab er 12hr
deter 40 mg
3
•
OXECTA - oxycodone hcl tab
abuse deter 5 mg
3
•
NUCYNTA - tapentadol hcl tab 100
mg
3
•
OXECTA - oxycodone hcl tab
abuse deter 7.5 mg
3
•
NUCYNTA ER - tapentadol hcl tab
sr 12hr 50 mg
3
•
OXYCODONE HCL - oxycodone
hcl conc 100 mg/5ml (20 mg/ml)
1
•
NUCYNTA ER - tapentadol hcl tab
sr 12hr 100 mg
3
•
OXYCODONE HCL - oxycodone
hcl soln 5 mg/5ml
1
•
NUCYNTA ER - tapentadol hcl tab
sr 12hr 150 mg
3
•
oxycodone hcl cap 5 mg
1
1
NUCYNTA ER - tapentadol hcl tab
sr 12hr 200 mg
3
•
oxycodone hcl conc 100 mg/5ml
(20 mg/ml) (Oxycodone hcl)
•
•
3
•
NUCYNTA ER - tapentadol hcl tab
sr 12hr 250 mg
3
•
OXYCODONE HCL ER oxycodone hcl tab er 12hr deter
10 mg
OPANA - oxymorphone hcl tab 5
mg
3
•
3
•
OPANA - oxymorphone hcl tab 10
mg
3
•
OXYCODONE HCL ER oxycodone hcl tab er 12hr deter
20 mg
3
•
OPANA ER (CRUSH RESISTANT
- oxymorphone hcl tab er 12hr
deter 5 mg
2
•
OXYCODONE HCL ER oxycodone hcl tab er 12hr deter
40 mg
3
•
OPANA ER (CRUSH RESISTANT
- oxymorphone hcl tab er 12hr
deter 7.5 mg
2
•
OXYCODONE HCL ER oxycodone hcl tab er 12hr deter
80 mg
1
•
OPANA ER (CRUSH RESISTANT
- oxymorphone hcl tab er 12hr
deter 10 mg
2
oxycodone hcl soln 5 mg/5ml
(Oxycodone hcl)
oxycodone hcl tab 10 mg
1
1
OPANA ER (CRUSH RESISTANT
- oxymorphone hcl tab er 12hr
deter 15 mg
2
oxycodone hcl tab 15 mg
(Roxicodone)
•
•
oxycodone hcl tab 20 mg
1
1
OPANA ER (CRUSH RESISTANT
- oxymorphone hcl tab er 12hr
deter 20 mg
2
oxycodone hcl tab 30 mg
(Roxicodone)
•
•
oxycodone hcl tab 5 mg
(Roxicodone)
1
•
oxycodone w/ acetaminophen
cap 5-500 mg
1
•
114
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
oxycodone w/ acetaminophen
tab 10-325 mg (Percocet)
1
•
oxymorphone hcl tab sr 12hr
5 mg
1
•
oxycodone w/ acetaminophen
tab 10-650 mg
1
•
oxymorphone hcl tab sr 12hr
7.5 mg
1
•
oxycodone w/ acetaminophen
tab 2.5-325 mg (Percocet)
1
•
oxymorphone hcl tab 10 mg
(Opana)
1
•
oxycodone w/ acetaminophen
tab 5-325 mg (Percocet)
1
•
oxymorphone hcl tab 5 mg
(Opana)
1
•
oxycodone w/ acetaminophen
tab 7.5-325 mg (Percocet)
1
•
pentazocine w/ naloxone tab
50-0.5 mg
1
oxycodone w/ acetaminophen
tab 7.5-500 mg
1
•
pentazocine-acetaminophen tab
25-650 mg
1
•
oxycodone-aspirin tab
4.8355-325 mg (Percodan)
1
•
PERCOCET - oxycodone w/
acetaminophen tab 2.5-325 mg
3
•
oxycodone-ibuprofen tab
5-400 mg
1
•
PERCOCET - oxycodone w/
acetaminophen tab 5-325 mg
3
• •
OXYCONTIN - oxycodone hcl tab
er 12hr deter 10 mg
2
•
PERCOCET - oxycodone w/
acetaminophen tab 7.5-325 mg
3
• •
OXYCONTIN - oxycodone hcl tab
er 12hr deter 15 mg
2
•
PERCOCET - oxycodone w/
acetaminophen tab 7.5-500 mg
3
• •
OXYCONTIN - oxycodone hcl tab
er 12hr deter 20 mg
2
•
PERCOCET - oxycodone w/
acetaminophen tab 10-325 mg
3
• •
OXYCONTIN - oxycodone hcl tab
er 12hr deter 30 mg
2
•
PERCOCET - oxycodone w/
acetaminophen tab 10-650 mg
3
• •
OXYCONTIN - oxycodone hcl tab
er 12hr deter 40 mg
2
•
PERCODAN - oxycodone-aspirin
tab 4.8355-325 mg
3
•
OXYCONTIN - oxycodone hcl tab
er 12hr deter 60 mg
2
•
PRIMLEV - oxycodone w/
acetaminophen tab 5-300 mg
3
•
OXYCONTIN - oxycodone hcl tab
er 12hr deter 80 mg
2
•
PRIMLEV - oxycodone w/
acetaminophen tab 7.5-300 mg
3
•
oxymorphone hcl tab sr 12hr
10 mg
1
•
PRIMLEV - oxycodone w/
acetaminophen tab 10-300 mg
3
•
oxymorphone hcl tab sr 12hr
15 mg
1
•
REPREXAIN - hydrocodoneibuprofen tab 2.5-200 mg
3
•
oxymorphone hcl tab sr 12hr
20 mg
1
•
REPREXAIN - hydrocodoneibuprofen tab 5-200 mg
3
•
oxymorphone hcl tab sr 12hr
30 mg
1
•
3
•
oxymorphone hcl tab sr 12hr
40 mg
1
•
ROXICET - oxycodone w/
acetaminophen soln 5-325
mg/5ml
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
115
ROXICODONE - oxycodone hcl
tab 15 mg
3
• •
SUBSYS - fentanyl sublingual
spray 1200 mcg (600 mcg x 2)
3
•
•
ROXICODONE - oxycodone hcl
tab 30 mg
3
• •
SUBSYS - fentanyl sublingual
spray 1600 mcg (800 mcg x 2)
3
•
•
RYBIX ODT - tramadol hcl orally
disintegrating tab 50 mg
3
3
RYZOLT - tramadol hcl tab sr 24hr
biphasic release 100 mg
3
SYNALGOS-DC - aspirin-caffeinedihydrocodeine cap 356.4-30-16
mg
3
RYZOLT - tramadol hcl tab sr 24hr
biphasic release 200 mg
3
• •
SYNAPRYN FUSEPAQ - tramadol
hcl for oral susp 10 mg/ml
(compound kit)
RYZOLT - tramadol hcl tab sr 24hr
biphasic release 300 mg
3
• •
3
SUBOXONE - buprenorphine hclnaloxone hcl sl tab 2-0.5 mg
(base equiv)
2
•
THERACODEINE-300 - apapcodeine tab 300-30 mg & dietary
management cap pack
3
SUBOXONE - buprenorphine hclnaloxone hcl sl tab 8-2 mg (base
equiv)
2
THERACODOPHEN-LOW-90 hydrocodone-apap tab 5-500 mg
& dietary manage cap pack
3
SUBOXONE - buprenorphine hclnaloxone hcl sl film 2-0.5 mg
(base equiv)
2
THERACODOPHEN-325 hydrocodone-apap tab 10-325
mg & dietary manage cap pack
3
SUBOXONE - buprenorphine hclnaloxone hcl sl film 4-1 mg (base
equiv)
2
THERACODOPHEN-650 hydrocodone-apap tab 10-650
mg & dietary manage cap pack
3
SUBOXONE - buprenorphine hclnaloxone hcl sl film 8-2 mg (base
equiv)
2
THERACODOPHEN-750 hydrocodone-apap tab 7.5-750
mg & dietary manage cap pack
3
SUBOXONE - buprenorphine hclnaloxone hcl sl film 12-3 mg
(base equiv)
2
THERATRAMADOL-60 - tramadol
hcl tab 50 mg & dietary
management cap pack
3
SUBSYS - fentanyl sublingual
spray 100 mcg
3
THERATRAMADOL-90 - tramadol
hcl tab 50 mg & dietary
management cap pack
1
•
SUBSYS - fentanyl sublingual
spray 200 mcg
• •
•
•
•
•
•
•
•
•
3
•
•
TRAMADOL HCL ER - tramadol
hcl cap sr 24hr biphasic release
150 mg
3
•
•
tramadol hcl tab sr 24hr biphasic
release 100 mg
1
SUBSYS - fentanyl sublingual
spray 400 mcg
•
3
•
•
tramadol hcl tab sr 24hr biphasic
release 200 mg
1
SUBSYS - fentanyl sublingual
spray 600 mcg
•
tramadol hcl tab sr 24hr biphasic
release 300 mg
1
•
116
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
•
Quantity Limits
Prior Authorization
•
Drug Name
"Smart" PA
Drug Tier
3
Specialty
SUBSYS - fentanyl sublingual
spray 800 mcg
Quantity Limits
• •
"Smart" PA
3
Drug Tier
ROXICODONE - oxycodone hcl
tab 5 mg
Drug Name
Prior Authorization
2015
tramadol hcl tab sr 24hr 100 mg
(Ultram er)
1
•
XODOL - hydrocodoneacetaminophen tab 5-300 mg
3
•
tramadol hcl tab sr 24hr 200 mg
(Ultram er)
1
•
XODOL - hydrocodoneacetaminophen tab 7.5-300 mg
3
•
tramadol hcl tab sr 24hr 300 mg
(Ultram er)
1
•
XODOL - hydrocodoneacetaminophen tab 10-300 mg
3
•
tramadol hcl tab 50 mg (Ultram)
1
•
1
XOLOX - oxycodone w/
acetaminophen tab 10-500 mg
3
tramadol-acetaminophen tab
37.5-325 mg (Ultracet)
•
•
3
•
•
TREZIX - acetaminophen-caffeinedihydrocodeine cap 320.5-30-16
mg
3
ZOHYDRO ER - hydrocodone
bitartrate cap sr 12hr 10 mg
ZOHYDRO ER - hydrocodone
bitartrate cap sr 12hr 15 mg
3
•
•
TREZIX - acetaminophen-caffeinedihydrocodeine cap 356.4-30-16
mg
3
ZOHYDRO ER - hydrocodone
bitartrate cap sr 12hr 20 mg
3
•
•
3
•
•
TYLENOL/CODEINE acetaminophen w/ codeine tab
300-15 mg
3
ZOHYDRO ER - hydrocodone
bitartrate cap sr 12hr 30 mg
3
•
•
TYLENOL/CODEINE #3 acetaminophen w/ codeine tab
300-30 mg
3
• •
ZOHYDRO ER - hydrocodone
bitartrate cap sr 12hr 40 mg
ZOHYDRO ER - hydrocodone
bitartrate cap sr 12hr 50 mg
3
•
•
3
• •
ZOLVIT - hydrocodoneacetaminophen soln 10-300
mg/15ml
3
TYLENOL/CODEINE #4 acetaminophen w/ codeine tab
300-60 mg
•
3
•
•
ULTRACET - tramadolacetaminophen tab 37.5-325 mg
3
•
ZUBSOLV - buprenorphine hclnaloxone hcl sl tab 1.4-0.36 mg
(base eq)
3
TYLOX - oxycodone w/
acetaminophen cap 5-500 mg
3
•
ULTRAM - tramadol hcl tab 50 mg
3
ULTRAM ER - tramadol hcl tab sr
24hr 100 mg
3
•
• •
ZUBSOLV - buprenorphine hclnaloxone hcl sl tab 5.7-1.4 mg
(base eq)
ZYDONE - hydrocodoneacetaminophen tab 5-400 mg
3
•
ULTRAM ER - tramadol hcl tab sr
24hr 200 mg
3
• •
ZYDONE - hydrocodoneacetaminophen tab 7.5-400 mg
3
•
ULTRAM ER - tramadol hcl tab sr
24hr 300 mg
3
• •
ZYDONE - hydrocodoneacetaminophen tab 10-400 mg
3
•
VICOPROFEN - hydrocodoneibuprofen tab 7.5-200 mg
3
• •
XARTEMIS XR - oxycodone w/
acetaminophen tab cr 7.5-325
mg
3
ANALGESICS - ANTI-INFLAMMATORY
3
ACTEMRA - tocilizumab
subcutaneous soln prefilled
syringe 162 mg/0.9ml
ANAPROX - naproxen sodium tab 3
275 mg
•
• •
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
• •
•
117
ANAPROX DS - naproxen sodium
tab 550 mg
3
ARAVA - leflunomide tab 10 mg
3
ARAVA - leflunomide tab 20 mg
3
ARCALYST - rilonacept for inj 220
mg
2
ARTHROTEC 50 - diclofenac w/
misoprostol tab delayed release
50-0.2 mg
3
ARTHROTEC 75 - diclofenac w/
misoprostol tab delayed release
75-0.2 mg
3
CATAFLAM - diclofenac potassium
tab 50 mg
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
diclofenac w/ misoprostol tab
delayed release 75-0.2 mg
(Arthrotec 75)
1
DUEXIS - ibuprofen-famotidine tab
800-26.6 mg
3
• •
EC-NAPROSYN - naproxen tab ec
375 mg
3
•
EC-NAPROSYN - naproxen tab ec
500 mg
3
•
•
ENBREL - etanercept
subcutaneous soln prefilled
syringe 25 mg/0.5ml
2
•
• •
3
•
2
•
• •
CELEBREX - celecoxib cap 50 mg
3
3
ENBREL - etanercept for
subcutaneous inj kit 25 mg
2
CELEBREX - celecoxib cap 100
mg
• •
• •
ENBREL - etanercept
subcutaneous soln prefilled
syringe 50 mg/ml
•
• •
CELEBREX - celecoxib cap 200
mg
3
• •
•
• •
CELEBREX - celecoxib cap 400
mg
3
• •
ENBREL SURECLICK - etanercept 2
subcutaneous solution autoinjector 50 mg/ml
1
etodolac cap 200 mg
celecoxib cap 100 mg (Celebrex)
1
celecoxib cap 200 mg (Celebrex)
1
celecoxib cap 400 mg (Celebrex)
1
celecoxib cap 50 mg (Celebrex)
1
DAYPRO - oxaprozin tab 600 mg
3
diclofenac potassium tab 50 mg
(Cataflam)
1
diclofenac sodium tab delayed
release 25 mg
•
•
etodolac cap 300 mg
1
etodolac tab sr 24hr 400 mg
1
etodolac tab sr 24hr 500 mg
1
etodolac tab sr 24hr 600 mg
1
etodolac tab 400 mg
1
etodolac tab 500 mg
1
FELDENE - piroxicam cap 10 mg
3
1
FELDENE - piroxicam cap 20 mg
3
1
diclofenac sodium tab delayed
release 50 mg
1
FENOPROFEN CALCIUM fenoprofen calcium cap 400 mg
•
•
•
1
•
diclofenac sodium tab delayed
release 75 mg
1
FENOPROFEN CALCIUM fenoprofen calcium tab 600 mg
flurbiprofen tab 100 mg
1
diclofenac sodium tab sr 24hr
100 mg (Voltaren-xr)
1
flurbiprofen tab 50 mg
1
•
• •
diclofenac w/ misoprostol tab
delayed release 50-0.2 mg
(Arthrotec 50)
HUMIRA - adalimumab prefilled
syringe kit 10 mg/0.2ml
2
1
HUMIRA - adalimumab inj kit 20
mg/0.4ml
2
•
• •
118
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
HUMIRA PEN - adalimumab inj kit
40 mg/0.8ml (50 mg/ml)
2
•
• •
HUMIRA PEN-CROHNS DISEASE
- adalimumab inj kit 40 mg/0.8ml
(50 mg/ml)
2
•
• •
HUMIRA PEN-PSORIASIS STAR
- adalimumab inj kit 40 mg/0.8ml
(50 mg/ml)
2
IBUPROFEN COMFORT PAC ibuprofen tab 800 mg & liniment
topical gel kit
3
ibuprofen susp 100 mg/5ml
1
ibuprofen tab 400 mg
1
ibuprofen tab 600 mg
1
ibuprofen tab 800 mg
1
IC 400 - ibuprofen tab 400 mg &
caffeine-vitamins cap kit
3
IC 800 - ibuprofen tab 800 mg &
caffeine-vitamins cap kit
3
INDOCIN - indomethacin susp 25
mg/5ml
3
INDOCIN - indomethacin suppos
50 mg
3
indomethacin cap cr 75 mg
1
indomethacin cap 25 mg
1
indomethacin cap 50 mg
1
ketoprofen cap 50 mg
1
ketoprofen cap 75 mg
1
KETOPROFEN ER - ketoprofen
cap sr 24hr 200 mg
1
ketorolac tromethamine tab
10 mg
1
KINERET - anakinra subcutaneous
soln prefilled syringe 100
mg/0.67ml
3
•
• •
1
MECLOFENAMATE SODIUM meclofenamate sodium cap 50
mg
1
MECLOFENAMATE SODIUM meclofenamate sodium cap 100
mg
1
mefenamic acid cap 250 mg
(Ponstel)
1
MELOXICAM - meloxicam susp 7.5 1
mg/5ml
3
MELOXICAM COMFORT PAC meloxicam tab 15 mg & liniment
topical gel kit
1
meloxicam tab 15 mg (Mobic)
• •
• •
•
•
• •
• •
• •
meloxicam tab 7.5 mg (Mobic)
1
MOBIC - meloxicam tab 7.5 mg
3
MOBIC - meloxicam tab 15 mg
3
MOBIC - meloxicam susp 7.5
mg/5ml
3
nabumetone tab 500 mg
1
nabumetone tab 750 mg
1
•
NALFON - fenoprofen calcium cap
400 mg
3
•
•
NAPRELAN - naproxen sodium tab 3
sr 24hr 375 mg (base equiv)
NAPRELAN - naproxen sodium tab 3
sr 24hr 500 mg (base equiv)
NAPRELAN - naproxen sodium tab 3
sr 24hr 750 mg (base equiv)
NAPRELAN - naproxen sodium tab 3
sr 24hr 500 mg (14) & 750 mg (6)
pack
3
NAPROSYN - naproxen tab 250
mg
3
NAPROSYN - naproxen tab 375
mg
3
NAPROSYN - naproxen tab 500
mg
•
•
•
leflunomide tab 20 mg (Arava)
• •
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
• •
Quantity Limits
•
1
"Smart" PA
HUMIRA PEDIATRIC CROHNS D
- adalimumab inj kit 40 mg/0.8ml
(50 mg/ml)
2
leflunomide tab 10 mg (Arava)
Prior Authorization
• •
Drug Name
Drug Tier
•
Specialty
2
Quantity Limits
Prior Authorization
HUMIRA - adalimumab inj kit 40
mg/0.8ml (50 mg/ml)
Drug Name
"Smart" PA
Drug Tier
2015
•
•
•
•
•
•
119
NAPROSYN - naproxen susp 125
mg/5ml
3
•
PRASTERA - prasterone cap 200
mg & ibuprofen tab 400 mg kit
3
NAPROXEN COMFORT PAC naproxen tab 500 mg & liniment
topical gel kit
3
•
RASUVO - methotrexate soln pf
auto-injector 7.5 mg/0.15ml
3
•
•
naproxen sodium tab 220 mg
RASUVO - methotrexate soln pf
auto-injector 10 mg/0.2ml
3
1
naproxen sodium tab 275 mg
(Anaprox)
1
RASUVO - methotrexate soln pf
auto-injector 12.5 mg/0.25ml
3
•
naproxen sodium tab 550 mg
(Anaprox ds)
1
RASUVO - methotrexate soln pf
auto-injector 15 mg/0.3ml
3
•
naproxen susp 125 mg/5ml
(Naprosyn)
1
RASUVO - methotrexate soln pf
auto-injector 17.5 mg/0.35ml
3
•
naproxen tab ec 375 mg (Ecnaprosyn)
1
RASUVO - methotrexate soln pf
auto-injector 20 mg/0.4ml
3
•
naproxen tab ec 500 mg (Ecnaprosyn)
1
RASUVO - methotrexate soln pf
auto-injector 22.5 mg/0.45ml
3
•
naproxen tab 250 mg (Naprosyn)
1
3
•
naproxen tab 375 mg (Naprosyn)
1
RASUVO - methotrexate soln pf
auto-injector 25 mg/0.5ml
naproxen tab 500 mg (Naprosyn)
1
3
•
ORENCIA - abatacept
subcutaneous soln prefilled
syringe 125 mg/ml
3
RASUVO - methotrexate soln pf
auto-injector 27.5 mg/0.55ml
RASUVO - methotrexate soln pf
auto-injector 30 mg/0.6ml
3
•
OTEZLA - apremilast tab starter
therapy pack 10 mg & 20 mg &
30 mg
•
• •
3
•
• •
RHEUMATREX - methotrexate
sodium tab 2.5 mg
(antirheumatic)
3
OTEZLA - apremilast tab 30 mg
3
• •
RIDAURA - auranofin cap 3 mg
2
OTREXUP - methotrexate soln pf
auto-injector 10mg/0.4ml
3
•
•
3
•
•
OTREXUP - methotrexate soln pf
auto-injector 15mg/0.4ml
3
•
SIMPONI - golimumab
subcutaneous soln auto-injector
50 mg/0.5ml
3
•
•
OTREXUP - methotrexate soln pf
auto-injector 20mg/0.4ml
3
•
SIMPONI - golimumab
subcutaneous soln auto-injector
100 mg/ml
3
•
SIMPONI - golimumab
subcutaneous soln prefilled
syringe 50 mg/0.5ml
3
OTREXUP - methotrexate soln pf
auto-injector 25mg/0.4ml
•
•
oxaprozin tab 600 mg (Daypro)
1
•
•
1
piroxicam cap 20 mg (Feldene)
1
SIMPONI - golimumab
subcutaneous soln prefilled
syringe 100 mg/ml
3
piroxicam cap 10 mg (Feldene)
PONSTEL - mefenamic acid cap
250 mg
3
SPRIX - ketorolac tromethamine
nasal spray 15.75 mg/spray
3
sulindac tab 150 mg
1
120
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
THERAPROFEN-60 - ibuprofen tab 3
600 mg & dietary management
cap pack
3
THERAPROFEN-800 ibuprofen tab 800 mg & dietary
management cap pack
THERAPROFEN-90 - ibuprofen tab 3
600 mg & dietary management
cap pack
3
THERAPROXEN-500 naproxen tab 500 mg & dietary
management cap pack
3
THERAPROXEN-60 - naproxen
tab 250 mg & dietary
management cap pack
3
THERAPROXEN-90 - naproxen
tab 250 mg & dietary
management cap pack
1
TOLMETIN SODIUM - tolmetin
sodium tab 200 mg
1
TOLMETIN SODIUM - tolmetin
sodium tab 600 mg
1
tolmetin sodium cap 400 mg
TREPADICLOFEN-25 - diclofenac
tab dr 25 mg & dietary
management cap pack
3
TREPOXEN-250 - naproxen tab
250 mg & dietary management
cap pack
3
TREPOXICAM-7.5 - meloxicam tab 3
7.5 mg & dietary management
cap pack
VIMOVO - naproxen-esomeprazole 3
magnesium tab dr 375-20 mg
VIMOVO - naproxen-esomeprazole 3
magnesium tab dr 500-20 mg
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
3
Specialty
THERAFELDAMINE - piroxicam
cap 20 mg & dietary
management cap pack
Quantity Limits
1
"Smart" PA
sulindac tab 200 mg
Prior Authorization
Drug Name
Drug Tier
2015
•
VOLTAREN-XR - diclofenac
sodium tab sr 24hr 100 mg
3
XELJANZ - tofacitinib citrate tab 5
mg (base equivalent)
3
ZIPSOR - diclofenac potassium
cap 25 mg
3
•
ZORVOLEX - diclofenac cap 18
mg
3
•
ZORVOLEX - diclofenac cap 35
mg
3
•
•
• •
MIGRAINE PRODUCTS
• •
• •
acetaminophen-isometheptenecaffeine tab 325-65-20 mg
(Prodrin)
1
acetaminophen-isometheptenedichloral cap 325-65-100 mg
1
ALSUMA - sumatriptan succinate
solution auto-injector 6 mg/0.5ml
3
• •
AMERGE - naratriptan hcl tab 1 mg 3
(base equiv)
3
AMERGE - naratriptan hcl tab 2.5
mg (base equiv)
3
AXERT - almotriptan malate tab
6.25 mg
3
AXERT - almotriptan malate tab
12.5 mg
3
CAFERGOT - ergotamine w/
caffeine tab 1-100 mg
3
CAMBIA - diclofenac potassium
packet 50 mg
3
D.H.E. 45 - dihydroergotamine
mesylate inj 1 mg/ml
1
DIHYDROERGOTAMINE
MESYLAT - dihydroergotamine
mesylate nasal spray 4 mg/ml
1
dihydroergotamine mesylate inj
1 mg/ml (D.h.e. 45)
ERGOMAR - ergotamine tartrate sl 2
tab 2 mg
• •
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
• •
• •
• •
• •
•
121
FROVA - frovatriptan succinate tab
2.5 mg (base equivalent)
3
• •
MIGRAL - isometheptene mucate
tab 130 mg
3
IMITREX - sumatriptan nasal spray
5 mg/act
2
• •
3
IMITREX - sumatriptan nasal spray
20 mg/act
2
• •
MIGRALAM - acetaminophenisometheptene-caffeine cap
325-65-100 mg
3
•
IMITREX - sumatriptan succinate
tab 25 mg
3
• •
MIGRANAL - dihydroergotamine
mesylate nasal spray 4 mg/ml
1
•
IMITREX - sumatriptan succinate
tab 50 mg
3
• •
naratriptan hcl tab 1 mg (base
equiv) (Amerge)
1
•
IMITREX - sumatriptan succinate
tab 100 mg
3
• •
naratriptan hcl tab 2.5 mg (base
equiv) (Amerge)
3
IMITREX - sumatriptan succinate
inj 6 mg/0.5ml
3
• •
PRODRIN - acetaminophenisometheptene-caffeine tab
325-65-20 mg
IMITREX STATDOSE REFILL sumatriptan succinate solution
cartridge 4 mg/0.5ml
3
• •
PRODRIN - acetaminophenisometheptene-caffeine tab
500-130-20 mg
3
IMITREX STATDOSE REFILL sumatriptan succinate solution
cartridge 6 mg/0.5ml
3
• •
RELPAX - eletriptan hydrobromide
tab 20 mg (base equivalent)
3
• •
3
• •
IMITREX STATDOSE SYSTEM sumatriptan succinate solution
auto-injector 4 mg/0.5ml
3
• •
RELPAX - eletriptan hydrobromide
tab 40 mg (base equivalent)
1
•
IMITREX STATDOSE SYSTEM sumatriptan succinate solution
auto-injector 6 mg/0.5ml
3
• •
rizatriptan benzoate orally
disintegrating tab 10 mg
(Maxalt-mlt)
1
•
ISOMETHEPTENE/CAFFEINE/AC
- acetaminophen-isometheptenecaffeine tab 500-130-20 mg
1
rizatriptan benzoate orally
disintegrating tab 5 mg
(Maxalt-mlt)
rizatriptan benzoate tab 10 mg
(Maxalt)
1
•
MAXALT - rizatriptan benzoate tab
5 mg
3
•
rizatriptan benzoate tab 5 mg
(Maxalt)
1
•
MAXALT - rizatriptan benzoate tab
10 mg
3
•
SUMATRIPTAN - sumatriptan
nasal spray 5 mg/act
1
• •
MAXALT-MLT - rizatriptan
benzoate orally disintegrating tab
5 mg
3
•
SUMATRIPTAN - sumatriptan
nasal spray 20 mg/act
1
• •
•
• •
3
SUMATRIPTAN SUCCINATE sumatriptan succinate solution
prefilled syringe 6 mg/0.5ml
1
MAXALT-MLT - rizatriptan
benzoate orally disintegrating tab
10 mg
• •
MIGERGOT - ergotamine w/
caffeine suppos 2-100 mg
SUMATRIPTAN SUCCINATE
- sumatriptan succinate inj 4
mg/0.5ml
1
3
122
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
sumatriptan succinate inj
6 mg/0.5ml (Imitrex)
1
•
ZOMIG - zolmitriptan nasal spray 5
mg/spray unit
3
• •
sumatriptan succinate solution
auto-injector 4 mg/0.5ml
(Imitrex statdose sys)
1
•
ZOMIG NASAL SPRAY zolmitriptan nasal spray 5 mg/
spray unit
3
• •
sumatriptan succinate solution
auto-injector 6 mg/0.5ml
(Imitrex statdose sys)
1
•
ZOMIG ZMT - zolmitriptan orally
disintegrating tab 2.5 mg
3
• •
•
• •
1
ZOMIG ZMT - zolmitriptan orally
disintegrating tab 5 mg
3
sumatriptan succinate solution
cartridge 4 mg/0.5ml (Imitrex
statdose ref)
sumatriptan succinate solution
cartridge 6 mg/0.5ml (Imitrex
statdose ref)
1
sumatriptan succinate solution
prefilled syringe 6 mg/0.5ml
1
sumatriptan succinate tab
100 mg (Imitrex)
1
•
sumatriptan succinate tab 25 mg
(Imitrex)
1
•
sumatriptan succinate tab 50 mg
(Imitrex)
1
•
SUMAVEL DOSEPRO sumatriptan succinate solution
jet-injector 4 mg/0.5ml
3
SUMAVEL DOSEPRO sumatriptan succinate solution
jet-injector 6 mg/0.5ml
3
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
GOUT AGENTS
•
•
• •
• •
allopurinol tab 100 mg (Zyloprim)
1
allopurinol tab 300 mg (Zyloprim)
1
colchicine w/ probenecid tab
0.5-500 mg
1
COLCRYS - colchicine tab 0.6 mg
2
MITIGARE - colchicine cap 0.6 mg
3
probenecid tab 500 mg
1
ULORIC - febuxostat tab 40 mg
3
ULORIC - febuxostat tab 80 mg
3
ZYLOPRIM - allopurinol tab 100
mg
3
ZYLOPRIM - allopurinol tab 300
mg
3
•
•
NEUROMUSCULAR DRUGS
ANTICONVULSANTS
TREXIMET - sumatriptan-naproxen 3
sodium tab 85-500 mg
zolmitriptan orally disintegrating 1
tab 2.5 mg (Zomig zmt)
zolmitriptan orally disintegrating 1
tab 5 mg (Zomig zmt)
1
zolmitriptan tab 2.5 mg (Zomig)
zolmitriptan tab 5 mg (Zomig)
1
ZOMIG - zolmitriptan tab 2.5 mg
3
ZOMIG - zolmitriptan tab 5 mg
3
ZOMIG - zolmitriptan nasal spray
2.5 mg/spray unit
3
• •
APTIOM - eslicarbazepine acetate
tab 200 mg
3
•
APTIOM - eslicarbazepine acetate
tab 400 mg
3
•
APTIOM - eslicarbazepine acetate
tab 600 mg
3
APTIOM - eslicarbazepine acetate
tab 800 mg
3
BANZEL - rufinamide tab 200 mg
2
BANZEL - rufinamide tab 400 mg
2
BANZEL - rufinamide susp 40 mg/
ml
2
•
•
• •
• •
• •
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
123
carbamazepine cap sr 12hr
100 mg (Carbatrol)
1
carbamazepine cap sr 12hr
200 mg (Carbatrol)
1
carbamazepine cap sr 12hr
300 mg (Carbatrol)
1
carbamazepine chew tab 100 mg
1
carbamazepine susp 100 mg/5ml
(Tegretol)
1
carbamazepine tab sr 12hr
200 mg (Tegretol-xr)
1
carbamazepine tab sr 12hr
400 mg (Tegretol-xr)
1
carbamazepine tab 200 mg
(Tegretol)
1
CARBATROL - carbamazepine cap 2
sr 12hr 100 mg
CARBATROL - carbamazepine cap 2
sr 12hr 200 mg
CARBATROL - carbamazepine cap 2
sr 12hr 300 mg
3
CELONTIN - methsuximide cap
300 mg
clonazepam orally disintegrating 1
tab 0.125 mg
clonazepam orally disintegrating 1
tab 0.25 mg
clonazepam orally disintegrating 1
tab 0.5 mg
clonazepam orally disintegrating 1
tab 1 mg
clonazepam orally disintegrating 1
tab 2 mg
1
clonazepam tab 0.5 mg
(Klonopin)
1
clonazepam tab 1 mg (Klonopin)
clonazepam tab 2 mg (Klonopin)
1
DEPAKENE - valproate sodium
syrup 250 mg/5ml (base equiv)
3
124
DEPAKENE - valproic acid cap 250 3
mg
3
DEPAKOTE - divalproex sodium
tab delayed release 125 mg
3
DEPAKOTE - divalproex sodium
tab delayed release 250 mg
3
DEPAKOTE - divalproex sodium
tab delayed release 500 mg
3
DEPAKOTE ER - divalproex
sodium tab sr 24 hr 250 mg
3
DEPAKOTE ER - divalproex
sodium tab sr 24 hr 500 mg
3
DEPAKOTE SPRINKLES divalproex sodium cap sprinkle
125 mg
2
DIASTAT ACUDIAL - diazepam
rectal gel delivery system 10 mg
2
DIASTAT ACUDIAL - diazepam
rectal gel delivery system 20 mg
2
DIASTAT PEDIATRIC - diazepam
rectal gel delivery system 2.5 mg
1
DIAZEPAM - diazepam rectal gel
delivery system 2.5 mg
1
DIAZEPAM - diazepam rectal gel
delivery system 10 mg
1
DIAZEPAM - diazepam rectal gel
delivery system 20 mg
3
DILANTIN - phenytoin susp 125
mg/5ml
2
DILANTIN - phenytoin sodium
extended cap 30 mg
2
DILANTIN - phenytoin sodium
extended cap 100 mg
2
DILANTIN INFATABS - phenytoin
chew tab 50 mg
3
DILANTIN-125 - phenytoin susp
125 mg/5ml
1
divalproex sodium cap sprinkle
125 mg (Depakote sprinkles)
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
divalproex sodium tab delayed
release 125 mg (Depakote)
1
gabapentin tab 600 mg
(Neurontin)
1
divalproex sodium tab delayed
release 250 mg (Depakote)
1
gabapentin tab 800 mg
(Neurontin)
1
divalproex sodium tab delayed
release 500 mg (Depakote)
1
GABITRIL - tiagabine hcl tab 2 mg
3
GABITRIL - tiagabine hcl tab 4 mg
3
divalproex sodium tab sr 24 hr
250 mg (Depakote er)
1
GABITRIL - tiagabine hcl tab 12
mg
2
divalproex sodium tab sr 24 hr
500 mg (Depakote er)
1
GABITRIL - tiagabine hcl tab 16
mg
2
ethosuximide cap 250 mg
(Zarontin)
1
KEPPRA - levetiracetam tab 250
mg
3
ethosuximide soln 250 mg/5ml
(Zarontin)
1
KEPPRA - levetiracetam tab 500
mg
3
felbamate susp 600 mg/5ml
(Felbatol)
1
KEPPRA - levetiracetam tab 750
mg
3
felbamate tab 400 mg (Felbatol)
1
1
KEPPRA - levetiracetam tab 1000
mg
3
felbamate tab 600 mg (Felbatol)
KEPPRA - levetiracetam oral soln
100 mg/ml
3
KEPPRA XR - levetiracetam tab sr
24hr 500 mg
3
•
KEPPRA XR - levetiracetam tab sr
24hr 750 mg
3
•
KLONOPIN - clonazepam tab 0.5
mg
3
FELBATOL - felbamate tab 400 mg 3
FELBATOL - felbamate tab 600 mg 3
FELBATOL - felbamate susp 600
mg/5ml
3
FYCOMPA - perampanel tab 2 mg
3
FYCOMPA - perampanel tab 4 mg
3
FYCOMPA - perampanel tab 6 mg
3
FYCOMPA - perampanel tab 8 mg
3
FYCOMPA - perampanel tab 10
mg
3
FYCOMPA - perampanel tab 12
mg
3
gabapentin cap 100 mg
(Neurontin)
1
gabapentin cap 300 mg
(Neurontin)
1
gabapentin cap 400 mg
(Neurontin)
1
gabapentin oral soln 250 mg/5ml
(Neurontin)
1
•
•
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
KLONOPIN - clonazepam tab 1 mg 3
KLONOPIN - clonazepam tab 2 mg 3
LAMICTAL - lamotrigine tab 25 mg
3
LAMICTAL - lamotrigine tab 100
mg
3
LAMICTAL - lamotrigine tab 150
mg
3
LAMICTAL - lamotrigine tab 200
mg
3
LAMICTAL - lamotrigine tab
chewable dispersible 2 mg
3
LAMICTAL CHEWABLE DISPERS
- lamotrigine tab chewable
dispersible 5 mg
3
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
125
LAMICTAL CHEWABLE DISPERS
- lamotrigine tab chewable
dispersible 25 mg
3
LAMICTAL ODT - lamotrigine tab
disp 25 mg (21) & 50 mg (7)
titration kit
3
LAMICTAL ODT - lamotrigine tab
disp 50 mg (42) & 100 mg (14)
titration kit
3
LAMICTAL ODT - lamotrigine tab
disp 25 (14) & 50 mg (14) & 100
mg (7) kit
3
LAMICTAL ODT - lamotrigine orally 3
disintegrating tab 25 mg
LAMICTAL ODT - lamotrigine orally 3
disintegrating tab 50 mg
LAMICTAL ODT - lamotrigine orally 3
disintegrating tab 100 mg
LAMICTAL ODT - lamotrigine orally 3
disintegrating tab 200 mg
LAMICTAL STARTER/NOT TAKI - 3
lamotrigine tab 25 mg (42) & 100
mg (7) starter kit
LAMICTAL STARTER/TAKING C - 3
lamotrigine tab 25 mg (84) & 100
mg (14) starter kit
LAMICTAL STARTER/TAKING V - 3
lamotrigine tab 25 mg (35) starter
kit
3
LAMICTAL XR - lamotrigine tab
sr 24hr 25 mg (21) & 50 mg (7)
titration kit
LAMICTAL XR - lamotrigine tab sr 3
24hr 25 (14) & 50 mg (14) & 100
mg(7) kit
LAMICTAL XR - lamotrigine tab sr 3
24hr 50 (14) & 100 mg(14) & 200
mg(7) kit
LAMICTAL XR - lamotrigine tab sr 3
24hr 25 mg
LAMICTAL XR - lamotrigine tab sr 3
24hr 50 mg
126
LAMICTAL XR - lamotrigine tab sr
24hr 100 mg
3
LAMICTAL XR - lamotrigine tab sr
24hr 200 mg
3
LAMICTAL XR - lamotrigine tab sr
24hr 250 mg
3
LAMICTAL XR - lamotrigine tab sr
24hr 300 mg
3
lamotrigine tab chewable
dispersible 25 mg (Lamictal
chewable di)
1
lamotrigine tab chewable
dispersible 5 mg (Lamictal
chewable di)
1
lamotrigine tab sr 24hr 100 mg
(Lamictal xr)
1
lamotrigine tab sr 24hr 200 mg
(Lamictal xr)
1
lamotrigine tab sr 24hr 25 mg
(Lamictal xr)
1
lamotrigine tab sr 24hr 250 mg
(Lamictal xr)
1
lamotrigine tab sr 24hr 300 mg
(Lamictal xr)
1
lamotrigine tab sr 24hr 50 mg
(Lamictal xr)
1
lamotrigine tab 100 mg (Lamictal)
1
lamotrigine tab 150 mg (Lamictal)
1
lamotrigine tab 200 mg (Lamictal)
1
lamotrigine tab 25 mg (Lamictal)
1
levetiracetam oral soln 100 mg/
ml (Keppra)
1
levetiracetam tab sr 24hr 500 mg
(Keppra xr)
1
levetiracetam tab sr 24hr 750 mg
(Keppra xr)
1
levetiracetam tab 1000 mg
(Keppra)
1
levetiracetam tab 250 mg
(Keppra)
1
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
levetiracetam tab 500 mg
(Keppra)
1
oxcarbazepine tab 600 mg
(Trileptal)
1
levetiracetam tab 750 mg
(Keppra)
1
OXTELLAR XR - oxcarbazepine
tab sr 24hr 150 mg
3
LYRICA - pregabalin cap 25 mg
3
3
LYRICA - pregabalin cap 50 mg
3
OXTELLAR XR - oxcarbazepine
tab sr 24hr 300 mg
LYRICA - pregabalin cap 75 mg
3
3
LYRICA - pregabalin cap 100 mg
3
OXTELLAR XR - oxcarbazepine
tab sr 24hr 600 mg
3
PEGANONE - ethotoin tab 250 mg
2
LYRICA - pregabalin cap 150 mg
3
PHENYTEK - phenytoin sodium
extended cap 200 mg
3
LYRICA - pregabalin cap 200 mg
LYRICA - pregabalin cap 225 mg
3
LYRICA - pregabalin cap 300 mg
PHENYTEK - phenytoin sodium
extended cap 300 mg
3
3
LYRICA - pregabalin soln 20 mg/ml 3
MYSOLINE - primidone tab 50 mg 3
phenytoin chew tab 50 mg
(Dilantin infatabs)
1
MYSOLINE - primidone tab 250 mg 3
NEURONTIN - gabapentin cap 100 3
mg
NEURONTIN - gabapentin cap 300 3
mg
NEURONTIN - gabapentin cap 400 3
mg
NEURONTIN - gabapentin tab 600 3
mg
NEURONTIN - gabapentin tab 800 3
mg
3
NEURONTIN - gabapentin oral
soln 250 mg/5ml
2
ONFI - clobazam tab 5 mg
phenytoin sodium extended cap
100 mg (Dilantin)
1
phenytoin sodium extended cap
200 mg (Phenytek)
1
phenytoin sodium extended cap
300 mg (Phenytek)
1
phenytoin susp 125 mg/5ml
(Dilantin)
1
POTIGA - ezogabine tab 50 mg
2
POTIGA - ezogabine tab 200 mg
2
POTIGA - ezogabine tab 300 mg
2
POTIGA - ezogabine tab 400 mg
2
primidone tab 250 mg (Mysoline)
1
primidone tab 50 mg (Mysoline)
1
QUDEXY XR - topiramate cap er
24hr sprinkle 25 mg
3
ONFI - clobazam tab 10 mg
2
ONFI - clobazam tab 20 mg
2
ONFI - clobazam suspension 2.5
mg/ml
3
QUDEXY XR - topiramate cap er
24hr sprinkle 50 mg
3
oxcarbazepine susp 300 mg/5ml
(60 mg/ml) (Trileptal)
1
QUDEXY XR - topiramate cap er
24hr sprinkle 100 mg
3
oxcarbazepine tab 150 mg
(Trileptal)
1
QUDEXY XR - topiramate cap er
24hr sprinkle 150 mg
3
oxcarbazepine tab 300 mg
(Trileptal)
1
QUDEXY XR - topiramate cap er
24hr sprinkle 200 mg
3
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
127
STAVZOR - valproic acid cap
delayed release 500 mg
3
TEGRETOL - carbamazepine tab
200 mg
3
TEGRETOL - carbamazepine susp
100 mg/5ml
3
TEGRETOL-XR - carbamazepine
tab sr 12hr 100 mg
2
TEGRETOL-XR - carbamazepine
tab sr 12hr 200 mg
3
TEGRETOL-XR - carbamazepine
tab sr 12hr 400 mg
TOPIRAMATE ER - topiramate cap 1
er 24hr sprinkle 50 mg
TOPIRAMATE ER - topiramate cap 1
er 24hr sprinkle 100 mg
TOPIRAMATE ER - topiramate cap 1
er 24hr sprinkle 150 mg
TOPIRAMATE ER - topiramate cap 1
er 24hr sprinkle 200 mg
1
topiramate sprinkle cap 15 mg
(Topamax sprinkle)
1
topiramate sprinkle cap 25 mg
(Topamax sprinkle)
topiramate tab 100 mg (Topamax) 1
topiramate tab 200 mg (Topamax) 1
topiramate tab 25 mg (Topamax) 1
topiramate tab 50 mg (Topamax)
1
3
TRILEPTAL - oxcarbazepine tab
150 mg
3
3
TRILEPTAL - oxcarbazepine tab
300 mg
3
THERAPENTIN-60 - gabapentin
cap 300 mg & dietary
management cap pack
3
THERAPENTIN-90 - gabapentin
cap 300 mg & dietary
management cap pack
3
TRILEPTAL - oxcarbazepine tab
600 mg
TRILEPTAL - oxcarbazepine susp
300 mg/5ml (60 mg/ml)
3
tiagabine hcl tab 2 mg (Gabitril)
1
3
tiagabine hcl tab 4 mg (Gabitril)
1
TROKENDI XR - topiramate cap sr
24hr 25 mg
3
TROKENDI XR - topiramate cap sr
24hr 50 mg
3
TOPAMAX - topiramate tab 25 mg
TOPAMAX - topiramate tab 50 mg
3
TOPAMAX - topiramate tab 100
mg
TROKENDI XR - topiramate cap sr
24hr 100 mg
3
3
TOPAMAX - topiramate tab 200
mg
TROKENDI XR - topiramate cap sr
24hr 200 mg
3
3
valproate sodium syrup
250 mg/5ml (base equiv)
(Depakene)
1
valproic acid cap 250 mg
(Depakene)
1
VIMPAT - lacosamide tab 50 mg
2
VIMPAT - lacosamide tab 100 mg
2
TOPAMAX SPRINKLE - topiramate 3
sprinkle cap 15 mg
TOPAMAX SPRINKLE - topiramate 3
sprinkle cap 25 mg
TOPIRAMATE ER - topiramate cap 1
er 24hr sprinkle 25 mg
128
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
3
Quantity Limits
STAVZOR - valproic acid cap
delayed release 250 mg
"Smart" PA
3
Prior Authorization
STAVZOR - valproic acid cap
delayed release 125 mg
• •
• •
Drug Name
Drug Tier
2
Specialty
SABRIL - vigabatrin powd pack
500 mg
Quantity Limits
2
"Smart" PA
SABRIL - vigabatrin tab 500 mg
Prior Authorization
Drug Name
Drug Tier
2015
ZARONTIN - ethosuximide cap 250 3
mg
3
ZARONTIN - ethosuximide soln
250 mg/5ml
3
ZONEGRAN - zonisamide cap 25
mg
ZONEGRAN - zonisamide cap 100 3
mg
1
zonisamide cap 100 mg
(Zonegran)
1
zonisamide cap 25 mg
(Zonegran)
1
zonisamide cap 50 mg
ANTIPARKINSON AGENTS
AMANTADINE HCL - amantadine
hcl tab 100 mg
1
amantadine hcl cap 100 mg
1
amantadine hcl syrup 50 mg/5ml
1
APOKYN - apomorphine
hydrochloride inj 10 mg/ml
2
• •
AZILECT - rasagiline mesylate tab
0.5 mg (base equiv)
2
•
AZILECT - rasagiline mesylate tab
1 mg (base equiv)
2
•
benztropine mesylate inj 1 mg/ml
(Cogentin)
1
benztropine mesylate tab 0.5 mg
1
benztropine mesylate tab 1 mg
1
benztropine mesylate tab 2 mg
1
bromocriptine mesylate cap
5 mg (Parlodel)
1
bromocriptine mesylate tab
2.5 mg
1
carbidopa & levodopa orally
disintegrating tab 10-100 mg
1
1
carbidopa & levodopa orally
disintegrating tab 25-250 mg
1
carbidopa & levodopa tab cr
25-100 mg (Sinemet cr)
1
carbidopa & levodopa tab cr
50-200 mg (Sinemet cr)
1
carbidopa & levodopa tab
10-100 mg (Sinemet)
1
carbidopa & levodopa tab
25-100 mg (Sinemet)
1
carbidopa & levodopa tab
25-250 mg (Sinemet)
1
carbidopa tab 25 mg (Lodosyn)
1
CARBIDOPA/LEVODOPA/
ENTACA - carbidopa-levodopaentacapone tabs 12.5-50-200 mg
1
CARBIDOPA/LEVODOPA/
ENTACA - carbidopa-levodopaentacapone tabs 18.75-75-200
mg
1
CARBIDOPA/LEVODOPA/
ENTACA - carbidopa-levodopaentacapone tabs 25-100-200 mg
1
CARBIDOPA/LEVODOPA/
ENTACA - carbidopa-levodopaentacapone tabs 31.25-125-200
mg
1
CARBIDOPA/LEVODOPA/
ENTACA - carbidopa-levodopaentacapone tabs 37.5-150-200
mg
1
CARBIDOPA/LEVODOPA/
ENTACA - carbidopa-levodopaentacapone tabs 50-200-200 mg
1
Specialty
Quantity Limits
"Smart" PA
2
carbidopa & levodopa orally
disintegrating tab 25-100 mg
Prior Authorization
VIMPAT - lacosamide oral solution
10 mg/ml
Drug Name
Drug Tier
2
Specialty
VIMPAT - lacosamide tab 200 mg
Quantity Limits
2
"Smart" PA
VIMPAT - lacosamide tab 150 mg
Prior Authorization
Drug Name
Drug Tier
2015
COGENTIN - benztropine mesylate 3
inj 1 mg/ml
COMTAN - entacapone tab 200 mg 2
ELDEPRYL - selegiline hcl cap 5
mg
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
3
129
NEUPRO - rotigotine td patch 24hr
4 mg/24hr
2
•
•
NEUPRO - rotigotine td patch 24hr
6 mg/24hr
2
•
3
•
NEUPRO - rotigotine td patch 24hr
8 mg/24hr
2
•
MIRAPEX - pramipexole
dihydrochloride tab 0.5 mg
3
•
3
MIRAPEX - pramipexole
dihydrochloride tab 0.75 mg
3
•
PARCOPA - carbidopa & levodopa
orally disintegrating tab 10-100
mg
3
MIRAPEX - pramipexole
dihydrochloride tab 1 mg
3
•
PARCOPA - carbidopa & levodopa
orally disintegrating tab 25-100
mg
3
•
PARCOPA - carbidopa & levodopa
orally disintegrating tab 25-250
mg
3
MIRAPEX - pramipexole
dihydrochloride tab 1.5 mg
MIRAPEX ER - pramipexole
dihydrochloride tab sr 24hr 0.375
mg
3
PARLODEL - bromocriptine
mesylate cap 5 mg
3
3
PARLODEL - bromocriptine
mesylate tab 2.5 mg
3
MIRAPEX ER - pramipexole
dihydrochloride tab sr 24hr 0.75
mg
1
MIRAPEX ER - pramipexole
dihydrochloride tab sr 24hr 1.5
mg
3
pramipexole dihydrochloride tab
0.125 mg (Mirapex)
pramipexole dihydrochloride tab
0.25 mg (Mirapex)
1
MIRAPEX ER - pramipexole
dihydrochloride tab sr 24hr 2.25
mg
3
pramipexole dihydrochloride tab
0.5 mg (Mirapex)
1
1
MIRAPEX ER - pramipexole
dihydrochloride tab sr 24hr 3 mg
3
pramipexole dihydrochloride tab
0.75 mg (Mirapex)
1
MIRAPEX ER - pramipexole
dihydrochloride tab sr 24hr 3.75
mg
3
pramipexole dihydrochloride tab
1 mg (Mirapex)
pramipexole dihydrochloride tab
1.5 mg (Mirapex)
1
MIRAPEX ER - pramipexole
dihydrochloride tab sr 24hr 4.5
mg
3
REQUIP - ropinirole hydrochloride
tab 0.25 mg
3
NEUPRO - rotigotine td patch 24hr
1 mg/24hr
•
REQUIP - ropinirole hydrochloride
tab 0.5 mg
3
2
2
•
REQUIP - ropinirole hydrochloride
tab 1 mg
3
NEUPRO - rotigotine td patch 24hr
2 mg/24hr
2
•
REQUIP - ropinirole hydrochloride
tab 2 mg
3
NEUPRO - rotigotine td patch 24hr
3 mg/24hr
REQUIP - ropinirole hydrochloride
tab 3 mg
3
130
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
MIRAPEX - pramipexole
dihydrochloride tab 0.25 mg
"Smart" PA
3
Prior Authorization
MIRAPEX - pramipexole
dihydrochloride tab 0.125 mg
Drug Name
Drug Tier
3
Specialty
LODOSYN - carbidopa tab 25 mg
Quantity Limits
1
"Smart" PA
entacapone tab 200 mg (Comtan)
Prior Authorization
Drug Name
Drug Tier
2015
REQUIP - ropinirole hydrochloride
tab 4 mg
3
ropinirole hydrochloride tab
3 mg (Requip)
1
REQUIP - ropinirole hydrochloride
tab 5 mg
3
ropinirole hydrochloride tab
4 mg (Requip)
1
REQUIP XL - ropinirole
hydrochloride tab sr 24hr 2 mg
(base equivalent)
3
ropinirole hydrochloride tab
5 mg (Requip)
1
selegiline hcl cap 5 mg (Eldepryl)
1
REQUIP XL - ropinirole
hydrochloride tab sr 24hr 4 mg
(base equivalent)
3
selegiline hcl tab 5 mg
1
3
REQUIP XL - ropinirole
hydrochloride tab sr 24hr 6 mg
(base equivalent)
3
SINEMET - carbidopa & levodopa
tab 10-100 mg
SINEMET - carbidopa & levodopa
tab 25-100 mg
3
REQUIP XL - ropinirole
hydrochloride tab sr 24hr 8 mg
(base equivalent)
3
SINEMET - carbidopa & levodopa
tab 25-250 mg
3
3
REQUIP XL - ropinirole
hydrochloride tab sr 24hr 12 mg
(base equivalent)
3
SINEMET CR - carbidopa &
levodopa tab cr 25-100 mg
SINEMET CR - carbidopa &
levodopa tab cr 50-200 mg
3
ropinirole hydrochloride tab sr
24hr 12 mg (base equivalent)
(Requip xl)
1
STALEVO 100 - carbidopalevodopa-entacapone tabs
25-100-200 mg
3
ropinirole hydrochloride tab sr
24hr 2 mg (base equivalent)
(Requip xl)
1
STALEVO 125 - carbidopalevodopa-entacapone tabs
31.25-125-200 mg
3
ropinirole hydrochloride tab sr
24hr 4 mg (base equivalent)
(Requip xl)
1
STALEVO 150 - carbidopalevodopa-entacapone tabs
37.5-150-200 mg
3
ropinirole hydrochloride tab sr
24hr 6 mg (base equivalent)
(Requip xl)
1
STALEVO 200 - carbidopalevodopa-entacapone tabs
50-200-200 mg
3
ropinirole hydrochloride tab sr
24hr 8 mg (base equivalent)
(Requip xl)
1
STALEVO 50 - carbidopalevodopa-entacapone tabs
12.5-50-200 mg
3
ropinirole hydrochloride tab
0.25 mg (Requip)
1
3
ropinirole hydrochloride tab
0.5 mg (Requip)
1
STALEVO 75 - carbidopalevodopa-entacapone tabs
18.75-75-200 mg
TASMAR - tolcapone tab 100 mg
3
ropinirole hydrochloride tab
1 mg (Requip)
1
trihexyphenidyl hcl elixir 0.4 mg/
ml
1
ropinirole hydrochloride tab
2 mg (Requip)
1
trihexyphenidyl hcl tab 2 mg
1
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
131
NEUROMUSCULAR AGENTS
RILUTEK - riluzole tab 50 mg
2
riluzole tab 50 mg (Rilutek)
1
MUSCULOSKELETAL THERAPY AGENTS
ACTIVE-CYCLOBENZAPRINE KI - 3
cyclobenzaprine hcl td cream 5%
(compound kit)
3
AMRIX - cyclobenzaprine hcl cap
sr 24hr 15 mg
3
AMRIX - cyclobenzaprine hcl cap
sr 24hr 30 mg
1
baclofen tab 10 mg
• •
• •
DANTROLENE SODIUM dantrolene sodium cap 100 mg
1
dantrolene sodium cap 25 mg
(Dantrium)
1
dantrolene sodium cap 50 mg
(Dantrium)
1
ENOVARX-CYCLOBENZAPRINE
H - cyclobenzaprine hcl td cream
20 mg/gm (compound kit)
3
FEXMID - cyclobenzaprine hcl tab
7.5 mg
3
• •
FLEXERIL - cyclobenzaprine hcl
tab 5 mg
3
• •
FLEXERIL - cyclobenzaprine hcl
tab 10 mg
3
• •
LORZONE - chlorzoxazone tab
375 mg
3
•
baclofen tab 20 mg
1
CARISOPRODOL - carisoprodol
tab 250 mg
1
•
LORZONE - chlorzoxazone tab
750 mg
3
•
carisoprodol tab 350 mg (Soma)
1
1
carisoprodol w/ aspirin tab
200-325 mg
1
•
chlorzoxazone tab 500 mg
(Parafon forte dsc)
1
•
CYCLOBENZAPRINE COMFORT
P - cyclobenzaprine hcl tab 10
mg & liniment topical gel kit
3
cyclobenzaprine hcl tab 10 mg
1
cyclobenzaprine hcl tab 5 mg
1
cyclobenzaprine hcl tab 7.5 mg
(Fexmid)
1
DANTRIUM - dantrolene sodium
cap 25 mg
3
DANTRIUM - dantrolene sodium
cap 50 mg
3
DANTRIUM - dantrolene sodium
cap 100 mg
3
metaxalone tab 800 mg (Skelaxin) 1
1
methocarbamol tab 500 mg
(Robaxin)
1
methocarbamol tab 750 mg
(Robaxin-750)
1
orphenadrine citrate tab sr 12hr
100 mg
3
ORPHENADRINE COMPOUND
DS - orphenadrine w/ aspirin &
caffeine tab 50-770-60 mg
1
orphenadrine w/ aspirin &
caffeine tab 25-385-30 mg
ORPHENADRINE/ASA/CAFFEINE 1
- orphenadrine w/ aspirin &
caffeine tab 50-770-60 mg
3
PARAFON FORTE DSC chlorzoxazone tab 500 mg
PRAZOLAMINE - carisoprodol tab 3
350 mg & dietary management
cap pack
3
ROBAXIN - methocarbamol tab
500 mg
•
carisoprodol w/ aspirin &
codeine tab 200-325-16 mg
•
•
132
•
•
•
• •
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
3
Specialty
ZELAPAR - selegiline hcl orally
disintegrating tab 1.25 mg
Quantity Limits
1
"Smart" PA
trihexyphenidyl hcl tab 5 mg
Prior Authorization
Drug Name
Drug Tier
2015
ROBAXIN-750 - methocarbamol
tab 750 mg
3
•
SKELAXIN - metaxalone tab 800
mg
3
• •
SOMA - carisoprodol tab 250 mg
3
SOMA - carisoprodol tab 350 mg
3
THERABENZAPRINE-60 cyclobenzaprine tab 10 mg &
dietary management cap pack
3
THERABENZAPRINE-90 cyclobenzaprine tab 10 mg &
dietary management cap pack
3
THERABENZAPRINE-90-5 cyclobenzaprine tab 5 mg &
dietary management cap pack
AMINOBENZOATE POTASSIUM
- potassium aminobenzoate
packet 2 gm
1
3
1
TIZANIDINE COMFORT PAC tizanidine tab 4 mg & liniment
topical gel pack
3
ASCORBIC ACID - ascorbic acid
oral granules
BABY DDROPS - cholecalciferol
drops 400 unit/0.03ml (per drop)
A
tizanidine hcl cap 2 mg (Zanaflex) 1
tizanidine hcl cap 4 mg (Zanaflex) 1
cholecalciferol cap 1000 unit
A
cholecalciferol chew tab 1000
unit
A
tizanidine hcl cap 6 mg (Zanaflex) 1
1
tizanidine hcl tab 2 mg
tizanidine hcl tab 4 mg (Zanaflex) 1
cholecalciferol chew tab 400 unit
A
A
•
cholecalciferol drops 400
unit/0.03ml (per drop)
A
•
cholecalciferol drops 5000 unit/
ml (1000 unit/0.2ml)
A
•
cholecalciferol oral liquid 400
unit/ml
cholecalciferol tab 1000 unit
A
cholecalciferol tab 400 unit
A
CVS VITAMIN D3 - cholecalciferol
cap 400 unit
A
•
• •
MESTINON TIMESPAN pyridostigmine bromide tab cr
180 mg
3
MYTELASE - ambenonium
chloride tab 10 mg
3
PROSTIGMIN - neostigmine
bromide tab 15 mg
2
pyridostigmine bromide tab
60 mg (Mestinon)
1
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
NUTRITIONAL PRODUCTS
VITAMINS
ZANAFLEX - tizanidine hcl cap 2
mg
3
ZANAFLEX - tizanidine hcl cap 4
mg
3
ZANAFLEX - tizanidine hcl cap 6
mg
3
ZANAFLEX - tizanidine hcl tab 4
mg
3
ANTIMYASTHENIC AGENTS
•
GUANIDINE HCL - guanidine hcl
tab 125 mg
1
D-VI-SOL - cholecalciferol oral
liquid 400 unit/ml
A
MESTINON - pyridostigmine
bromide tab 60 mg
3
DDROPS - cholecalciferol drops
1000 unit/0.03ml (per drop)
A
MESTINON - pyridostigmine
bromide syrup 60 mg/5ml
3
DECARA - cholecalciferol cap
25000 unit
3
DRISDOL - ergocalciferol cap
50000 unit
3
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
133
1
1
pediatric multiple vitamin w/
minerals & c drops 45 mg/ml
1
MEPHYTON - phytonadione tab 5
mg
2
pediatric multiple vitamins w/ flfe drops 0.25-10 mg/ml
1
POTABA - potassium
aminobenzoate cap 500 mg
3
pediatric multiple vitamins w/
fluoride chew tab 0.25 mg
1
POTABA - potassium
aminobenzoate tab 500 mg
3
pediatric multiple vitamins w/
fluoride chew tab 0.5 mg
1
SUPER DAILY D3 - cholecalciferol
drops 1000 unit/0.03ml (per drop)
A
pediatric multiple vitamins w/
fluoride chew tab 1 mg
1
VITAMIN D - cholecalciferol cap
400 unit
A
pediatric multiple vitamins w/
fluoride soln 0.25 mg/ml
1
VITAMIN D2 - ergocalciferol tab
400 unit
A
pediatric multiple vitamins w/
fluoride soln 0.5 mg/ml
1
VITAMIN D3 - cholecalciferol cap
400 unit
A
pediatric vitamins acd w/
fluoride soln 0.25 mg/ml
pediatric vitamins acd w/
fluoride soln 0.5 mg/ml
1
speciality vitamin product tab
1
ACTIVE OB - prenatal w/o a w/fe
cbn-fa-dha cap 20-1-320 mg
3
ADRENAL C FORMULA bioflavonoid products tab
3
ADVANCED AM/PM - multiple
vitamins w/ calcium therapy pack
3
VITAMIN D3 - cholecalciferol spray A
1000 unit/spray
A
VITAMIN D3 400 - cholecalciferol
cap 400 unit
A
WELLESSE VITAMIN D3 cholecalciferol oral liquid 1000
unit/10ml
MULTIVITAMINS
b-complex w/ c & folic acid cap
1 mg (Nephrocaps)
1
AP-ZEL - multiple vitamins w/
minerals tab
3
b-complex w/ c & folic acid tab
1 mg (Nephro-vite rx)
1
ATABEX EC - prenatal vit w/ dssiron carbonyl-fa tab dr 29-1 mg
3
b-complex w/ c & folic acid tab
5 mg
1
ATABEX PRENATAL - prenatal vit
w/ iron carbonyl-fa tab 65-1 mg
3
b-complex w/ c & folic acid tab
1
3
b-complex w/ c-biotin-minerals &
folic acid tab 5 mg (Diatx zn)
1
B-NEXA - prenatal w/ calcium-vit
b6-fa-ginger tab 1.2 mg
3
multiple vitamins w/ minerals &
fa tab 1.25 mg (Corvite)
1
B-NEXA - prenatal w/ calcium-vit
b6-fa-ginger tab 1.22 mg
3
multiple vitamins w/ minerals
cap
1
BACMIN - multiple vitamins w/
minerals tab
multiple vitamins w/ minerals tab
(Strovite forte)
1
134
BAL-CARE DHA - prenat w/fe poly- 3
na fered-fa tab 27-1 & omega
cap dr 430mg
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
ergocalciferol cap 50000 unit
(Drisdol)
Quantity Limits
A
"Smart" PA
D3 - cholecalciferol cap 400 unit
Prior Authorization
Drug Name
Drug Tier
2015
BAL-CARE DHA ESSENTIAL prenat w/fe poly-na fered-fa tab
27-1 & omega cap dr 374mg
3
CITRANATAL HARMONY prenatal w/o vit a w/ fe cbn-dssfa-dha cap 30-1-260 mg
3
BP FOLINATAL PLUS B - prenatal
w/ calcium carbonate-b6-b12-fa
tab 1 mg
3
CITRANATAL HARMONY - prenat
w/o a w/fe fum-fe cbn-dss-fa-dha
cap 27-1-260 mg
3
BP MULTINATAL PLUS - prenatal
w/o a vit w/ fe fumarate-fa tab
30-1 mg
3
CITRANATAL RX - prenatal w/o a
w/ fe carbonyl-fe gluc-dss-fa tab
27-1mg
3
BP MULTINATAL PLUS - prenatal
w/o a vit w/ fe fum-fa tab chew
40-1 mg
3
CITRANATAL 90 DHA - prenat w/
o a w/fecbn-fegl-dss-fa tab 90
&dha cap 300mg pak
3
C-NATE DHA - prenatal vit w/ fe
fum-fa-omega 3 cap 28-1-200
mg
3
CO-NATAL FA - prenatal vit w/ fe
fumarate-fa tab 29-1 mg
3
CALCIUM PNV - prenatal w/o
vit a w/ fe fum-fa-omega 3 cap
28-1-250 mg
COMPLETE NATAL DHA - prenatfe bis-fe prot succ-fa-ca tab &
omega 3 cap 250 pk
3
3
3
COMPLETENATE - prenatal vit w/
fe fumarate-fa chew tab 29-1 mg
3
CAVAN-ALPHA KIT - prenat w/
fe poly-na fered-fa tab 27-1 &
omega cap dr 300mg
3
CAVAN-EC SOD DHA - prenatal
w/ sod feredetate-fa tab 30-1 &
omega 3 cap dr
3
CONCEPT DHA - prenatal w/fe
fum-fe poly -fa-omega 3 cap
53.5-38-1 mg
3
CHOICE-OB+DHA - prenatal mv
w/fe poly-fa chw 29-1 mg & dha
cap 250 mg pak
3
CONCEPT OB - prenatal w/o a w/
fe fum-fe poly-fa cap 130-92.4-1
mg
CORVITE - multiple vitamins w/
minerals & fa tab 1.25 mg
3
CRNATAL - prenatal mv w/fecbnfegl-dss-fa tab & dha cap 275 mg
pack
3
CITRANATAL ASSURE - prenat w/ 3
o a w/fecbn-fegl-dss-fa tab & dha
cap 300 mg pack
CITRANATAL B-CALM - prenat w/ 3
o a w/ fe cbnyl-fa tab 20-1 mg &
vit b6 tab pak
CITRANATAL B-CALM - prenat w/ 3
o a w/fecbn-feglu-fa tab 20-1 mg
& vit b6 tab pak
3
CITRANATAL DHA - prenat w/o
a w/fecbn-fegl-dss-fa tab & dha
cap 250 mg pack
3
CITRANATAL HARMONY prenatal w/o a w/fe cbn-dss-fadha cap 29-1-265 mg
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
DIALYVITE SUPREME D - multiple 3
vitamins w/ minerals & fa tab 3
mg
DIALYVITE 3000 - b-complex w/ c- 3
biotin-e-minerals & folic acid tab
3 mg
DIALYVITE 5000 - b-complex w/ c- 3
biotin-e-minerals & folic acid tab
5 mg
DIALYVITE/ZINC - b-complex w/ c- 3
zn & folic acid tab 1 mg
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
135
DIATX ZN - b-complex w/ c-biotinminerals & folic acid tab 5 mg
3
DUET DHA - prenat w/fe poly-na
fered-fa tab 25-1 & omega cap
400 mg
3
3
ESCAVITE - pediatric multiple
vitamins w/ fl-fe chew tab
0.25-7.5 mg
3
DUET DHA - prenat w/fe poly-na
fered-fa tab 25-1 & omega cap
430 mg
3
ESCAVITE D - pediatric multiple
vitamins w/ fl-fe chew tab 0.25-6
mg
1
DUET DHA BALANCED - prenat
w/fe poly-na fered-fa tab 24-1 &
omega cap 272 mg
3
ESCAVITE LQ - pediatric multiple
vitamins w/ fl-fe drops 0.25-6 mg/
ml
DUET DHA BALANCED - prenat
w/fe poly-na fered-fa tab 25-1 &
omega cap 267 mg
3
DUET DHA BALANCED - prenat
w/fe poly-na fered-fa tab 26-1 &
omega cap 278 mg
3
DUET DHA BALANCED - prenat
w/fe poly-na fered-fa tab 27-1 &
omega cap dr 380mg
3
DUET DHA EC - prenat w/fe polyna fered-fa tab 25-1 & omega
cap dr 400mg
3
DUET DHA EC - prenat w/fe polyna fered-fa tab 25-1 & omega
cap dr 430mg
3
DUET DHA 400 - prenat w/fe polyna fered-fa tab 25-1 & omega
cap 400 mg
3
DUET DHA 400EC - prenat w/
fe poly-na fered-fa tab 25-1 &
omega cap dr 400mg
3
DUET DHA 430 - prenat w/fe polyna fered-fa tab 25-1 & omega
cap 430 mg
3
DUET DHA 430EC - prenat w/
fe poly-na fered-fa tab 25-1 &
omega cap dr 430mg
3
ELITE-OB - prenatal vit w/ iron
carbonyl-fa tab 50-1.25 mg
3
136
EXTRA-VIRT PLUS DHA - prenatal 3
w/o vit a w/ fe fum-doc-fa-dha
cap 29-1.25-350 mg
FLORIVA - ped multiple vitamins & 3
minerals w/ fl chew tab 0.5 mg
FLORIVA - ped multiple vitamins & 3
minerals w/ fl chew tab 1 mg
3
FOCALGIN-B - prenatal w/
calcium-vit b6-fa-ginger tab 1.22
mg
3
FOLBECAL - prenatal w/ calcium
carbonate-b6-b12-fa tab 1 mg
3
FOLCAL DHA - prenatal w/o vit
a w/ fe fum-dss-fa-dha cap
27-1.25-300 mg
FOLCAPS OMEGA 3 - prenatal vit 3
w/ fe cbn-fe asp glyc-fa-omega 3
cap 27-1mg
FOLET DHA - prenat w/fecbn-bisg- 3
methylf-dss tab dr & dha cap pak
3
FOLET ONE - prenat w/o a w/
fecbn-bisg-methylf-dss-dha cap
38-1-225 mg
FOLGARD OS - multiple vit w/ min 3
& calcium-folic acid tab 500-1.1
mg
FOLIVANE-OB - prenatal w/o a w/ 3
fe fum-fe poly-fa cap 130-92.4-1
mg
3
FOLIVANE-PRX DHA NF prenatal w/o vit a w/fe fum-dssfa-dha cap 30-1.24-265 mg
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
FORTAVIT - multiple vitamins w/
minerals cap
3
GESTICARE DHA - prenatal w/fe
fum-fa tab dr 27-1 mg & dha cap
250 mg pack
3
HEMENATAL OB - prenat vit-fe
poly cmplx-fe heme poly-fa tab
28-6-1 mg
3
HEMENATAL OB + DHA - prenatfe poly cmplx-fe heme poly-fa tab
& omega 3 cap pck
3
INATAL ADVANCE - prenatal vit w/ 3
dss-iron carbonyl-fa tab 90-1 mg
3
INATAL GT - prenatal vit w/ dssiron carbonyl-fa tab 90-1 mg
3
INATAL ULTRA - prenatal vit w/
dss-iron carbonyl-fa tab 90-1 mg
3
INFANATE BALANCE - prenatal
w/o a w/fe cbn-dss-fa-dha cap
29-1-265 mg
3
INFANATE PLUS - prenat w/o a
w/fe fum-fe cbn-dss-fa-dha cap
27-1-260 mg
3
L-METHYLFOLATE PNV DHA prenat w/fe fum-l methylfolate-fadha cap 27-1.13-0.4 mg
3
LACTOCAL-F - prenatal vit w/ fe
fumarate-fa tab 65-1 mg
LEVOMEFOLATE DHA - prenat w/ 3
fe fum-l methylfolate-fa-dha cap
27-1.13-0.4 mg
3
LEVOMEFOLATE PNV - prenatal
w/ fe polycmplx-methylfol-fa pak
29-1.4-0.5 mg
M-VIT - prenatal vit w/ fe fumarate- 3
fa tab 27-1 mg
3
MACNATAL CN DHA - prenatal
w/o a w/fe cbn-dss-fa-dha cap
28-1-250 mg
3
MARNATAL-F - prenatal w/o vit a
w/ fe polysac cmplx-fa cap 60-1
mg
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
MAXINATE - prenatal vit w/ fe gluc- 3
fe fum-fa tab 20-0.8 mg
3
MOMS CHOICE RX - prenat w/
fe poly-na fered-fa tab 26-1 &
omega cap 278 mg
3
MYKIDZ IRON FL - pediatric
vitamins acd fluoride & fe susp
0.25-10 mg/2ml
MYNATAL - prenatal multivitamins 3
& minerals w/ iron & fa cap 1 mg
MYNATAL ADVANCE - prenatal vit 3
w/ dss-iron carbonyl-fa tab 90-1
mg
3
MYNATAL PLUS - prenatal vit w/
fe fumarate-fa tab 65-1 mg
3
MYNATAL ULTRACAPLET prenatal vit w/ dss-iron carbonylfa tab 90-1 mg
3
MYNATAL-Z - prenatal vit w/ fe
fumarate-fa tab 65-1 mg
MYNATE 90 PLUS - prenatal vit w/ 3
dss-fe fumarate-fa tab cr 90-1 mg
NATA KOMPLETE - prenatal vit w/ 3
fe fum-fe bisglycinate-fa tab 25-1
mg
3
NATACHEW - prenatal vit w/ fe
fum-fe bisglycin-fa chew tab 28-1
mg
NATAFORT - prenatal w/o a vit w/ 3
fe cbn-fe fum-fa tab 60-1 mg
3
NATAL-V RX - prenatal vit w/ iron
carbonyl-fa tab 29-1 mg
3
NATALVIRT CA - prenat w/o a w/
fecbn-fegl-dss-fa tab & dha cap
300 mg pack
NATALVIRT 90 DHA - prenat w/o a 3
w/fecbn-fegl-dss-fa tab 90 &dha
cap 300mg pak
3
NATALVIT - prenatal vit w/ fe
fumarate-fa tab 75-1 mg
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
137
NATELLE ONE - prenatal w/o
vit a w/ fe fum-fa-omega 3 cap
28-1-250 mg
3
NICAZEL - multiple vitamins w/
minerals tab
3
NEEVO - prenatal w/ fe polycmplxmethylfol-fa pak 29-1.4-0.5 mg
NICAZEL FORTE - multiple
vitamins w/ minerals tab
3
3
NEEVO DHA - prenat w/o a w/
fefum-methylfol-omegas cap
27-1.13 mg
NICOMIDE - niacinamide w/ zn-cumethylfolate tab 750-25-1.5-0.5
mg
3
3
3
NICOMIDE - niacinamide w/ zn-cumethylfol-se-cr tab 750-27-2-0.5
mg
3
NEEVO DHA - prenat w/o a w/
fefum-methylfol-fa-omegas cap
27-1.53 mg
NEPHPLEX RX - b-complex w/ czn & folic acid tab 1 mg
NUTRI-TAB OB - prenatal vit w/o
vit a w/ fe bisglycinate-fa tab 32-1
mg
3
3
NEPHRO-VITE RX - b-complex w/
c & folic acid tab 1 mg
3
3
NEPHROCAPS - b-complex w/ c &
folic acid cap 1 mg
3
NUTRI-TAB OB + DHA - prenat w/
o a w/ fe bisglyc-fa tab 32-1 mg &
omega cap pack
3
NEPHROCAPS QT - b-complex w/
c-biotin-d & folic acid tab disp 1
mg
3
NUTRICAP - multiple vitamins w/
minerals tab
NUTRIVIT - b-complex w/ lysinemin-fe & fa liqd 800-15-1
mg/15ml
3
O-CAL FA - prenatal vit w/ fe
fumarate-fa tab 27-1 mg
3
NESTABS - prenatal vit w/o vit a w/ 3
fe bisglycinate-fa tab 32-1 mg
NESTABS ABC - prenatal w/o vit a 3
w/fe polysac-fa-ca tab & omega 3
cap
3
NESTABS DHA - prenat w/o a
w/ fe bisglyc-fa tab 32-1 mg &
omega cap pack
NEWGEN - prenatal vit w/o vit a w/ 3
fe bisglycinate-fa tab 32-1 mg
3
NEXA PLUS - prenatal w/o vit
a w/ fe fum-doc-fa-dha cap
29-1.25-350 mg
3
NEXA SELECT - prenatal w/o
vit a w/ fe fum-dss-fa-dha cap
29-1.25-325 mg
3
NEXA SELECT - prenat w/o vit
a w/ fe fum-dss-fa-dha cap
29-1.25-337.5 mg
3
NICADAN - multiple vitamins w/
minerals tab
138
O-CAL PRENATAL - prenatal vit w/ 3
fe fumarate-fa tab 15-1 mg
3
OB COMPLETE - prenatal vit w/
iron carbonyl-fa tab 50-1.25 mg
3
OB COMPLETE - prenatal w/o a
w/fecbn-feaspglyc-fa-dha chew
15-5-1-100 mg
3
OB COMPLETE ONE - prenatal
w/o a w/fecbn-fe asp glyc-fa-fish
cap 50-1-476 mg
3
OB COMPLETE PETITE - prenat
w/o a w/fecbn-feaspglyc-faomega cap 35-5-1-200 mg
3
OB COMPLETE PREMIER prenatal vit w/ fe cbn-fe asp glycfa tab 30-20-1 mg
OB COMPLETE 400 - prenatal w/o 3
a w/fecbn-fe asp glyc-fa-fish cap
40-10-1 mg
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
OB COMPLETE/DHA - prenat w/
iron cbn-fe asp glyc-fa-omega
cap 30-10-1-200 mg
3
OB-NATAL ONE - prenatal vit w/ fe 3
cbn-fe asp glyc-fa-omega 3 cap
27-1mg
3
OBSTETRIX DHA - prenat w/
fecbn-fa-dss tab 29-1 mg &
omega 3 cap 387 mg pak
3
OBSTETRIX EC - prenatal vit w/
dss-iron carbonyl-fa tab 29-1 mg
3
OCUVEL - multiple vitamins w/
minerals & fa cap 1 mg
3
PAIRE OB - prenat w/ fe poly
cmplx-fe asp-fe gly-fa tab & dha
cap pak
3
PNV FERROUS FUMARATE/
DOCU - prenatal vit w/ dss-fe
fumarate-fa tab 29-1 mg
3
PNV FOLIC ACID + IRON MUL prenatal vit w/ fe fumarate-fa tab
27-1 mg
3
PNV OB+DHA - prenat w/o a w/
fecbn-fegl-dss-fa tab & dha cap
250 mg pack
PNV PRENATAL PLUS MULTIVI - 3
prenatal vit w/ fe fumarate-fa tab
27-1 mg
3
PNV TABS 29-1 - prenatal vit w/
iron carbonyl-fa tab 29-1 mg
3
PNV-DHA - prenat w/o a w/
fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg
PNV-DHA+DOCUSATE - prenatal 3
w/o vit a w/ fe fum-dss-fa-dha
cap 27-1.25-300 mg
3
PNV-FIRST - prenatal mv w/
fe polysac cmplx-fa-dha cap
29-1-200 mg
3
PNV-OB/DHA - prenatal mv w/fe
fum-fa tab 65-1 mg & dha cap
250 mg pack
PNV-OMEGA - prenat w/o a w/ fe
fumerate-methylfolate-fa-omega
3 cap
3
PNV-SELECT - prenatal vit w/
fe fum-methylfolate-fa tab
27-0.6-0.4 mg
3
PNV-TOTAL - prenat w/ fe cbn-fe
bisglyc-fa-fish oil cap 35-5-1.2
mg
3
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
PNV-VP-U - prenatal w/o a vit w/ fe 3
fumarate-fa cap 106.5-1 mg
3
POLY-VI-FLOR - ped multiple vit
w/ fluoride biphasic chew tab
0.25 mg
3
POLY-VI-FLOR - ped multiple vit
w/ fluoride biphasic chew tab 0.5
mg
3
POLY-VI-FLOR - ped multiple vit
w/ fluoride biphasic chew tab 1
mg
3
POLY-VI-FLOR - ped multiple vit
w/ fluoride biphasic susp 0.25
mg/ml
3
POLY-VI-FLOR/IRON - ped
multiple vit w/ fl-fe biphasic chew
tab 0.5-10 mg
3
POLY-VI-FLOR/IRON - ped
multiple vitamin w/ fl-fe biphasic
susp 0.25-7 mg/ml
3
PR NATAL 400 - prenat-fe bis-fe
prot succ-fa-ca tab & omega 3
cap 400 pk
PR NATAL 400 EC - prenat-fe bis- 3
fe prot succ-fa-ca tab & omega
cap dr 400 pk
3
PR NATAL 430 - prenat-fe bis-fe
prot succ-fa-ca tab & omega 3
cap 430 pk
PR NATAL 430 EC - prenat-fe bis- 3
fe prot succ-fa-ca tab & omega
cap dr 430 pk
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
139
PREFERA OB - prenat vit-fe poly
cmplx-fe heme poly-fa tab 28-6-1
mg
3
PREFERA OB + DHA - prenat-fe
poly cmplx-fe heme poly-fa tab &
omega 3 cap pck
3
PREFERAOB ONE - prenat-fe poly 3
cmplx-fe heme poly-fa-dha cap
22-6-1-200 mg
3
PREFOL-DHA - prenatal w/o
vit a w/ fe fum-dss-fa-dha cap
26-1.2-300 mg
3
PRENAISSANCE - prenatal w/o
vit a w/ fe fum-dss-fa-dha cap
29-1.25-325 mg
3
PRENAISSANCE BALANCE prenatal w/o vit a w/ fe cbn-dssfa-dha cap 30-1-260 mg
PRENAISSANCE DHA - prenat w/ 3
o a w/fecbn-fegl-dss-fa tab & dha
cap 250 mg pack
PRENAISSANCE HARMONY DHA 3
- prenat w/fe poly-na fered-fa tab
27-1 & omega cap dr 380mg
PRENAISSANCE NEXT - prenatal 3
w/ calcium-vit b6-fa-ginger tab
1.2 mg
3
PRENAISSANCE NEXT-B prenatal w/ calcium-vit b6-faginger tab 1.22 mg
PRENAISSANCE PLUS - prenatal 3
w/o a w/fe cbn-dss-fa-dha cap
28-1-250 mg
3
PRENAISSANCE PROMISE prenat w/o a w/fecbn-fegl-dss-fa
tab & dha cap 300 mg pack
PRENAISSANCE 90 DHA - prenat 3
w/o a w/fecbn-fegl-dss-fa tab 90
&dha cap 300mg pak
3
PRENAPLUS - prenatal vit w/ fe
fumarate-fa tab 27-1 mg
140
PRENATA - prenatal w/o a vit w/ fe
fum-fa tab chew 29-1 mg
3
PRENATABS FA - prenatal vit w/
fe fumarate-fa tab 29-1 mg
3
PRENATABS RX - prenatal vit w/
iron carbonyl-fa tab 29-1 mg
3
PRENATAL - prenatal vit w/ fe
fumarate-fa tab 27-0.8 mg
3
PRENATAL - prenatal vit w/ fe
fumarate-fa tab 27-1 mg
3
PRENATAL + DHA - prenat w/o
a w/fecbn-fegl-dss-fa tab & dha
cap 250 mg pack
3
PRENATAL AD - prenatal vit w/
dss-iron carbonyl-fa tab 90-1 mg
3
PRENATAL FORMULA - prenatal
vit w/ fe fumarate-fa tab 27-1 mg
3
PRENATAL LOW IRON - prenatal
vit w/ fe fumarate-fa tab 27-1 mg
3
PRENATAL MULTIVITAMIN-ULT prenatal vit w/ dss-iron carbonylfa tab 90-1 mg
3
PRENATAL MV & MIN/FE-FA-D prenat-fe poly cmplx-fe hem polyfa-dha cap 11-3-0.5-100mg
3
PRENATAL PLUS - prenatal vit w/
fe fumarate-fa tab 27-1 mg
3
PRENATAL PLUS IRON - prenatal
vit w/ iron carbonyl-fa tab 29-1
mg
3
PRENATAL PLUS/IRON - prenatal
vit w/ fe fumarate-fa tab 27-1 mg
3
PRENATAL VITAMINS PLUS prenatal vit w/ fe fumarate-fa tab
27-1 mg
3
PRENATAL 19 - prenatal vit w/ fe
fumarate-fa chew tab 29-1 mg
3
PRENATAL 19 - prenatal vit w/
dss-fe fumarate-fa tab 29-1 mg
3
PRENATAL-U - prenatal w/o a vit
w/ fe fumarate-fa cap 106.5-1 mg
3
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
PRENATAL/FOLIC ACID - prenatal 3
vit w/ fe fumarate-fa tab 27-1 mg
3
PRENATE - prenat mv & min w/ lmethylfolate-fa chew tab 0.6-0.4
mg
3
PRENATE AM - prenatal w/
calcium-vit b6-vit b12-fa-ginger
tab 1 mg
3
PRENATE DHA - prenat w/o a
w/fefum-methfol-fa-dha cap
28-0.6-0.4-300 mg
3
PRENATE DHA - prenat w/o a
w/feaspg-methfol-fa-dha cap
18-0.6-0.4-300 mg
3
PRENATE ELITE - prenatal w/
fe asp gly-l methylfol-fa tab
20-0.6-0.4 mg
3
PRENATE ELITE - prenatal vit
w/ fe fum-methylfolate-fa tab
26-0.6-0.4 mg
3
PRENATE ENHANCE - prenat w/
o a w/fefum-methfol-fa-dha cap
28-0.6-0.4-400 mg
PRENATE ESSENTIAL - prenat w/ 3
o a w/feasp-methylf-fa-omeg cap
29-0.6-0.4-340 mg
PRENATE ESSENTIAL - prenat w/ 3
o a w/feaspg-methfol-fa-dha cap
18-0.6-0.4-300 mg
3
PRENATE MINI - prenat w/o a
w/fecbn-methylf-fa-dha cap
29-0.6-0.4-350 mg
3
PRENATE MINI - prenat w/oa
w/fecb-feasp-meth-fa-dha cap
18-0.6-0.4-350 mg
3
PRENATE PIXIE - prenat w/o a
w/feaspg-methfol-fa-dha cap
10-0.6-0.4-200 mg
3
PRENATE RESTORE - prenat w/
o a w/fefum-methfol-fa-dha cap
27-0.6-0.4-400 mg
PRENATE STAR - prenatal vit w/
fe asparto glycinate-fa tab 20-1
mg
3
PRENA1 CHEW - prenat w/ b2-b6b12-d3-folic acid chew tab 1.4
mg
3
PRENA1 CHEW/QUATREFOLIC
- prenat w/ b2-b6-b12-d3methylfol-fa chew tab 0.6-0.4 mg
3
PRENA1 PEARL - prenat w/oa
w/fefum-na fered-fa-dha cap cr
30-1.4-200 mg
3
PRENA1 PLUS/QUATREFOLIC
- prenat w/o a w/ fe chelate-l
methylfol-fa tab & dha cap pk
3
PRENA1/QUATREFOLIC - prenat
w/o a w/fefum-methfol-fa-dha cap
30-0.6-0.4-200 mg
3
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
PRENEXA - prenatal w/o vit a w/ fe 3
fum-dss-fa-dha cap 27-1.25-300
mg
3
PREPLUS - prenatal vit w/ fe
fumarate-fa tab 27-1 mg
3
PREQUE 10 - prenatal mv w/
fe carbonyl-dss-fa-dha tab
15-25-0.5-50 mg
3
PRETAB - prenatal vit w/ fe
fumarate-fa tab 29-1 mg
3
PROMAR - iron & b12 w/ vitamin
cap
3
PROTECT CARDIO - speciality
vitamin product cap
3
PROTECT PLUS - multiple
vitamins w/ minerals cap
3
PROTECT PLUS - multiple
vitamins w/ minerals liquid
3
PROTECT PLUS NR - multiple
vitamins w/ minerals cap
3
PROTECTBONE - multiple vit w/
min & calcium-folic acid wafer
500-1 mg
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
141
PROTECTNATAL - prenatal
vit w/poly fe-fa-fish oil tab dr
13.5-0.5-700 mg
3
PROVIDA OB - prenatal w/o a w/fe
fum-fe poly-fa cap 20-20-1.25 mg
3
PUREFE OB PLUS - prenatal
w/o a w/fe fum-fe poly-fa cap
162.115.2-1 mg
SE-NATAL 19 - prenatal vit w/ dssfe fumarate-fa tab 29-1 mg
3
SE-TAN DHA - prenatal w/fe fumfe poly -fa-omega 3 cap 15-15-1
mg
3
3
SELECT-OB - prenatal vit w/ fe
polysac cmplx-fa chew tab 29-1
mg
3
QUFLORA PEDIATRIC - pediatric
multiple vitamins w/ fluoride chew
tab 0.25 mg
1
SELECT-OB - prenat w/
fepolycmplx-methylfol-fa chew
tab 29-0.6-0.4 mg
3
QUFLORA PEDIATRIC - pediatric
multiple vitamins w/ fluoride chew
tab 0.5 mg
1
SELECT-OB+DHA - prenatal mv
w/fe poly-fa chw 29-1 mg & dha
cap 250 mg pak
3
QUFLORA PEDIATRIC - pediatric
multiple vitamins w/ fluoride chew
tab 1 mg
1
SETON ET-EC - prenat-fe bis-fe
prot succ-fa-ca tab & omega cap
dr 430 pk
3
QUFLORA PEDIATRIC - pediatric
multiple vitamins w/ fluoride soln
0.25 mg/ml
1
SETONET - prenat-fe bis-fe prot
succ-fa-ca tab & omega 3 cap
430 pk
3
QUFLORA PEDIATRIC - pediatric
multiple vitamins w/ fluoride soln
0.5 mg/ml
1
SIDEROL - multiple vitamins w/
minerals tab
3
R-NATAL OB - prenatal w/o a w/fe
cbn-fa-dha cap 20-1-320 mg
SM B-COMPLEX/VITAMIN C - bcomplex w/ c & folic acid tab
3
3
REAPHIRM - prenatal mv w/
fe polysac cmplx-fa-dha cap
29-1-200 mg
STROVITE - b-complex w/ c & folic
acid tab
3
3
STROVITE FORTE - multiple
vitamins w/ minerals tab
3
RELNATE DHA - prenatal vit w/ fe
fum-fa-omega 3 cap 28-1-200
mg
3
STROVITE FORTE - multiple
vitamins w/ minerals & fa syrup 1
mg/15ml
3
RENATABS - b-complex w/ cbiotin-vit e & folic acid tab 1 mg
3
RENATABS WITH IRON - b
complex-c-biotin-e-fa tab 1mg &
fe cbn tab 100 mg pack
3
RENAX - multiple vitamins w/
minerals & fa tab 2.5 mg
3
REQ 49+ - multiple vitamins w/
minerals tab
3
SE-NATAL 19 - prenatal vit w/ fe
fumarate-fa chew tab 29-1 mg
3
142
STROVITE ONE - multiple vitamins 3
w/ minerals tab
SUPERVITE - b-complex w/ lysine- 3
zn & folic acid liquid
SUPERVITE EC - multiple vitamins 3
w/ minerals & fa tab dr 1 mg
3
SUPPORT - multiple vitamins w/
minerals liquid
SUPPORT-500 - speciality vitamin 3
product cap
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
SYNAGEX - multiple vitamins w/
minerals & fa cap 1.25 mg
3
SYNATEK - multiple vitamins w/
minerals & fa cap 1.25 mg
3
TARON-BC - prenat w/o a w/ fe
cbnyl-fa tab 20-1 mg & vit b6 tab
pak
3
TARON-C DHA - prenatal w/fe
fum-fe poly -fa-omega 3 cap
53.5-38-1 mg
3
TARON-DUO EC - prenat-fe bis-fe
prot succ-fa-ca tab & omega cap
dr 400 pk
3
TARON-PREX - prenatal w/o
vit a w/ fe fum-dss-fa-dha cap
30-1.2-265 mg
3
TL FOLATE - prenatal vit w/
fe fum-methylfolate-fa tab
27-0.5-0.5 mg
3
TL G-FOL OS - multiple vit w/ min
& calcium-folic acid tab 500-1.1
mg
3
TL-ASSURE ONE - prenatal mv
w/ fe polysac cmplx-fa-dha cap
29-1-200 mg
3
TL-ASSURE+DHA - prenatal mv
w/fe poly-fa chw 29-1 mg & dha
cap 250 mg pak
3
TL-CARE DHA - prenatal w/fe
fumarate-fa-dss-fish oil cap
27-1-500 mg
3
TL-FLUORIVITE - pediatric
multiple vitamins w/ fl-fe chew
tab 0.25-7.5 mg
3
TL-SELECT - prenatal w/o vit
a w/ fe fum-dss-fa-dha cap
29-1.25-325 mg
3
TL-SELECT DHA - prenatal w/o
vit a w/ fe fum-doc-fa-dha cap
29-1.25-350 mg
3
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
TRI-TABS DHA - prenat w/o a w/ fe 3
bisglyc-fa tab 32-1 mg & omega
cap pack
3
TRI-VI-FLOR - ped vit acd & lmethylfol w/ fl biphasic susp 0.25
mg/ml
3
TRI-VI-FLOR - ped vit acd & lmethylfol w/ fl biphasic susp 0.5
mg/ml
3
TRI-VI-FLORO - ped vit acd & lmethylfol w/ fl biphasic susp 0.25
mg/ml
3
TRI-VI-FLORO - ped vit acd & lmethylfol w/ fl biphasic susp 0.5
mg/ml
3
TRI-VIT/FLUORIDE/IRON pediatric vitamins acd fluoride &
fe drops 0.25-10 mg/ml
3
TRI-ZEL - multiple vitamins w/
minerals tab
TRIADVANCE - prenatal vit w/ dss- 3
iron carbonyl-fa tab 90-1 mg
3
TRICARE - prenatal vit w/ fe
fumarate-fa tab 27-1 mg
TRICARE PRENATAL COMPLEAT 3
- prenat w/o a fefum-fa tab 27-1
mg & fish oil chew cap pak
3
TRICARE PRENATAL DHA ONE
- prenatal w/fe fumarate-fa-dssfish oil cap 27-1-500 mg
TRINATAL GT - prenatal vit w/ dss- 3
iron carbonyl-fa tab 90-1 mg
TRINATAL RX 1 - prenatal vit w/ fe 3
fumarate-fa tab 60-1 mg
TRINATAL ULTRA - prenatal vit w/ 3
dss-iron carbonyl-fa tab 90-1 mg
3
TRINATE - prenatal vit w/ fe
fumarate-fa tab 28-1 mg
3
TRIVEEN-DUO DHA - prenatfe bis-fe prot succ-fa-ca tab &
omega 3 cap 400 pk
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
143
TRIVEEN-PRX RNF - prenatal w/
o vit a w/ fe fum-dss-fa-dha cap
26-1.2-300 mg
3
TRIVEEN-TEN - prenatal mv &
min w/fe carbonyl-fa-dha tab
15-0.5-50 mg
3
TRIVEEN-U - prenatal w/o a vit w/
fe fumarate-fa cap 106.5-1 mg
3
UDAMIN - multiple vitamins w/
minerals & fa tab 2 mg
3
UDAMIN SP - multiple vitamins w/
minerals & fa tab 1 mg
3
ULTIMATE OB DHA - prenat w/ fe
poly cmplx-fe asp-fe gly-fa tab &
dha cap pak
3
ULTIMATECARE ONE - prenatal
vit w/ fe cbn-fe asp glyc-faomega 3 cap 27-1mg
3
ULTIMATECARE ONE NF prenatal w/fe cbnyl-fe asp glycfa-dss-omega cap 20-7-1 mg
3
ULTRA NATALCARE - prenatal vit
w/ dss-iron carbonyl-fa tab 90-1
mg
3
ULTRA TABS - prenatal vit w/ dssiron carbonyl-fa tab 90-1 mg
3
V-NATAL - prenatal vit w/o vit a w/
fe bisglycinate-fa tab 32-1 mg
3
V-NATAL DHA - prenat w/o a w/ fe
bisglyc-fa tab 32-1 mg & omega
cap pack
3
VEMAVITE-PRX 2 - prenatal w/
o vit a w/ fe fum-dss-fa-dha cap
27-1.25-300 mg
3
VENA-BAL DHA - prenat w/fe poly- 3
na fered-fa tab 27-1 & omega
cap dr 430mg
3
VENATAL-FA - prenatal vit w/ fe
fumarate-fa tab 29-1 mg
3
VINACAL - prenatal w/o a w/
fe carbonyl-fe gluc-dss-fa tab
27-1mg
144
VINACAL B - prenat w/o a w/fecbn- 3
feglu-fa tab 20-1 mg & vit b6 tab
pak
3
VINATE AZ EXTRA - prenatal vit
w/ fe bisglycinate chelate-fa tab
29-1 mg
VINATE C - prenatal w/o a vit w/ fe 3
fumarate-fa tab 30-1 mg
VINATE CALCIUM - prenatal vit w/ 3
iron carbonyl-fe gluc-fa tab 27-1
mg
VINATE CARE - prenatal w/o a vit 3
w/ fe fum-fa tab chew 40-1 mg
3
VINATE DHA - prenat w/o a w/
fefum-methylfol-fa-omegas cap
27-1.53 mg
3
VINATE DHA RF - prenat w/o a
w/fefum-methylfol-omegas cap
27-1.13 mg
3
VINATE GT - prenatal vit w/ dssiron carbonyl-fa tab 90-1 mg
3
VINATE IC - prenatal w/o a w/fe
fum-fe poly-fa cap 162.115.2-1
mg
3
VINATE II - prenatal vit w/ fe
bisglycinate chelate-fa tab 29-1
mg
3
VINATE M - prenatal vit w/ sel-fe
fumarate-fa tab 27-1 mg
3
VINATE ONE - prenatal vit w/ fe
fumarate-fa tab 60-1 mg
3
VINATE PN CARE - prenatal
without a w/ fe asparto gly-doc-fa
tab 30-1mg
3
VINATE ULTRA - prenatal vit w/
dss-iron carbonyl-fa tab 90-1 mg
3
VIRT NATE - prenatal vit w/ fe
fumarate-fa tab 28-1 mg
3
VIRT-ADVANCE - prenatal vit w/
dss-iron carbonyl-fa tab 90-1 mg
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
VIRT-BAL DHA - prenat-fepolynafered-fa tab 13-13-1 & omega
cap dr 374 mg
3
VITAFOL-ONE - prenatal mv w/
fe polysac cmplx-fa-dha cap
29-1-200 mg
2
VIRT-BAL DHA PLUS - prenat w/
fe poly-na fered-fa tab 27-1 &
omega cap dr 380mg
3
VITAFOL-PLUS - prenatal mv w/
fe polysac cmplx-fa-dha cap
27-1-200 mg
2
VIRT-C DHA - prenatal w/fe fum-fe
poly -fa-omega 3 cap 53.5-38-1
mg
3
VITAFOL-PN - prenatal vit w/ fe
fumarate-fa tab 65-1 mg
2
3
VITAL-D RX - b-complex w/ cbiotin-d-zinc & folic acid tab 1 mg
3
VIRT-CARE ONE - prenatal vit w/
fe cbn-fe asp glyc-fa-omega 3
cap 27-1mg
3
VIRT-PN - prenatal vit w/ fe fummethylfolate-fa tab 27-0.6-0.4 mg
3
VITAMEDMD ONE RX/
QUATREFO - prenat w/o a
w/fefum-methfol-fa-dha cap
30-0.6-0.4-200 mg
VIRT-PN DHA - prenat w/o a
w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg
3
VITAMEDMD PLUS RX/QUATRE
- prenat w/o a w/ fe chelate-l
methylfol-fa tab & dha cap pk
3
VIRT-PN PLUS - prenat w/o a w/ fe 3
fumerate-methylfolate-fa-omega
3 cap
3
VIRT-SELECT - prenatal w/o
vit a w/ fe fum-dss-fa-dha cap
29-1.25-325 mg
VIRT-VITE GT - prenatal vit w/ dss- 3
iron carbonyl-fa tab 90-1 mg
3
VIRTPREX - prenatal w/o vit a w/
fe fum-dss-fa-dha cap 26-1.2-300
mg
3
VITA-PREN - prenatal vit w/
docusate-iron-fa tab 65-1 mg
2
VITAFOL - iron w/ vitamin tab
VITAMEDMD REDICHEW RX prenat w/ b2-b6-b12-d3-folic acid
chew tab 1.4 mg
3
VITAMEDMD REDICHEW RX/
QUA - prenat w/ b2-b6-b12-d3methylfol-fa chew tab 0.6-0.4 mg
3
VITAPEARL - prenat w/oa w/
fefum-na fered-fa-dha cap cr
30-1.4-200 mg
3
VITAROCA PLUS - multiple
vitamins w/ minerals tab
3
VIVA CT PRENATAL - prenatal w/
o a vit w/ fe fum-fa tab chew 28-1
mg
3
VITAFOL ULTRA - prenat w/
fe poly-methylfol-fa-dha cap
29-0.6-0.4-200 mg
2
VIVA DHA - prenatal vit w/ fe fumfa-omega 3 cap 28-1-200 mg
3
3
VITAFOL-NANO - prenatal w/
o a w/ fefum-l methylfol-fa tab
18-0.6-0.4 mg
2
VOL-NATE - prenatal vit w/ fe
fumarate-fa tab 28-1 mg
VOL-PLUS - prenatal vit w/ fe
fumarate-fa tab 27-1 mg
3
VITAFOL-OB - prenatal vit w/ fe
fumarate-fa tab 65-1 mg
2
VOL-TAB RX - prenatal vit w/ iron
carbonyl-fa tab 29-1 mg
3
VITAFOL-OB+DHA - prenatal mv
w/fe fum-fa tab 65-1 mg & dha
cap 250 mg pack
2
VP CH ULTRA - prenat w/o a w/
fe fum-fe cbn-dss-fa-dha cap
27-1-260 mg
3
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
145
VP-CH PLUS - prenatal w/o a w/fe
cbn-dss-fa-dha cap 29-1-265 mg
1
VP-CH-PNV - prenatal w/o vit a w/
fe cbn-dss-fa-dha cap 30-1-260
mg
1
VP-ERA OB PLUS - prenat vit-fe
poly cmplx-fe heme poly-fa tab
22-6-1 mg
3
VP-GGR-B6 PRENATAL - prenatal
w/ calcium-vit b6-fa-ginger tab
1.2 mg
3
VP-HEME OB - prenat vit-fe poly
cmplx-fe heme poly-fa tab 28-6-1
mg
3
VP-HEME OB + DHA - prenat-fe
poly cmplx-fe heme poly-fa tab &
omega 3 cap pck
3
VP-HEME ONE - prenat-fe poly
cmplx-fe heme poly-fa-dha cap
22-6-1-200 mg
3
VP-PNV-DHA - prenatal vit w/ fe
fum-fa-omega 3 cap 28-1-215.8
mg
3
VP-ZEL - multiple vitamins w/
minerals tab
3
ZATEAN-CH - prenatal w/o a w/fe
cbn-dss-fa-dha cap 27-1-250 mg
3
ZATEAN-PN - prenatal vit w/
fe fum-methylfolate-fa tab
27-0.6-0.4 mg
CALCIUM-FOLIC ACID PLUS D
- ca carb-folic acid-vit d-b6-b12boron-mag wafer 1342-1 mg
3
EFFER-K - potassium bicarbonatecitric acid effer tab 10 meq
3
EFFER-K - potassium bicarbonatecitric acid effer tab 20 meq
3
FLORICAL - sodium fluoride w/
calcium carb cap 8.3-364 mg
A
FLORICAL - sodium fluoride w/
calcium carb tab 8.3-364 mg
A
FLORIVA - sodium fluoride-vitamin
d liqd drops 0.25 mg/ml-400 unit/
ml
3
FLUOR-A-DAY - sodium fluoridexylitol chew tab 0.55 (0.25 mg
f)-236.79 mg
A
FLUOR-A-DAY - sodium fluoridexylitol chew tab 1.1 (0.5 mg
f)-236.79 mg
A
FLUOR-A-DAY - sodium fluoridexylitol chew tab 2.2 (1 mg
f)-236.79 mg
A
FLUORABON - sodium fluoride
soln 0.25 mg/0.6ml (from 0.55
mg/0.6ml naf)
A
FLURA-DROPS - sodium fluoride
soln 0.25 mg/drop f (from 0.55
mg/drop naf)
A
3
ZATEAN-PN DHA - prenat w/o
a w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg
GALZIN - zinc acetate cap 25 mg
(elemental zinc)
3
3
GALZIN - zinc acetate cap 50 mg
(elemental zinc)
3
ZATEAN-PN PLUS - prenat w/o a
w/ fe fumerate-methylfolate-faomega 3 cap
3
GNP VITAMIN D-400 - calcium
carbonate-cholecalciferol tab 90
mg-400 unit
1
ZINGIBER - prenatal w/ calcium-vit
b6-fa-ginger tab 1.2 mg
3
IODINE STRONG - iodine solution
strong 5% (lugol's)
1
K-PHOS - potassium phosphate
monobasic tab 500 mg
3
MINERALS and ELECTROLYTES
CALCIFOL - ca carb-folic acidvit d-b6-b12-boron-mag wafer
1342-1.6 mg
146
3
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
K-PHOS NEUTRAL - pot phos
monobasic w/sod phos di &
monobas tab 155-852-130mg
3
K-TAB - potassium chloride tab cr
10 meq
3
K-TAB - potassium chloride tab cr
20 meq (1500 mg)
3
KLOR-CON M15 - potassium
chloride microencapsulated crys
cr tab 15 meq
potassium chloride cap cr 8 meq
(Micro-k)
1
POTASSIUM CHLORIDE ER potassium chloride tab cr 20 meq
(1500 mg)
1
1
3
potassium chloride
microencapsulated crys cr tab
10 meq
1
KLOR-CON 25 - potassium
chloride powder packet 25 meq
3
potassium chloride
microencapsulated crys cr tab
20 meq
1
LOZI-FLUR - sodium fluoride
lozenge 1 mg f (from 2.2 mg naf)
A
potassium chloride oral liq 10%
(20 meq/15ml)
potassium chloride oral liq 20%
(40 meq/15ml)
1
potassium chloride powder
packet 20 meq
1
potassium chloride tab cr 10
meq (K-tab)
1
potassium chloride tab cr 8 meq
(600 mg)
1
SODIUM FLUORIDE - sodium
fluoride tab 0.5 mg f (from 1.1 mg
naf)
A
SODIUM FLUORIDE - sodium
fluoride tab 1 mg f (from 2.2 mg
naf)
A
sodium fluoride chew tab
0.25 mg f (from 0.55 mg naf)
(Luride)
A
sodium fluoride chew tab 0.5 mg
f (from 1.1 mg naf) (Luride)
A
sodium fluoride chew tab 1 mg f
(from 2.2 mg naf) (Luride)
A
sodium fluoride soln 0.125 mg/
drop f (0.275 mg/drop naf)
A
sodium fluoride soln 0.5 mg/ml f
(from 1.1 mg/ml naf) (Luride)
A
zinc sulfate cap 220 mg (50 mg
elemental zn)
1
LURIDE - sodium fluoride chew tab A
0.25 mg f (from 0.55 mg naf)
LURIDE - sodium fluoride chew tab A
0.5 mg f (from 1.1 mg naf)
LURIDE - sodium fluoride chew tab A
1 mg f (from 2.2 mg naf)
LURIDE - sodium fluoride soln 0.5 A
mg/ml f (from 1.1 mg/ml naf)
3
MAGNEBIND 400 - magnesiumcalcium-folic acid tab 400-200-1
mg
MICRO-K - potassium chloride cap 3
cr 8 meq
MICRO-K - potassium chloride cap 3
cr 10 meq
A
MONOCAL - sodium
monofluorophosphate-calcium
carb tab 22.75-625 mg
1
pot bicarbonate & chloride effer
tab 25 meq
1
pot phos monobasic w/sod
phos di & monobas tab
155-852-130mg (K-phos neutral)
1
potassium bicarbonate effer tab
25 meq
1
potassium chloride cap cr 10
meq (Micro-k)
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
NUTRIENTS
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
147
3
3
FALESSA - levomefolate
glucosamine tab 1 mg (folate
equivalent)
1
NUTRESTORE - glutamine powd
pack 5 gm
3
flaxseed oil-evening primrosebilberry cap 1000-500-40 mg
(Tears again hydrate)
TRYPTOPHAN - tryptophan cap
500 mg
1
FOLBEE AR - folic acid-b12-b6arginine-black pepper tab
3
WHEY PROTEIN DRINK MIX protein oral powder
1
FOLBIC RF - l-methylfolate w/ vit
b6-vit b12 tab 1.13-25-2 mg
3
folic acid-pyridoxinecyanocobalamin tab
2.5-25-2 mg
1
DIETARY PRODUCTS
ALZ-NAC - l-methylfolatemethylcobalamin-acetylcyst tab
6-2-600 mg
3
AVAILNEX - carbocysteine chew
tab 750 mg
3
CALAFOL RX - fahydroxocobalamin-policosanol-vit
b6-vit d-ca tab
3
CARDIOTEK-RX - folic acid-b12b6-arginine-black pepper tab
3
CEREFOLIN - l-methylfolate w/ vit
b12-vit b6-vit b2 tab 6-1-50-5 mg
3
CEREFOLIN NAC - l-methylfolatemethylcobalamin-acetylcyst tab
6-2-600 mg
3
CEREFOLIN NAC - l-methylfolatealgae-b12-acetylcyst tab
6-90.314-2-600mg
3
CYANOCOBALAMIN/
LEVOMEFOLA - l-methylfolate
w/ vit b6-vit b12 tab 1.13-25-2 mg
1
DEPLIN - l-methylfolate tab 7.5 mg
3
DEPLIN - l-methylfolate tab 15 mg
3
DEPLIN 15 - l-methylfolate-algae
cap 15-90.314 mg
3
DEPLIN 7.5 - l-methylfolate-algae
cap 7.5-90.314 mg
3
ENTERAGAM - serum-derived
bovine immunoglob/protein
isolate 5 gm packet
3
148
FOLTANX - l-methylfolate w/ vit b6- 3
vit b12 tab 3-35-2 mg
3
FOLTANX RF - l-methylfolatealgae-vit b12-b6 cap
3-90.314-2-35 mg
3
FOLTX - folic acid-pyridoxinecyanocobalamin tab 2.5-25-2 mg
FOLTX - l-methylfolate w/ vit b6-vit 3
b12 tab 1.13-25-2 mg
3
FOSTEUM - genistein-zinc amino
acid chelate-vitamin d cap
L-METHYL-B6-B12 - l-methylfolate 1
w/ vit b6-vit b12 tab 3-35-2 mg
3
L-METHYL-MC - l-methylfolate w/
vit b12-vit b6-vit b2 tab 6-1-50-5
mg
3
L-METHYL-MC NAC - lmethylfolate-methylcobalaminacetylcyst tab 6-2-600 mg
L-METHYLFOLATE - l-methylfolate 1
tab 7.5 mg
L-METHYLFOLATE - l-methylfolate 1
tab 15 mg
3
L-METHYLFOLATE CA MECBL - l-methylfolate-algae-b12acetylcyst tab 6-90.314-2-600mg
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
CARDIOVID PLUS - dha-epavit b6-b12-folic acid cap
240-360-20-0.5-0.8 mg
Quantity Limits
1
"Smart" PA
acetylcysteine cap 600 mg
Prior Authorization
Drug Name
Drug Tier
2015
L-METHYLFOLATE CA/ME-CBL/ l-methylfolate-methylcobalaminacetylcyst tab 6-2-600 mg
1
L-METHYLFOLATE CA/P-5-P/M l-methylfolate w/ vit b6-vit b12 tab
3-35-2 mg
1
L-METHYLFOLATE CA/P-5-P/M
- l-methylfolate-algae-vit b12-b6
cap 3-90.314-2-35 mg
1
L-METHYLFOLATE CALCIUM - lmethylfolate tab 7.5 mg
1
L-METHYLFOLATE CALCIUM - lmethylfolate tab 15 mg
1
L-METHYLFOLATE FORMULA
15 - l-methylfolate-algae cap
15-90.314 mg
3
L-METHYLFOLATE FORMULA
7. - l-methylfolate-algae cap
7.5-90.314 mg
3
L-METHYLFOLATE FORTE
- l-methylfolate-algae cap
7.5-90.314 mg
3
L-METHYLFOLATE FORTE - lmethylfolate-algae cap 15-90.314
mg
3
LEVOMEFOLATE CALCIUM/
ACET - l-methylfolate-algae-b12acetylcyst tab 6-90.314-2-600mg
1
LEVOMEFOLATE CALCIUM/
ALGA - l-methylfolate-algae cap
7.5-90.314 mg
1
LEVOMEFOLATE CALCIUM/
ALGA - l-methylfolate-algae cap
15-90.314 mg
1
LEVOMEFOLATE CALCIUM/PYRI
- l-methylfolate-algae-vit b12-b6
cap 3-90.314-2-35 mg
1
LIMBREL - flavocoxid cap 250 mg
3
LIMBREL - flavocoxid cap 500 mg
3
LIMBREL250 - flavocoxid-citrated
zinc bisglycinate cap 250-50 mg
3
LIMBREL500 - flavocoxid-citrated
zinc bisglycinate cap 500-50 mg
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
3
LMTHF/PYRIDOXINE HCL/CYAN - 1
l-methylfolate w/ vit b6-vit b12 tab
1.13-25-2 mg
3
METAFOLBIC - l-methylfolate w/
vit b12-vit b6-vit b2 tab 6-1-50-5
mg
3
METAFOLBIC PLUS - lmethylfolate-methylcobalaminacetylcyst tab 6-2-600 mg
3
METAFOLBIC PLUS RF - lmethylfolate-algae-b12acetylcyst tab 6-90.314-2-600mg
METANX - l-methylfolate w/ vit b6- 3
vit b12 tab 3-35-2 mg
METANX - l-methylfolate-algae-vit 3
b12-b6 cap 3-90.314-2-35 mg
METHYLFOL-ALGAE-B12-ACETY 1
- l-methylfolate-algae-b12acetylcyst tab 6-90.314-2-600mg
PODIAPN - l-methylfolate-b12-b6- 3
alpha lipoic ac cap 5-2-35-300
mg
3
Q-TABS - levomefolate
glucosamine tab 1 mg (folate
equivalent)
1
SACCHARIN SODIUM - sodium
saccharin powder
SODIUM SACCHARIN DIHYDRAT 1
- sodium saccharin powder
3
TEARS AGAIN HYDRATE flaxseed oil-evening primrosebilberry cap 1000-500-40 mg
3
VASCAZEN - omega-3-acid ethyl
esters (dietary management) cap
1 gm
3
VAYACOG - phosphatidylserinedha-epa cap 100-19.5-6.5 mg
3
VAYARIN - phosphatidylserinedha-epa cap 75-21.5-8.5 mg
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
149
2
•
• •
VP-GSTN - genistein-zinc amino
acid chelate-vitamin d cap
3
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80
soln inj 60 mcg/0.3ml
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80
soln inj 100 mcg/ml
2
•
• •
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80
soln inj 100 mcg/0.5ml
2
•
• •
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80
soln inj 150 mcg/0.75ml
2
•
• •
2
•
• •
HEMATOLOGICAL AGENTS
HEMATOPOIETIC AGENTS
Specialty
3
Quantity Limits
Prior Authorization
• •
Drug Name
"Smart" PA
Drug Tier
•
VITA-RESPA - folic acidpyridoxine-cyanocobalamin tab
2.2-25-1.3 mg
Specialty
2
VITACIRC-B - l-methylfolate w/ vit
b6-vit b12 tab 3-35-2 mg
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80
soln inj 60 mcg/ml
3
Quantity Limits
• •
VAYAROL - phytosterol estersdha-epa cap 630-232.5-92.5 mg
"Smart" PA
•
Drug Tier
2
3
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80
soln inj 40 mcg/0.4ml
Drug Name
Prior Authorization
2015
fe fum-iron polysacch complexfa-b cmplx-c-zn-mn-cu cap
(Tandem plus)
1
ferrous fumarate-fa-b complex-czn-mg-mn-cu tab 106-1 mg
1
folic acid-vit b6-vit b12-omega 3phytosterols cap 1 mg
1
iron combination cap
1
iron-docusate-b12-folic acidc-e-cu-biotin tab 150-1 mg
(Hematron-af)
1
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80
soln inj 150 mcg/0.3ml
2
•
• •
ACTIVE FE - fe carbonyl-fa-b
complex-a-c-d-e-min tab 75-1.25
mg
3
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80
soln inj 200 mcg/ml
2
•
• •
ANIMI-3 - folic acid-vit b6-vit b12omega 3-phytosterols cap 1 mg
3
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80
soln inj 200 mcg/0.4ml
2
•
• •
ANIMI-3 - folic acid-b6-b12-domega 3-phytosterols cap 1 mg
3
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80
soln inj 300 mcg/ml
ANIMI-3/VITAMIN D - folic acid-b6b12-d-omega 3-phytosterols cap
1 mg
3
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80
soln inj 300 mcg/0.6ml
2
•
• •
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80
soln inj 25 mcg/ml
2
•
• •
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80
soln inj 500 mcg/ml
2
•
• •
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80
soln inj 25 mcg/0.42ml
2
•
• •
B-6 FOLIC ACID - cobalamine
combination cap
1
3
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80
soln inj 40 mcg/ml
2
• •
BIFERARX - polysacch fe
cmplx-fe heme poly-fa-b12 tab
22-6-1-0.025 mg
150
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
FA-8 - folic acid cap 0.8 mg
A
CENFOL - folic acid-vitamin b6vitamin b12 tab 2.3-24.5-2 mg
fe fumarate w/ b12-vit c-fa-ifc
cap 110-0.015-75-0.5-240 mg
1
3
3
fe fumarate-vit c-vit b12-fa cap
460 (151 fe)-60-0.01-1 mg
1
CENTRATEX - ferrous fumaratefa-b complex-c-zn-mg-mn-cu cap
106-1 mg
FE 90 PLUS - fe carbonyl-fe
gluconate-fa-vit b12-vit c-dss tab
90-1 mg
3
FER-IN-SOL - ferrous sulfate soln
75 mg/ml (15 mg/ml elemental
fe)
A
FERIVA - fe bisglycin-fe carbonylc-fa-b12-biotin-dss cap 75-1 mg
3
FERIVA 21/7 - fe asparto gly-b12fa-c-dss-succinic acid-zn tab
75-1 mg
3
FERIVAFA - iron-c-fa-b12-biotincopper-docusate cap 110-1 mg
3
FERRALET 90 - fe carbonyl-fe
gluconate-fa-vit b12-vit c-dss tab
90-1 mg
3
FERRAPLUS 90 - iron-folic acid-vit
b12-vit c-docusate sod tab 90-1
mg
3
FERRETTS CHEWABLE IRON
- carbonyl iron chew tab 18 mg
(elemental iron)
A
FERREX 150 FORTE PLUS - fe
asp gly-fe polysacch-succ ac-cthreon ac-b12-fa cap
3
FERREX 28 - fe asparto gly-fe
fum-b12-fa-c-succinic ac tab ther
pack
3
3
3
CERDELGA - eliglustat tartrate cap 3
84 mg (base equivalent)
3
CIFEREX - folic acidcholecalciferol cap 1 mg-3775
unit
3
CORVITE FE - iron combination
tab
3
CORVITE 150 - iron combination
tab
CORVITE 150 - iron-folic acid-vit c- 3
vit b6-vit b12-zinc tab 150-1.25
mg
3
DIVISTA - folic acid-vit b6-vit b12omega 3-biotin-cr cap 1 mg
DROXIA - hydroxyurea cap 200 mg 3
•
• •
DROXIA - hydroxyurea cap 300 mg 3
DROXIA - hydroxyurea cap 400 mg 3
DURACHOL - folic acidcholecalciferol cap 1 mg-3775
unit
3
ED CYTE F - ferrous fumaratefolic acid-docusate sodium tab
324-1-50 mg
3
EPOGEN - epoetin alfa inj 2000
unit/ml
3
•
• •
EPOGEN - epoetin alfa inj 3000
unit/ml
3
•
• •
EPOGEN - epoetin alfa inj 4000
unit/ml
3
•
• •
FERRO-PLEX HEMATINIC - fe
fum-dss-vit c-vit e-vit b12-if-fa tab
115-1 mg
EPOGEN - epoetin alfa inj 10000
unit/ml
3
•
• •
FERROTRIN - iron w/ b12-vit c-faifc cap 36-0.015-75-0.5-240 mg
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
A
Quantity Limits
Prior Authorization
carbonyl iron susp 15 mg/1.25ml
(elemental iron)
Drug Name
"Smart" PA
Drug Tier
•
Specialty
3
Quantity Limits
EPOGEN - epoetin alfa inj 20000
unit/ml
"Smart" PA
3
Drug Tier
BP VIT 3 - folic acid-vit b6-vit b12omega 3-phytosterols cap 1 mg
Drug Name
Prior Authorization
2015
• •
151
ferrous fumarate-folic acid tab
324-1 mg
1
FERROUS SULFATE - ferrous
sulfate liquid 220 mg/5ml (44
mg/5ml elemental fe)
3
A
HEMATOGEN FA - fe fumarate-vit
c-vit b12-fa cap 200-250-0.01-1
mg
3
FERROUS SULFATE - ferrous
sulfate syrup 300 mg/5ml (60
mg/5ml elemental fe)
A
HEMATRON-AF - iron-docusateb12-folic acid-c-e-cu-biotin tab
150-1 mg
3
ferrous sulfate elixir 220 mg/5ml
(44 mg/5ml elemental fe)
A
HEMETAB - polysacch fe cmplxfe heme poly-fa-b12 tab
22-6-1-0.025 mg
3
ferrous sulfate soln 75 mg/ml
(15 mg/ml elemental fe)
A
HEMOCYTE PLUS - ferrous
fumarate-fa-b complex-c-zn-mgmn-cu cap 106-1 mg
ferrous sulfate-vit c-folic acid tab
cr 105-500-0.8 mg
1
HEMOCYTE-F - iron combination
elixir
3
FOLGARD RX - folic acid-vitamin
b6-vitamin b12 tab 2.2-25-1 mg
3
1
folic acid tab 1 mg
1
HYDROXOCOBALAMIN hydroxocobalamin inj 1000 mcg/
ml
A
ICAR - carbonyl iron chew tab 15
mg (elemental iron)
A
folic acid tab 400 mcg
folic acid tab 800 mcg
A
folic acid-vitamin b6-vitamin b12
tab 2.2-25-0.5 mg
ICAR PEDIATRIC - carbonyl iron
susp 15 mg/1.25ml (elemental
iron)
A
1
folic acid-vitamin b6-vitamin b12
tab 2.2-25-1 mg (Folgard rx)
1
3
folic acid-vitamin b6-vitamin b12
tab 2.5-25-1 mg
1
ICAR-C PLUS - iron-vit c-vit b12folic acid tab 100-250-0.025-1
mg
FOLIVANE-F - fe fum-fe poly-fa-cb3 cap 62.5-62.5-1-40-3mg(125
mg fe)
3
FOLIVANE-PLUS - fe fum-iron
polysacch complex-fa-b complexc-biotin cap
3
FOLPACE RX - folic acidhydroxocobal-vit b6-vit e-mag tab
2.05 mg-425 mcg
3
IRON ASP GLY/ POLYSACCH C fe asp gly-fe polysacch-succ acc-threon ac-b12-fa cap
1
FOLTRATE - cobalamine
combination tab
3
A
FUSION PLUS - fe fum-iron
poly cmplx-fa-b cmplx-c-biotinprobiotic cap
3
IRON CHEWS PEDIATRIC carbonyl iron chew tab 15 mg
(elemental iron)
iron polysacch complex-vit b12fa cap 150-0.025-1 mg
1
152
INTEGRA F - fe fum-fe poly-fa-c-b3 3
cap 62.5-62.5-1-40-3mg(125 mg
fe)
3
INTEGRA PLUS - fe fum-iron
polysacch complex-fa-b complexc-biotin cap
1
IRON - iron combination tab
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
iron-folic acid-vit c-vit b6-vit b12zinc tab 150-1.25 mg (Corvite
150)
1
iron-vit c-vit b12-folic acid tab
100-250-0.025-1 mg (Icar-c plus)
1
IROSPAN 24/6 - fe asp gly-fe
polys-succ acd-b cmplx-c-ca-fa
tab ther pk
3
IS 24/6 - fe asp gly-fe polys-succ
acd-b cmplx-c-ca-fa tab ther pk
3
LEUKINE - sargramostim inj 500
mcg/ml
2
•
• •
LEUKINE - sargramostim
lyophilized for inj 250 mcg
2
•
• •
MAXARON FORTE - fe gly-fe fumvit c-vit b12-methylfolate tab
3
MAXFE - iron-fa-vit b12-biotin-vit c- 3
docusate-mg-zn tab 160-1 mg
3
MULTIGEN - fe asparto gly-succ
acd-c-threonic acd-b12-des stom
tab
MULTIGEN FOLIC - fe asparto gly- 3
succinic acd-vit c-threonic acdb12-fa tab
3
MULTIGEN PLUS - fe aspart glyfe fum-succ acd-c-threonic acdb12-fa tab
MV FE ASPARTO GLY/FE FUM/ - 1
fe aspart gly-fe fum-succ acd-cthreonic acd-b12-fa tab
1
MV FE ASPARTO GLY/VIT C/
V - fe asparto gly-succ acd-cthreonic acd-b12-des stom tab
A
MYKIDZ IRON 10 - iron susp 15
mg/1.5ml
3
NASCOBAL - cyanocobalamin
nasal spray 500 mcg/0.1ml
3
NATALVIRT FLT - fe carbonyl-fe
gluconate-fa-vit b12-vit c-dss tab
90-1 mg
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
NEPHRON FA - ferrous fumarate
w/ fa-dss-b complex-vit c tab
3
NEULASTA - pegfilgrastim inj 6
mg/0.6ml
3
•
• •
NEUMEGA - oprelvekin for inj 5 mg 2
2
NEUPOGEN - filgrastim inj 300
mcg/ml
2
NEUPOGEN - filgrastim inj 480
mcg/1.6ml (300 mcg/ml)
2
NEUPOGEN - filgrastim inj 300
mcg/0.5ml (600 mcg/ml)
2
NEUPOGEN - filgrastim inj 480
mcg/0.8ml (600 mcg/ml)
3
NEURIN-SL - cyanocobalaminmethylcobalamin tab sl 600-600
mcg
3
NIRON KOMPLETE - fe
bisglycinate-fe fum-vit c-vit b12vit e-fa tab 30-1 mg
3
NOVAFERRUM - polysacch iron
complex-vit c-fa for soln 100-60-1
mg/5ml
3
PRE-FOLIC - folic acid-vitamin c
tab 1-100 mg
2
PROCRIT - epoetin alfa inj 2000
unit/ml
2
PROCRIT - epoetin alfa inj 3000
unit/ml
2
PROCRIT - epoetin alfa inj 4000
unit/ml
2
PROCRIT - epoetin alfa inj 10000
unit/ml
2
PROCRIT - epoetin alfa inj 20000
unit/ml
2
PROCRIT - epoetin alfa inj 40000
unit/ml
3
PROFERRIN-FORTE - iron heme
polypeptide-folic acid tab 12-1
mg (fe equiv)
3
PROMACTA - eltrombopag
olamine tab 12.5 mg (base equiv)
•
•
• •
• •
•
• •
•
• •
•
• •
•
• •
•
• •
•
• •
•
• •
•
• •
•
• •
•
• •
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
153
3
•
• •
COUMADIN - warfarin sodium tab
5 mg
2
PROMACTA - eltrombopag
olamine tab 75 mg (base equiv)
3
•
• •
COUMADIN - warfarin sodium tab
6 mg
2
PROTECTIRON - iron polysacchfa-b complex-vit c-e & minerals
tab 60-1 mg
3
COUMADIN - warfarin sodium tab
7.5 mg
2
PUREFE PLUS - ferrous fumaratefa-b complex-c-zn-mg-mn-cu cap
106-1 mg
COUMADIN - warfarin sodium tab
10 mg
2
3
ELIQUIS - apixaban tab 2.5 mg
2
A
ELIQUIS - apixaban tab 5 mg
2
SPATONE PUR-ABSORB IRON ferrous sulfate liquid 5 mg/20ml
(elemental iron)
enoxaparin sodium inj 100 mg/
ml (Lovenox)
1
•
•
•
TANDEM F - ferrous fum-iron
polysacch-fa cap 162-115.2-1 mg
(106 mg fe)
3
enoxaparin sodium inj
120 mg/0.8ml (Lovenox)
1
•
1
•
TANDEM PLUS - fe fum-iron
polysacch complex-fa-b cmplx-czn-mn-cu cap
3
enoxaparin sodium inj 150 mg/
ml (Lovenox)
enoxaparin sodium inj
30 mg/0.3ml (Lovenox)
1
•
TARON FORTE - fe bisglycinate-fe
polysacch-vit c-vit b12-fa cap
3
enoxaparin sodium inj
300 mg/3ml (Lovenox)
1
•
ZAVESCA - miglustat cap 100 mg
2
• •
enoxaparin sodium inj
40 mg/0.4ml (Lovenox)
1
•
ARIXTRA - fondaparinux sodium
inj 2.5 mg/0.5ml
3
•
enoxaparin sodium inj
60 mg/0.6ml (Lovenox)
1
•
ARIXTRA - fondaparinux sodium
inj 5 mg/0.4ml
3
•
enoxaparin sodium inj
80 mg/0.8ml (Lovenox)
1
•
ARIXTRA - fondaparinux sodium
inj 7.5 mg/0.6ml
3
•
fondaparinux sodium inj
10 mg/0.8ml (Arixtra)
1
•
ARIXTRA - fondaparinux sodium
inj 10 mg/0.8ml
3
•
fondaparinux sodium inj
2.5 mg/0.5ml (Arixtra)
1
•
COUMADIN - warfarin sodium tab
1 mg
2
fondaparinux sodium inj
5 mg/0.4ml (Arixtra)
1
•
COUMADIN - warfarin sodium tab
2 mg
2
fondaparinux sodium inj
7.5 mg/0.6ml (Arixtra)
1
•
COUMADIN - warfarin sodium tab
2.5 mg
2
FRAGMIN - dalteparin sodium inj
10000 unit/ml
3
•
COUMADIN - warfarin sodium tab
3 mg
2
FRAGMIN - dalteparin sodium inj
2500 unit/0.2ml
3
•
154
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
PROMACTA - eltrombopag
olamine tab 50 mg (base equiv)
Quantity Limits
2
"Smart" PA
COUMADIN - warfarin sodium tab
4 mg
ANTICOAGULANTS
Prior Authorization
• •
Drug Name
Drug Tier
•
Specialty
3
Quantity Limits
Prior Authorization
PROMACTA - eltrombopag
olamine tab 25 mg (base equiv)
Drug Name
"Smart" PA
Drug Tier
2015
FRAGMIN - dalteparin sodium inj
5000 unit/0.2ml
3
•
warfarin sodium tab 2.5 mg
(Coumadin)
1
FRAGMIN - dalteparin sodium inj
7500 unit/0.3ml
3
•
warfarin sodium tab 3 mg
(Coumadin)
1
FRAGMIN - dalteparin sodium inj
12500 unit/0.5ml
3
•
warfarin sodium tab 4 mg
(Coumadin)
1
FRAGMIN - dalteparin sodium inj
15000 unit/0.6ml
3
•
warfarin sodium tab 5 mg
(Coumadin)
1
FRAGMIN - dalteparin sodium inj
18000 unit/0.72ml
3
•
warfarin sodium tab 6 mg
(Coumadin)
1
FRAGMIN - dalteparin sodium inj
25000 unit/ml
3
•
warfarin sodium tab 7.5 mg
(Coumadin)
1
LOVENOX - enoxaparin sodium inj
30 mg/0.3ml
3
•
XARELTO - rivaroxaban tab 10 mg
2
LOVENOX - enoxaparin sodium inj
40 mg/0.4ml
3
•
XARELTO - rivaroxaban tab 15 mg
2
XARELTO - rivaroxaban tab 20 mg
2
3
•
LOVENOX - enoxaparin sodium inj
80 mg/0.8ml
3
•
XARELTO STARTER PACK rivaroxaban tab starter therapy
pack 15 mg & 20 mg
2
LOVENOX - enoxaparin sodium inj
60 mg/0.6ml
3
•
AMICAR - aminocaproic acid tab
500 mg
3
LOVENOX - enoxaparin sodium inj
100 mg/ml
3
•
AMICAR - aminocaproic acid tab
1000 mg
3
LOVENOX - enoxaparin sodium inj
120 mg/0.8ml
3
•
AMICAR - aminocaproic acid syrup
25%
3
LOVENOX - enoxaparin sodium inj
150 mg/ml
3
•
AMINOCAPROIC ACID aminocaproic acid tab 1000 mg
1
LOVENOX - enoxaparin sodium inj
300 mg/3ml
2
•
aminocaproic acid syrup 25%
(Amicar)
1
PRADAXA - dabigatran etexilate
mesylate cap 75 mg (etexilate
base eq)
1
PRADAXA - dabigatran etexilate
mesylate cap 150 mg (etexilate
base eq)
2
aminocaproic acid tab 500 mg
(Amicar)
ASTRINGYN - ferric subsulfate
soln 259 mg/gm
3
warfarin sodium tab 1 mg
(Coumadin)
1
LYSTEDA - tranexamic acid tab
650 mg
3
warfarin sodium tab 10 mg
(Coumadin)
1
MONSELS FERRIC SUBSULFATE
- ferric subsulfate soln
3
warfarin sodium tab 2 mg
(Coumadin)
1
tranexamic acid tab 650 mg
(Lysteda)
1
•
•
•
•
•
•
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
HEMOSTATICS
HEMATOLOGICAL AGENTS - MISC.
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
155
•
3
•
ZONTIVITY - vorapaxar sulfate tab
2.08 mg (base equivalent)
•
•
•
•
•
BRILINTA - ticagrelor tab 90 mg
3
cilostazol tab 100 mg (Pletal)
1
cilostazol tab 50 mg (Pletal)
1
clopidogrel bisulfate tab 300 mg
(base equiv) (Plavix)
1
clopidogrel bisulfate tab 75 mg
(base equiv) (Plavix)
1
dipyridamole tab 25 mg
(Persantine)
1
•
dipyridamole tab 50 mg
(Persantine)
1
•
dipyridamole tab 75 mg
(Persantine)
1
•
EFFIENT - prasugrel hcl tab 5 mg
(base equiv)
3
•
•
EFFIENT - prasugrel hcl tab 10 mg
(base equiv)
3
•
•
FIRAZYR - icatibant acetate inj 30
mg/3ml (base equivalent)
2
•
• •
pentoxifylline tab cr 400 mg
1
PERSANTINE - dipyridamole tab
25 mg
3
•
PERSANTINE - dipyridamole tab
50 mg
3
•
PERSANTINE - dipyridamole tab
75 mg
3
•
PLAVIX - clopidogrel bisulfate tab
75 mg (base equiv)
3
• •
PLAVIX - clopidogrel bisulfate tab
300 mg (base equiv)
3
• •
PLETAL - cilostazol tab 50 mg
3
PLETAL - cilostazol tab 100 mg
3
•
•
156
•
•
•
•
TOPICAL PRODUCTS
OPHTHALMIC AGENTS
ophthalmic irrigation solution intraocular (Bss plus)
1
ACULAR - ketorolac tromethamine
ophth soln 0.5%
3
ACULAR LS - ketorolac
tromethamine ophth soln 0.4%
3
ACUVAIL - ketorolac tromethamine 3
ophth soln 0.45%
3
AKTEN - lidocaine hcl ophth gel
3.5%
ALCAINE - proparacaine hcl ophth 3
soln 0.5%
2
ALOCRIL - nedocromil sodium
ophth soln 2%
3
ALOMIDE - lodoxamide
tromethamine ophth soln 0.1%
2
ALPHAGAN P - brimonidine
tartrate ophth soln 0.1%
3
ALPHAGAN P - brimonidine
tartrate ophth soln 0.15%
2
ALREX - loteprednol etabonate
ophth susp 0.2%
1
apraclonidine hcl ophth soln
0.5% (base equivalent)
(Iopidine)
1
ATROPINE SULFATE - atropine
sulfate ophth oint 1%
1
atropine sulfate ophth soln 1%
(Isopto atropine)
AZASITE - azithromycin ophth soln 3
1%
1
azelastine hcl ophth soln 0.05%
(Optivar)
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
TRENTAL - pentoxifylline tab cr
400 mg
3
•
Quantity Limits
1
"Smart" PA
ticlopidine hcl tab 250 mg
Specialty
•
Prior Authorization
Quantity Limits
Drug Name
Drug Tier
AGGRENOX - aspirin-dipyridamole 3
cap sr 12hr 25-200 mg
3
AGRYLIN - anagrelide hcl cap 0.5
mg
1
anagrelide hcl cap 0.5 mg
(Agrylin)
1
anagrelide hcl cap 1 mg
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
AZOPT - brinzolamide ophth susp
1%
3
BACITRACIN - bacitracin ophth
oint 500 unit/gm
2
1
BROMDAY - bromfenac sodium
ophth soln 0.09% (base equiv)
(once-daily)
1
bacitracin-polymyxin b ophth
oint
1
bromfenac sodium ophth soln
0.09% (base equiv) (once-daily)
1
bacitracin-polymyxin-neomycinhc ophth oint 1%
1
bromfenac sodium ophth soln
0.09% (base equivalent)
carteolol hcl ophth soln 1%
1
BEPREVE - bepotastine besilate
ophth soln 1.5%
3
CILOXAN - ciprofloxacin hcl ophth
soln 0.3%
3
BESIVANCE - besifloxacin hcl
ophth susp 0.6% (base equiv)
3
CILOXAN - ciprofloxacin hcl ophth
oint 0.3%
3
BETADINE OPHTHALMIC PREP povidone-iodine ophth soln 5%
3
ciprofloxacin hcl ophth soln
0.3% (Ciloxan)
1
BETAGAN - levobunolol hcl ophth
soln 0.5%
3
3
•
BETAGAN C CAP QD levobunolol hcl ophth soln 0.5%
3
COMBIGAN - brimonidine tartratetimolol maleate ophth soln
0.2-0.5%
3
•
betaxolol hcl ophth soln 0.5%
1
BETIMOL - timolol ophth soln
0.25%
3
COSOPT - dorzolamide hcl-timolol
maleate ophth soln 22.3-6.8 mg/
ml
COSOPT PF - dorzolamide
hcl-timolol maleate ophth sol
22.3-6.8 mg/ml pf
3
•
cromolyn sodium ophth soln 4%
1
CYCLOGYL - cyclopentolate hcl
ophth soln 0.5%
3
CYCLOGYL - cyclopentolate hcl
ophth soln 1%
3
CYCLOGYL - cyclopentolate hcl
ophth soln 2%
3
CYCLOMYDRIL - cyclopentolate
w/ phenylephrine ophth soln
0.2-1%
3
cyclopentolate hcl ophth soln
1% (Cyclogyl)
1
cyclopentolate hcl ophth soln
2% (Cyclogyl)
1
BETIMOL - timolol ophth soln 0.5% 3
BETOPTIC-S - betaxolol hcl ophth 2
susp 0.25%
BLEPH-10 - sulfacetamide sodium 3
ophth soln 10%
3
BLEPHAMIDE - sulfacetamide
sodium-prednisolone ophth susp
10-0.2%
3
BLEPHAMIDE LIQUIFILM
- sulfacetamide sodiumprednisolone ophth susp
10-0.2%
2
BLEPHAMIDE S.O.P. sulfacetamide sodiumprednisolone ophth oint 10-0.2%
1
brimonidine tartrate ophth soln
0.15% (Alphagan p)
1
brimonidine tartrate ophth soln
0.2%
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
CYSTARAN - cysteamine hcl ophth 3
soln 0.44% (base equivalent)
1
dexamethasone sodium
phosphate ophth soln 0.1%
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
157
diclofenac sodium ophth soln
0.1%
1
homatropine hbr ophth soln 5%
(Isopto homatropine)
1
dorzolamide hcl ophth soln 2%
(Trusopt)
1
ILEVRO - nepafenac ophth susp
0.3%
3
dorzolamide hcl-timolol maleate
ophth soln 22.3-6.8 mg/ml
(Cosopt)
1
IOPIDINE - apraclonidine hcl ophth
soln 0.5% (base equivalent)
3
3
IOPIDINE - apraclonidine hcl ophth
soln 1% (base equivalent)
2
DUREZOL - difluprednate ophth
emulsion 0.05%
ELESTAT - epinastine hcl ophth
soln 0.05%
ISOPTO ATROPINE - atropine
sulfate ophth soln 1%
3
3
ISOPTO CARBACHOL - carbachol
ophth soln 1.5%
2
ISOPTO CARBACHOL - carbachol
ophth soln 3%
2
ISOPTO CARPINE - pilocarpine
hcl ophth soln 1%
3
ISOPTO CARPINE - pilocarpine
hcl ophth soln 2%
3
ISOPTO CARPINE - pilocarpine
hcl ophth soln 4%
3
ISOPTO HOMATROPINE homatropine hbr ophth soln 2%
3
ISOPTO HOMATROPINE homatropine hbr ophth soln 5%
3
ISOPTO HYOSCINE scopolamine hbr ophth soln
0.25%
2
ISTALOL - timolol maleate ophth
soln 0.5% (once-daily)
3
ketorolac tromethamine ophth
soln 0.4% (Acular ls)
1
ketorolac tromethamine ophth
soln 0.5% (Acular)
1
ketotifen fumarate ophth soln
0.025% (base equiv)
1
•
LASTACAFT - alcaftadine ophth
soln 0.25%
3
•
latanoprost ophth soln 0.005%
(Xalatan)
1
•
EMADINE - emedastine difumarate 3
ophth soln 0.05% (base equiv)
1
epinastine hcl ophth soln 0.05%
(Elestat)
1
erythromycin ophth oint 5 mg/
gm
FLAREX - fluorometholone acetate 3
ophth susp 0.1%
1
fluorometholone ophth susp
0.1% (Fml liquifilm)
1
flurbiprofen sodium ophth soln
0.03% (Ocufen)
2
FML - fluorometholone ophth oint
0.1%
3
FML FORTE - fluorometholone
ophth susp 0.25%
FML LIQUIFILM - fluorometholone 3
ophth susp 0.1%
3
GARAMYCIN - gentamicin sulfate
ophth soln 0.3%
1
gatifloxacin ophth soln 0.5%
(Zymaxid)
3
GELFILM OP - gelatin adsorbable
ophth film
1
gentamicin sulfate ophth oint
0.3%
1
gentamicin sulfate ophth soln
0.3% (Garamycin)
158
•
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
LEVOBUNOLOL HCL - levobunolol 1
hcl ophth soln 0.25%
1
levobunolol hcl ophth soln 0.5%
(Betagan)
1
levofloxacin ophth soln 0.5%
LOTEMAX - loteprednol etabonate
ophth susp 0.5%
2
LOTEMAX - loteprednol etabonate
ophth gel 0.5%
3
LOTEMAX - loteprednol etabonate
ophth oint 0.5%
2
LUMIGAN - bimatoprost ophth soln
0.01%
3
• •
LUMIGAN - bimatoprost ophth soln
0.03%
3
• •
MAXIDEX - dexamethasone ophth
susp 0.1%
2
MAXITROL - neomycin-polymyxindexamethasone ophth susp 0.1%
3
MAXITROL - neomycin-polymyxindexamethasone ophth oint 0.1%
3
METIPRANOLOL - metipranolol
ophth soln 0.3%
1
MITOSOL - mitomycin for ophth
soln kit 0.2 mg
3
MOXEZA - moxifloxacin hcl ophth
soln 0.5% (base eq) (2 times
daily)
3
MYDFRIN - phenylephrine hcl
ophth soln 2.5%
3
NAPHAZOLINE HCL - naphazoline 1
hcl ophth soln 0.1%
NATACYN - natamycin ophth susp 2
5%
1
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op
oin
1
neomycin-polymy-gramicid op
sol 1.75-10000-0.025mg-untmg/ml (Neosporin)
neomycin-polymyxindexamethasone ophth oint
0.1% (Maxitrol)
1
neomycin-polymyxindexamethasone ophth susp
0.1% (Maxitrol)
1
NEOMYCIN/POLYMYXIN/
HYDROC - neomycin-polymyxinhc ophth susp
1
NEOSPORIN - neomycinpolymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml
3
NEVANAC - nepafenac ophth susp
0.1%
2
OCUFEN - flurbiprofen sodium
ophth soln 0.03%
3
OCUFLOX - ofloxacin ophth soln
0.3%
3
ofloxacin ophth soln 0.3%
(Ocuflox)
1
OMNIPRED - prednisolone acetate
ophth susp 1%
3
OPTIVAR - azelastine hcl ophth
soln 0.05%
3
•
PATADAY - olopatadine hcl ophth
soln 0.2%
3
•
PATANOL - olopatadine hcl ophth
soln 0.1%
3
•
phenylephrine hcl ophth soln
10%
1
phenylephrine hcl ophth soln
2.5%
1
PHOSPHOLINE IODIDE echothiophate iodide ophth for
soln 0.125%
2
pilocarpine hcl ophth soln 1%
(Isopto carpine)
1
pilocarpine hcl ophth soln 2%
(Isopto carpine)
1
pilocarpine hcl ophth soln 4%
(Isopto carpine)
1
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
159
PILOPINE HS - pilocarpine hcl
ophth gel 4%
2
polymyxin b-trimethoprim
ophth soln 10000 unit/ml-0.1%
(Polytrim)
1
POLYTRIM - polymyxin btrimethoprim ophth soln 10000
unit/ml-0.1%
3
PRED FORTE - prednisolone
acetate ophth susp 1%
3
PRED MILD - prednisolone acetate 3
ophth susp 0.12%
PRED-G - gentamicin-prednisolone 2
ace ophth susp 0.3-1%
2
PRED-G S.O.P. - gentamicinprednisolone ace ophth oint
0.3-0.6%
prednisolone acetate ophth susp 1
1% (Pred forte)
1
PREDNISOLONE SODIUM
PHOSP - prednisolone sodium
phosphate ophth soln 1%
3
PROLENSA - bromfenac sodium
ophth soln 0.07% (base
equivalent)
1
proparacaine hcl ophth soln
0.5% (Alcaine)
RESCULA - unoprostone isopropyl 3
ophth soln 0.15%
2
RESTASIS - cyclosporine (ophth)
emulsion 0.05%
2
SIMBRINZA - brinzolamidebrimonidine tartrate ophth susp
1-0.2%
1
SULFACETAMIDE SODIUM sulfacetamide sodium ophth oint
10%
1
sulfacetamide sodium ophth
soln 10% (Bleph-10)
160
• •
•
sulfacetamide sodiumprednisolone ophth soln
10-0.23(0.25)%
1
SULFACETAMIDE/
PREDNISOLON - sulfacetamide
sodium-prednisolone ophth susp
10-0.2%
1
tetracaine hcl ophth soln 0.5%
1
timolol maleate ophth gel
forming soln 0.25% (Timopticxe)
1
1
timolol maleate ophth gel
forming soln 0.5% (Timoptic-xe)
1
timolol maleate ophth soln
0.25% (Timoptic)
1
timolol maleate ophth soln 0.5%
(Timoptic)
TIMOPTIC - timolol maleate ophth 3
soln 0.25%
TIMOPTIC - timolol maleate ophth 3
soln 0.5%
3
TIMOPTIC OCUDOSE - timolol
maleate preservative free ophth
soln 0.25%
3
TIMOPTIC OCUDOSE - timolol
maleate preservative free ophth
soln 0.5%
3
TIMOPTIC-XE - timolol maleate
ophth gel forming soln 0.25%
3
TIMOPTIC-XE - timolol maleate
ophth gel forming soln 0.5%
3
TOBRADEX - tobramycindexamethasone ophth susp
0.3-0.1%
3
TOBRADEX - tobramycindexamethasone ophth oint
0.3-0.1%
3
TOBRADEX ST - tobramycindexamethasone ophth susp
0.3-0.05%
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
tobramycin ophth soln 0.3%
(Tobrex)
1
1
tobramycin-dexamethasone
ophth susp 0.3-0.1% (Tobradex)
3
TOBREX - tobramycin ophth soln
0.3%
3
TOBREX - tobramycin ophth oint
0.3%
3
TRAVATAN Z - travoprost ophth
soln 0.004% (benzalkonium free)
(bak free)
1
TRAVOPROST - travoprost ophth
soln 0.004%
1
trifluridine ophth soln 1%
(Viroptic)
TRUSOPT - dorzolamide hcl ophth 3
soln 2%
3
VEXOL - rimexolone ophth susp
1%
VIGAMOX - moxifloxacin hcl ophth 2
soln 0.5% (base equiv)
3
VIROPTIC - trifluridine ophth soln
1%
XALATAN - latanoprost ophth soln 3
0.005%
3
ZIOPTAN - tafluprost ophth soln
0.0015%
3
ZIRGAN - ganciclovir ophth gel
0.15%
3
ZYLET - loteprednol etabonatetobramycin ophth susp 0.5-0.3%
ZYMAXID - gatifloxacin ophth soln 3
0.5%
OTIC AGENTS
antipyrine-benzocainepolycosanol otic sol
5.4-1.4-0.0097% (Treagan otic)
1
acetic acid otic soln 2%
1
ACETIC ACID/ALUMINUM ACET
- acetic acid 2% in aluminum
acetate otic soln
1
antipyrine-benzocaine otic soln
54-14 mg/ml (5.4-1.4%)
1
antipyrine-benzocaine otic soln
55-14 mg/ml (5.5-1.4%)
1
1
• •
ANTIPYRINE/BENZOCAINE antipyrine-benzocaine otic soln
55-14 mg/ml (5.5-1.4%)
3
• •
AURALGAN - antipyrinebenzocaine otic soln 55-14 mg/
ml (5.5-1.4%)
CETRAXAL - ciprofloxacin hcl otic
soln 0.2% (base equivalent)
3
CIPRO HC - ciprofloxacinhydrocortisone otic susp 0.2-1%
3
CIPRODEX - ciprofloxacindexamethasone otic susp
0.3-0.1%
2
CIPROFLOXACIN - ciprofloxacin
hcl otic soln 0.2% (base
equivalent)
1
COLY-MYCIN S - neomycincolistin-hc-thonzonium otic susp
3.3-3-10-0.5 mg/ml
3
CORTANE-B AQUEOUS pramoxine-hc-chloroxylenol
aqueous otic soln 10-10-1 mg/ml
3
CORTANE-B-OTIC - pramoxinehc-chloroxylenol otic soln
10-10-1 mg/ml
3
CORTISPORIN - neomycinpolymyxin-hc otic soln 1%
3
CORTISPORIN-TC - neomycincolistin-hc-thonzonium otic susp
3.3-3-10-0.5 mg/ml
3
CRESYLATE - cresyl acetate otic
soln 25%
3
DERMOTIC - fluocinolone
acetonide (otic) oil 0.01%
3
• •
• •
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161
fluocinolone acetonide (otic) oil
0.01% (Dermotic)
1
cevimeline hcl cap 30 mg
(Evoxac)
1
hydrocortisone w/ acetic acid
otic soln 1-2% (Vosol hc)
1
chlorhexidine gluconate soln
0.12% (Peridex)
1
MYOXIN - benzocainechloroxylenol-hc otic soln
15-1-10 mg/ml
3
clotrimazole troche 10 mg
1
A
neomycin-polymyxin-hc otic
soln 1% (Cortisporin)
1
COLGATE DRY MOUTH RELIEF
- sodium fluoride mouthwash 2.1
mg/10ml
neomycin-polymyxin-hc otic
susp 3.5 mg/ml-10000 unit/
ml-1%
DEBACTEROL - sulfuric acidsulfonated phenolics soln
30-50%
3
1
ofloxacin otic soln 0.3%
EVOXAC - cevimeline hcl cap 30
mg
3
1
OTICIN HC NR - pramoxine-hcchloroxylenol otic soln 10-10-1
mg/ml
3
FIRST-BXN MOUTHWASH diphenhydramine-lidocainenystatin susp
3
OTOZIN - antipyrine-benzocaineglycerin-zinc ace otic liqd
5.4-1-2-1%
3
FIRST-DUKES MOUTHWASH
- diphenhydraminehydrocortisone-nystatin susp
3
PINNACAINE OTIC - benzocaine
otic soln 20%
3
3
PRAMOTIC - pramoxinechloroxylenol otic liquid 1-0.1%
3
FIRST-MARYS MOUTHWASH
- diphenhydraminehydrocortisone-nystatintetracycline susp
pramoxine-chloroxylenol otic
liquid 1-0.1% (Pramotic)
1
3
pramoxine-hc-chloroxylenol
aqueous otic soln 10-10-1 mg/
ml (Cortane-b aqueous)
1
FIRST-MOUTHWASH BLM
- diphenhyd-lidocaine-al
hydroxide-mg hydroxide-simeth
susp
A
pramoxine-hc-chloroxylenol otic
soln 10-10-1 mg/ml (Cortane-botic)
1
FLUORIDEX DAILY DEFENSE S sodium fluoride-potassium nitrate
gel 1.1-5%
A
TREAGAN OTIC - antipyrinebenzocaine-polycosanol otic sol
5.4-1.4-0.0097%
3
GEL-KAM - stannous fluoride gel
0.4%
GEL-KAM ORAL CARE RINSE stannous fluoride conc 0.63%
A
VOSOL HC - hydrocortisone w/
acetic acid otic soln 1-2%
3
GELCLAIR - povidone-sodium
hyaluronate-glycyrrhetinic acid
gel
3
GELX - oral wound care products gel
3
lidocaine hcl viscous soln 2%
1
MOUTH/THROAT/DENTAL AGENTS
ACT TOTAL CARE DRY MOUTH - A
sodium fluoride rinse 0.02%
1
benzocaine dental soln 20%
162
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LISTERINE ESSENTIAL CARE sod monofluorophosph-eucalmen-methyl sal-thymol gel 0.76%
A
LISTERINE ESSENTIAL CARE sod monofluorophos-eucal-menmethyl sal-thymol paste 0.76%
A
LISTERINE RESTORING - sodium
fluoride rinse 0.0221% (0.01% f)
A
LISTERINE SMART RINSE sodium fluoride rinse 0.0221%
(0.01% f)
A
LISTERINE SMART RINSE ANT sodium fluoride rinse 0.02%
ORAFATE - sucralfate-malate
paste 10%
3
ORAMAGICRX - oral wound care
products - for susp rinse
3
ORAVIG - miconazole buccal tab
50 mg (mouth-throat)
3
PERIDEX - chlorhexidine
gluconate soln 0.12%
3
PHOS FLUR - sodium fluoride
rinse 0.044%
A
A
PHOS-FLUR ORTHO DEFENSE sodium fluoride rinse 0.044%
A
A
pilocarpine hcl tab 5 mg
(Salagen)
1
LISTERINE TOOTH DEFENSE sodium fluoride rinse 0.0221%
(0.01% f)
1
LISTERINE TOTAL CARE sodium fluoride rinse 0.0221%
(0.01% f)
A
pilocarpine hcl tab 7.5 mg
(Salagen)
PREVIDENT - sodium fluoride
rinse 0.2%
A
LISTERINE TOTAL CARE PLUS
- sodium fluoride rinse 0.0221%
(0.01% f)
A
PREVIDENT - sodium fluoride gel
1.1% (0.5% f)
A
A
LISTERINE TOTAL CARE ZERO sodium fluoride rinse 0.02%
A
PREVIDENT FLUORIDE - sodium
fluoride gel 1.1% (0.5% f)
A
LISTERINE WHITENING/RESTO
- sodium fluoride rinse 0.0221%
(0.01% f)
A
PREVIDENT 5000 BOOSTER sodium fluoride paste 1.1%
PREVIDENT 5000 BOOSTER PL sodium fluoride paste 1.1%
A
MUCOTROL - oral wound care
products - wafer
3
PREVIDENT 5000 DRY MOUTH sodium fluoride gel 1.1% (0.5% f)
A
NAFRINSE DAILY/ACIDULATED sodium fluoride-phosphoric acid
for soln 1 mg/5ml (f equiv)
A
NAFRINSE DAILY/NEUTRAL sodium fluoride for soln rinse
0.05%
A
NAFRINSE WEEKLY - sodium
fluoride for soln rinse 0.2%
A
nystatin susp 100000 unit/ml
1
OMNI GEL - stannous fluoride gel
0.4%
A
PREVIDENT 5000 ENAMEL PRO - A
sodium fluoride-potassium nitrate
paste 1.1-5%
PREVIDENT 5000 PLUS - sodium A
fluoride cream 1.1%
A
PREVIDENT 5000 SENSITIVE sodium fluoride-potassium nitrate
paste 1.1-5%
3
PROTHELIAL - sucralfate-malate
paste 10%
A
REACH KIDS - sodium fluoride
paste 0.15%
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REMBRANDT CANKER SORE sodium fluoride paste 0.243%
A
REMBRANDT DEEPLY
WHITE+PE - sodium
monofluorophosphate paste
0.884%
A
REMBRANDT INTENSE STAIN sodium fluoride paste 0.243%
A
REMBRANDT WHITENING sodium fluoride rinse 0.02%
A
SALAGEN - pilocarpine hcl tab 5
mg
3
SALAGEN - pilocarpine hcl tab 7.5
mg
3
SALICEPT - oral wound care
products - for susp rinse
3
sodium fluoride cream 1.1%
(Prevident 5000 plus)
A
sodium fluoride gel 1.1% (0.5% f)
(Prevident fluoride)
A
sodium fluoride paste 1.1%
(Prevident 5000 boost)
A
sodium fluoride rinse 0.0221%
(0.01% f)
hc-pramoxine emol cream
2.5-1% & pramoxine wipe 1%
kit (Analpram e)
1
ANALPRAM ADVANCED - hcpramoxine cr & diet manage prod
tab & cleans wipe kit
3
ANALPRAM E - hc-pramoxine
emol cream 2.5-1% & pramoxine
wipe 1% kit
3
ANALPRAM-HC - hydrocortisone
acetate w/ pramoxine rectal
cream 1-1%
3
ANALPRAM-HC - hydrocortisone
acetate w/ pramoxine rectal
cream 2.5-1%
3
ANALPRAM-HC - hydrocortisone
acetate w/ pramoxine rectal lotn
2.5-1%
2
ANALPRAM-HC SINGLES hydrocortisone acetate w/
pramoxine rectal cream 1-1%
3
3
A
ANALPRAM-HC SINGLES hydrocortisone acetate w/
pramoxine rectal cream 2.5-1%
sodium fluoride rinse 0.05%
ANUSOL-HC - hydrocortisone
rectal cream 2.5%
3
A
sodium fluoride rinse 0.2%
(Prevident)
A
ANUSOL-HC - hydrocortisone
acetate suppos 25 mg
3
sodium fluoride-potassium
nitrate paste 1.1-5% (Prevident
5000 sensi)
A
CORTENEMA - hydrocortisone
enema 100 mg/60ml
3
stannous fluoride conc 0.63%
(Gel-kam oral care ri)
CORTIFOAM - hydrocortisone
acetate rectal foam 90 mg/dose
2
A
stannous fluoride gel 0.4%
hydrocortisone acetate suppos
25 mg (Anusol-hc)
1
A
STANNOUS FLUORIDE RINSE stannous fluoride liq 0.1%
3
hydrocortisone acetate suppos
30 mg (Proctocort)
1
THERA-FLUR-N - sodium fluoride
gel 1.1% (0.5% f)
A
1
triamcinolone acetonide dental
paste 0.1%
1
hydrocortisone acetate w/
pramoxine rectal cream 1-1%
(Analpram-hc)
hydrocortisone acetate w/
pramoxine rectal cream 2.5-1%
(Analpram-hc)
1
ANORECTAL AGENTS
164
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hydrocortisone enema
100 mg/60ml (Cortenema)
1
salicylic acid lotion 6% &
cleanser liqd kit (Salex lotion)
1
hydrocortisone rectal cream 1%
(Proctocort)
1
scar treatment products - gel
1
hydrocortisone rectal cream
2.5% (Anusol-hc)
sulfacetamide sod-sulfur wash
9-4.5% & skin cleanser kit
(Sumadan kit)
1
1
LIDOCAINE HCL-HYDROCORTIS
- lidocaine-hydrocortisone
acetate rectal gel 2.8-0.55%
1
sulfacetamide sod-sulfur
wash 9-4.5% & sunscreen kit
(Sumadan xlt)
1
lidocaine-hydrocortisone acetate
rectal cream kit 2-2%
1
sulfacetamide sodium-sulfur w/
sunscreens cream 10-5%
1
lidocaine-hydrocortisone acetate
rectal cream kit 3-0.5%
1
3
lidocaine-hydrocortisone acetate
rectal cream kit 3-1%
1
A.A.G.C. KIT IN TERODERM amantad-amitript-gaba-cycloben
cream 8-4-10-4% (cmpd kit)
3
•
lidocaine-hydrocortisone acetate
rectal cream 3-0.5%
1
ABSORICA - isotretinoin cap 10
mg
3
•
lidocaine-hydrocortisone acetate
rectal gel kit 3-2.5%
1
ABSORICA - isotretinoin cap 20
mg
3
•
PROCORT - hydrocortisone
acetate w/ pramoxine rectal
cream 1.85-1.15%
3
ABSORICA - isotretinoin cap 25
mg
ABSORICA - isotretinoin cap 30
mg
3
•
PROCTOCORT - hydrocortisone
rectal cream 1%
3
ABSORICA - isotretinoin cap 35
mg
3
•
PROCTOCORT - hydrocortisone
acetate suppos 30 mg
3
ABSORICA - isotretinoin cap 40
mg
3
•
PROCTOFOAM HC hydrocortisone acetate w/
pramoxine rectal foam 1-1%
2
ACANYA - clindamycin phosphatebenzoyl peroxide gel 1.2-2.5%
3
acitretin cap 10 mg (Soriatane)
1
RECTIV - nitroglycerin oint 0.4%
3
acitretin cap 17.5 mg (Soriatane)
1
UCERIS - budesonide rectal foam
2 mg/act
3
acitretin cap 25 mg (Soriatane)
1
3
ACLOVATE - alclometasone
dipropionate cream 0.05%
3
Z-PRAM - hydrocortisone acetate
w/ pramoxine rectal cream kit
2.35-1%
ACTIVE-KETOPROFEN KIT ketoprofen cream 5% (compound
kit)
3
ACTIVE-PREP KIT I - flurbiprofencyclobenzaprine cream (cmpd
kit)
3
DERMATOLOGICALS
nystatin topical powder
1
salicylic acid cream 6% &
cleanser liqd kit (Salex cream)
1
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•
•
165
ACTIVE-PREP KIT II - ketoprofenbaclofen-gabapentin cream
(cmpd kit)
3
ALCORTIN A - iodoquinolhydrocortisone-aloe
polysaccharide gel 1-2-1%
3
ACTIVE-PREP KIT III - ketoprofenlidocaine-gabapentin cream
(cmpd kit)
3
ALDARA - imiquimod cream 5%
3
ALOQUIN - iodoquinol-aloe
polysaccharides gel 1.25-1%
3
ACTIVE-PREP KIT IV - tramadolgabapentin-menthol-camphor
cream (cmpd kit)
3
ALTABAX - retapamulin oint 1%
3
1
ACTIVE-PREP KIT V itraconazole-phenytoin sodium
cream (cmpd kit)
3
aluminum chloride soln 20%
(Drysol)
ALUVEA - urea cream 39%
3
1
ACTIVE-TRAMADOL KIT
- tramadol hcl cream 8%
(compound kit)
3
AMCINONIDE - amcinonide cream
0.1%
AMCINONIDE - amcinonide lotion
0.1%
1
acyclovir oint 5% (Zovirax)
1
1
ACZONE - dapsone gel 5%
3
AMCINONIDE - amcinonide oint
0.1%
adapalene cream 0.1% (Differin)
1
amcinonide cream 0.1%
1
adapalene gel 0.1% (Differin)
1
ANACAINE - benzocaine oint 10%
3
adapalene gel 0.3% (Differin)
1
3
ADAZIN - benzo-capsaicinlido-methyl salicylate cream
2-0.035-2-10%
3
APEXICON E - diflorasone
diacetate emollient base cream
0.05%
3
AIF #2 DRUG PREPARATION flurbiprofen-gabapent-cyclobenlido-dexameth cr (cmp kit)
3
APOP - sulfacetamide sodium in
bakuchiol vehicle gel 10%
3
AIF #3 DRUG PREPARATION K flurbiprofen-baclofen-cyclobenlido cream (cmp kit)
3
ARZOL SILVER NITRATE APP silver nitrate-potassium nitrate
applicator 75-25%
ATRALIN - tretinoin gel 0.05%
3
3
•
AKNE-MYCIN - erythromycin oint
2%
3
AVAR - sulfacetamide sodium w/
sulfur cleansing pad 9.5-5%
3
•
ALA QUIN - clioquinol-hc cream
3-0.5%
3
AVAR LS - sulfacetamide sodium
w/ sulfur cleansing pad 10-2%
3
•
ALA SCALP - hydrocortisone lotion
2%
3
AVAR LS CLEANSER sulfacetamide sodium w/ sulfur
cleanser 10-2%
alclometasone dipropionate
cream 0.05% (Aclovate)
1
AVAR-E LS - sulfacetamide
sodium w/ sulfur cream 10-2%
3
•
alclometasone dipropionate oint
0.05%
1
AZELEX - azelaic acid cream 20%
3
•
BACTROBAN - mupirocin oint 2%
3
BACTROBAN - mupirocin calcium
cream 2%
3
166
•
•
•
•
•
•
•
•
•
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BENSAL HP - salicylic acid &
benzoic acid oint 3-6%
3
BENZAC AC WASH - benzoyl
peroxide liq 5%
3
BENZAC W WASH - benzoyl
peroxide liq 5%
3
BENZACLIN - clindamycin
phosphate-benzoyl peroxide gel
1-5%
3
BENZACLIN WITH PUMP clindamycin phosphate-benzoyl
peroxide gel 1-5%
3
BENZAMYCIN - benzoyl peroxideerythromycin gel 5-3%
3
BENZAMYCINPAK - benzoyl
peroxide-erythromycin gel pack
5-3%
3
BENZEFOAM - benzoyl peroxide
foam 5.3%
3
BENZEFOAMULTRA - benzoyl
peroxide foam 9.8%
3
BENZIQ - benzoyl peroxide gel
5.25 %
3
•
BENZIQ LS - benzoyl peroxide gel
2.75%
3
•
BENZOIN COMPOUND
TINCTURE - benzoin compound
tincture
1
BENZOIN TINCTURE - benzoin
tincture
1
benzoyl peroxide cleanser 4.25%
1
benzoyl peroxide cloth 3%
1
benzoyl peroxide cloth 6%
1
benzoyl peroxide cloth 9%
1
benzoyl peroxide creamy wash
4% & cleanser lotion kit
benzoyl peroxide creamy wash
8% & cleanser lotion kit
1
•
benzoyl peroxide creamy wash
8% &benzoyl peroxide bar 5%
kit (Bpo creamy wash comp)
1
•
benzoyl peroxide foam 5.3%
(Benzefoam)
1
•
benzoyl peroxide foam 9.8%
(Benzefoamultra)
benzoyl peroxide gel 10%
1
benzoyl peroxide gel 5%
1
benzoyl peroxide liq 10%
1
benzoyl peroxide liq 2.5%
1
benzoyl peroxide liq 5.25%
1
benzoyl peroxide liq 7%
1
benzoyl peroxide lotion 3%
1
benzoyl peroxide lotion 6%
1
•
benzoyl peroxide lotion 9%
1
benzoyl peroxide pad 3%
1
•
benzoyl peroxide pad 6%
1
benzoyl peroxide pad 9%
1
benzoyl peroxideerythromycin gel 5-3%
(Benzamycin)
1
betamethasone dipropionate
augmented cream 0.05%
(Diprolene af)
1
betamethasone dipropionate
augmented gel 0.05%
1
betamethasone dipropionate
augmented lotion 0.05%
(Diprolene)
1
betamethasone dipropionate
augmented oint 0.05%
(Diprolene)
1
1
betamethasone dipropionate
cream 0.05%
1
1
betamethasone dipropionate
lotion 0.05%
1
betamethasone dipropionate
oint 0.05%
1
•
•
•
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BETAMETHASONE VALERATE
- betamethasone valerate oint
0.1%
1
betamethasone valerate aerosol
foam 0.12% (Luxiq)
1
betamethasone valerate cream
0.1%
1
betamethasone valerate lotion
0.1%
CENTANY AT - mupirocin oint kit
2%
3
CETACAINE - butambentetracaine-benzocaine aerosol
spray 2-2-14%
3
3
1
CICLODAN CREAM KIT ciclopirox olamine cream 0.77%
(base equiv) & cleanser kit
3
betamethasone valerate oint
0.1%
1
CICLODAN SOLUTION KIT ciclopirox solution kit 8%
ciclopirox gel 0.77%
1
BORIC ACID - boric acid granules
1
1
BPO - benzoyl peroxide gel 4%
3
ciclopirox olamine cream 0.77%
(base equiv)
BPO - benzoyl peroxide gel 8%
3
1
BPO 3% FOAMING CLOTHS benzoyl peroxide cloth 3%
3
ciclopirox olamine susp 0.77%
(base equiv)
1
BPO 6% FOAMING CLOTHS benzoyl peroxide cloth 6%
3
ciclopirox shampoo 1% (Loprox
shampoo)
1
BPO 9% FOAMING CLOTHS benzoyl peroxide cloth 9%
3
ciclopirox solution kit 8%
(Ciclodan solution ki)
1
butamben-tetracaine-benzocaine
aerosol spray 2-2-14%
1
ciclopirox solution 8% (Penlac
Nail Lacquer)
1
calcipotriene cream 0.005%
(Dovonex)
1
CICLOPIROX TOPICAL SOLUTI ciclopirox solution 8% & vitamin e
5% topical kit
calcipotriene oint 0.005%
1
calcipotriene soln 0.005%
(50 mcg/ml)
1
calcipotriene-betamethasone
dipropionate oint 0.005-0.064%
(Taclonex)
1
CALCITRIOL - calcitriol oint 3 mcg/
gm
1
CAPEX - fluocinolone acetonide
shampoo 0.01%
3
CARAC - fluorouracil cream 0.5%
2
CARMOL-HC - urea-hc acetate
cream 1%
3
CEM-UREA - urea soln 45%
3
CENTANY - mupirocin oint 2%
3
168
•
•
•
•
•
•
CLARAVIS - isotretinoin cap 30 mg 3
3
CLARIFOAM EF - sulfacetamide
sodium w/ sulfur foam 10-5%
3
CLEOCIN-T - clindamycin
phosphate soln 1%
3
CLEOCIN-T - clindamycin
phosphate gel 1%
3
CLEOCIN-T - clindamycin
phosphate lotion 1%
3
CLEOCIN-T - clindamycin
phosphate swab 1%
3
CLINDACIN ETZ - clindamycin
phosphate swab 1% & cleanser
kit
3
CLINDACIN PAC - clindamycin
phosphate swab 1% & cleanser
kit
•
•
•
•
•
•
•
•
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CLINDAGEL - clindamycin
phosphate gel 1%
3
clindamycin phosph-benzoyl
peroxide (refrig) gel 1.2 (1)-5%
(Duac)
1
clindamycin phosphate foam 1%
(Evoclin)
1
clindamycin phosphate gel 1%
(Cleocin-t)
1
clindamycin phosphate lotion
1% (Cleocin-t)
•
3
CLOCORTOLONE PIVALATE clocortolone pivalate cream 0.1%
1
•
CLOCORTOLONE PIVALATE
PUM - clocortolone pivalate
cream 0.1%
1
•
3
•
1
CLODAN KIT - clobetasol
propionate shampoo 0.05% &
cleanser kit
3
•
clindamycin phosphate soln 1%
(Cleocin-t)
1
CLODERM - clocortolone pivalate
cream 0.1%
3
•
clindamycin phosphate swab 1%
(Cleocin-t)
1
CLODERM PUMP - clocortolone
pivalate cream 0.1%
clotrimazole cream 1%
1
clindamycin phosphate-benzoyl
peroxide gel 1-5% (Benzaclin)
1
clotrimazole soln 1%
1
1
clotrimazole w/ betamethasone
cream 1-0.05% (Lotrisone)
1
clobetasol propionate cream
0.05% (Temovate)
clobetasol propionate emollient
base cream 0.05% (Temovate e)
clotrimazole w/ betamethasone
lotion 1-0.05%
1
1
clobetasol propionate emulsion
foam 0.05% (Olux-e)
CNL8 NAIL KIT - ciclopirox soln
8% & lacquer removal pads kit
3
1
COAL TAR - coal tar soln 20%
1
clobetasol propionate foam
0.05% (Olux)
1
CONDYLOX - podofilox soln 0.5%
3
1
CONDYLOX - podofilox gel 0.5%
2
clobetasol propionate gel 0.05%
(Temovate)
clobetasol propionate lotion
0.05% (Clobex)
1
clobetasol propionate oint 0.05%
(Temovate)
1
clobetasol propionate shampoo
0.05% (Clobex)
1
clobetasol propionate soln
0.05% (Temovate)
1
CLOBEX - clobetasol propionate
spray 0.05%
2
CLOBEX - clobetasol propionate
lotion 0.05%
3
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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•
CLOBEX - clobetasol propionate
shampoo 0.05%
CORDRAN - flurandrenolide cream 3
0.05%
CORDRAN - flurandrenolide lotion 2
0.05%
3
CORDRAN - flurandrenolide oint
0.05%
CORDRAN TAPE - flurandrenolide 2
tape 4 mcg/sqcm
3
CORTANE-B - hydrocortisonepramoxine-chloroxylenol lot
10-10-1mg/ml
3
CORTISPORIN - neomycinpolymyxin-hc cream 0.5%
3
CORTISPORIN - bacitracinpolymyxin-neomycin hc oint 1%
"Smart" PA
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•
•
•
169
•
CUTIVATE - fluticasone propionate 3
cream 0.05%
CUTIVATE - fluticasone propionate 3
lotion 0.05%
CUTIVATE - fluticasone propionate 3
oint 0.005%
3
DELOS - benzoyl peroxide lotion
3.5%
2
DENAVIR - penciclovir cream 1%
•
DENDRACIN
NEURODENDRAXCIN capsaicin-menthol-methyl
salicylate lotion 0.025-10-30%
3
DERMA-SMOOTHE/FS BODY fluocinolone acetonide oil 0.01%
(body oil)
3
DERMA-SMOOTHE/FS BODY
OIL - fluocinolone acetonide oil
0.01% (body oil)
3
•
DERMA-SMOOTHE/FS SCALP fluocinolone acetonide oil 0.01%
(scalp oil)
3
•
DERMA-SMOOTHE/FS SCALP
OI - fluocinolone acetonide oil
0.01% (scalp oil)
3
DERMASORB AF - clioquinol-hc
cream 3-0.5% & emollient liqd kit
3
DERMASORB HC - hydrocortisone 3
lot 2% & cleanser liq kit
3
DERMASORB TA - triamcinolone
cream 0.1% & emollient cream
kit
DERMATOP - prednicarbate cream 3
0.1%
3
DERMATOP - prednicarbate oint
0.1%
DESONATE - desonide gel 0.05% 3
desonide cream 0.05%
(Desowen)
1
desonide lotion 0.05% (Desowen) 1
1
desonide oint 0.05% (Desowen)
170
•
•
•
•
•
DESOWEN - desonide cream
0.05%
3
•
DESOWEN - desonide lotion
0.05%
3
•
DESOWEN - desonide oint 0.05%
3
•
DESOWEN CREAM/CETAPHIL
LO - desonide cream 0.05% w/
moisturizing lotion kit
3
•
DESOWEN LOTION/CETAPHIL
C - desonide lotion 0.05% w/
moisturizing cream kit
3
•
DESOWEN OINTMENT/
CETAPHIL - desonide ointment
0.05% w/ moisturizing lotion kit
3
•
DESOXIMETASONE desoximetasone cream 0.05%
1
•
DESOXIMETASONE desoximetasone oint 0.05%
1
•
desoximetasone cream 0.25%
(Topicort)
1
desoximetasone gel 0.05%
(Topicort)
1
desoximetasone oint 0.25%
(Topicort)
1
diclofenac sodium (actinic
keratoses) gel 3% (Solaraze)
1
diclofenac sodium soln 1.5%
(Pennsaid)
1
DIFFERIN - adapalene cream
0.1%
3
•
DIFFERIN - adapalene gel 0.1%
3
DIFFERIN - adapalene gel 0.3%
3
DIFFERIN - adapalene lotion 0.1%
3
•
•
•
DIFLORASONE DIACETATE diflorasone diacetate cream
0.05%
1
diflorasone diacetate oint 0.05%
1
DIPROLENE - betamethasone
dipropionate augmented lotion
0.05%
3
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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Drug Name
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DIPROLENE - betamethasone
dipropionate augmented oint
0.05%
3
•
ENOVARX-LIDOCAINE HCL
- lidocaine hcl cream 5%
(compound kit)
3
DIPROLENE AF - betamethasone
dipropionate augmented cream
0.05%
3
•
ENOVARX-LIDOCAINE HCL
- lidocaine hcl cream 10%
(compound kit)
3
DOVONEX - calcipotriene cream
0.005%
3
3
DOXYCYCLINE - doxycycline
(rosacea) cap delayed release 40
mg
3
ENOVARX-NAPROXEN naproxen cream 10% (compound
kit)
ENOVARX-TRAMADOL - tramadol
hcl cream 5% (compound kit)
3
DRITHO-CREME HP - anthralin
cream 1%
3
EPIDUO - adapalene-benzoyl
peroxide gel 0.1-2.5%
3
DRYSOL - aluminum chloride soln
20%
3
EPIFOAM - pramoxine-hc aerosol
foam 1-1%
3
DUAC - clindamycin phosphbenzoyl peroxide (refrig) gel 1.2
(1)-5%
3
ERTACZO - sertaconazole nitrate
cream 2%
3
ERYGEL - erythromycin gel 2%
3
econazole nitrate cream 1%
1
ECOZA - econazole nitrate foam
1%
ERYTHROMYCIN - erythromycin
gel 2%
1
3
erythromycin gel 2% (Erygel)
1
EFUDEX - fluorouracil cream 5%
3
erythromycin pads 2%
1
ELENZAPATCH - lidocainementhol patch 4-1%
3
erythromycin soln 2%
1
3
ETHYL CHLORIDE - ethyl chloride
aerosol spray
1
ELIDEL - pimecrolimus cream 1%
ELIMITE - permethrin cream 5%
3
3
•
ETHYL CHLORIDE/FINE PINPO ethyl chloride aerosol spray
1
ELOCON - mometasone furoate
solution 0.1% (lotion)
ELOCON - mometasone furoate
cream 0.1%
•
ETHYL CHLORIDE/FINE STREA ethyl chloride aerosol spray
1
3
ELOCON - mometasone furoate
oint 0.1%
3
•
EMLA - lidocaine-prilocaine cream
2.5-2.5%
3
ENOVARX-BACLOFEN - baclofen
cream 1% (compound kit)
3
ENOVARX-IBUPROFEN
- ibuprofen cream 10%
(compounding kit)
3
•
•
•
Specialty
Quantity Limits
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•
•
•
ETHYL CHLORIDE/MEDIUM JET - 1
ethyl chloride aerosol spray
1
ETHYL CHLORIDE/MEDIUM STR
- ethyl chloride aerosol spray
1
ETHYL CHLORIDE/MIST - ethyl
chloride aerosol spray
3
EURAX - crotamiton cream 10%
EURAX - crotamiton lotion 10%
3
EVOCLIN - clindamycin phosphate
foam 1%
3
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
171
EXELDERM - sulconazole nitrate
solution 1%
3
FLUOROPLEX - fluorouracil cream
1%
3
EXELDERM - sulconazole nitrate
cream 1%
3
FLUOROURACIL - fluorouracil
cream 0.5%
3
EXTINA - ketoconazole foam 2%
3
fluorouracil cream 5% (Efudex)
1
FABIOR - tazarotene (acne) foam
0.1%
3
fluorouracil soln 2%
1
fluorouracil soln 5%
1
FBL KIT - flurbiprofen-baclofenlidocaine cream 15-4-5% (cmpd
kit)
3
fluticasone propionate cream
0.05% (Cutivate)
1
3
fluticasone propionate lotion
0.05% (Cutivate)
1
FINACEA - azelaic acid gel 15%
FINACEA PLUS - azelaic acid gel
15% w/cleanser & moisturizing
lotion kit
3
fluticasone propionate oint
0.005% (Cutivate)
1
3
GEBAUERS PAIN EASE
- pentafluoropropanetetrafluoroethane aero spray
3
FIRST-HYDROCORTISONE hydrocortisone gel 10%
FLECTOR - diclofenac epolamine
patch 1.3%
3
3
fluocinolone acetonide cream
0.01%
1
GEBAUERS SPRAY AND
STRETC - pentafluoropropanetetrafluoroethane aero spray
fluocinolone acetonide cream
0.025% (Synalar)
GENTAMICIN SULFATE gentamicin sulfate cream 0.1%
1
1
fluocinolone acetonide oil 0.01%
(body oil) (Derma-smoothe/fs
bod)
GENTAMICIN SULFATE gentamicin sulfate oint 0.1%
1
1
GORDOFILM - salicylic & lactic
acids soln 16.7-16.7%
3
fluocinolone acetonide oil 0.01%
(scalp oil) (Derma-smoothe/fs
sca)
1
GORDONS UREA - urea ointment
40%
3
1
halobetasol prop oint 0.05% &
ammonium lactate lot 12% kit
1
fluocinolone acetonide oint
0.025% (Synalar)
1
halobetasol propionate cream
0.05% (Ultravate)
1
fluocinolone acetonide soln
0.01% (Synalar)
1
halobetasol propionate oint
0.05% (Ultravate)
1
fluocinonide cream 0.05%
fluocinonide cream 0.1% (Vanos)
1
HALOG - halcinonide cream 0.1%
3
fluocinonide emulsified base
cream 0.05%
1
HALOG - halcinonide oint 0.1%
3
1
fluocinonide oint 0.05%
1
HALONATE - halobetasol prop oint
0.05% & ammonium lactate foam
12% kit
3
fluocinonide gel 0.05%
fluocinonide soln 0.05%
1
HALOTIN - haloprogin cream 1%
3
172
•
•
• •
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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Specialty
Quantity Limits
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Drug Name
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INOVA 4/1 ACNE CONTROL TH benzoyl perox pad 4% & salicylic
ac pad 1% & vit e 5% kit
3
•
3
•
HYDRO 40 FOAM - urea foam
40%
3
INOVA 8/2 ACNE CONTROL TH benzoyl perox pad 8% & salicylic
ac pad 2% & vit e 5% kit
hydrocortisone acetate-aloe
vera gel 2% (Nuzon)
1
iodoquinol-hc cream 1%
1
isotretinoin cap 10 mg
1
hydrocortisone butyrate cream
0.1% (Locoid)
1
isotretinoin cap 20 mg
1
isotretinoin cap 40 mg
1
hydrocortisone butyrate
hydrophilic lipo base cream
0.1% (Locoid lipocream)
1
JUBLIA - efinaconazole soln 10%
3
3
hydrocortisone butyrate oint
0.1% (Locoid)
1
K.B.G.L. IN TERODERM CREA ketoprofen-baclofen-gabapentlido crm 15-4-10-2% (cmp kit)
1
KENALOG - triamcinolone
acetonide aerosol soln
3
hydrocortisone butyrate soln
0.1% (Locoid)
1
KERAFOAM - urea foam 30%
3
hydrocortisone cream 1%
1
KERAFOAM 42 - urea foam 42%
3
hydrocortisone cream 2.5%
1
KERALAC - urea cream 47%
3
hydrocortisone lotion 2.5%
1
KERALYT - salicylic acid gel 6%
3
hydrocortisone lotion 2% (Ala
scalp)
3
hydrocortisone oint 1%
1
KERALYT SCALP - salicylic acid
shampoo 6% & salicylic acid gel
6% kit
hydrocortisone oint 2.5%
1
KERYDIN - tavaborole soln 5%
3
hydrocortisone valerate cream
0.2%
1
ketoconazole cream 2%
1
1
ketoconazole foam 2% (Extina)
1
hydrocortisone valerate oint
0.2% (Westcort)
1
HYLASE WOUND - hyaluronate
sodium gel
3
ketoconazole shampoo 2%
(Nizoral)
3
HYLIRA - hyaluronate sodium
(emollient) gel 0.2%
3
KETODAN KIT - ketoconazole
foam 2% & cleanser kit
3
HYLIRA - hyaluronate sodium
(emollient) lotion 0.1%
3
KETOROLAC 2% GEL - ketorolac
tromethamine gel 2% (cmpd kit)
(base equiv)
1
INOVA - benzoyl peroxide pad 4%
& vitamin e topical 5% kit
3
•
KLARON - sulfacetamide sodium
lotion 10% (acne)
3
imiquimod cream 5% (Aldara)
3
INOVA - benzoyl peroxide pad 8%
& vitamin e topical 5% kit
3
•
LAC-HYDRIN - lactic acid
(ammonium lactate) cream 12%
LAC-HYDRIN - lactic acid
(ammonium lactate) lotion 12%
3
hyaluronate sodium
(emollient) gel 0.2% (Hylira)
1
HYDRO 35 - urea in lactic acid
vehicle foam 35%
3
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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"Smart" PA
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Specialty
Quantity Limits
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•
•
•
•
•
•
173
lactic acid (ammonium lactate)
cream 12% (Lac-hydrin)
1
LOCOID - hydrocortisone butyrate
soln 0.1%
3
•
lactic acid (ammonium lactate)
lotion 10%
1
LOCOID - hydrocortisone butyrate
cream 0.1%
3
•
lactic acid (ammonium lactate)
lotion 12% (Lac-hydrin)
1
LOCOID - hydrocortisone butyrate
lotion 0.1%
3
lactic acid w/ vitamin e cream
10%-3500 unit/30gm
1
LOCOID - hydrocortisone butyrate
oint 0.1%
3
•
LAMISIL SPRAY - terbinafine hcl
soln 1%
3
3
•
LATRIX XM - urea in zinc
undecylenate-lactic acid vehicle
emulsion 45%
3
LOCOID LIPOCREAM hydrocortisone butyrate
hydrophilic lipo base cream 0.1%
LOPROX - ciclopirox gel 0.77%
3
3
LAVOCLEN-4 CREAMY WASH benzoyl peroxide liq 4%
3
LOPROX SHAMPOO - ciclopirox
shampoo 1%
•
•
3
LAVOCLEN-8 CREAMY WASH benzoyl peroxide liq 8%
3
LOTRISONE - clotrimazole w/
betamethasone cream 1-0.05%
1
LUXIQ - betamethasone valerate
aerosol foam 0.12%
3
LIDOCAINE HCL - lidocaine hcl
lotion 3%
LUZU - luliconazole cream 1%
3
lidocaine hcl cream 3%
1
LYCELLE - nit remover - gel
3
lidocaine hcl gel 2%
1
lidocaine hcl soln 4% (Xylocaine)
lidocaine oint 5%
1
mafenide acetate packet for
topical soln 5% (50 gm)
(Sulfamylon)
1
1
lidocaine patch 5% (Lidoderm)
1
malathion lotion 0.5% (Ovide)
1
lidocaine-prilocaine cream
2.5-2.5% (Emla)
1
3
LIDOCAINE/PRILOCAINE lidocaine-prilocaine kit 2.5-2.5%
1
MEDI-DERM-RX - capsaicinmenthol-methyl salicylate cream
0.035-5-20%
3
LIDODERM - lidocaine patch 5%
3
MEDI-DERM/L-RX - lidocainecapsaicin-menthol-methyl sal
cream 2-0.035-5-20%
LIDODEXTRAPINE - lidocainementhol patch 4-1%
3
3
LIDOPIN - lidocaine hcl cream
3.25%
3
MEDI-PATCH RX - lidocainecapsaicin-menthol-methyl sal
patch 0.5-0.035-5-20%
3
LIDORX - lidocaine hcl gel 3%
3
MEDROX-RX - capsaicin-mentholmethyl salicylate oint 0.05-7-20%
LIDOVIR - acyclovir-lidocaine hcl
oint 4-4% (compounding kit)
3
MENTAX - butenafine hcl cream
1%
3
lindane lotion 1%
1
1
lindane shampoo 1%
1
methoxsalen rapid cap 10 mg
(Oxsoralen ultra)
174
•
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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Specialty
Quantity Limits
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Drug Name
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METHYL SALICYLATE - methyl
salicylate liquid
1
METROCREAM - metronidazole
cream 0.75%
3
METROGEL - metronidazole gel
1%
3
•
METROLOTION - metronidazole
lotion 0.75%
3
•
metronidazole cream 0.75%
(Metrocream)
1
metronidazole gel 0.75%
1
metronidazole gel 1% (Metrogel)
1
metronidazole lotion 0.75%
(Metrolotion)
1
METVIXIA - methyl aminolevulinate 3
hcl cream 16.8% (base equiv)
MIRVASO - brimonidine tartrate gel 3
0.33% (base equivalent)
mometasone furoate cream 0.1% 1
(Elocon)
1
mometasone furoate oint 0.1%
(Elocon)
1
mometasone furoate solution
0.1% (lotion) (Elocon)
1
mupirocin calcium cream 2%
(Bactroban)
1
mupirocin oint 2% (Bactroban)
NAFTIN - naftifine hcl cream 1%
3
NAFTIN - naftifine hcl cream 2%
3
NAFTIN - naftifine hcl gel 1%
3
NAFTIN - naftifine hcl gel 2%
3
NAPRO 15% COMPOUNDING KIT
- naproxen cream 15%
3
NAPRODERM COMPOUNDING
KIT - naproxen cream 15%
3
NATROBA - spinosad susp 0.9%
3
NEO-SYNALAR - neomycinfluocinolone cream 0.35-0.025%
3
•
NEO-SYNALAR KIT - neomycinfluocinolone cream 0.35-0.025%
& emollient cr kit
3
NEUAC KIT - clindamycin-benzoyl
perox gel 1.2-5% & moisturizer cr
kit
3
NIVATOPIC PLUS - dermatological 3
products misc - cream
NIZORAL - ketoconazole shampoo 3
2%
NORITATE - metronidazole cream 3
1%
NOVACORT - hydrocortisone ace- 3
pramoxine-aloe polysacch gel
2-1-1%
3
NP #2 DRUG PREPARATION KI
- tramadol-flurbip-amitrip-gabaclonidine-lido crm (cmp kit)
NUCORT - hydrocortisone acetate 3
lotion 2%
NUOX - benzoyl peroxide-sulfur gel 3
6-3%
3
NUZON - hydrocortisone acetatealoe vera gel 2%
1
nystatin cream 100000 unit/gm
nystatin oint 100000 unit/gm
1
nystatin-triamcinolone cream
100000-0.1 unit/gm-%
1
nystatin-triamcinolone oint
100000-0.1 unit/gm-%
1
NYSTATIN/TRIAMCINOLONE nystatin-triamcinolone cream
100000-0.1 unit/gm-%
1
OLUX - clobetasol propionate foam 3
0.05%
3
OLUX-E - clobetasol propionate
emulsion foam 0.05%
3
ONEXTON - clindamycin
phosphate-benzoyl peroxide gel
1.2-3.75%
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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•
•
•
•
•
175
PENNSAID - diclofenac sodium
soln 1.5%
3
• •
3
PENNSAID - diclofenac sodium
soln 2%
3
• •
OVACE PLUS - sulfacetamide
sodium lotion 9.8%
3
permethrin cream 5% (Elimite)
1
3
•
PICATO - ingenol mebutate gel
0.015%
3
OVACE PLUS - sulfacetamide
sodium shampoo 10%
3
•
PICATO - ingenol mebutate gel
0.05%
3
OVACE PLUS WASH sulfacetamide sodium liquid 10%
•
OVACE PLUS WASH sulfacetamide sodium cleansing
gel 10%
•
PLEXION - sulfacetamide sodium
w/ sulfur cream 9.8-4.8%
3
3
PLEXION - sulfacetamide sodium
w/ sulfur lotion 9.8-4.8%
3
•
OVACE WASH - sulfacetamide
sodium liquid 10%
3
3
•
OVIDE - malathion lotion 0.5%
3
PLEXION CLEANSER sulfacetamide sodium w/ sulfur
cleanser 9.8-4.8%
OXISTAT - oxiconazole nitrate
cream 1%
3
3
•
OXISTAT - oxiconazole nitrate
lotion 1%
3
PLEXION CLEANSING CLOTHS
- sulfacetamide sodium w/ sulfur
cleansing cloth 9.8-4.8%
3
OXSORALEN - methoxsalen lotion
1%
3
PLIAGLIS - lidocaine-tetracaine
cream 7-7%
3
OXSORALEN ULTRA methoxsalen rapid cap 10 mg
3
PODOCON 25 IN BENZOIN TIN podophyllum resin soln 25%
podofilox soln 0.5% (Condylox)
1
PANDEL - hydrocortisone
probutate cream 0.1%
3
PRAMOSONE - pramoxine-hc
cream 1-1%
3
PANRETIN - alitretinoin gel 0.1%
3
PRAMOSONE - pramoxine-hc
cream 1-2.5%
3
PRAMOSONE - pramoxine-hc
lotion 1-1%
3
PRAMOSONE - pramoxine-hc
lotion 1-2.5%
3
PRAMOSONE - pramoxine-hc oint
1-1%
3
PRAMOSONE - pramoxine-hc oint
1-2.5%
3
PRAMOSONE E - pramoxine-hc
emollient base cream 1-2.5%
3
pramoxine hcl gel 1%
1
PEDIADERM AF COMPLETE KIT - 3
nystatin cream 100000 unit/gm &
diaper rash cream kit
PEDIADERM HC - hydrocortisone 3
lot 2% & emollient cream kit
3
PEDIADERM TA - triamcinolone
cream 0.1% & emollient cream
kit
3
PEDIPIROX-4 NAIL - ciclopirox
soln 8% & lacquer removal pads
& foot powd kit
3
PENLAC NAIL LACQUER ciclopirox solution 8%
176
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
OVACE PLUS - sulfacetamide
sodium cream 10%
•
Drug Name
Drug Tier
•
Specialty
3
Quantity Limits
Prior Authorization
ORACEA - doxycycline (rosacea)
cap delayed release 40 mg
Drug Name
"Smart" PA
Drug Tier
2015
RETIN-A MICRO PUMP - tretinoin
microsphere gel 0.08%
3
•
prednicarbate oint 0.1%
(Dermatop)
1
RETIN-A MICRO PUMP - tretinoin
microsphere gel 0.1%
3
•
REXAPHENAC - diclofenac
sodium cream 1%
3
PROTOPIC - tacrolimus oint 0.03% 2
PROTOPIC - tacrolimus oint 0.1% 2
PRUDOXIN - doxepin hcl cream
5%
3
RIAX - benzoyl peroxide foam
5.5%
3
•
PYROGALLIC ACID - pyrogallolchlorobutanol oint 25-2%
1
RIAX - benzoyl peroxide foam
9.5%
3
•
QROXIN - capsaicin-menthol
topical patch 0.0375-5%
3
ROSADAN KIT - metronidazole gel
0.75% w/ cleanser kit
3
•
QUTENZA - capsaicin patch 8% &
cleansing gel kit
3
ROSADAN KIT - metronidazole
cream 0.75% w/ cleanser kit
3
•
RECIPHEXAMINE - lidocainementhol patch 4-1%
3
3
•
REGENECARE - lidocaine hclcollagen-aloe vera gel 2%
3
ROSANIL - sulfacetamide sodsulfur emul 10-5% & skin
cleanser kit
3
REGRANEX - becaplermin gel
0.01%
2
SALEX - salicylic acid shampoo
6%
3
RELEEVIA - capsaicin-menthol
topical patch 0.0375-5%
3
SALEX CREAM - salicylic acid
cream 6% & cleanser liqd kit
3
RELYYKS - lidocaine-menthol
patch 4-5%
3
SALEX LOTION - salicylic acid
lotion 6% & cleanser liqd kit
1
RELYYT - capsaicin-menthol
topical patch 0.025-5%
3
SALICYLIC ACID - salicylic acid
soln 26%
salicylic acid cream 6%
1
RENOVO - capsaicin-menthol
topical patch 0.0375-5%
3
salicylic acid film forming liquid
27.5% (Virasal)
1
RETIN-A - tretinoin cream 0.025%
3
salicylic acid foam 6% (Salvax)
1
RETIN-A - tretinoin cream 0.05%
3
salicylic acid gel 6% (Keralyt)
1
RETIN-A - tretinoin cream 0.1%
3
3
SALICYLIC ACID IN AMMONIU
- salicylic acid in ammonium
lactate vehicle foam 6%
1
RETIN-A - tretinoin gel 0.01%
RETIN-A - tretinoin gel 0.025%
3
salicylic acid lotion 6%
1
RETIN-A MICRO - tretinoin
microsphere gel 0.04%
3
•
•
•
•
•
•
1
RETIN-A MICRO - tretinoin
microsphere gel 0.1%
3
•
salicylic acid shampoo 6%
(Salex)
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
1
Quantity Limits
Prior Authorization
prednicarbate cream 0.1%
(Dermatop)
Drug Name
"Smart" PA
Drug Tier
•
Specialty
3
Quantity Limits
RETIN-A MICRO PUMP - tretinoin
microsphere gel 0.04%
"Smart" PA
1
Drug Tier
pramoxine-hc cream 1-2.5%
(Pramosone)
Drug Name
Prior Authorization
2015
177
SALKERA - salicylic acid in
ammonium lactate vehicle foam
6%
3
silver nitrate-potassium nitrate
applicator 75-25% (Arzol silver
nitrate)
1
SALVAX - salicylic acid foam 6%
3
silver sulfadiazine cream 1%
(Silvadene)
1
SILVERA PAIN RELIEF capsaicin-lidocaine-menthol
patch 0.0375-1-5%
3
SINELEE - capsaicin-menthol
topical patch 0.0375-5%
3
SKLICE - ivermectin lotion 0.5%
3
SODIUM SULFACETAMIDE
WASH - sulfacetamide sodium in
bakuchiol vehicle wash 10%
3
SODIUM SULFACETAMIDE/SULF
- sulfacetamide sodium w/ sulfur
susp 10-5%
1
•
SODIUM SULFACETAMIDE/SULF
- sulfacetamide sodium-sulfur in
urea emulsion 10-5%
1
•
SODIUM SULFACETAMIDE/SULF
- sulfacetamide sodium-sulfur in
urea gel 10-5%
1
•
SALVAX DUO PLUS - salicylic acid 3
foam 6% & urea in lactic acid
foam 35% kit
2
SANTYL - collagenase oint 250
unit/gm
3
SCALACORT DK - hc lot 2% &
sal acid-sulfur shampoo 2-2% &
shampoo kit
SE BPO 7-5.5 WASH KIT - benzoyl 3
peroxide wash 7% & benzoyl
peroxide cream 5.5% kit
SEB-PREV - sulfacetamide sodium 3
lotion 10%
1
SELENIUM SULFIDE - selenium
sulfide-pyrithione zinc in urea
shampoo 2.25%
1
selenium sulfide lotion 2.5%
•
selenium sulfide-pyrithione zinc
in urea shampoo 2.25%
1
SELRX - selenium sulfidepyrithione zinc in urea shampoo
2.3%
3
SODIUM SULFACETAMIDE/UREA
- sulfacetamide sodium-urea pad
10%
1
SELSUN SHAMPOO - selenium
sulfide lotion 2.5%
3
sodium thiosulfate-salicylic acid
lotion 25-1%
1
SILVADENE - silver sulfadiazine
cream 1%
3
SOLAICE - capsaicin-menthol
topical patch 0.05-5%
3
SILVER NITRATE - silver nitrate
soln 0.5%
1
SOLARAZE - diclofenac sodium
(actinic keratoses) gel 3%
3
SILVER NITRATE - silver nitrate
soln 10%
1
SORIATANE - acitretin cap 10 mg
3
3
SILVER NITRATE - silver nitrate
soln 25%
1
SORIATANE - acitretin cap 17.5
mg
SORIATANE - acitretin cap 25 mg
3
SILVER NITRATE - silver nitrate
soln 50%
1
SORILUX - calcipotriene foam
0.005%
3
SILVER NITRATE - silver nitrate
oint 10%
1
SPINOSAD - spinosad susp 0.9%
1
SSS 10-4 - sulfacetamide sodium
w/ sulfur foam 10-4%
3
178
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
3
•
• •
sulfacetamide sodium w/ sulfur
wash 9-4.5% (Sumadan wash)
1
STELARA - ustekinumab inj 45
mg/0.5ml
3
•
•
sulfacetamide sodium w/ sulfur
wash 9-4% (Sumaxin wash)
1
sulfacetamide sodium
cleansing gel 10% (Ovace plus
wash)
1
sulfacetamide sodium-sulfur in
urea emulsion 10-4%
1
sulfacetamide sodium liquid 10%
(Ovace wash)
SULFAMYLON - mafenide acetate
packet for topical soln 5% (50
gm)
3
1
sulfacetamide sodium lotion
10% (acne) (Klaron)
1
SULFAMYLON - mafenide acetate
cream 85 mg/gm
3
sulfacetamide sodium shampoo
10% (Ovace plus)
1
SULFOAM - sulfur shampoo 2%
3
1
sulfacetamide sodium w/
sulfur cleanser 10-2% (Avar ls
cleanser)
1
SULFURATED LIME - sulfurated
lime solution
3
•
sulfacetamide sodium w/ sulfur
cleanser 9.8-4.8% (Plexion
cleanser)
1
SUMADAN KIT - sulfacetamide
sod-sulfur wash 9-4.5% & skin
cleanser kit
SUMADAN WASH - sulfacetamide
sodium w/ sulfur wash 9-4.5%
3
•
sulfacetamide sodium w/ sulfur
cleansing cloth 10-5%
1
3
sulfacetamide sodium w/ sulfur
cleansing pad 10-4% (Sumaxin)
1
SUMADAN XLT - sulfacetamide
sod-sulfur wash 9-4.5% &
sunscreen kit
3
•
sulfacetamide sodium w/ sulfur
cream 10-2% (Avar-e ls)
1
SUMAXIN - sulfacetamide sodium
w/ sulfur cleansing pad 10-4%
•
1
SUMAXIN CP KIT - sulfacetamide
sod-sulfur pad 10-4% & skin
cleanser kit
3
sulfacetamide sodium w/ sulfur
cream 10-5%
sulfacetamide sodium w/ sulfur
cream 9.8-4.8% (Plexion)
1
SUMAXIN TS - sulfacetamide
sodium w/ sulfur susp 8-4%
3
•
sulfacetamide sodium w/ sulfur
emulsion 10-1%
1
SUMAXIN WASH - sulfacetamide
sodium w/ sulfur wash 9-4%
3
•
sulfacetamide sodium w/ sulfur
emulsion 10-5%
1
SYNALAR - fluocinolone acetonide
soln 0.01%
3
sulfacetamide sodium w/ sulfur
foam 10-5% (Clarifoam ef)
1
SYNALAR - fluocinolone acetonide
cream 0.025%
3
sulfacetamide sodium w/ sulfur
lotion 10-5%
1
SYNALAR - fluocinolone acetonide
oint 0.025%
3
sulfacetamide sodium w/ sulfur
lotion 9.8-4.8% (Plexion)
1
Specialty
STELARA - ustekinumab soln
prefilled syringe 90 mg/ml
Quantity Limits
1
"Smart" PA
sulfacetamide sodium w/ sulfur
susp 8-4% (Sumaxin ts)
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Prior Authorization
• •
Drug Name
Drug Tier
•
Specialty
3
Quantity Limits
Prior Authorization
STELARA - ustekinumab soln
prefilled syringe 45 mg/0.5ml
Drug Name
"Smart" PA
Drug Tier
2015
179
•
SYNALAR CREAM KIT fluocinolone cream 0.025%emollient cream kit
3
TEMOVATE E - clobetasol
propionate emollient base cream
0.05%
3
SYNALAR OINTMENT KIT fluocinolone oint 0.025%emollient cream kit
3
TERSI FOAM - selenium sulfide
foam 2.25%
3
3
•
SYNALAR TS - fluocinolone
acetonide soln 0.01% & cleanser
kit
3
TEXACORT - hydrocortisone soln
2.5%
TOPICORT - desoximetasone
spray 0.25%
3
•
SYNERA - lidocaine-tetracaine
topical patch 70-70 mg
3
TOPICORT - desoximetasone
cream 0.05%
3
•
SYNVEXIA - lidocaine-menthol
patch 4-1%
3
TOPICORT - desoximetasone
cream 0.25%
3
•
SYNVEXIA TC - lidocaine-menthol
cream 4-1%
3
TOPICORT - desoximetasone gel
0.05%
3
•
TACLONEX - calcipotrienebetamethasone dipropionate
susp 0.005-0.064%
3
TOPICORT - desoximetasone oint
0.05%
3
3
TOPICORT - desoximetasone oint
0.25%
3
TACLONEX - calcipotrienebetamethasone dipropionate oint
0.005-0.064%
3
•
tacrolimus oint 0.03% (Protopic)
1
TRETIN-X - tretinoin cream
0.0375%
1
TRETIN-X - tretinoin cream
0.075%
3
tacrolimus oint 0.1% (Protopic)
•
TARGRETIN - bexarotene gel 1%
2
•
•
TAZORAC - tazarotene cream
0.05%
TRETIN-X - tretinoin gel 0.01% w/
cleanser & moisturizer kit
3
2
2
•
TAZORAC - tazarotene gel 0.05%
2
TAZORAC - tazarotene gel 0.1%
2
•
•
TEMOVATE - clobetasol
propionate soln 0.05%
3
•
TEMOVATE - clobetasol
propionate cream 0.05%
3
•
TEMOVATE - clobetasol
propionate gel 0.05%
3
•
TRETIN-X - tretinoin gel 0.025% w/ 3
cleanser & moisturizer kit
3
TRETIN-X - tretinoin cream
0.025% w/ cleanser & moisturizer
kit
TRETIN-X - tretinoin cream 0.05% 3
w/ cleanser & moisturizer kit
3
TRETIN-X - tretinoin cream 0.1%
w/ cleanser & moisturizer kit
1
tretinoin cream 0.025% (Retin-a)
•
TAZORAC - tazarotene cream
0.1%
TEMOVATE - clobetasol
propionate oint 0.05%
3
180
•
•
•
tretinoin cream 0.05% (Retin-a)
1
tretinoin cream 0.1% (Retin-a)
1
tretinoin gel 0.01% (Retin-a)
1
tretinoin gel 0.025% (Retin-a)
1
•
•
•
•
•
•
•
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
•
tretinoin microsphere gel 0.1%
(Retin-a micro)
1
•
3
•
TRI-CHLOR - trichloroacetic acid
liqd 80%
3
ULTRAVATE X - halobetasol prop
oint 0.05% & lactic acid cream
10% kit
TRIAMCINOLONE ACETONIDE
- triamcinolone acetonide oint
0.5%
1
UMECTA - urea emulsion 40%
3
UMECTA - urea suspension 40%
3
triamcinolone acetonide cream
0.025%
UMECTA NAIL FILM - urea
suspension 40%
3
1
triamcinolone acetonide cream
0.1%
UMECTA PD - urea-hyaluronate
sodium emulsion 40-0.3%
3
1
triamcinolone acetonide cream
0.5%
UMECTA PD - urea-hyaluronate
sodium susp 40-0.3%
3
1
URAMAXIN - urea cream 45%
3
triamcinolone acetonide lotion
0.025%
1
URAMAXIN - urea gel 45%
3
1
URAMAXIN - urea lotion 45%
3
triamcinolone acetonide lotion
0.1%
3
triamcinolone acetonide oint
0.025%
1
URAMAXIN - urea in ammonium
lactate vehicle foam 20%
URAMAXIN GT - urea gel 45%
3
triamcinolone acetonide oint
0.1%
1
urea cream 39% (Aluvea)
1
urea cream 40%
1
TRIANEX - triamcinolone
acetonide oint 0.05%
3
urea cream 45% (Uramaxin)
1
1
1
urea cream 47% (Keralac)
U-CORT - urea-hc acetate cream
1%
urea cream 50%
1
2
urea foam 40% (Hydro 40 foam)
1
ULESFIA - benzyl alcohol lotion
5%
urea gel 40%
1
ULTRASAL-ER - salicylic acid filmforming soln 28.5%
3
urea gel 45% (Uramaxin)
1
1
ULTRAVATE - halobetasol
propionate cream 0.05%
3
•
urea in lactic acid vehicle foam
35% (Hydro 35)
ULTRAVATE - halobetasol
propionate oint 0.05%
•
urea in lactic acid-salicylic acid
vehicle susp 50%
1
3
1
ULTRAVATE PAC - halobetasol
prop cream 0.05% & ammonium
lactate lot 12% kit
3
urea in zinc undecylenate-lactic
acid vehicle emulsion 50%
urea lotion 40%
1
urea lotion 45% (Uramaxin)
1
ULTRAVATE PAC - halobetasol
prop oint 0.05% & ammonium
lactate lot 12% kit
3
•
•
•
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
3
Quantity Limits
Prior Authorization
ULTRAVATE X - halobetasol prop
cream 0.05% & lactic acid cream
10% kit
Drug Name
"Smart" PA
Drug Tier
•
Specialty
1
Quantity Limits
Prior Authorization
tretinoin microsphere gel 0.04%
(Retin-a micro)
Drug Name
"Smart" PA
Drug Tier
2015
181
UREA NAIL - urea in zinc
undecylenate-lactic acid vehicle
stick 50%
3
UREA NAIL KIT - urea susp 40% & 3
hyaluronate sodium gel 0.2% kit
1
urea suspension 40% (Umecta)
UTOPIC - urea cream 41%
3
VALCHLOR - mechlorethamine hcl
gel 0.016% (base equivalent)
2
VANOS - fluocinonide cream 0.1%
3
VANOXIDE HC - benzoyl peroxide- 3
hc lot 5-0.5% & cleanser lot kit
VANOXIDE-HC - benzoyl peroxide- 3
hc lotion 5-0.5%
3
VECTICAL - calcitriol oint 3 mcg/
gm
3
VELMA PAIN RELIEF - methyl
salicylate-lidocaine-menthol
patch 16-4-2%
3
VELTIN - clindamycin phosphatetretinoin gel 1.2-0.025%
VENELEX - balsam peru-castor oil 3
oint
VERDESO - desonide foam 0.05% 3
•
•
•
•
•
•
VYTONE - iodoquinolhydrocortisone in aloe vehicle
cream 1-1.9%
3
WESTCORT - hydrocortisone
valerate oint 0.2%
3
XCLAIR - dermatological products
misc - cream
3
3
XOLEGEL DUO/HEAD & SHOULD
- ketoconazole gel 2% &
pyrithione zinc shampoo 1% kit
3
XOLEGEL DUO/XOLEX ketoconazole gel 2% & pyrithione
zinc shampoo 1% kit
3
XYLOCAINE - lidocaine hcl soln
4%
3
ZACARE 4% KIT - benzoyl
peroxide lotion 4% & hyaluronate
sodium gel 0.2% kit
3
•
ZACARE 8% KIT - benzoyl
peroxide lotion 8% & hyaluronate
sodium gel 0.2% kit
3
•
•
VEXA - allantoin-lidocainepetrolatum patch 2-4-30%
3
ZACLIR CLEANSING - benzoyl
peroxide lotion 8%
3
VIRASAL - salicylic acid film
forming liquid 27.5%
3
ZERUVIA - lidocaine-menthol
patch 4-1%
3
VOLTAREN - diclofenac sodium
gel 1%
3
ZIANA - clindamycin phosphatetretinoin gel 1.2-0.025%
3
VOPAC - ketoprofen-lidocaine hcl
cream 10-2% (compound kit)
3
ZITHRANOL - anthralin shampoo
1%
3
VOPAC GB - ketoprofen-lidocainegabapentin cream 5-2-5% (cmpd
kit)
3
ZITHRANOL-RR - anthralin cream
1.2%
3
ZONALON - doxepin hcl cream 5%
3
VUSION - miconazole-zinc
oxide-white petrolatum oint
0.25-15-81.35%
3
ZOVIRAX - acyclovir cream 5%
3
ZOVIRAX - acyclovir oint 5%
3
•
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
XOLEGEL COREPAK ketoconazole gel 2% &
hydrocortisone gel 1% kit
3
182
•
XERESE - acyclovir-hydrocortisone 3
cream 5-1%
3
XOLEGEL - ketoconazole gel 2%
VEREGEN - sinecatechins oint
15%
• •
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
3
EXJADE - deferasirox tab for oral
susp 250 mg
2
•
•
ZYCLARA PUMP - imiquimod
cream 3.75%
3
EXJADE - deferasirox tab for oral
susp 500 mg
2
•
•
8-MOP - methoxsalen cap 10 mg
3
3
•
• •
MISCELLANEOUS PRODUCTS
FERRIPROX - deferiprone tab 500
mg
ANTISEPTICS & DISINFECTANTS
naltrexone hcl tab 50 mg (Revia)
1
BENZALKONIUM CHLORIDE benzalkonium chloride soln
1
RADIOGARDASE - prussian blue
insoluble cap 0.5 gm
3
BENZALKONIUM CHLORIDE benzalkonium chloride soln 17%
1
REVIA - naltrexone hcl tab 50 mg
3
BENZALKONIUM CHLORIDE benzalkonium chloride soln 50%
1
ACCU-CHEK ACTIVE STRIPS glucose blood test strip
2
•
CHLORHEXIDINE DIGLUCONATE
- chlorhexidine gluconate soln
20%
1
ACCU-CHEK AVIVA - glucose
blood test strip
2
•
•
CHLORHEXIDINE GLUCONATE
- chlorhexidine gluconate soln
20%
ACCU-CHEK AVIVA PLUS glucose blood test strip
2
1
ACCU-CHEK COMFORT CURVE
T - glucose blood test strip
2
•
FORMA-RAY - formaldehyde
solution 20%
3
ACCU-CHEK COMPACT PLUS glucose blood test strip
2
•
FORMALDEHYDE - formaldehyde
solution 37%
1
•
formaldehyde solution 10%
1
ACCU-CHEK COMPACT STRIPS - 2
glucose blood test strip
2
ACCU-CHEK COMPACT TEST
DR - glucose blood test strip
ACCU-CHEK SMARTVIEW STRIP 2
- glucose blood test strip
2
ACCUTREND GLUCOSE glucose blood test strip
3
ACURA BLOOD GLUCOSE TEST
- glucose blood test strip
ADVANCE INTUITION TEST ST - 3
glucose blood test strip
ADVANCE MICRO-DRAW TEST S 3
- glucose blood test strip
ADVOCATE REDI-CODE - glucose 3
blood test strip
Specialty
ZYCLARA PUMP - imiquimod
cream 2.5%
Quantity Limits
Prior Authorization
•
Drug Name
"Smart" PA
Drug Tier
•
Specialty
2
Quantity Limits
EXJADE - deferasirox tab for oral
susp 125 mg
"Smart" PA
3
Drug Tier
ZYCLARA - imiquimod cream
3.75%
Drug Name
Prior Authorization
2015
DIAGNOSTIC PRODUCTS
GLUTARALDEHYDE - glutaral soln 1
25%
1
IODINE TINCTURE - iodine
tincture
1
LUGOLS STRONG IODINE iodine solution
3
PHISOHEX - hexachlorophene liq
3%
ANTIDOTES
CHEMET - succimer cap 100 mg
2
CYANIDE ANTIDOTE PKG cyanide antidote kit
1
EVZIO - naloxone hcl solution
auto-injector 0.4 mg/0.4ml
2
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
•
•
•
•
•
•
•
183
ADVOCATE REDI-CODE+ TEST glucose blood test strip
3
•
BG STAR BLOOD GLUCOSE TES
- glucose blood test strip
3
•
ADVOCATE TEST STRIPS glucose blood test strip
3
•
BIOSCANNER GLUCOSE TEST S
- glucose blood test strip
3
•
AGAMATRIX AMP NO CODE TES
- glucose blood test strip
3
•
BL TEST STRIP - glucose blood
test strip
3
•
AGAMATRIX JAZZ TEST STRIP glucose blood test strip
3
•
BLOOD GLUCOSE TEST STRIPS
- glucose blood test strip
3
•
AGAMATRIX KEYNOTE TEST ST
- glucose blood test strip
3
•
CAREONE BLOOD GLUCOSE
TES - glucose blood test strip
3
•
AGAMATRIX PRESTO TEST STR
- glucose blood test strip
3
•
CARESENS N BLOOD GLUCOSE
- glucose blood test strip
3
•
ASCENSIA AUTODISC TEST ST glucose blood test disk
3
•
CHOICE DM FORA G20 TEST S glucose blood test strip
3
•
ASSURE II - glucose blood test
strip
3
•
CLEVER CHEK AUTO-CODE TES
- glucose blood test strip
3
•
ASSURE II CHECK STRIP glucose blood test strip
3
•
CLEVER CHEK AUTO-CODE VOI
- glucose blood test strip
3
•
ASSURE II TEST STRIPS glucose blood test strip
3
•
CLEVER CHEK TEST STRIPS glucose blood test strip
3
•
ASSURE PLATINUM TEST STRI glucose blood test strip
3
•
CLEVER CHOICE AUTO-CODE P
- glucose blood test strip
3
•
ASSURE PRISM MULTI TEST S glucose blood test strip
3
•
CLEVER CHOICE MICRO TEST glucose blood test strip
3
•
ASSURE PRO TEST STRIPS glucose blood test strip
3
•
CONTROL AST - glucose blood
test strip
3
•
ASSURE 3 TEST STRIPS glucose blood test strip
3
•
CONTROL TEST STRIPS glucose blood test strip
3
•
ASSURE 4 TEST STRIPS glucose blood test strip
3
•
CVS ADVANCED GLUCOSE
METE - glucose blood test strip
3
•
AT LAST TEST STRIPS - glucose
blood test strip
3
•
CVS BLOOD GLUCOSE STRIPS glucose blood test strip
3
•
BAYER BREEZE 2 TEST DISC glucose blood test disk
3
•
DIATRUE PLUS BLOOD GLUCOS
- glucose blood test strip
3
•
BAYER CONTOUR BLOOD
GLUCO - glucose blood test strip
3
•
DUO-CARE TEST STRIPS glucose blood test strip
3
•
BAYER CONTOUR NEXT BLOOD
- glucose blood test strip
3
•
EASY PLUS BLOOD GLUCOSE T
- glucose blood test strip
3
•
BD TEST STRIPS - glucose blood
test strip
3
•
EASY PLUS II BLOOD GLUCOS glucose blood test strip
3
•
184
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EASY STEP TEST STRIPS glucose blood test strip
3
•
EASY TALK BLOOD GLUCOSE T
- glucose blood test strip
3
EASY TOUCH GLUCOSE TEST S
- glucose blood test strip
3
EASY TOUCH HEALTHPRO
GLUC - glucose blood test strip
3
EASY TRAK BLOOD GLUCOSE T
- glucose blood test strip
3
EASYGLUCO - glucose blood test
strip
3
EASYMAX TEST STRIPS glucose blood test strip
3
EASYMAX 15 TEST STRIPS glucose blood test strip
3
EASYPLUS BLOOD GLUCOSE
TE - glucose blood test strip
3
EASYPRO BLOOD GLUCOSE
TES - glucose blood test strip
3
EASYPRO PLUS - glucose blood
test strip
3
ECLIPSE TEST STRIPS - glucose
blood test strip
3
ELEMENT COMPACT TEST STRI
- glucose blood test strip
3
ELEMENT PLUS TEST STRIPS glucose blood test strip
3
ELEMENT TEST STRIPS glucose blood test strip
3
EMBRACE BLOOD GLUCOSE
TES - glucose blood test strip
3
EMBRACE EVO BLOOD
GLUCOSE - glucose blood test
strip
3
EMBRACE PRO BLOOD
GLUCOSE - glucose blood test
strip
3
•
ENVISION AUTOCODE TEST ST - 3
glucose blood test strip
•
3
•
•
EQL TRUETEST BLOOD
GLUCOS - glucose blood test
strip
3
•
•
EQL TRUETRACK TEST - glucose
blood test strip
3
•
•
EVENCARE + BLOOD GLUCOSE
- glucose blood test strip
3
•
•
EVENCARE BLOOD GLUCOSE
TE - glucose blood test strip
3
•
•
EVENCARE G2 TEST STRIPS glucose blood test strip
3
•
•
EVENCARE G3 TEST STRIPS glucose blood test strip
3
•
•
EVOLUTION AUTOCODE glucose blood test strip
3
•
•
EXACTECH R-S-G TEST STRIP glucose blood test strip
3
•
•
EXACTECH TEST STRIPS glucose blood test strip
3
•
•
EZ SMART BLOOD GLUCOSE TE
- glucose blood test strip
3
•
•
EZ SMART PLUS BLOOD GLUCO
- glucose blood test strip
2
•
•
FASTTAKE TEST STRIPS glucose blood test strip
3
•
•
FIFTY50 GLUCOSE TEST STRI glucose blood test strip
3
•
•
FORA D10 BLOOD GLUCOSE TE
- glucose blood test strip
3
•
•
FORA D15C BLOOD GLUCOSE T
- glucose blood test strip
3
•
•
FORA D15G BLOOD GLUCOSE T
- glucose blood test strip
FORA D15Z BLOOD GLUCOSE T
- glucose blood test strip
3
•
FORA D20 BLOOD GLUCOSE TE
- glucose blood test strip
3
•
FORA GD20 TEST STRIPS glucose blood test strip
3
•
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185
FORA GD50 BLOOD GLUCOSE T
- glucose blood test strip
3
•
GLUCO PERFECT 3 TEST STRI glucose blood test strip
3
•
FORA G20 BLOOD GLUCOSE TE
- glucose blood test strip
3
•
GLUCOCARD EXPRESSION
BLOO - glucose blood test strip
3
•
FORA G30A BLOOD GLUCOSE T
- glucose blood test strip
3
•
•
FORA G71A BLOOD GLUCOSE T
- glucose blood test strip
3
•
FORA G90 BLOOD GLUCOSE TE
- glucose blood test strip
3
•
FORA TEST N' GO BLOOD GLU glucose blood test strip
3
•
FORA V10 BLOOD GLUCOSE TE
- glucose blood test strip
3
•
FORA V12 BLOOD GLUCOSE TE
- glucose blood test strip
3
•
FORA V20 BLOOD GLUCOSE TE
- glucose blood test strip
3
•
FORA V22 BLOOD GLUCOSE TE
- glucose blood test strip
3
•
FORA V30A BLOOD GLUCOSE T
- glucose blood test strip
3
•
FORACARE GD40 - glucose blood
test strip
3
•
FORACARE PREMIUM V10 TEST
- glucose blood test strip
3
•
FORACARE TEST N GO TEST S - 3
glucose blood test strip
FORTISCARE BLOOD GLUCOSE 3
- glucose blood test strip
FREESTYLE INSULINX BLOOD - 3
glucose blood test strip
3
FREESTYLE LITE TEST STRIP glucose blood test strip
3
FREESTYLE TEST STRIPS glucose blood test strip
GE100 BLOOD GLUCOSE TEST - 3
glucose blood test strip
3
GHT TEST STRIPS - glucose
blood test strip
•
GLUCOCARD SHINE TEST STRI - 3
glucose blood test strip
GLUCOCARD VITAL TEST STRI - 3
glucose blood test strip
3
GLUCOCARD X-SENSOR glucose blood test strip
3
GLUCOCARD 01 SENSOR glucose blood test strip
GLUCOCARD 01 TEST STRIPS - 3
glucose blood test strip
3
GLUCOCOM TEST STRIPS glucose blood test strip
3
GLUCOLAB TEST STRIPS glucose blood test strip
GLUCONAVII BLOOD GLUCOSE - 3
glucose blood test strip
3
GMATE BLOOD GLUCOSE TEST
- glucose blood test strip
INFINITY BLOOD GLUCOSE TE - 3
glucose blood test strip
3
KROGER BLOOD GLUCOSE
TEST - glucose blood test strip
3
KROGER PREMIUM BLOOD
GLUC - glucose blood test strip
KROGER TEST STRIPS - glucose 3
blood test strip
LIBERTY NEXT GENERATION B - 3
glucose blood test strip
LIBERTY TEST STRIPS - glucose 3
blood test strip
MAXIMA BLOOD GLUCOSE TEST 3
- glucose blood test strip
MEIJER BLOOD GLUCOSE TEST 3
- glucose blood test strip
MEIJER PREMIUM BLOOD GLUC 3
- glucose blood test strip
186
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
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MEIJER TRUETEST BLOOD GLU
- glucose blood test strip
3
•
PRECISION PCX - glucose blood
test strip
3
•
MEIJER TRUETRACK BLOOD GL
- glucose blood test strip
3
•
PRECISION PCX PLUS TEST S glucose blood test strip
3
•
MICRODOT TEST STRIPS glucose blood test strip
3
•
PRECISION POINT OF CARE T glucose blood test strip
3
•
MYGLUCOHEALTH BLOOD
GLUCO - glucose blood test strip
3
•
PRECISION QID TEST STRIPS glucose blood test strip
3
•
NEUTEK 2TEK TEST STRIPS glucose blood test strip
3
•
PRECISION SOF-TACT TEST S glucose blood test strip
3
•
NEXGEN TEST STRIPS - glucose
blood test strip
3
•
PRECISION XTRA BLOOD GLUC
- glucose blood test strip
3
•
NOVA MAX GLUCOSE TEST STR
- glucose blood test strip
3
•
PRESTIGE SMART SYSTEM CO- glucose blood test strip
3
•
ON CALL EXPRESS BLOOD GLU
- glucose blood test strip
3
•
PRESTIGE TEST STRIPS glucose blood test strip
3
•
ON CALL PLUS BLOOD GLUCOS
- glucose blood test strip
3
•
PRODIGY AUTOCODE BLOOD
GL - glucose blood test strip
3
•
ON CALL VIVID BLOOD GLUCO glucose blood test strip
3
•
PRODIGY NO CODING BLOOD G
- glucose blood test strip
3
•
ONETOUCH BASIC/PROFILE TE - 2
glucose blood test strip
2
ONETOUCH ULTRA BLUE glucose blood test strip
2
ONETOUCH ULTRA TEST STRIP
- glucose blood test strip
2
ONETOUCH VERIO TEST STRIP
- glucose blood test strip
3
OPTIUM TEST STRIPS - glucose
blood test strip
3
OPTIUMEZ TEST STRIPS glucose blood test strip
3
OPTUMRX BLOOD GLUCOSE
TES - glucose blood test strip
3
PHARMACIST CHOICE
AUTOCOD - glucose blood test
strip
3
POCKETCHEM EZ BLOOD
GLUCO - glucose blood test strip
•
PTS PANELS GLUCOSE TEST glucose blood test strip
3
•
•
QUICKTEK TEST STRIPS glucose blood test strip
3
•
•
QUINTET AC BLOOD GLUCOSE - 3
glucose blood test strip
QUINTET BLOOD GLUCOSE TES 3
- glucose blood test strip
RA TRUETEST STRIPS - glucose 3
blood test strip
3
REFUAH PLUS BLOOD
GLUCOSE - glucose blood test
strip
RELION BLOOD GLUCOSE TEST 3
- glucose blood test strip
RELION CONFIRM/MICRO TEST - 3
glucose blood test strip
RELION PRIME BLOOD GLUCOS 3
- glucose blood test strip
•
•
•
•
•
•
•
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•
•
•
•
•
•
187
RELION ULTIMA BLOOD GLUCO
- glucose blood test strip
3
•
TRUE METRIX BLOOD GLUCOSE
- glucose blood test strip
3
•
RELION ULTIMA TEST STRIPS glucose blood test strip
3
•
TRUE METRIX SELF MONITORI glucose blood test strip
3
•
REVEAL BLOOD GLUCOSE TEST
- glucose blood test strip
3
•
•
REXALL BLOOD GLUCOSE TEST
- glucose blood test strip
3
•
RIGHTEST GS100 BLOOD GLUC
- glucose blood test strip
3
•
RIGHTEST GS300 BLOOD GLUC
- glucose blood test strip
3
•
RIGHTEST GS550 BLOOD GLUC
- glucose blood test strip
3
•
SMART DIABETES XPRES BLOO
- glucose blood test strip
3
•
SMART SENSE PREMIUM
BLOOD - glucose blood test strip
3
•
SMART SENSE VALUE BLOOD G
- glucose blood test strip
3
•
SMARTEST BLOOD GLUCOSE
TE - glucose blood test strip
3
•
SOLUS V2 AUDIBLE TEST glucose blood test strip
3
•
SUPREME TEST STRIPS glucose blood test strip
3
•
TRUETEST BLOOD GLUCOSE T - 3
glucose blood test strip
3
TRUETEST STRIPS - glucose
blood test strip
3
TRUETRACK BLOOD GLUCOSE
T - glucose blood test strip
3
TRUETRACK TEST - glucose
blood test strip
3
ULTIMA TEST STRIPS - glucose
blood test strip
ULTRATRAK PRO TEST STRIPS - 3
glucose blood test strip
ULTRATRAK ULTIMATE TEST S - 3
glucose blood test strip
3
UNISTRIP1 GENERIC - glucose
blood test strip
VICTORY AGM-4000 TEST STR - 3
glucose blood test strip
VOCAL POINT BLOOD GLUCOSE 3
- glucose blood test strip
3
WAVESENSE PRESTO TEST
STR - glucose blood test strip
SURE EDGE BLOOD GLUCOSE T
- glucose blood test strip
3
•
CHEMICALS
SURE-TEST EASYPLUS MINI B glucose blood test strip
3
•
ENOVARX-AMITRIPTYLINE amitriptyline hcl cream 2% kit
(compounding kit)
SURECHEK BLOOD GLUCOSE
TE - glucose blood test strip
3
•
MEDICAL DEVICES
SURESTEP PRO TEST STRIPS glucose blood test strip
2
•
SURESTEP TEST STRIPS glucose blood test strip
2
•
TELCARE BLOOD GLUCOSE
TES - glucose blood test strip
3
•
TGT BLOOD GLUCOSE TEST ST
- glucose blood test strip
3
•
188
•
•
•
•
•
•
•
•
•
•
3
ACCU-CHEK ACTIVE GLUCOSE - 2
blood glucose calibration - liquid
3
ACCU-CHEK AVIVA - blood
glucose calibration - liquid
ACCU-CHEK AVIVA PLUS - blood 2
glucose monitoring kit w/ device
2
ACCU-CHEK COMFORT CURVE
C - blood glucose calibration liquid
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ACCU-CHEK COMFORT CURVE
L - blood glucose calibration liquid
2
ACCU-CHEK COMPACT BLUE
CO - blood glucose calibration liquid
3
ACCU-CHEK COMPACT PLUS
CA - blood glucose monitoring kit
2
ACCU-CHEK COMPACT PLUS CL
- blood glucose calibration - liquid
ACCU-CHEK SOFTCLIX LANCET
- lancets
3
ACCU-CHEK SOFTCLIX LANCET
- lancet devices
3
ACCU-CHEK VOICEMATE - blood
glucose monitoring kit w/ device
2
3
2
ACCUTREND GLUCOSE
CONTROL - blood glucose
calibration - liquid
ACCU-CHEK FASTCLIX LANCET
- lancets
ACTI-LANCE LANCETS 28G lancets
3
3
ACCU-CHEK INSTANT GLUCOSE
- blood glucose calibration - liquid
ACTI-LANCE LITE SAFETY LA lancets
3
2
ACCU-CHEK INSTANT GLUCOSE
- blood glucose calibration - liquid
ACTI-LANCE SPECIAL SAFETY lancets
3
3
ACTI-LANCE UNIVERSAL SAFE lancets
3
ACURA BLOOD GLUCOSE
MONIT - blood glucose
monitoring kit w/ device
3
ACURA CONTROL SOLUTION HI
- blood glucose calibration - liquid
- high
3
ACURA CONTROL SOLUTION LO
- blood glucose calibration - liquid
- low
3
ACURA CONTROL SOLUTION
NO - blood glucose calibration liquid - normal
3
ACURA PLUS BLOOD GLUCOSE
- blood glucose monitoring kit w/
device
3
ADJUSTABLE LANCING DEVICE
- lancet devices
1
ADVANCE INTUITION BLOOD G
- blood glucose monitoring kit w/
device
3
ADVANCE INTUITION CONTROL
- blood glucose calibration - liquid
- normal
3
ACCU-CHEK MULTICLIX LANCE - 2
lancets
ACCU-CHEK MULTICLIX LANCE - 3
lancets
ACCU-CHEK NANO SMARTVIEW 2
- blood glucose monitoring kit w/
device
2
ACCU-CHEK SAFE-T-PRO LANC
- lancets
3
ACCU-CHEK SAFE-T-PRO LANC
- lancets
2
ACCU-CHEK SAFE-T-PRO PLUS
- lancets
3
ACCU-CHEK SAFE-T-PRO PLUS
- lancets
3
ACCU-CHEK SMARTVIEW
CONTR - blood glucose
calibration - liquid
ACCU-CHEK SOFT TOUCH LANC 2
- lancets
ACCU-CHEK SOFT TOUCH LANC 3
- lancets
2
ACCU-CHEK SOFTCLIX LANCET
- lancets
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189
ADVANCE MICRO-DRAW
CONTRO - blood glucose
calibration - liquid
3
ADVOCATE INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
31 x 5/16"
2
ADVANCE MICRO-DRAW
NORMAL - blood glucose
calibration - liquid
3
ADVOCATE INSULIN SYRINGE/ insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
ADVOCATE BLOOD GLUCOSE
MO - blood glucose monitoring
kit w/ device
3
ADVOCATE LANCETS - lancets
3
ADVOCATE LANCING DEVICE lancet devices
3
ADVOCATE CONTROL
SOLUTION - blood glucose
calibration - liquid - high
3
ADVOCATE REDI-CODE
+ CONTR - blood glucose
calibration - liquid - high
3
ADVOCATE CONTROL
SOLUTION - blood glucose
calibration - liquid - low
3
ADVOCATE REDI-CODE
+ CONTR - blood glucose
calibration - liquid - low
3
ADVOCATE INSULIN PEN NEED
- insulin pen needle 31 g x 5 mm
(3/16")
2
ADVOCATE REDI-CODE+/ TALK
- blood glucose monitoring kit w/
device
3
ADVOCATE INSULIN PEN NEED
- insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
ADVOCATE REDI-CODE/TALKIN
- blood glucose monitoring kit w/
device
3
ADVOCATE INSULIN SYRINGE/ insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
ADVOCATE SAFETY LANCETS lancets
3
2
AEROCHAMBER MINI AEROSOL
- spacer/aerosol-holding
chambers - device
3
ADVOCATE INSULIN SYRINGE/ insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
AEROCHAMBER MV - spacer/
aerosol-holding chambers device
3
ADVOCATE INSULIN SYRINGE/ insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
AEROCHAMBER PLUS - spacer/
aerosol-holding chambers device
3
ADVOCATE INSULIN SYRINGE/ insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
AEROCHAMBER PLUS FLOW
VU - spacer/aerosol-holding
chambers - device
3
ADVOCATE INSULIN SYRINGE/ insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
AEROCHAMBER PLUS FLOWVU - spacer/aerosol-holding
chambers - device
3
ADVOCATE INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
29 x 1/2"
2
AEROCHAMBER PLUS FLOWVU/ - spacer/aerosol-holding
chambers - device
3
ADVOCATE INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
30 x 5/16"
190
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AEROCHAMBER PLUS/MASK spacer/aerosol-holding chambers
- device
3
ANTI-STICK INSULIN SYRING insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
AEROCHAMBER PLUS/SMALL
MA - spacer/aerosol-holding
chambers - device
3
ANTI-STICK INSULIN SYRING insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
AEROCHAMBER Z-STAT PLUS
V - spacer/aerosol-holding
chambers - device
3
ANTI-STICK INSULIN SYRING insulin syringe/needle u-100 1 ml
29 x 1/2"
2
AEROCHAMBER Z-STAT PLUS/
F - spacer/aerosol-holding
chambers - device
3
AQUA LANCE ADJUSTABLE LAN
- lancet devices
3
AEROCHAMBER Z-STAT PLUS/
L - spacer/aerosol-holding
chambers - device
ASCENSIA AUTODISC LOW AND
- blood glucose calibration - liquid
3
3
AEROCHAMBER Z-STAT PLUS/
M - spacer/aerosol-holding
chambers - device
3
AEROCHAMBER Z-STAT PLUS/
S - spacer/aerosol-holding
chambers - device
3
AEROCHAMBER/FLOWSIGNAL spacer/aerosol-holding chambers
- device
3
AF LANCETS SUPER THIN lancets
3
AGAMATRIX CONTROL HIGH blood glucose calibration - liquid
- high
3
AGAMATRIX CONTROL NORMAL
- blood glucose calibration - liquid
3
AGAMATRIX CONTROL NORMAL
- blood glucose calibration - liquid
- normal
3
AGAMATRIX JAZZ - blood glucose 3
monitoring kit w/ device
3
AGAMATRIX PRESTO - blood
glucose monitoring kit w/ device
AGAMATRIX ULTRA-THIN LANC - 3
lancets
ALTERNATE SITE LANCING DE - 1
lancet devices
Specialty
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"Smart" PA
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Specialty
Quantity Limits
"Smart" PA
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2015
ASCENSIA AUTODISC NORMAL - 3
blood glucose calibration - liquid normal
3
ASSURE COMFORT LANCETS
UL - lancets
3
ASSURE DOSE NORMAL
CONTRO - blood glucose
calibration - liquid - normal
ASSURE DOSE NORMAL/HIGH C 3
- blood glucose calibration - liquid
ASSURE HAEMOLANCE PLUS HI 3
- lancets
3
ASSURE HAEMOLANCE PLUS
LO - lancets
ASSURE HAEMOLANCE PLUS MI 3
- lancets
3
ASSURE HAEMOLANCE PLUS
NO - lancets
3
ASSURE HAEMOLANCE PLUS
PE - lancets
2
ASSURE ID INSULIN SAFETY insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
ASSURE ID INSULIN SAFETY insulin syringe/needle u-100 1 ml
29 x 1/2"
3
ASSURE II CONTROL LEVEL 1 blood glucose calibration - liquid
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191
ASSURE LANCE LANCETS lancets
3
AUTOLET MINI - lancet devices
3
ASSURE LANCETS - lancets
AUTOPEN - injection device for
insulin
1
3
ASSURE PRISM CONTROL LEV blood glucose calibration - liquid
3
AUTOPEN - injection device for
insulin
3
A1C NOW - blood glucose
monitoring kit w/ device
3
B-D INSULIN SYRINGE MICRO insulin syringe/needle u-100 1 ml
28 x 1/2"
2
B-D INSULIN SYRINGE ULTRA insulin syringe/needle u-100 0.3
ml 30 x 1/2"
2
B-D INSULIN SYRINGE ULTRA insulin syringe/needle u-100 1 ml
31 x 5/16"
2
B-D INSULIN SYRINGE ULTRA insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
BAYER BREEZE 2 BLOOD GLUC
- blood glucose monitoring kit w/
device
3
BAYER BREEZE 2 HIGH CONTR
- blood glucose calibration - liquid
- high
3
BAYER BREEZE 2 LOW CONTRO
- blood glucose calibration - liquid
- low
3
BAYER BREEZE 2 NORMAL CON
- blood glucose calibration - liquid
- normal
3
BAYER CONTOUR BLOOD
GLUCO - blood glucose
monitoring kit w/ device
3
BAYER CONTOUR HIGH
CONTRO - blood glucose
calibration - liquid - high
3
BAYER CONTOUR LINK BLOOD
- blood glucose monitoring kit w/
device
3
ASSURE PRO CONTROL LEVEL - 3
blood glucose calibration - liquid
ASSURE 3 CONTROL LEVEL 1/ - 3
blood glucose calibration - liquid
ASSURE 4 CONTROL LEVEL 1/ - 3
blood glucose calibration - liquid
AT LAST CONTROL SOLUTION - 3
blood glucose calibration - liquid
3
AT LAST LANCETS - lancets
AURORA LANCET SUPER THIN lancets
3
AURORA LANCET THIN 23G lancets
3
AURORA PEN NEEDLES 29GX12
- insulin pen needle 29 g x 12
mm (1/2")
2
AURORA PEN NEEDLES 31G X insulin pen needle 31 g x 6 mm
(1/4")
2
AURORA PEN NEEDLES 31G X insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
AURORA UNIFINE PENTIPS/MI insulin pen needle 31 g x 5 mm
(3/16")
2
AURORA UNIFINE PENTIPS/32 insulin pen needle 32 g x 4 mm
(5/32")
2
AUTO-LANCET - lancet devices
3
AUTO-LANCET MINI - lancet
devices
3
AUTOLET IMPRESSION - lancet
devices
3
AUTOLET IMPRESSION LANCIN - 3
lancet devices
192
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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"Smart" PA
Drug Name
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Drug Tier
2015
BAYER CONTOUR LOW
CONTROL - blood glucose
calibration - liquid - low
3
BD AUTOSHIELD 29G X 3/16" insulin pen needle 29 g x 5 mm
(3/16")
2
BAYER CONTOUR NEXT BLOOD
- blood glucose monitoring kit w/
device
3
BD AUTOSHIELD 29G X 5/16" insulin pen needle 29 g x 8 mm
(5/16")
2
BAYER CONTOUR NEXT
CONTRO - blood glucose
calibration - liquid - normal
3
BD INSULIN SYRINGE LUER-L insulin syringe (disp) u-100 1 ml
2
3
BD INSULIN SYRINGE MICROF insulin syringe/needle u-100 0.3
ml 28 x 1/2"
2
BAYER CONTOUR NEXT
CONTRO - blood glucose
calibration - liquid - low
BAYER CONTOUR NEXT EZ BLO
- blood glucose monitoring kit w/
device
BD INSULIN SYRINGE MICROF insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
3
BAYER CONTOUR NEXT LINK B
- blood glucose monitoring kit w/
device
BD INSULIN SYRINGE MICROF insulin syringe/needle u-100 1 ml
27 x 5/8"
2
3
3
BD INSULIN SYRINGE MICROF insulin syringe/needle u-100 1 ml
28 x 1/2"
2
BAYER CONTOUR NEXT USB BL
- blood glucose monitoring kit w/
device
BAYER CONTOUR NORMAL
CONT - blood glucose calibration
- liquid - normal
BD INSULIN SYRINGE SAFETY insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
3
BAYER CONTOUR USB BLOOD
G - blood glucose monitoring kit
w/ device
BD INSULIN SYRINGE SAFETY insulin syringe/needle u-100 1 ml
29 x 1/2"
2
3
2
BAYER MICROLET LANCETS lancets
3
BD INSULIN SYRINGE SAFETY insulin syringe/needle u-100 0.3
ml 31 x 5/16"
BAYER MICROLET 2 LANCING lancet devices
3
BD INSULIN SYRINGE SLIP T insulin syringe (disp) u-100 1 ml
2
BD LO-DOSE INSULIN SYRIN insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
BD INSULIN SYRINGE U-40/1 insulin syringe/needle u-40 1 ml
25 x 5/8"
2
BD AUTOSHIELD DUO 30G X 3 insulin pen needle 30 g x 5 mm
(3/16")
2
BD INSULIN SYRINGE ULTRAF insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
BD AUTOSHIELD 29G X 1/2" insulin pen needle 29 g x 12 mm
(1/2")
2
BD INSULIN SYRINGE ULTRAF insulin syringe/needle u-100 0.3
ml 30 x 1/2"
2
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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Quantity Limits
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Prior Authorization
Drug Name
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Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
193
BD INSULIN SYRINGE ULTRAF insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
BD INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1 ml
27 x 1/2"
2
BD INSULIN SYRINGE ULTRAF insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
BD INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1 ml
28 x 1/2"
2
BD INSULIN SYRINGE ULTRAF insulin syringe/needle u-100 1/2
ml 30 x 1/2"
2
BD INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 2 ml
27.5 x 5/8"
2
BD INSULIN SYRINGE ULTRAF insulin syringe/needle u-100 0.3
ml 31 x 15/64"
2
BD INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 2 ml
29 x 1/2"
2
BD INSULIN SYRINGE ULTRAF insulin syringe/needle u-100 1 ml
29 x 1/2"
2
BD INTEGRA INSULIN SYRING insulin syringe/needle u-100 1 ml
29 x 1/2"
2
BD INSULIN SYRINGE ULTRAF insulin syringe/needle u-100 1 ml
30 x 1/2"
2
BD INTEGRA SYRINGE/RETRAC
- insulin syringe/needle u-100 1
ml 25 x 1"
2
BD INSULIN SYRINGE ULTRAF insulin syringe/needle u-100 1 ml
31 x 5/16"
2
BD LANCET DEVICE - lancet
devices
3
BD INSULIN SYRINGE ULTRAF insulin syringe/needle u-100 0.3
ml 31 x 5/16"
BD LANCET ULTRAFINE 30G lancets
3
2
BD LANCET ULTRAFINE 33G lancets
3
BD INSULIN SYRINGE ULTRAF insulin syringe/needle u-100 1/2
ml 31 x 15/64"
2
BD LATITUDE DIABETES MANA
- blood glucose monitoring kit w/
device
3
BD INSULIN SYRINGE ULTRAF insulin syringe/needle u-100 1 ml
31 x 15/64"
2
BD LOGIC BLOOD GLUCOSE MO
- blood glucose monitoring kit w/
device
3
BD INSULIN SYRINGE/DETACH insulin syringe/needle u-100 1 ml
25 x 5/8"
2
BD MICROTAINER LANCETS lancets
3
2
BD PEN - injection device for
insulin
3
BD INSULIN SYRINGE/DETACH insulin syringe/needle u-100 1 ml
25 x 1"
3
BD INSULIN SYRINGE/DETACH insulin syringe/needle u-100 1 ml
26 x 1/2"
2
BD PEN MINI - injection device for
insulin
2
BD INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1/2
ml 30 x 1/2"
2
BD PEN NEEDLE/MINI/ULTRAF insulin pen needle 31 g x 5 mm
(3/16")
BD PEN NEEDLE/NANO/ULTRA
- insulin pen needle 32 g x 4 mm
(5/32")
2
194
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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Specialty
Quantity Limits
"Smart" PA
Drug Name
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Drug Tier
2015
BD PEN NEEDLE/SHORT/ULTRA
- insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
BULLSEYE SAFETY LANCETS lancets
3
BD PEN NEEDLE/ULTRAFINE/2
- insulin pen needle 29 g x 12.7
mm
CARDIOCOM LANCING DEVICE lancet devices
3
2
2
BD PEN NEEDLES SHORT/ULTR
- insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
CAREFINE PEN NEEDLE 32GX4
- insulin pen needle 32 g x 4 mm
(5/32")
2
BD SAFETY-LOK INSULIN SYR insulin syringe/needle u-100 1 ml
29 x 1/2"
2
CAREFINE PEN NEEDLES 29GX
- insulin pen needle 29 g x 12
mm (1/2")
2
BD SAFETYGLIDE INSULIN SY insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
CAREFINE PEN NEEDLES 30GX
- insulin pen needle 30 g x 8 mm
(1/3" or 5/16")
2
BD ULTRA FINE LANCETS lancets
3
CAREFINE PEN NEEDLES 31GX
- insulin pen needle 31 g x 6 mm
(1/4")
1
CAREFINE PEN NEEDLES 31GX
- insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
BLOOD GLUCOSE MONITORING
- blood glucose monitoring kit w/
device
BLOOD GLUCOSE SYSTEM PAK
- blood glucose monitoring kit w/
device
CAREFINE PEN NEEDLES 32GX
- insulin pen needle 32 g x 5 mm
(1/5" or 3/16")
2
1
BREATHERITE - spacer/aerosolholding chambers - device
CAREFINE PEN NEEDLES 32GX
- insulin pen needle 32 g x 6 mm
(1/4")
2
3
BREATHERITE COLLAPSIBLE spacer/aerosol-holding chambers
- device
3
CAREONE ADVANCED LANCING
- lancet devices
3
3
CAREONE BLOOD GLUCOSE
MON - blood glucose monitoring
kit w/ device
3
BREATHERITE RIGID SPACER spacer/aerosol-holding chambers
- device
CAREONE LANCET THIN lancets
3
CAREONE LANCET ULTRA THIN
- lancets
3
CAREONE ULTIGUARD INSULIN
- insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
CAREONE ULTIGUARD INSULIN
- insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
BREATHERITE W/LARGE MASK - 3
spacer/aerosol-holding chambers
- device
3
BREATHERITE W/MEDIUM
MASK - spacer/aerosol-holding
chambers - device
BREATHERITE W/SMALL MASK - 3
spacer/aerosol-holding chambers
- device
BULLSEYE MINI SAFETY LANC - 3
lancets
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
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Drug Name
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Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
195
CAREONE ULTIGUARD INSULIN
- insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
CLEANLET LANCETS 28G lancets
3
CAREONE ULTIGUARD INSULIN
- insulin syringe/needle u-100 1/2
ml 30 x 5/16"
CLEVER CHEK BLOOD
GLUCOSE - blood glucose
monitoring kit w/ device
3
2
3
CAREONE ULTIGUARD INSULIN
- insulin syringe/needle u-100 1
ml 29 x 1/2"
2
CLEVER CHEK LANCETS ULTRA
- lancets
2
CAREONE ULTIGUARD INSULIN
- insulin syringe/needle u-100 1
ml 30 x 5/16"
2
CLEVER CHOICE COMFORT EZ
- insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
CAREONE UNIFINE PENTIPS P insulin pen needle 29 g x 12 mm
(1/2")
2
CLEVER CHOICE COMFORT EZ
- insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
CAREONE UNIFINE PENTIPS P
- insulin pen needle 31 g x 5 mm
(3/16")
2
CLEVER CHOICE COMFORT EZ
- insulin syringe/needle u-100 0.3
ml 30 x 1/2"
2
CAREONE UNIFINE PENTIPS P
- insulin pen needle 31 g x 6 mm
(1/4")
2
CLEVER CHOICE COMFORT EZ
- insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
CAREONE UNIFINE PENTIPS P
- insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
CLEVER CHOICE COMFORT EZ
- insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
CAREONE UNIFINE PENTIPS P
- insulin pen needle 32 g x 4 mm
(5/32")
2
CLEVER CHOICE COMFORT EZ
- insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
CAREONE UNIFINE PENTIPS 2 insulin pen needle 29 g x 12 mm
(1/2")
2
CLEVER CHOICE COMFORT EZ
- insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
CAREONE UNIFINE PENTIPS 3 insulin pen needle 31 g x 5 mm
(3/16")
2
CLEVER CHOICE COMFORT EZ
- insulin syringe/needle u-100 1/2
ml 30 x 1/2"
CAREONE UNIFINE PENTIPS 3 insulin pen needle 31 g x 6 mm
(1/4")
2
CAREONE UNIFINE PENTIPS 3 insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
CARESENS CONTROL A SOLUTI
- blood glucose calibration - liquid
3
196
CLEVER CHOICE COMFORT EZ - 2
insulin syringe/needle u-100 1 ml
28 x 1/2"
CLEVER CHOICE COMFORT EZ - 2
insulin syringe/needle u-100 1 ml
29 x 1/2"
CLEVER CHOICE COMFORT EZ - 2
insulin syringe/needle u-100 1 ml
30 x 5/16"
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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Specialty
Quantity Limits
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Drug Name
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2015
CLEVER CHOICE COMFORT EZ - 2
insulin syringe/needle u-100 1 ml
30 x 1/2"
CLEVER CHOICE COMFORT EZ - 2
insulin syringe/needle u-100 1 ml
31 x 5/16"
2
CLEVER CHOICE COMFORT EZ
- insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
CLEVER CHOICE COMFORT EZ
- insulin pen needle 31 g x 5 mm
(3/16")
2
CLEVER CHOICE COMFORT EZ
- insulin pen needle 31 g x 6 mm
(1/4")
2
CLEVER CHOICE COMFORT EZ
- insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
CLEVER CHOICE COMFORT EZ
- insulin pen needle 32 g x 4 mm
(5/32")
3
CLEVER CHOICE GLUCOSE
CON - blood glucose calibration liquid - high
3
CLEVER CHOICE GLUCOSE
CON - blood glucose calibration liquid - low
CLEVER CHOICE MICRO BLOOD 3
- blood glucose monitoring kit w/
device
CLICKFINE PEN NEEDLE UNIV - 2
insulin pen needle 31 g x 6 mm
(1/4")
CLICKFINE PEN NEEDLE UNIV - 2
insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
CLICKFINE PEN NEEDLE 32GX - 2
insulin pen needle 32 g x 4 mm
(5/32")
CLICKFINE PEN NEEDLES/31G - 2
insulin pen needle 31 g x 6 mm
(1/4")
CLICKFINE PEN NEEDLES/31G insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
CLICKFINE UNIVERSAL PEN N insulin pen needle 31 g x 6 mm
(1/4")
2
CLICKFINE UNIVERSAL PEN N insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
CLOSERCARE - lancet devices
3
COAGUCHEK LANCETS - lancets
2
COAGUCHEK LANCETS - lancets
3
COMFORT ASSURED LANCETS
M - lancets
3
COMFORT ASSURED LANCETS
S - lancets
3
COMFORT LANCETS - lancets
3
CONTROL BLOOD GLUCOSE
MON - blood glucose monitoring
kit w/ device
3
CONTROL SOLUTION NORMAL blood glucose calibration - liquid normal
3
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
3
CVS ADVANCED GLUCOSE
METE - blood glucose monitoring
kit w/ device
2
CVS INSULIN SYRINGE/0.3ML insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
CVS INSULIN SYRINGE/0.3ML insulin syringe/needle u-100 0.3
ml 30 x 1/2"
2
CVS INSULIN SYRINGE/0.5ML insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
CVS INSULIN SYRINGE/0.5ML insulin syringe/needle u-100 1/2
ml 30 x 1/2"
2
CVS INSULIN SYRINGE/1ML/2 insulin syringe/needle u-100 1 ml
29 x 1/2"
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
197
CVS LANCETS MICRO THIN 33 lancets
3
DRUG MART ON-THE-GO LANCE
- lancets
3
CVS LANCETS ORIGINAL lancets
3
2
CVS LANCETS THIN - lancets
3
DRUG MART ULTRA COMFORT I
- insulin syringe/needle u-100 0.3
ml 29 x 1/2"
CVS LANCETS THIN 26G lancets
3
2
CVS LANCETS ULTRA THIN 30 lancets
3
DRUG MART ULTRA COMFORT I
- insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
CVS LANCETS 21G - lancets
3
DRUG MART ULTRA COMFORT I
- insulin syringe/needle u-100 1/2
ml 31 x 5/16"
CVS LANCING DEVICE - lancet
devices
3
2
CVS ULTRA THIN LANCETS lancets
3
DRUG MART ULTRA COMFORT I
- insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
DIASTAR EASY TEST II LANC lancets
3
DRUG MART ULTRA COMFORT
I - insulin syringe/needle u-100 1
ml 29 x 1/2"
DRUG MART ULTRA COMFORT
I - insulin syringe/needle u-100 1
ml 30 x 5/16"
2
DRUG MART ULTRA COMFORT I
- insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
DRUG MART UNIFINE PENTIPS insulin pen needle 29 g x 12 mm
(1/2")
2
DRUG MART UNIFINE PENTIPS
- insulin pen needle 31 g x 5 mm
(3/16")
2
DRUG MART UNIFINE PENTIPS
- insulin pen needle 31 g x 6 mm
(1/4")
2
DRUG MART UNIFINE PENTIPS
- insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
DRUG MART UNIFINE PENTIPS
- insulin pen needle 32 g x 4 mm
(5/32")
2
DRUG MART UNILET LANCETS lancets
3
DUANE READE LANCET ALTERN
- lancets
3
DIASTAR EASY TEST LANCETS - 3
lancets
DIATRUE GLUCOSE CONTROL S 3
- blood glucose calibration - liquid
- high
DIATRUE GLUCOSE CONTROL S 3
- blood glucose calibration - liquid
- normal
DIATRUE GLUCOSE CONTROL S 3
- blood glucose calibration - liquid
- low
3
DIDGET - blood glucose
monitoring kit w/ device
DROPLET LANCETS ULTRA THI - 3
lancets
3
DROPLET LANCING DEVICE lancet devices
DRUG MART ADJUSTABLE LANC 3
- lancet devices
3
DRUG MART LANCETS THIN lancets
DRUG MART LANCETS ULTRA T 3
- lancets
198
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
DUANE READE LANCET SUPER
- lancets
3
DUANE READE LANCET ULTRA - 3
lancets
DUANE READE UNIFINE PENTI - 2
insulin pen needle 29 g x 12 mm
(1/2")
2
DUANE READE UNIFINE PENTI
- insulin pen needle 31 g x 6 mm
(1/4")
2
DUANE READE UNIFINE PENTI
- insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
3
DUO-CARE CONTROL
SOLUTION - blood glucose
calibration - liquid
3
E-Z JECT LANCETS - lancets
EASIVENT/MASK-SMALL spacer/aerosol-holding chambers
- device
3
EASY COMFORT INSULIN SYRI insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
EASY COMFORT INSULIN SYRI insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
EASY COMFORT INSULIN SYRI insulin syringe/needle u-100 1/2
ml 30 x 1/2"
2
EASY COMFORT INSULIN SYRI insulin syringe/needle u-100 1 ml
30 x 5/16"
2
EASY COMFORT INSULIN SYRI insulin syringe/needle u-100 1 ml
30 x 1/2"
2
EASY COMFORT LANCETS lancets
3
EASY COMFORT PEN NEEDLES
- insulin pen needle 31 g x 5 mm
(3/16")
2
EASY COMFORT PEN NEEDLES
- insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
2
E-Z JECT LANCETS COLOR lancets
3
E-Z JECT LANCETS SUPER TH lancets
3
E-Z JECT LANCETS THIN 26G lancets
3
E-Z JECT LANCETS 21G - lancets
3
E-Z SPACER - spacer/aerosolholding chambers - device
3
E-Z SPACER THE BODY GUARD
- spacer/aerosol-holding
chambers - device
3
EASY COMFORT PEN NEEDLES
- insulin pen needle 32 g x 4 mm
(5/32")
E-ZJECT LANCETS MICRO-THI lancets
EASY MINI LANCING DEVICE lancet devices
3
3
EASIVENT - spacer/aerosolholding chambers - device
EASY PLUS BLOOD GLUCOSE M
- blood glucose monitoring kit w/
device
3
3
EASIVENT/MASK-LARGE spacer/aerosol-holding chambers
- device
3
EASY PLUS CONTROL SOLUTIO
- blood glucose calibration - liquid
- high
3
EASIVENT/MASK-MEDIUM spacer/aerosol-holding chambers
- device
3
EASY PLUS CONTROL SOLUTIO
- blood glucose calibration - liquid
- normal
3
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
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Drug Name
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Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
199
EASY PLUS CONTROL SOLUTIO
- blood glucose calibration - liquid
- low
3
EASY PLUS II CONTROL SOLU blood glucose calibration - liquid
- high
3
EASY PLUS II CONTROL SOLU blood glucose calibration - liquid
- low
3
EASY STEP BLOOD GLUCOSE M
- blood glucose monitoring kit w/
device
3
EASY STEP CONTROL SOLUTIO
- blood glucose calibration - liquid
- high
3
EASY STEP CONTROL SOLUTIO
- blood glucose calibration - liquid
- normal
3
EASY STEP CONTROL SOLUTIO
- blood glucose calibration - liquid
- low
3
EASY TALK BLOOD GLUCOSE M
- blood glucose monitoring kit w/
device
3
EASY TALK CONTROL SOLUTIO
- blood glucose calibration - liquid
- high
3
EASY TALK CONTROL SOLUTIO
- blood glucose calibration - liquid
- normal
3
EASY TALK CONTROL SOLUTIO
- blood glucose calibration - liquid
- low
3
EASY TOUCH CONTROL SOLUTI
- blood glucose calibration - liquid
3
EASY TOUCH GLUCOSE
MONITO - blood glucose
monitoring kit w/ device
3
3
EASY TOUCH HEALTHPRO
CONT - blood glucose calibration
- liquid
200
3
EASY TOUCH HEALTHPRO
GLUC - blood glucose monitoring
kit w/ device
EASY TOUCH INSULIN SYRING - 2
insulin syringe/needle u-100 0.3
ml 30 x 5/16"
EASY TOUCH INSULIN SYRING - 2
insulin syringe/needle u-100 0.3
ml 30 x 1/2"
EASY TOUCH INSULIN SYRING - 2
insulin syringe/needle u-100 1/2
ml 27 x 1/2"
EASY TOUCH INSULIN SYRING - 2
insulin syringe/needle u-100 1/2
ml 31 x 5/16"
EASY TOUCH INSULIN SYRING - 2
insulin syringe/needle u-100 1/2
ml 28 x 1/2"
EASY TOUCH INSULIN SYRING - 2
insulin syringe/needle u-100 1/2
ml 29 x 1/2"
EASY TOUCH INSULIN SYRING - 2
insulin syringe/needle u-100 1/2
ml 30 x 5/16"
EASY TOUCH INSULIN SYRING - 2
insulin syringe/needle u-100 1/2
ml 30 x 1/2"
EASY TOUCH INSULIN SYRING - 2
insulin syringe/needle u-100 1 ml
27 x 1/2"
EASY TOUCH INSULIN SYRING - 2
insulin syringe/needle u-100 1 ml
28 x 1/2"
EASY TOUCH INSULIN SYRING - 2
insulin syringe/needle u-100 1 ml
29 x 1/2"
EASY TOUCH INSULIN SYRING - 2
insulin syringe/needle u-100 1 ml
30 x 5/16"
EASY TOUCH INSULIN SYRING - 2
insulin syringe/needle u-100 1 ml
30 x 1/2"
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
EASY TOUCH INSULIN SYRING insulin syringe/needle u-100 1 ml
31 x 5/16"
2
EASY TOUCH PEN NEEDLES 32
- insulin pen needle 32 g x 5 mm
(1/5" or 3/16")
2
EASY TOUCH INSULIN SYRING insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
EASY TOUCH PEN NEEDLES 32
- insulin pen needle 32 g x 6 mm
(1/4")
2
EASY TOUCH LANCETS - lancets
3
2
EASY TOUCH LANCETS 21G/PR
- lancets
3
EASY TOUCH PEN NEEDLES/31
- insulin pen needle 31 g x 5 mm
(3/16")
EASY TOUCH LANCETS 23G/PR
- lancets
3
EASY TOUCH SAFETY LANCETS
- lancets
3
EASY TOUCH LANCETS 26G/PR
- lancets
3
2
EASY TOUCH LANCETS 28G/PR
- lancets
3
EASY TOUCH 32GX5MM - insulin
pen needle 32 g x 5 mm (1/5" or
3/16")
2
EASY TOUCH LANCETS 28G/TW
- lancets
3
EASY TOUCH 32GX6MM - insulin
pen needle 32 g x 6 mm (1/4")
3
EASY TOUCH LANCETS 30G/PR
- lancets
3
EASY TRAK BLOOD GLUCOSE M
- blood glucose monitoring kit w/
device
3
EASY TRAK GLUCOSE
CONTROL - blood glucose
calibration - liquid - high
3
EASY TOUCH LANCETS 30G/TW
- lancets
EASY TOUCH LANCETS 32G/PR
- lancets
3
3
EASY TOUCH LANCETS 32G/TW
- lancets
3
EASY TRAK GLUCOSE
CONTROL - blood glucose
calibration - liquid - normal
3
EASY TOUCH LANCETS 33G/TW
- lancets
3
EASY TRAK GLUCOSE
CONTROL - blood glucose
calibration - liquid - low
EASY TOUCH LANCING DEVICE
- lancet devices
3
EASY TWIST & CAP LANCETS lancets
3
EASY TOUCH PEN NEEDLES 29
- insulin pen needle 29 g x 12
mm (1/2")
2
EASYGLUCO CONTROL
SOLUTIO - blood glucose
calibration - liquid - high
3
EASY TOUCH PEN NEEDLES 31
- insulin pen needle 31 g x 6 mm
(1/4")
2
EASYGLUCO CONTROL
SOLUTIO - blood glucose
calibration - liquid - normal
3
EASY TOUCH PEN NEEDLES 31
- insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
EASYGLUCO CONTROL
SOLUTIO - blood glucose
calibration - liquid - low
3
EASY TOUCH PEN NEEDLES 32
- insulin pen needle 32 g x 4 mm
(5/32")
2
EASYMAX CONTROL SOLUTION
- blood glucose calibration - liquid
- high
3
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Quantity Limits
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201
EASYMAX CONTROL SOLUTION
- blood glucose calibration - liquid
- normal
3
ECLIPSE HIGH CONTROL - blood
glucose calibration - liquid - high
3
EASYMAX CONTROL SOLUTION
- blood glucose calibration - liquid
- low
ECLIPSE LOW CONTROL - blood
glucose calibration - liquid - low
3
3
3
EASYMAX L BLOOD GLUCOSE S
- blood glucose monitoring kit w/
device
3
ECLIPSE NORMAL CONTROL blood glucose calibration - liquid
- normal
3
EASYMAX N BLOOD GLUCOSE S
- blood glucose monitoring kit w/
device
3
ELEMENT AUTOCODE SYSTEM
- blood glucose monitoring kit w/
device
3
EASYMAX NG SELF-MONITORIN
- blood glucose monitoring kit w/
device
3
ELEMENT COMPACT CONTROL
S - blood glucose calibration liquid
3
EASYMAX V BLOOD GLUCOSE S
- blood glucose monitoring kit w/
device
3
ELEMENT HIGH CONTROL blood glucose calibration - liquid
- high
3
EASYMAX V2 SELF-MONITORIN
- blood glucose monitoring kit w/
device
3
ELEMENT LOW CONTROL blood glucose calibration - liquid
- low
3
EASYMAX 15 LEVEL 1 GLUCOS blood glucose calibration - liquid
3
ELEMENT NORMAL CONTROL blood glucose calibration - liquid normal
EASYMAX 15 LEVEL 2 GLUCOS blood glucose calibration - liquid
ELEMENT PLUS CONTROL
SOLU - blood glucose calibration
- liquid - high
3
3
EASYPLUS R13N SELF-MONITO
- blood glucose monitoring kit w/
device
3
ELEMENT PLUS CONTROL
SOLU - blood glucose calibration
- liquid - normal
3
EASYPLUS V SELF-MONITORIN
- blood glucose monitoring kit w/
device
3
ELEMENT PLUS CONTROL
SOLU - blood glucose calibration
- liquid - low
3
EASYPRO BLOOD GLUCOSE
MON - blood glucose monitoring
kit w/ device
3
ELITE-THIN INSULIN SYRING insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
EASYPRO PLUS - blood glucose
monitoring kit w/ device
3
2
EASYTEST II LANCETS - lancets
3
ELITE-THIN INSULIN SYRING insulin syringe/needle u-100 1/2
ml 28 x 5/16"
EASYTEST LANCETS - lancets
3
2
ECLIPSE BLOOD GLUCOSE
MON - blood glucose monitoring
kit w/ device
3
ELITE-THIN INSULIN SYRING insulin syringe/needle u-100 1/2
ml 28 x 1/2"
202
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ELITE-THIN INSULIN SYRING insulin syringe/needle u-100 1/2
ml 29 x 5/16"
2
ENVISION AUTOCODE - blood
glucose monitoring kit w/ device
3
ELITE-THIN INSULIN SYRING insulin syringe/needle u-100 1/2
ml 29 x 1/2"
ENVISION CONTROL HIGH blood glucose calibration - liquid
- high
3
2
3
ELITE-THIN INSULIN SYRING insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
ENVISION CONTROL LOW blood glucose calibration - liquid
- low
2
ENVISION CONTROL NORMAL blood glucose calibration - liquid normal
3
ELITE-THIN INSULIN SYRING insulin syringe/needle u-100 1 ml
28 x 5/16"
ELITE-THIN INSULIN SYRING insulin syringe/needle u-100 1 ml
28 x 1/2"
EQL COLOR LANCETS MICRO T
- lancets
3
2
EQL COLOR LANCETS 21G lancets
3
ELITE-THIN INSULIN SYRING insulin syringe/needle u-100 1 ml
29 x 1/2"
2
EQL INSULIN SYRINGE/U-100 insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
ELITE-THIN INSULIN SYRING insulin syringe/needle u-100 1 ml
29 x 5/16"
2
EQL INSULIN SYRINGE/U-100 insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
ELITE-THIN INSULIN SYRING insulin syringe/needle u-100 1 ml
30 x 5/16"
2
EQL INSULIN SYRINGE/U-100 insulin syringe/needle u-100 1 ml
29 x 1/2"
2
ELITE-THIN INSULIN SYRING insulin syringe/needle u-100 1 ml
31 x 5/16"
2
EQL INSULIN SYRINGE/0.3ML insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
ELITE-THIN INSULIN SYRING insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
EQL INSULIN SYRINGE/0.3ML insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
EMBRACE CONTROL SOLUTION
- blood glucose calibration - liquid
- low
3
EQL INSULIN SYRINGE/0.3ML insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
EMBRACE EVO BLOOD
GLUCOSE - blood glucose
monitoring kit w/ device
3
EQL INSULIN SYRINGE/0.5ML insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
EMBRACE LANCETS ULTRA THI
- lancets
3
2
EMBRACE PRO GLUCOSE
CONTR - blood glucose
calibration - liquid
3
EQL INSULIN SYRINGE/0.5ML insulin syringe/needle u-100 1/2
ml 29 x 1/2"
EQL INSULIN SYRINGE/0.5ML insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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Specialty
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203
EQL INSULIN SYRINGE/1ML/2 insulin syringe/needle u-100 1 ml
29 x 1/2"
2
EXEL INSULIN PEN NEEDLES insulin pen needle 31 g x 6 mm
(1/4")
2
EQL INSULIN SYRINGE/1ML/3 insulin syringe/needle u-100 1 ml
30 x 5/16"
2
EXEL INSULIN PEN NEEDLES insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
EQL INSULIN SYRINGE/1ML/3 insulin syringe/needle u-100 1 ml
31 x 5/16"
2
EXEL INSULIN SYRINGE/0.3M insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
EQL SHORT PEN NEEDLES 31G
- insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
EXEL INSULIN SYRINGE/0.3M insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
EQL SUPER THIN LANCETS 30 lancets
3
EXEL INSULIN SYRINGE/0.5M insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
EXEL INSULIN SYRINGE/0.5M insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
EXEL INSULIN SYRINGE/0.5M insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
EXEL INSULIN SYRINGE/1ML/ insulin syringe/needle u-100 1 ml
28 x 1/2"
2
EXEL INSULIN SYRINGE/1ML/ insulin syringe/needle u-100 1 ml
29 x 1/2"
2
EXEL INSULIN SYRINGE/1ML/ insulin syringe/needle u-100 1 ml
30 x 5/16"
2
EZ SMART BLOOD GLUCOSE LA
- lancets
3
EZ-LETS LANCETS 21G - lancets
3
EZ-LETS LANCETS 23G - lancets
3
EZ-LETS LANCETS 26G SUPER lancets
3
EZ-LETS LANCETS 28G ULTRA lancets
3
EZ-LETS LANCETS 30G - lancets
3
EQL THIN LANCETS 26G - lancets 3
3
EQL TRUE2GO BLOOD
GLUCOSE - blood glucose
monitoring kit w/ device
EQL ULTRA COMFORT INSULIN - 2
insulin syringe/needle u-100 1 ml
30 x 5/16"
2
EQL ULTRA COMFORT INSULIN
- insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
EQL ULTRA SHORT PEN NEEDL
- insulin pen needle 31 g x 6 mm
(1/4")
3
EVENCARE CONTROL
SOLUTION - blood glucose
calibration - liquid
3
EVENCARE G2 GLUCOSE
CONTR - blood glucose
calibration - liquid
3
EVENCARE G3 GLUCOSE
CONTR - blood glucose
calibration - liquid
EVOLUTION CONTROL SOLUTIO 3
- blood glucose calibration - liquid
- normal
2
EXEL INSULIN PEN NEEDLES insulin pen needle 29 g x 12 mm
(1/2")
204
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Specialty
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"Smart" PA
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Drug Tier
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FASTTAKE COMPACT MONITORI
- blood glucose monitoring kit w/
device
2
FC FEMALE CONDOM - condoms
- female
A
FC2 FEMALE CONDOM condoms - female
A
FEMCAP - cervical cap 22 mm
A
FEMCAP - cervical cap 26 mm
A
FEMCAP - cervical cap 30 mm
A
FIFTY50 CONTROL SOLUTION blood glucose calibration - liquid
3
FIFTY50 GLUCOSE METER 2.0 blood glucose monitoring kit w/
device
3
FIFTY50 LANCING DEVICE lancet devices
3
FIFTY50 PEN NEEDLES 31G X insulin pen needle 31 g x 5 mm
(3/16")
2
FIFTY50 PEN NEEDLES 31G X insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
FIFTY50 SAFETY SEAL LANCE lancets
3
FIFTY50 SUPERIOR COMFORT insulin syringe/needle u-100 1/2
ml 31 x 5/16"
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
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Drug Name
Drug Tier
2015
3
FORA CONTROL SOLUTION
LOW - blood glucose calibration liquid - low
3
FORA CONTROL SOLUTION
NOR - blood glucose calibration liquid - normal
3
FORA G20 BLOOD GLUCOSE
MO - blood glucose monitoring
kit w/ device
FORA G71A BLOOD GLUCOSE M 3
- blood glucose monitoring kit w/
device
3
FORA LANCETS - lancets
FORA LANCING DEVICE - lancet
devices
3
FORA V22 BLOOD GLUCOSE MO
- blood glucose monitoring kit w/
device
3
FORA V30A BLOOD GLUCOSE M
- blood glucose monitoring kit w/
device
3
FORACARE GDH CONTROL
SOLU - blood glucose calibration
- liquid - high
3
3
2
FORACARE GDH CONTROL
SOLU - blood glucose calibration
- liquid - normal
3
FIFTY50 SUPERIOR COMFORT insulin syringe/needle u-100 1 ml
31 x 5/16"
2
FORACARE GDH CONTROL
SOLU - blood glucose calibration
- liquid - low
3
FIFTY50 SUPERIOR COMFORT insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
FORTISCARE CONTROL SOLUTI
- blood glucose calibration - liquid
- high
3
FINE 30 - lancets
3
FORTISCARE CONTROL SOLUTI
- blood glucose calibration - liquid
- normal
FINGERSTIX LANCETS - lancets
3
3
FORA CONTROL SOLUTION HIG
- blood glucose calibration - liquid
- high
3
FORTISCARE CONTROL SOLUTI
- blood glucose calibration - liquid
- low
FORTISCARE SELF-MONITORIN
- blood glucose monitoring kit w/
device
3
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205
FREDS PHARMACY AUTOLET LA
- lancet devices
3
GENTLE-LET GP LANCETS lancets
3
FREDS PHARMACY UNIFINE PE
- insulin pen needle 31 g x 5 mm
(3/16")
2
GENTLE-LET LANCETS GENERA
- lancets
3
FREDS PHARMACY UNIFINE PE
- insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
GENTLE-LET LANCETS SAFETY
- lancets
3
2
3
FREDS PHARMACY UNIFINE PE
- insulin pen needle 32 g x 4 mm
(5/32")
2
GE100 BLOOD GLUCOSE MONIT
- blood glucose monitoring kit w/
device
3
FREDS PHARMACY UNILET LAN
- lancets
3
GE100 CONTROL SOLUTION NO
- blood glucose calibration - liquid
- normal
FREESTYLE CONTROL SOLUTIO
- blood glucose calibration - liquid
GHT BLOOD GLUCOSE MONITO
- blood glucose monitoring kit w/
device
3
3
FREESTYLE FREEDOM - blood
glucose monitoring kit w/ device
3
2
FREESTYLE FREEDOM LITE blood glucose monitoring kit w/
device
3
GLOBAL EASE INJECT PEN NE insulin pen needle 29 g x 12 mm
(1/2")
2
FREESTYLE INSULINX BLOOD blood glucose monitoring kit w/
device
3
GLOBAL EASE INJECT PEN NE
- insulin pen needle 31 g x 5 mm
(3/16")
2
FREESTYLE LANCETS - lancets
3
GLOBAL EASE INJECT PEN NE
- insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
FREESTYLE PRECISION INSUL insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
GLOBAL EASE INJECT PEN NE
- insulin pen needle 32 g x 4 mm
(5/32")
2
FREESTYLE PRECISION INSUL insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
GLOBAL INJECT EASE INSULI insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
FREESTYLE PRECISION INSUL insulin syringe/needle u-100 1 ml
30 x 5/16"
2
GLOBAL INJECT EASE INSULI insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
FREESTYLE PRECISION INSUL insulin syringe/needle u-100 1 ml
31 x 5/16"
2
GLOBAL INJECT EASE INSULI insulin syringe/needle u-100 0.3
ml 30 x 1/2"
2
FREESTYLE SIDEKICK II VAL blood glucose monitoring kit w/
device
3
GLOBAL INJECT EASE INSULI insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
FREESTYLE UNISTICK II LAN lancets
3
GLOBAL INJECT EASE INSULI insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
206
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Specialty
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2015
GLOBAL INJECT EASE INSULI insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
GLUCOCARD VITAL BLOOD GLU
- blood glucose monitoring kit w/
device
3
GLOBAL INJECT EASE INSULI insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
GLUCOCARD X-METER - blood
glucose monitoring kit w/ device
3
3
GLOBAL INJECT EASE INSULI insulin syringe/needle u-100 1/2
ml 30 x 1/2"
2
GLUCOCARD X-METER
CONTROL - blood glucose
calibration - liquid - normal
2
GLUCOCARD 01 BLOOD
GLUCOS - blood glucose
monitoring kit w/ device
3
GLOBAL INJECT EASE INSULI insulin syringe/needle u-100 1 ml
28 x 1/2"
GLOBAL INJECT EASE INSULI insulin syringe/needle u-100 1 ml
29 x 1/2"
GLUCOCARD 01 CONTROL
SOLU - blood glucose calibration
- liquid
3
2
GLOBAL INJECT EASE INSULI insulin syringe/needle u-100 1 ml
30 x 5/16"
GLUCOCARD 01 CONTROL
SOLU - blood glucose calibration
- liquid - normal
3
2
2
GLUCOCARD 01-MINI BLOOD G
- blood glucose monitoring kit w/
device
3
GLOBAL INJECT EASE INSULI insulin syringe/needle u-100 1 ml
30 x 1/2"
GLOBAL INJECT EASE INSULI insulin syringe/needle u-100 1 ml
31 x 5/16"
GLUCOCOM BLOOD GLUCOSE
MO - blood glucose monitoring
kit w/ device
3
2
GLOBAL INJECT EASE INSULI insulin syringe/needle u-100 0.3
ml 31 x 5/16"
GLUCOCOM HIGH CONTROL blood glucose calibration - liquid
- high
3
2
3
GLOBAL INJECT EASE LANCET lancets
3
GLUCOCOM LANCETS 28G lancets
3
GLUCOCOM LANCETS 30G lancets
3
GLOBAL LANCING DEVICE lancet devices
GLUCOCARD EXPRESSION
AUDI - blood glucose monitoring
kit w/ device
GLUCOCOM LANCETS 33G lancets
3
3
GLUCOCOM NORMAL CONTROL
- blood glucose calibration - liquid
- normal
3
GLUCOLAB HIGH CONTROL blood glucose calibration - liquid
- high
3
GLUCOLAB LOW CONTROL blood glucose calibration - liquid
- low
3
3
GLUCOCARD EXPRESSION
CONT - blood glucose calibration
- liquid
3
GLUCOCARD SHINE - blood
glucose monitoring kit w/ device
3
GLUCOCARD SHINE CONTROL
S - blood glucose calibration liquid
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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Specialty
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207
GLUCOLAB NORMAL CONTROL
- blood glucose calibration - liquid
- normal
3
GLUCOLET 2 AUTOMATIC LANC
- lancet devices
3
GLUCONAVII BLOOD GLUCOSE
- blood glucose monitoring kit w/
device
3
GLUCOPRO INSULIN SYRINGE/
- insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
GLUCOPRO INSULIN SYRINGE/
- insulin syringe/needle u-100 0.3
ml 30 x 1/2"
2
GLUCOPRO INSULIN SYRINGE/
- insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
GLUCOPRO INSULIN SYRINGE/
- insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
GLUCOPRO INSULIN SYRINGE/
- insulin syringe/needle u-100 1/2
ml 30 x 1/2"
2
GLUCOPRO INSULIN SYRINGE/ - 2
insulin syringe/needle u-100 1 ml
30 x 5/16"
GLUCOPRO INSULIN SYRINGE/ - 2
insulin syringe/needle u-100 1 ml
30 x 1/2"
GLUCOPRO INSULIN SYRINGE/ - 2
insulin syringe/needle u-100 1 ml
31 x 5/16"
2
GLUCOPRO INSULIN SYRINGE/
- insulin syringe/needle u-100 0.3
ml 31 x 5/16"
GLUCOSE CONTROL NORMAL - 1
blood glucose calibration - liquid normal
GLUCOSE CONTROL SOLUTION 1
- blood glucose calibration - liquid
3
GLUCOSOURCE LANCET
DEVICE - lancet devices
208
GLUCOSOURCE LANCETS lancets
3
GMATE CONTROL SOLUTION LE
- blood glucose calibration - liquid
3
GMATE LANCETS 30G - lancets
3
GMATE LANCING DEVICE lancet devices
3
GMATE SMART STARTER KIT blood glucose monitoring kit w/
device
3
GNP CLICKFINE PEN NEEDLE insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
GNP CLICKFINE UNIVERSAL P insulin pen needle 31 g x 6 mm
(1/4")
2
GNP CLICKFINE UNIVERSAL P insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
GNP INSULIN SYRINGE/0.3ML insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
GNP INSULIN SYRINGE/0.3ML insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
GNP INSULIN SYRINGE/0.3ML insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
GNP INSULIN SYRINGE/0.5ML insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
GNP INSULIN SYRINGE/0.5ML insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
GNP INSULIN SYRINGE/0.5ML insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
GNP INSULIN SYRINGE/0.5ML insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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Specialty
Quantity Limits
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2015
GNP INSULIN SYRINGE/1ML/2 insulin syringe/needle u-100 1 ml
28 x 1/2"
2
GNP ULTRA COMFORT INSULIN
- insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
GNP INSULIN SYRINGE/1ML/2 insulin syringe/needle u-100 1 ml
29 x 1/2"
2
GNP ULTRA COMFORT INSULIN
- insulin syringe/needle u-100 1
ml 28 x 1/2"
2
GNP INSULIN SYRINGE/1ML/3 insulin syringe/needle u-100 1 ml
30 x 5/16"
2
GNP ULTRA COMFORT INSULIN
- insulin syringe/needle u-100 1
ml 29 x 1/2"
2
GNP INSULIN SYRINGE/1ML/3 insulin syringe/needle u-100 1 ml
31 x 5/16"
2
GNP ULTRA COMFORT INSULIN
- insulin syringe/needle u-100 1
ml 30 x 5/16"
2
GNP LANCETS - lancets
3
2
GNP LANCETS MICRO THIN 33 lancets
3
GNP ULTRA COMFORT INSULIN
- insulin syringe/needle u-100 1
ml 31 x 5/16"
GNP LANCETS SUPER THIN 30 lancets
3
2
GNP LANCETS THIN - lancets
3
GNP ULTRA COMFORT INSULIN
- insulin syringe/needle u-100 0.3
ml 31 x 5/16"
3
H&H THINLET LANCETS 26G lancets
3
GNP LANCETS THIN 26G lancets
3
H&H THINLET SUPER THIN LA lancets
3
GNP LANCETS 21G - lancets
GNP MICRO THIN LANCETS 33 lancets
3
2
GNP SUPER THIN LANCETS/30 lancets
3
H-E-B IN CONTROL PEN NEED insulin pen needle 31 g x 5 mm
(3/16")
2
GNP ULTRA COMFORT INSULIN
- insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
H-E-B IN CONTROL PEN NEED insulin pen needle 31 g x 6 mm
(1/4")
2
H-E-B IN CONTROL PEN NEED insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
GNP ULTRA COMFORT INSULIN
- insulin syringe/needle u-100 0.3
ml 30 x 5/16"
GNP ULTRA COMFORT INSULIN
- insulin syringe/needle u-100 1/2
ml 31 x 5/16"
H-E-B IN CONTROL PEN NEED insulin pen needle 32 g x 4 mm
(5/32")
2
2
GNP ULTRA COMFORT INSULIN
- insulin syringe/needle u-100 1/2
ml 28 x 1/2"
H-E-B INCONTROL ADVANCED lancet devices
3
2
H-E-B INCONTROL LANCETS S lancets
3
GNP ULTRA COMFORT INSULIN
- insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
H-E-B INCONTROL LANCETS U lancets
3
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
209
H-E-B INCONTROL PEN NEEDL insulin pen needle 29 g x 12 mm
(1/2")
2
HEALTHY ACCENTS UNIFINE P
- insulin pen needle 31 g x 6 mm
(1/4")
2
HAEMOLANCE - lancets
3
2
HAEMOLANCE LOW FLOW
LANCE - lancets
3
HEALTHY ACCENTS UNIFINE P
- insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
HAEMOLANCE PLUS - lancets
3
2
HAEMOLANCE PLUS HIGH
FLOW - lancets
3
HEALTHY ACCENTS UNIFINE P
- insulin pen needle 32 g x 4 mm
(5/32")
HAEMOLANCE PLUS LOW FLOW
- lancets
3
HAEMOLANCE PLUS MAX FLOW
- lancets
3
HAEMOLANCE PLUS PEDIATRIC
- lancets
3
HEALTH CARE LANCING DEVIC - 3
lancet devices
3
HEALTHWISE LANCETS 30G lancets
3
HEALTHWISE LANCING PEN lancet devices
2
HEALTHWISE MINI PEN NEEDL
- insulin pen needle 31 g x 6 mm
(1/4")
2
HEALTHWISE PEN NEEDLES 29
- insulin pen needle 29 g x 12
mm (1/2")
HEALTHWISE SHORT PEN NEED 2
- insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
HEALTHWISE UNIFINE PENTIP - 2
insulin pen needle 32 g x 4 mm
(5/32")
HEALTHY ACCENTS AUTOLET I - 3
lancet devices
HEALTHY ACCENTS UNIFINE P - 2
insulin pen needle 29 g x 12 mm
(1/2")
2
HEALTHY ACCENTS UNIFINE P
- insulin pen needle 31 g x 5 mm
(3/16")
210
HEALTHY ACCENTS UNILET LA - 3
lancets
HM LANCETS MICRO THIN 33G - 3
lancets
HM LANCETS ULTRA THIN 30G - 3
lancets
HUMAPEN LUXURA HD - injection 3
device for insulin
3
HY-VEE LANCETS - lancets
HY-VEE THIN LANCETS - lancets
3
IBG STAR BLOOD GLUCOSE MO
- blood glucose monitoring kit w/
device
3
INFINITY BLOOD GLUCOSE MO
- blood glucose monitoring kit w/
device
3
INFINITY CONTROL SOLUTION blood glucose calibration - liquid
- high
3
INFINITY CONTROL SOLUTION blood glucose calibration - liquid normal
3
INFINITY CONTROL SOLUTION blood glucose calibration - liquid
- low
3
INSPIREASE DRUG DELIVERY spacer/aerosol-holding chambers
- device
3
INSULIN SYRINGE/U-100/0.3 insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
INSULIN SYRINGE/U-100/0.5 insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
INSULIN SYRINGE/0.5ML/30G insulin syringe/needle u-100 1/2
ml 30 x 1/2"
2
INSULIN SYRINGE/U-100/0.5 insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
INSULIN SYRINGE/0.5ML/31G insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
INSULIN SYRINGE/U-100/1ML insulin syringe/needle u-100 1 ml
28 x 1/2"
2
INSULIN SYRINGE/1ML/28G X insulin syringe/needle u-100 1 ml
28 x 1/2"
2
INSULIN SYRINGE/U-100/1ML insulin syringe/needle u-100 1 ml
29 x 1/2"
2
INSULIN SYRINGE/1ML/29G X insulin syringe/needle u-100 1 ml
29 x 1/2"
2
INSULIN SYRINGE/U-100/1ML insulin syringe/needle u-100 1 ml
30 x 5/16"
2
INSULIN SYRINGE/1ML/30G X insulin syringe/needle u-100 1 ml
30 x 5/16"
2
INSULIN SYRINGE/U-100/1ML insulin syringe/needle u-100 1 ml
31 x 5/16"
2
INSULIN SYRINGE/1ML/31G X insulin syringe/needle u-100 1 ml
31 x 5/16"
2
INSULIN SYRINGE/0.3ML/29G insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
INSUPEN PEN NEEDLES 32G X
- insulin pen needle 32 g x 4 mm
(5/32")
2
INSULIN SYRINGE/0.3ML/29G insulin syringe/needle u-100 0.3
ml 29 x 1"
2
INSUPEN SENSITIVE 32GX6MM
- insulin pen needle 32 g x 6 mm
(1/4")
2
INSULIN SYRINGE/0.3ML/30G insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
INSULIN SYRINGE/0.3ML/31G insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
INSULIN SYRINGE/0.5ML/27G insulin syringe/needle u-100 1/2
ml 27 x 1/2"
2
INSULIN SYRINGE/0.5ML/28G insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
INSULIN SYRINGE/0.5ML/29G insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
INSULIN SYRINGE/0.5ML/30G insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
INSUPEN SENSITIVE 32GX8MM - 2
insulin pen needle 32 g x 8 mm
2
INSUPEN ULTRAFIN 29GX12MM
- insulin pen needle 29 g x 12
mm (1/2")
INSUPEN ULTRAFIN 30GX8MM - 2
insulin pen needle 30 g x 8 mm
(1/3" or 5/16")
INSUPEN ULTRAFIN 31GX6MM - 2
insulin pen needle 31 g x 6 mm
(1/4")
INSUPEN ULTRAFIN 31GX8MM - 2
insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
INSUPEN 33GX4MM - insulin pen 2
needle 33 g x 4 mm (5/32")
3
KINNEY LANCETS - lancets
KINNEY THIN LANCETS - lancets
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
3
211
KINRAY INSULIN SYRINGE PR insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
KROGER INSULIN SYRINGE/0. insulin syringe/needle u-100 0.3
ml 31 x 5/16"
KINRAY INSULIN SYRINGE PR insulin syringe/needle u-100 1 ml
31 x 5/16"
2
KINRAY INSULIN SYRINGE PR insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
KINRAY INSULIN SYRINGE/0. insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
KMART VALU PLUS INSULIN S insulin syringe (disp) u-100 0.3
ml
2
KROGER INSULIN SYRINGE/1M - 2
insulin syringe/needle u-100 1 ml
29 x 1/2"
KROGER INSULIN SYRINGE/1M - 2
insulin syringe/needle u-100 1 ml
30 x 5/16"
KROGER INSULIN SYRINGE/1M - 2
insulin syringe/needle u-100 1 ml
31 x 5/16"
3
KROGER LANCETS - lancets
KMART VALU PLUS INSULIN S insulin syringe (disp) u-100 1/2
ml
2
KMART VALU PLUS INSULIN S insulin syringe (disp) u-100 1 ml
3
KROGER LANCETS SUPER THIN
- lancets
3
2
KROGER LANCETS THIN lancets
3
3
KROGER LANCETS THIN 26G lancets
3
KROGER BLOOD GLUCOSE
MONI - blood glucose monitoring
kit w/ device
KROGER INSULIN SYRINGE/U- insulin syringe/needle u-100 0.3
ml 30 x 1/2"
2
KROGER LANCETS ULTRATHIN - 3
lancets
KROGER LANCETS 21G - lancets 3
KROGER INSULIN SYRINGE/0. insulin syringe/needle u-100 0.3
ml 29 x 1/2"
3
2
KROGER LANCING DEVICE lancet devices
2
KROGER INSULIN SYRINGE/0. insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
KROGER PEN NEEDLES 29G X insulin pen needle 29 g x 12 mm
(1/2")
2
KROGER INSULIN SYRINGE/0. insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
KROGER PEN NEEDLES 31G X
- insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
KROGER INSULIN SYRINGE/0. insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
KROGER PEN NEEDLES 31GX1/
- insulin pen needle 31 g x 6 mm
(1/4")
KROGER INSULIN SYRINGE/0. insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
3
KROGER PREMIUM BLOOD
GLUC - blood glucose monitoring
kit w/ device
3
LADY LITE LANCETS - lancets
LANCET DEVICE ADJUSTABLE lancet devices
1
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
2
KROGER LANCETS MICRO THIN
- lancets
212
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
LANCETS SAFETY SEAL 28G lancets
1
LANCETS SAFETY SEAL 30G lancets
1
LANCETS SUPER THIN 28G lancets
3
LANCETS THIN - lancets
1
LANCETS THIN - lancets
3
LANCETS TWIST TOP - lancets
1
LANCETS ULTRA FINE - lancets
3
LANCETS ULTRA THIN - lancets
3
LANCETS ULTRA THIN 30G lancets
3
LANCETS 26G TWIST TOP lancets
1
LANCETS 28G - lancets
1
LANCETS 30G - lancets
1
LANCETS 30G TWIST TOP lancets
1
LANCETS 31G TWIST TOP lancets
1
LANCING DEVICE - lancet devices 1
1
LANCING DEVICE ADJUSTABLE
- lancet devices
LEADER ADVANCED LANCING D 3
- lancet devices
2
LEADER INSULIN SYRINGE/0. insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
LEADER INSULIN SYRINGE/0. insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
LEADER INSULIN SYRINGE/0. insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
LEADER INSULIN SYRINGE/0. insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
LEADER INSULIN SYRINGE/0. insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
LEADER INSULIN SYRINGE/1M insulin syringe/needle u-100 1 ml
28 x 1/2"
2
LEADER INSULIN SYRINGE/1M insulin syringe/needle u-100 1 ml
29 x 1/2"
2
LEADER INSULIN SYRINGE/1M insulin syringe/needle u-100 1 ml
30 x 5/16"
2
LEADER INSULIN SYRINGE/1M insulin syringe/needle u-100 1 ml
31 x 5/16"
2
LEADER LANCETS COLORED lancets
3
LEADER SUPER THIN LANCET lancets
3
LEADER THIN LANCETS - lancets
3
LEADER UNIFINE PENTIPS PL insulin pen needle 31 g x 5 mm
(3/16")
2
LEADER UNIFINE PENTIPS PL insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
LEADER UNIFINE PENTIPS/MI insulin pen needle 31 g x 5 mm
(3/16")
2
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
1
LEADER INSULIN SYRINGE/0. insulin syringe/needle u-100 1/2
ml 28 x 1/2"
Quantity Limits
LANCETS SAFETY SEAL 26G lancets
2
"Smart" PA
1
LEADER INSULIN SYRINGE/0. insulin syringe/needle u-100 1/2
ml 31 x 5/16"
Prior Authorization
LANCETS SAFETY SEAL 21G lancets
Drug Name
Drug Tier
3
Specialty
LANCETS MICRO THIN 33G lancets
Quantity Limits
1
"Smart" PA
LANCETS - lancets
Prior Authorization
Drug Name
Drug Tier
2015
213
LEADER UNIFINE PENTIPS/NA insulin pen needle 32 g x 4 mm
(5/32")
2
LITETOUCH INSULIN SYRINGE insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
LEADER UNIFINE PENTIPS/PL insulin pen needle 32 g x 4 mm
(5/32")
2
LITETOUCH INSULIN SYRINGE insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
LIBERTY CONTROL SOLUTION blood glucose calibration - liquid
- high
3
LITETOUCH INSULIN SYRINGE insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
LIBERTY CONTROL SOLUTION blood glucose calibration - liquid normal
3
LITETOUCH INSULIN SYRINGE insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
LIBERTY GLUCOSE CONTROL L
- blood glucose calibration - liquid
3
2
LIBERTY GLUCOSE CONTROL M
- blood glucose calibration - liquid
3
LITETOUCH INSULIN SYRINGE insulin syringe/needle u-100 1 ml
28 x 1/2"
2
LIBERTY GLUCOSE CONTROL N
- blood glucose calibration - liquid
- normal
3
LITETOUCH INSULIN SYRINGE insulin syringe/needle u-100 1 ml
29 x 1/2"
2
LIBERTY MINI LANCING DEVI lancet devices
3
LITETOUCH INSULIN SYRINGE insulin syringe/needle u-100 1 ml
30 x 5/16"
LIFESCAN UNISTIK II LANCE lancets
2
2
LIFESCAN UNISTIK 2 DEEP P lancets
2
LITETOUCH INSULIN SYRINGE insulin syringe/needle u-100 1 ml
31 x 5/16"
2
LITE TOUCH LANCETS - lancets
3
LITETOUCH INSULIN SYRINGE insulin syringe/needle u-100 0.3
ml 31 x 5/16"
LITE TOUCH LANCING DEVICE lancet devices
3
LITE TOUCH LANCING PEN lancet devices
3
LITE TOUCH PEN NEEDLES/31 insulin pen needle 31 g x 5 mm
(3/16")
2
LITEAIRE - spacer/aerosol-holding
chambers - device
3
LITETOUCH INSULIN SYRINGE insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
LITETOUCH INSULIN SYRINGE insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
214
LITETOUCH LANCETS MICRO T - 3
lancets
2
LITETOUCH PEN NEEDLES 29G
- insulin pen needle 29 g x 12.7
mm
2
LITETOUCH PEN NEEDLES 31G
- insulin pen needle 31 g x 6 mm
(1/4")
2
LITETOUCH PEN NEEDLES 31G
- insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
3
LIVE BETTER ADVANCED LANC
- lancet devices
3
LIVE BETTER LANCET SUPER lancets
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
LIVE BETTER LANCET ULTRA lancets
3
LIVE BETTER PEN NEEDLES 2 insulin pen needle 29 g x 12 mm
(1/2")
2
2
MAXI-COMFORT INSULIN SYRI insulin syringe/needle u-100 1 ml
28 x 1/2"
3
LIVE BETTER PEN NEEDLES 3 insulin pen needle 31 g x 6 mm
(1/4")
2
MAXIMA BLOOD GLUCOSE
MONI - blood glucose monitoring
kit w/ device
MAXIMA CONTROL SOLUTION blood glucose calibration - liquid
3
LIVE BETTER PEN NEEDLES 3 insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
MAXIMA CONTROL SOLUTION/N
- blood glucose calibration - liquid
- normal
3
LONGS INSULIN SYRINGE/0.5 insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
MAXIMA METER KIT - blood
glucose monitoring kit w/ device
3
LONGS LANCETS STANDARD lancets
MAXIMA STARTER KIT - blood
glucose monitoring kit w/ device
3
3
MEDI-LANCE LANCETS - lancets
3
LONGS LANCETS THIN - lancets
3
3
MEDIC INSULIN SYRINGE/0.3 insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
LONGS LANCETS ULTRA THIN lancets
MAGELLAN INSULIN SAFETY S insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
MEDIC INSULIN SYRINGE/0.5 insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
MAGELLAN INSULIN SAFETY S insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
MEDICHOICE PRE-SET SAFETY
- lancets
3
MAGELLAN INSULIN SAFETY S insulin syringe/needle u-100 1/2
ml 29 x 1/2"
MEDICHOICE SAFETY LANCET lancets
3
2
MEDICINE SHOPPE LANCETS lancets
3
MAGELLAN INSULIN SAFETY S insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
MAGELLAN INSULIN SAFETY S insulin syringe/needle u-100 1 ml
29 x 1/2"
2
MAGELLAN INSULIN SAFETY S insulin syringe/needle u-100 1 ml
30 x 5/16"
2
MAJOR COMFORT LANCETS lancets
3
MAXI-COMFORT INSULIN SYRI insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
MEDICINE SHOPPE LANCETS T - 3
lancets
2
MEDICINE SHOPPE PEN NEEDL
- insulin pen needle 29 g x 12
mm (1/2")
2
MEDICINE SHOPPE PEN NEEDL
- insulin pen needle 31 g x 6 mm
(1/4")
2
MEDICINE SHOPPE PEN NEEDL
- insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
MEDISENSE GLUCOSE KETONE 3
- blood glucose calibration - liquid
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
215
3
MEIJER PEN NEEDLES 31G X insulin pen needle 31 g x 6 mm
(1/4")
2
MEDISENSE HIGH/MID/LOW CO - 3
blood glucose calibration - liquid
MEDISENSE MID CONTROL SOL 3
- blood glucose calibration - liquid
3
MEDISENSE THIN LANCETS lancets
MEDLANCE PLUS EXTRA LANCE 3
- lancets
3
MEDLANCE PLUS LANCETS lancets
MEDLANCE PLUS LANCETS LIT - 3
lancets
MEDLANCE PLUS LITE LANCET - 3
lancets
3
MEDLANCE PLUS SPECIAL LAN
- lancets
MEDLANCE PLUS SUPERLITE 3 - 3
lancets
3
MEDLANCE PLUS UNIVERSAL L
- lancets
3
MEDLANCE PLUS/LITE 25G lancets
3
MEDLANCE/EXTRA - lancets
MEIJER PEN NEEDLES 31G X insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
MEIJER PREMIUM BLOOD GLUC
- blood glucose monitoring kit w/
device
3
MEIJER SUPER THIN LANCETS lancets
3
MEIJER TRUERESULT BLOOD G
- blood glucose monitoring kit w/
device
3
MEIJER TRUETRACK BLOOD GL
- blood glucose monitoring kit w/
device
3
MEIJER TRUE2GO BLOOD GLUC
- blood glucose monitoring kit w/
device
3
MI PASTE - dentifrices - paste
3
MI PASTE PLUS - dentifrices paste
3
MICROCHAMBER - spacer/
aerosol-holding chambers device
3
MICRODOT BLOOD GLUCOSE
MO - blood glucose monitoring
kit w/ device
3
MICRODOT CONTROL
SOLUTION - blood glucose
calibration - liquid
3
MICROLET LANCETS - lancets
3
MICROSPACER - spacer/aerosolholding chambers - device
3
MICROTAINER SAFETY FLOW L
- lancets
3
MINI LANCING DEVICE - lancet
devices
3
MONOJECT INSULIN SYRINGE insulin syringe (disp) u-100 1 ml
2
MEDISENSE HIGH/LOW
CONTRO - blood glucose
calibration - liquid
MEDLANCE/LITE - lancets
3
MEDLANCE/UNIVERSAL - lancets
3
MEIJER BLOOD GLUCOSE MONI
- blood glucose monitoring kit w/
device
3
MEIJER COLOR LANCETS UNIV - 3
lancets
3
MEIJER LANCETS - lancets
MEIJER LANCETS THIN - lancets
3
MEIJER LANCETS UNIVERSAL lancets
3
MEIJER PEN NEEDLES 29G X insulin pen needle 29 g x 12 mm
(1/2")
2
216
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
MONOJECT INSULIN SYRINGE/ insulin syringe (disp) u-100 1 ml
2
MONOJECT INSULIN SYRINGE/ insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
2
MONOJECT ULTRA COMFORT
IN - insulin syringe/needle u-100
1/2 ml 31 x 5/16"
2
MONOJECT INSULIN SYRINGE/ insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
MONOJECT ULTRA COMFORT
IN - insulin syringe/needle u-100
1/2 ml 28 x 1/2"
2
MONOJECT INSULIN SYRINGE/ insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
MONOJECT ULTRA COMFORT
IN - insulin syringe/needle u-100
1/2 ml 29 x 1/2"
2
MONOJECT INSULIN SYRINGE/ insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
MONOJECT ULTRA COMFORT
IN - insulin syringe/needle u-100
1/2 ml 30 x 5/16"
2
MONOJECT INSULIN SYRINGE/ insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
MONOJECT ULTRA COMFORT
IN - insulin syringe/needle u-100
1 ml 28 x 1/2"
2
MONOJECT INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
25 x 5/8"
2
MONOJECT ULTRA COMFORT
IN - insulin syringe/needle u-100
1 ml 29 x 1/2"
2
MONOJECT INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
27 x 1/2"
2
MONOJECT ULTRA COMFORT
IN - insulin syringe/needle u-100
1 ml 30 x 5/16"
2
MONOJECT INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
28 x 1/2"
2
MONOJECT ULTRA COMFORT
IN - insulin syringe/needle u-100
0.3 ml 31 x 5/16"
MONOLET LANCETS - lancets
3
MONOJECT INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
29 x 1/2"
MONOLET OPD LANCETS lancets
3
2
MONOLETTOR SAFETY
LANCETS - lancets
3
MONOJECT INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
30 x 5/16"
2
MOORE MED MONOJECT INSULI
- insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
MONOJECT INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
31 x 5/16"
2
MOORE MED MONOJECT INSULI
- insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
MONOJECT ULTRA COMFORT
IN - insulin syringe/needle u-100
0.3 ml 29 x 1/2"
2
MOORE MED MONOJECT INSULI
- insulin syringe/needle u-100 1
ml 28 x 1/2"
2
MONOJECT ULTRA COMFORT
IN - insulin syringe/needle u-100
0.3 ml 30 x 5/16"
2
MOORE MED MONOJECT INSULI
- insulin syringe/needle u-100 1
ml 29 x 1/2"
2
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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217
MS INSULIN SYRINGE/0.3ML/ insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
NEXGEN NORMAL CONTROL blood glucose calibration - liquid
- normal
3
MS INSULIN SYRINGE/0.3ML/ insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
NORDIPEN 5 INJECTION DEVI injection device - misc
3
3
MS INSULIN SYRINGE/0.3ML/ insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
NOVA MAX BLOOD GLUCOSE
MO - blood glucose monitoring
kit w/ device
2
NOVA MAX PLUS GLU/KET CON
- blood glucose calibration - liquid
3
MS INSULIN SYRINGE/0.5ML/ insulin syringe/needle u-100 1/2
ml 31 x 5/16"
NOVA SAFETY LANCETS 23G lancets
3
MS INSULIN SYRINGE/0.5ML/ insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
NOVA SAFETY LANCETS 28G lancets
3
2
NOVA SUREFLEX LANCETS lancets
3
MS INSULIN SYRINGE/0.5ML/ insulin syringe/needle u-100 1/2
ml 30 x 5/16"
3
MS INSULIN SYRINGE/1ML/29 insulin syringe/needle u-100 1 ml
29 x 1/2"
2
NOVA SUREFLEX LANCING DEV
- lancet devices
2
MS INSULIN SYRINGE/1ML/30 insulin syringe/needle u-100 1 ml
30 x 5/16"
2
NOVOFINE AUTOCOVER
30GX8M - insulin pen needle 30
g x 8 mm (1/3" or 5/16")
2
MS INSULIN SYRINGE/1ML/31 insulin syringe/needle u-100 1 ml
31 x 5/16"
2
NOVOFINE PLUS 32GX4MM insulin pen needle 32 g x 4 mm
(5/32")
2
MULTI-LANCET DEVICE - lancet
devices
1
NOVOFINE 30GX8MM - insulin
pen needle 30 g x 8 mm (1/3" or
5/16")
2
MYGLUCOHEALTH BLOOD
GLUCO - blood glucose
monitoring kit w/ device
3
NOVOFINE 32GX6MM - insulin
pen needle 32 g x 6 mm (1/4")
NOVOPEN ECHO - injection
device for insulin
2
3
MYGLUCOHEALTH CONTROL
LOW - blood glucose calibration liquid
3
MYGLUCOHEALTH MGH
SOFTLAN - lancets
3
NETGROUP LANCETS - lancets
NOVOPEN JR (GREEN) - injection
device for insulin
2
NOVOPEN JR (YELLOW) injection device for insulin
2
NOVOPEN 3 INSULIN DELIVER injection device for insulin
2
3
NOVOPEN 3 PENMATE - injection
device for insulin
2
NEUTEK 2TEK CONTROL SOLUT
- blood glucose calibration - liquid
218
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NOVOTWIST 30GX8MM - insulin
pen needle 30 g x 8 mm (1/3" or
5/16")
2
NOVOTWIST 32GX5MM - insulin
pen needle 32 g x 5 mm (1/5" or
3/16")
2
OMNIFLEX DIAPHRAGM diaphragms
A
OMNITROPE PEN 5 INJECTION injection device - misc
3
ON CALL EXPRESS BLOOD GLU
- blood glucose monitoring kit w/
device
3
ON CALL EXPRESS GLUCOSE C
- blood glucose calibration - liquid
3
ON CALL LANCETS - lancets
3
ON CALL LANCING DEVICE lancet devices
3
ON CALL PLUS BLOOD GLUCOS
- blood glucose monitoring kit w/
device
3
ON CALL PLUS GLUCOSE CONT
- blood glucose calibration - liquid
3
ON CALL PLUS LANCETS lancets
3
ON CALL PLUS LANCING DEVI lancet devices
3
ON CALL VIVID BLOOD GLUCO
- blood glucose monitoring kit w/
device
ONETOUCH COMBO PACK lancets
2
ONETOUCH DELICA LANCETS E
- lancets
2
ONETOUCH DELICA LANCETS F
- lancets
2
ONETOUCH DELICA LANCING D
- lancet devices
3
ONETOUCH FINEPOINT LANCET
- lancets
2
ONETOUCH LANCETS - lancets
2
ONETOUCH PROFILE SYSTEM
- blood glucose monitoring kit w/
device
2
ONETOUCH ULTRA CONTROL blood glucose calibration - liquid
3
ONETOUCH ULTRA MINI - blood
glucose monitoring kit w/ device
2
ONETOUCH ULTRA SYSTEM KIT
- blood glucose monitoring kit w/
device
2
ONETOUCH ULTRA 2 - blood
glucose monitoring kit w/ device
2
ONETOUCH ULTRALINK
SYSTEM - blood glucose
monitoring kit w/ device
2
ONETOUCH ULTRASMART blood glucose monitoring kit w/
device
2
3
ON CALL VIVID GLUCOSE CON blood glucose calibration - liquid
ONETOUCH ULTRASOFT
LANCET - lancets
2
3
ON CALL VIVID PAL BLOOD G blood glucose monitoring kit w/
device
ONETOUCH ULTRASOFT
LANCET - lancets
3
3
ONETOUCH VERIO - blood
glucose monitoring kit w/ device
2
ONETOUCH BASIC SYSTEM blood glucose monitoring kit w/
device
2
ONETOUCH VERIO CONTROL
SO - blood glucose calibration liquid - high
3
ONETOUCH CLUB LANCETS FIN
- lancets
2
ONETOUCH VERIO IQ BLOOD G
- blood glucose monitoring kit w/
device
2
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219
ONETOUCH VERIO MID
CONTRO - blood glucose
calibration - liquid
3
OPTUMRX BLOOD GLUCOSE
MON - blood glucose monitoring
kit w/ device
3
ONETOUCH VERIO SYNC
BLOOD - blood glucose
monitoring kit w/ device
2
OPTUMRX GLUCOSE CONTROL
L - blood glucose calibration liquid
3
OPTICHAMBER ADVANTAGE spacer/aerosol-holding chambers
- device
3
ORSINI INSULIN SYRINGE/U- insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
OPTICHAMBER ADVANTAGE/
LAR - spacer/aerosol-holding
chambers - device
3
ORSINI INSULIN SYRINGE/U- insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
OPTICHAMBER ADVANTAGE/
MED - spacer/aerosol-holding
chambers - device
3
ORSINI INSULIN SYRINGE/U- insulin syringe/needle u-100 1 ml
30 x 5/16"
2
OPTICHAMBER ADVANTAGE/
SMA - spacer/aerosol-holding
chambers - device
3
OPTICHAMBER DIAMOND spacer/aerosol-holding chambers
- device
3
OPTICHAMBER DIAMOND/
LARGE - spacer/aerosol-holding
chambers - device
3
OPTICHAMBER DIAMOND/
MEDIU - spacer/aerosol-holding
chambers - device
3
OPTICHAMBER DIAMOND/
SMALL - spacer/aerosol-holding
chambers - device
3
OPTIHALER - spacer/aerosolholding chambers - device
3
OPTIHALER MDI DRUG DELIVE spacer/aerosol-holding chambers
- device
3
OPTIUM BLOOD GLUCOSE MONI
- blood glucose monitoring kit w/
device
3
OPTUMRX BLOOD GLUCOSE
MET - blood glucose monitoring
kit w/ device
3
ORTHO DIAPHRAGM ALL-FLEX/ - A
diaphragm arc-spring 65 mm
ORTHO DIAPHRAGM ALL-FLEX/ - A
diaphragm arc-spring 70 mm
ORTHO DIAPHRAGM ALL-FLEX/ - A
diaphragm arc-spring 75 mm
ORTHO DIAPHRAGM ALL-FLEX/ - A
diaphragm arc-spring 80 mm
A
ORTHO DIAPHRAGM COIL SPRI
- diaphragm coil spring kit 50 mm
A
ORTHO DIAPHRAGM COIL SPRI
- diaphragm coil spring kit 100
mm
A
ORTHO DIAPHRAGM COIL SPRI
- diaphragm coil spring kit 105
mm
A
ORTHO DIAPHRAGM FLAT SPRI
- diaphragm flat spring kit 55 mm
A
ORTHO DIAPHRAGM FLAT SPRI
- diaphragm flat spring kit 60 mm
A
ORTHO DIAPHRAGM FLAT SPRI
- diaphragm flat spring kit 65 mm
A
ORTHO DIAPHRAGM FLAT SPRI
- diaphragm flat spring kit 70 mm
A
ORTHO DIAPHRAGM FLAT SPRI
- diaphragm flat spring kit 75 mm
220
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ORTHO DIAPHRAGM FLAT SPRI
- diaphragm flat spring kit 80 mm
A
ORTHO DIAPHRAGM FLAT SPRI
- diaphragm flat spring kit 85 mm
A
ORTHO DIAPHRAGM FLAT SPRI
- diaphragm flat spring kit 90 mm
PEN NEEDLES 31G X 6MM insulin pen needle 31 g x 6 mm
(1/4")
2
2
A
PEN NEEDLES 31GX5/16" insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
ORTHO DIAPHRAGM FLAT SPRI
- diaphragm flat spring kit 95 mm
A
PERFECT LANCETS 30G lancets
3
PARADIGM LINK BLOOD GLUCO
- blood glucose monitoring kit w/
device
3
PERFECT PRESSURE ACTIVATE
- lancets
3
3
PC LANCETS SUPER THIN 30G lancets
3
PHARMACIST CHOICE
AUTOCOD - blood glucose
monitoring kit w/ device
PC UNIFINE PENTIPS 29G X insulin pen needle 29 g x 12 mm
(1/2")
2
PHARMACIST CHOICE ULTRA T
- lancets
3
3
PC UNIFINE PENTIPS 31G X insulin pen needle 31 g x 5 mm
(3/16")
2
PHARMACY COUNTER
LANCETS - lancets
3
PC UNIFINE PENTIPS 31G X insulin pen needle 31 g x 6 mm
(1/4")
2
POCKET CHAMBER - spacer/
aerosol-holding chambers device
3
PC UNIFINE PENTIPS 31G X insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
POCKET SPACER - spacer/
aerosol-holding chambers device
POCKETCHEM EZ BLOOD
GLUCO - blood glucose
monitoring kit w/ device
3
POCKETCHEM EZ CONTROL
LEV - blood glucose calibration liquid
3
PRECISION GLUCOSE
CONTROL - blood glucose
calibration - liquid
3
PCA INJECTOR - injection device - 1
misc
2
PEN NEEDLES 29G X 12MM insulin pen needle 29 g x 12 mm
(1/2")
PEN NEEDLES 29GX1/2" - insulin 2
pen needle 29 g x 12 mm (1/2")
2
PEN NEEDLES 30GX5/16" insulin pen needle 30 g x 8 mm
(1/3" or 5/16")
2
PEN NEEDLES 31G X 1/4" SH insulin pen needle 31 g x 6 mm
(1/4")
2
PEN NEEDLES 31G X 3/16" insulin pen needle 31 g x 5 mm
(3/16")
Specialty
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Specialty
Quantity Limits
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Drug Tier
2015
PRECISION GLUCOSE KETONE - 3
blood glucose calibration - liquid
PRECISION GLUCOSE/KETONE - 3
blood glucose calibration - liquid
3
PRECISION LINK - blood glucose
monitoring kit w/ device
PRECISION SURE-DOSE INSUL - 2
insulin syringe/needle u-100 0.3
ml 30 x 5/16"
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
221
PRECISION SURE-DOSE INSUL insulin syringe/needle u-100 1/2
ml 30 x 3/8"
2
PREFERRED PLUS INSULIN SY insulin syringe/needle u-100 1 ml
29 x 1/2"
2
PRECISION SURE-DOSE INSUL insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
PREFERRED PLUS INSULIN SY insulin syringe/needle u-100 1 ml
30 x 5/16"
2
PRECISION SURE-DOSE INSUL insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
PREFERRED PLUS LANCETS CO
- lancets
3
2
PREFERRED PLUS LANCETS SU
- lancets
3
PRECISION SURE-DOSE INSUL insulin syringe/needle u-100 1 ml
28 x 1/2"
PREFERRED PLUS LANCETS TH
- lancets
3
PRECISION SURE-DOSE PLUS insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
PREFERRED PLUS UNIFINE PE insulin pen needle 29 g x 12 mm
(1/2")
2
PRECISION SURE-DOSE PLUS insulin syringe/needle u-100 1 ml
29 x 1/2"
2
PREFERRED PLUS UNIFINE PE
- insulin pen needle 31 g x 5 mm
(3/16")
2
PRECISION THIN LANCETS lancets
3
2
PRECISION THINS GP LANCET lancets
3
PREFERRED PLUS UNIFINE PE
- insulin pen needle 31 g x 6 mm
(1/4")
PRECISION ULTRA LANCET lancets
PREFERRED PLUS UNIFINE PE
- insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
3
PREFERRED PLUS INSULIN SY insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
PREFERRED PLUS UNIFINE PE
- insulin pen needle 32 g x 4 mm
(5/32")
2
PREFERRED PLUS INSULIN SY insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
PRENTIF CAVITY-RIM CERVIC cervical cap 22 mm
A
PREFERRED PLUS INSULIN SY insulin syringe/needle u-100 1/2
ml 28 x 1/2"
PRENTIF CAVITY-RIM CERVIC cervical cap 25 mm
A
2
PRENTIF CAVITY-RIM CERVIC cervical cap 28 mm
A
PREFERRED PLUS INSULIN SY insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
PRENTIF CAVITY-RIM CERVIC cervical cap 31 mm
A
2
PRENTIF FITTING SET - cervical
caps
A
PREFERRED PLUS INSULIN SY insulin syringe/needle u-100 1/2
ml 30 x 5/16"
3
PREFERRED PLUS INSULIN SY insulin syringe/needle u-100 1 ml
28 x 1/2"
2
PRESTIGE GLUCOSE CONTROL
- blood glucose calibration - liquid
- high
222
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PRESTIGE GLUCOSE CONTROL
- blood glucose calibration - liquid
- low
3
PRODIGY AUTOCODE BLOOD
GL - blood glucose monitoring kit
w/ device
3
3
PRODIGY AUTOCODE PRO
BLOO - blood glucose monitoring
kit w/ device
3
PRODIGY CONTROL SOLUTION
- blood glucose calibration - liquid
- high
3
PRODIGY CONTROL SOLUTION
- blood glucose calibration - liquid
- low
2
PRODIGY INSULIN MINI PEN insulin pen needle 31 g x 5 mm
(3/16")
PRODIGY INSULIN PEN NEEDL - 2
insulin pen needle 29 g x 13 mm
(1/2")
2
PRODIGY INSULIN SHORT PEN
- insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
PRODIGY INSULIN SYRING/U- insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
PRODIGY INSULIN SYRINGE/1 insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
PRODIGY INSULIN SYRINGE/1 insulin syringe/needle u-100 1 ml
28 x 1/2"
3
PRODIGY LANCING DEVICE lancet devices
3
PRODIGY POCKET BLOOD
GLUC - blood glucose monitoring
kit w/ device
3
PRODIGY POCKET PRO BLOOD
- blood glucose monitoring kit w/
device
PRODIGY PRESSURE ACTIVATE
- lancets
3
PRODIGY TWIST TOP LANCETS
- lancets
3
PRODIGY VOICE BLOOD GLUCO
- blood glucose monitoring kit w/
device
3
PSS SELECT GP LANCETS lancets
3
PSS SELECT SAFETY LANCETS
- lancets
3
PX ADVANCED LANCING DEVIC
- lancet devices
3
PX EXTRA SHORT PEN NEEDLE
- insulin pen needle 31 g x 6 mm
(1/4")
2
PX INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 0.3
ml 30 x 1/2"
2
PX INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
PX INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1/2
ml 30 x 1/2"
2
PX INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1 ml
30 x 1/2"
2
PX INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1 ml
31 x 5/16"
2
PX INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
PX LANCET AUTO INJECTOR lancet devices
3
PX LANCETS - lancets
3
PX LANCETS ULTRA THIN lancets
3
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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223
PX MINI PEN NEEDLES 31GX5 insulin pen needle 31 g x 5 mm
(3/16")
2
QC INSULIN SYRINGE/1ML/30 insulin syringe/needle u-100 1 ml
30 g
2
PX PEN NEEDLE 29GX12MM insulin pen needle 29 g x 12 mm
(1/2")
2
QC INSULIN SYRINGE/1ML/31 insulin syringe/needle u-100 1 ml
31 x 5/16"
2
PX PEN NEEDLE 31GX8MM insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
QC LANCETS SUPER THIN lancets
3
2
QC LANCETS ULTRA THIN lancets
3
PX SHORTLENGTH PEN
NEEDLE - insulin pen needle 31
g x 8 mm (1/3" or 5/16")
2
Q-CARE Q2 ORAL CLEANSING/ oral hygiene products - kit
3
QC PEN NEEDLES 29G X 12MM insulin pen needle 29 g x 12 mm
(1/2")
Q-CARE Q4 ORAL CLEANSING/ oral hygiene products - kit
QC PEN NEEDLES 31G X 6MM insulin pen needle 31 g x 6 mm
(1/4")
2
3
QC ADVANCED LANCING DEVIC
- lancet devices
3
2
QC INSULIN SYRINGE 0.5ML/ insulin syringe/needle u-100 1/2
ml 29 g
2
QC PEN NEEDLES 31G X 8MM insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
QC INSULIN SYRINGE 0.5ML/ insulin syringe/needle u-100 1/2
ml 30 g
2
QC UNIFINE PENTIPS 32GX4M insulin pen needle 32 g x 4 mm
(5/32")
QUICKTEK - blood glucose
monitoring kit w/ device
3
QC INSULIN SYRINGE 1ML/29 insulin syringe/needle u-100 1 ml
29 g
2
QUICKTEK CONTROL SOLUTION
- blood glucose calibration - liquid
3
2
QUINTET GLUCOSE CONTROL/H
- blood glucose calibration - liquid
3
QC INSULIN SYRINGE/0.3ML/ insulin syringe/needle u-100 0.3
ml 29 g
RA E-ZJECT COLOR LANCETS lancets
3
QC INSULIN SYRINGE/0.3ML/ insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
RA E-ZJECT LANCETS THIN 2 lancets
3
2
RA E-ZJECT LANCETS ULTRA lancets
3
QC INSULIN SYRINGE/0.5ML/ insulin syringe/needle u-100 1/2
ml 31 x 5/16"
3
QC INSULIN SYRINGE/0.5ML/ insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
RA E-ZJECT LANCETS 28G lancets
2
QC INSULIN SYRINGE/1ML/29 insulin syringe/needle u-100 1 ml
29 x 1/2"
2
RA INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1/2
ml 30 x 5/16"
224
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Specialty
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Drug Name
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Drug Tier
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RA INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1 ml
30 x 5/16"
2
REFUAH PLUS GLUCOSE
CONTR - blood glucose
calibration - liquid
3
RA INSULIN SYRINGE/0.5ML/ insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
RELION CONFIRM BLOOD GLUC
- blood glucose monitoring kit w/
device
3
RA INSULIN SYRINGE/1ML/29 insulin syringe/needle u-100 1 ml
29 x 1/2"
2
RELION INSULIN SYRINGE/U insulin syringe/needle u-100 1/2
ml 29 g
2
RA LANCING DEVICE - lancet
devices
3
2
RA PEN NEEDLES 31G X 5MM insulin pen needle 31 g x 5 mm
(3/16")
2
RELION INSULIN SYRINGE/U- insulin syringe/needle u-100 0.3
ml 29 g
2
RA PEN NEEDLES 31G X 8MM insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
RELION INSULIN SYRINGE/U- insulin syringe/needle u-100 0.3
ml 30 g
2
RA TRUERESULT BLOOD
GLUCO - blood glucose
monitoring kit w/ device
3
RELION INSULIN SYRINGE/U- insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
RA TRUE2GO BLOOD GLUCOSE
- blood glucose monitoring kit w/
device
3
RELION INSULIN SYRINGE/U- insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
REALITY INSULIN SYRINGE/U insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
RELION INSULIN SYRINGE/U- insulin syringe/needle u-100 1/2
ml 30 g
2
REALITY INSULIN SYRINGE/U insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
RELION INSULIN SYRINGE/U- insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
REALITY INSULIN SYRINGE/U insulin syringe/needle u-100 1 ml
28 x 1/2"
2
RELION INSULIN SYRINGE/U- insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
REALITY INSULIN SYRINGE/U insulin syringe/needle u-100 1 ml
29 x 1/2"
2
RELION INSULIN SYRINGE/U- insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
REALITY LANCETS - lancets
3
RELION INSULIN SYRINGE/U- insulin syringe/needle u-100 1 ml
29 x 1/2"
REALITY TRIGGER LANCETS lancets
3
2
REFUAH PLUS BLOOD
GLUCOSE - blood glucose
monitoring kit w/ device
3
RELION INSULIN SYRINGE/U- insulin syringe/needle u-100 1 ml
30 g
RELION INSULIN SYRINGE/U- insulin syringe/needle u-100 1 ml
30 x 5/16"
2
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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Specialty
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225
RELION INSULIN SYRINGE/U- insulin syringe/needle u-100 1 ml
31 x 5/16"
2
RELION INSULIN SYRINGE/U- insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
RELION LANCETS - lancets
3
RELION LANCETS MICRO-THIN lancets
RELION ULTRA THIN PLUS LA lancets
3
REMESENSE - dental
desensitizing product - misc
3
RENEW ADVANCED LANCING
CA - lancets
3
RENEW ADVANCED LANCING
DE - lancet devices
3
3
RELION LANCETS STANDARD 2
- lancets
REVEAL BLOOD GLUCOSE
MONI - blood glucose monitoring
kit w/ device
3
3
RELION LANCETS THIN 26G lancets
3
3
RELION LANCETS ULTRA-THIN lancets
3
REXALL BLOOD GLUCOSE MONI
- blood glucose monitoring kit w/
device
3
RELION LANCING DEVICE lancet devices
3
REXALL LANCETS ULTRA THIN lancets
3
RELION MICRO BLOOD GLUCOS
- blood glucose monitoring kit w/
device
3
RIGHTEST GC300 HIGH CONTR
- blood glucose calibration - liquid
- high
3
RELION MINI PEN NEEDLES 3 insulin pen needle 31 g x 6 mm
(1/4")
2
RIGHTEST GC300 NORMAL CON
- blood glucose calibration - liquid
- normal
3
RELION PEN NEEDLES 29GX12 insulin pen needle 29 g x 12 mm
(1/2")
2
RIGHTEST GD500 LANCING DE lancet devices
RIGHTEST GL300 LANCETS lancets
3
RELION PEN NEEDLES 31GX8M
- insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
RIGHTEST GM100 BLOOD GLUC
- blood glucose monitoring kit w/
device
3
RELION PEN NEEDLES 32GX4M
- insulin pen needle 32 g x 4 mm
(5/32")
2
RIGHTEST GM300 BLOOD GLUC
- blood glucose monitoring kit w/
device
3
RELION SHORT PEN NEEDLES
- insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
RIGHTEST GM550 BLOOD GLUC
- blood glucose monitoring kit w/
device
3
RELION THIN LANCETS - lancets
3
3
RELION ULTIMA BLOOD GLUCO
- blood glucose monitoring kit w/
device
3
RITEFLO - spacer/aerosol-holding
chambers - device
RELION ULTRA THIN LANCETS lancets
3
226
SAFE-T-LANCE LOW FLOW 25G - 3
lancets
SAFE-T-LANCE NORMAL FLOW - 3
lancets
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2015
SAFE-T-LANCE PLUS SAFETY lancets
3
SAFESNAP INSULIN SYRINGE/ insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
2
SB INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1 ml
29 x 1/2"
2
SAFESNAP INSULIN SYRINGE/ insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
SB INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1 ml
30 x 5/16"
2
SAFESNAP INSULIN SYRINGE/ insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
SB INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1 ml
31 x 5/16"
SB LANCETS THIN - lancets
3
SAFESNAP INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
28 x 1/2"
SB LANCETS ULTRA THIN lancets
3
2
2
SAFESNAP INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
29 x 1/2"
2
SCHNUCKS INSULIN SYRINGE insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
SAFETY LANCET 2MM - lancets
3
SCHNUCKS INSULIN SYRINGE insulin syringe/needle u-100 1/2
ml 30 x 5/16"
SAFETY LANCET 21G/PRESSUR
- lancets
1
SELECT-LITE LANCING DEVIC lancet devices
3
SAFETY LANCET 28G/PRESSUR
- lancets
1
SHOPKO AUTOLET LANCING DE
- lancet devices
3
SAFETY LANCETS - lancets
3
3
SAFETY LANCETS 21G - lancets
3
SHOPKO ON-THE-GO COMFORT
- lancets
SAFETY LANCETS 28G - lancets
1
2
SAFETY LET LANCETS - lancets
3
SHOPKO UNIFINE PENTIPS PE insulin pen needle 29 g x 12 mm
(1/2")
SAFETY SEAL LANCETS 28G lancets
3
2
SAFETY SEAL LANCETS 30G lancets
3
SHOPKO UNIFINE PENTIPS PE
- insulin pen needle 31 g x 5 mm
(3/16")
SAFETY-GLIDE INSULIN SYRI insulin syringe/needle u-100 0.3
ml 29 x 1/2"
SHOPKO UNIFINE PENTIPS PE
- insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
2
SAPSCARE TWIST TOP LANCET
- lancets
SHOPKO UNIFINE PENTIPS PE
- insulin pen needle 32 g x 4 mm
(5/32")
2
3
SB INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
SHOPKO UNILET LANCETS SUP
- lancets
3
SB INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1/2
ml 30 x 5/16"
SHOPKO UNILET LANCETS ULT
- lancets
3
2
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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Specialty
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2015
227
SIMPLE DIAGNOSTICS LANCIN lancet devices
3
SM THIN LANCETS 26G - lancets
3
SINGLE-LET - lancets
SM INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
SM ULTRA COMFORT INSULIN insulin syringe/needle u-100 1 ml
30 x 5/16"
2
3
SMART DIABETES VANTAGE LA
- lancet devices
3
SM INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
SMART DIABETES VANTAGE UN
- lancets
3
SM INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1/2
ml 28 x 1/2"
SMART DIABETES XPRES BLOO
- blood glucose monitoring kit w/
device
3
2
SM INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1/2
ml 29 x 1/2"
SMART SENSE COLOR
LANCETS - lancets
3
2
3
SM INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
SMART SENSE PREMIUM
BLOOD - blood glucose
monitoring kit w/ device
SMART SENSE STANDARD
LANC - lancets
3
SM INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1 ml
28 x 1/2"
2
SM INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1 ml
29 x 1/2"
2
SM INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1 ml
30 x 5/16"
2
SM INSULIN SYRINGE/0.3ML/ insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
SM INSULIN SYRINGE/0.5ML/ insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
SM INSULIN SYRINGE/1ML/31 insulin syringe/needle u-100 1 ml
31 x 5/16"
2
SM LANCETS 21G - lancets
3
SM MICRO THIN LANCETS 33G lancets
3
SM SUPER THIN LANCETS 30G lancets
3
228
SMART SENSE SUPER THIN LA - 3
lancets
SMART SENSE THIN LANCETS - 3
lancets
SMART SENSE VALUE BLOOD - 3
blood glucose monitoring kit w/
device
3
SMARTEST CONTROL
SOLUTION - blood glucose
calibration - liquid
3
SMARTEST EJECT STARTER KI
- blood glucose monitoring kit w/
device
3
SMARTEST LANCETS 28G lancets
SMARTEST PERSONA STARTER 3
- blood glucose monitoring kit w/
device
3
SMARTEST PRONTO STARTER
- blood glucose monitoring kit w/
device
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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Specialty
Quantity Limits
"Smart" PA
Drug Name
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Drug Tier
2015
SMARTEST PROTEGE STARTER
- blood glucose monitoring kit w/
device
3
SURE COMFORT INSULIN SYRI insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
SOLARTEK GLUCOSE CONTROL
- blood glucose calibration - liquid
3
2
SOLUS V2 AUDIBLE BLOOD GL
- blood glucose monitoring kit w/
device
3
SURE COMFORT INSULIN SYRI insulin syringe/needle u-100 1/2
ml 30 x 1/2"
2
SOLUS V2 CONTROL HIGH blood glucose calibration - liquid
- high
3
SURE COMFORT INSULIN SYRI insulin syringe/needle u-100 1 ml
28 x 1/2"
2
SOLUS V2 CONTROL LOW blood glucose calibration - liquid
- low
3
SURE COMFORT INSULIN SYRI insulin syringe/needle u-100 1 ml
29 x 1/2"
2
SOLUS V2 LANCING DEVICE lancet devices
3
SURE COMFORT INSULIN SYRI insulin syringe/needle u-100 1 ml
30 x 5/16"
2
SOLUS V2 PRESSURE ACTIVAT
- lancets
3
SURE COMFORT INSULIN SYRI insulin syringe/needle u-100 1 ml
30 x 1/2"
SOLUS V2 TWIST LANCETS 30 lancets
3
2
STERILANCE TL - lancets
3
SURE COMFORT INSULIN SYRI insulin syringe/needle u-100 1 ml
31 x 5/16"
3
SURE COMFORT INSULIN SYRI insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
SURE COMFORT INSULIN SYRI insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
SUPER THIN LANCETS - lancets
SURE COMFORT LANCETS 28G
- lancets
3
SURE COMFORT INSULIN SYRI insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
SURE COMFORT LANCETS 30G
- lancets
3
2
SURE COMFORT LANCING PEN
- lancet devices
3
SURE COMFORT INSULIN SYRI insulin syringe/needle u-100 0.3
ml 30 x 1/2"
2
SURE COMFORT INSULIN SYRI insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
SURE COMFORT PEN NEEDLES
- insulin pen needle 29 g x 12.7
mm
2
SURE COMFORT INSULIN SYRI insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
SURE COMFORT PEN NEEDLES
- insulin pen needle 30 g x 8 mm
(1/3" or 5/16")
2
SURE COMFORT INSULIN SYRI insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
SURE COMFORT PEN NEEDLES
- insulin pen needle 31 g x 5 mm
(3/16")
SURE COMFORT PEN NEEDLES
- insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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Specialty
Quantity Limits
"Smart" PA
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2015
229
SURE COMFORT PEN NEEDLES
- insulin pen needle 32 g x 4 mm
(5/32")
2
SURE-JECT INSULIN SYRINGE insulin syringe/needle u-100 1 ml
29 x 1/2"
2
SURE EDGE GLUCOSE
CONTROL - blood glucose
calibration - liquid - high
3
SURE-JECT INSULIN SYRINGE insulin syringe/needle u-100 1 ml
30 x 5/16"
2
SURE EDGE GLUCOSE
CONTROL - blood glucose
calibration - liquid - normal
3
SURE-JECT INSULIN SYRINGE insulin syringe/needle u-100 1 ml
31 x 5/16"
2
SURE EDGE GLUCOSE
CONTROL - blood glucose
calibration - liquid - low
3
SURE-JECT INSULIN SYRINGE insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
SURE-FINE PEN NEEDLES 29G
- insulin pen needle 29 g x 12.7
mm
2
SURE-LANCE FLAT LANCETS lancets
3
SURE-FINE PEN NEEDLES 31G
- insulin pen needle 31 g x 5 mm
(3/16")
SURE-LANCE LANCETS 26G lancets
3
2
SURE-LANCE THIN LANCETS 2 lancets
3
SURE-FINE PEN NEEDLES 31G
- insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
SURE-LANCE ULTRA THIN LAN lancets
3
2
SURE-PEN - lancet devices
3
SURE-JECT INSULIN SYRINGE insulin syringe/needle u-100 0.3
ml 29 x 1/2"
3
SURE-JECT INSULIN SYRINGE insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
SURE-TEST EASYPLUS MINI C blood glucose calibration - liquid normal
SURE-TOUCH LANCETS UNIVER
- lancets
3
SURE-JECT INSULIN SYRINGE insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
SURECHEK BLOOD GLUCOSE
MO - blood glucose monitoring
kit w/ device
3
SURE-JECT INSULIN SYRINGE insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
SURECHEK GLUCOSE
CONTROL - blood glucose
calibration - liquid - high
3
SURE-JECT INSULIN SYRINGE insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
SURECHEK GLUCOSE
CONTROL - blood glucose
calibration - liquid - normal
3
SURE-JECT INSULIN SYRINGE insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
SURECHEK GLUCOSE
CONTROL - blood glucose
calibration - liquid - low
3
SURE-JECT INSULIN SYRINGE insulin syringe/needle u-100 1 ml
28 x 1/2"
2
SURELITE LANCETS - lancets
3
SURESTEP GLUCOSE CONTROL
- blood glucose calibration - liquid
3
230
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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Specialty
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"Smart" PA
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2015
SURESTEP PRO HIGH
GLUCOSE - blood glucose
calibration - liquid - high
3
TERUMO INSULIN SYRINGE/0. insulin syringe/needle u-100 1/2
ml 29 x 1/2"
SURESTEP PRO LOW GLUCOSE
- blood glucose calibration - liquid
- low
3
SURESTEP PRO NORMAL
GLUCO - blood glucose
calibration - liquid - normal
3
TAI DOC CONTROL - blood
glucose calibration - liquid normal
3
TECHLITE AST LANCETS lancets
3
TECHLITE LANCETS - lancets
3
TECHLITE LANCETS 30G lancets
3
TELCARE BLOOD GLUCOSE
MON - blood glucose monitoring
kit w/ device
3
TELCARE GLUCOSE CONTROL
S - blood glucose calibration liquid
3
TERUMO INSULIN SYRINGE/U- insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
TERUMO INSULIN SYRINGE/U- insulin syringe/needle u-100 1/2
ml 27 x 1/2"
2
TERUMO INSULIN SYRINGE/U- insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
TERUMO INSULIN SYRINGE/U- insulin syringe/needle u-100 1 ml
28 x 1/2"
2
TERUMO INSULIN SYRINGE/0. insulin syringe/needle u-100 0.3
ml 30 x 3/8"
2
TERUMO INSULIN SYRINGE/0. insulin syringe/needle u-100 1/2
ml 30 x 3/8"
2
TERUMO INSULIN SYRINGE/1M - 2
insulin syringe/needle u-100 1 ml
27 x 1/2"
TERUMO INSULIN SYRINGE/1M - 2
insulin syringe/needle u-100 1 ml
29 x 1/2"
TERUMO INSULIN SYRINGE/1M - 2
insulin syringe/needle u-100 1 ml
30 x 3/8"
TERUMO SURGUARD INSULIN S 2
- insulin syringe/needle u-100 0.3
ml 29 x 1/2"
TERUMO SURGUARD INSULIN S 2
- insulin syringe/needle u-100 1/2
ml 28 x 1/2"
TERUMO SURGUARD INSULIN S 2
- insulin syringe/needle u-100 1/2
ml 29 x 1/2"
TERUMO SURGUARD INSULIN S 2
- insulin syringe/needle u-100 1
ml 28 x 1/2"
TERUMO SURGUARD INSULIN S 2
- insulin syringe/needle u-100 1
ml 29 x 1/2"
3
TGT ADVANCED LANCING DEVI
- lancet devices
3
TGT BLOOD GLUCOSE
MONITOR - blood glucose
monitoring kit w/ device
TGT LANCET ALTERNATE SITE - 3
lancets
TGT LANCET MICRO THIN 33G - 3
lancets
TGT LANCET SUPER THIN 30G - 3
lancets
3
TGT LANCET THIN 23G - lancets
TGT LANCET THIN 26G - lancets
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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Specialty
Quantity Limits
"Smart" PA
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Drug Name
Drug Tier
2015
2
3
231
TGT LANCET ULTRA THIN 28G lancets
3
TODAYS HEALTH ADVANCED LA
- lancet devices
3
TGT LANCET ULTRA THIN 30G lancets
3
2
TGT LANCING DEVICE - lancet
devices
3
TODAYS HEALTH MINI PEN NE
- insulin pen needle 31 g x 6 mm
(1/4")
THINLETS GP LANCETS - lancets
3
THINLETS LANCET - lancets
3
THINPRO INSULIN SYRINGE/0 insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
THINPRO INSULIN SYRINGE/0 insulin syringe/needle u-100 0.3
ml 30 x 3/8"
2
THINPRO INSULIN SYRINGE/0 insulin syringe/needle u-100 1/2
ml 30 x 3/8"
2
THINPRO INSULIN SYRINGE/0 insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
THINPRO INSULIN SYRINGE/0 insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
THINPRO INSULIN SYRINGE/0 insulin syringe/needle u-100 1/2
ml 31 x 3/8"
2
THINPRO INSULIN SYRINGE/0 insulin syringe/needle u-100 0.3
ml 31 x 3/8"
2
THINPRO INSULIN SYRINGE/1 insulin syringe/needle u-100 1 ml
31 x 3/8"
2
THINPRO INSULIN SYRINGE/1 insulin syringe/needle u-100 1 ml
28 x 1/2"
2
THINPRO INSULIN SYRINGE/1 insulin syringe/needle u-100 1 ml
29 x 1/2"
2
THINPRO INSULIN SYRINGE/1 insulin syringe/needle u-100 1 ml
30 x 3/8"
2
232
TODAYS HEALTH ORIGINAL PE - 2
insulin pen needle 29 g x 12 mm
(1/2")
TODAYS HEALTH SHORT PEN N 2
- insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
TODAYS HEALTH SUPER THIN - 3
lancets
TODAYS HEALTH ULTRA THIN - 3
lancets
2
TOPCARE CLICKFINE UNIVERS
- insulin pen needle 31 g x 6 mm
(1/4")
2
TOPCARE CLICKFINE UNIVERS
- insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
TOPCARE ULTRA COMFORT INS 2
- insulin syringe/needle u-100 0.3
ml 29 x 1/2"
TOPCARE ULTRA COMFORT INS 2
- insulin syringe/needle u-100 0.3
ml 30 x 5/16"
TOPCARE ULTRA COMFORT INS 2
- insulin syringe/needle u-100 1/2
ml 31 x 5/16"
TOPCARE ULTRA COMFORT INS 2
- insulin syringe/needle u-100 1/2
ml 29 x 1/2"
TOPCARE ULTRA COMFORT INS 2
- insulin syringe/needle u-100 1/2
ml 30 x 5/16"
TOPCARE ULTRA COMFORT INS 2
- insulin syringe/needle u-100 1
ml 29 x 1/2"
TOPCARE ULTRA COMFORT INS 2
- insulin syringe/needle u-100 1
ml 30 x 5/16"
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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Specialty
Quantity Limits
"Smart" PA
Drug Name
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Drug Tier
2015
TOPCARE ULTRA COMFORT INS
- insulin syringe/needle u-100 1
ml 31 x 5/16"
2
TRUEPLUS INSULIN SYRINGE/ insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
TOPCARE ULTRA COMFORT INS
- insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
TRUEPLUS INSULIN SYRINGE/ insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
TOPCO INSULIN SYRINGE/U-1 insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
TRUEPLUS INSULIN SYRINGE/ insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
TOPCO INSULIN SYRINGE/U-1 insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
TRUEPLUS INSULIN SYRINGE/ insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
TOPCO INSULIN SYRINGE/U-1 insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
TRUEPLUS INSULIN SYRINGE/ insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
TOPCO INSULIN SYRINGE/U-1 insulin syringe/needle u-100 1 ml
28 x 1/2"
2
TRUEPLUS INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
28 x 1/2"
2
TOPCO INSULIN SYRINGE/U-1 insulin syringe/needle u-100 1 ml
29 x 1/2"
2
TRUEPLUS INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
29 x 1/2"
2
TRUE METRIX BLOOD GLUCOSE
- blood glucose monitoring kit w/
device
3
TRUEPLUS INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
30 x 5/16"
2
TRUE METRIX CONTROL SOLUT
- blood glucose calibration - liquid
- high
3
TRUEPLUS INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
31 x 5/16"
2
TRUE METRIX CONTROL SOLUT
- blood glucose calibration - liquid
- normal
3
TRUEPLUS INSULIN SYRINGE/ insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
TRUE METRIX CONTROL SOLUT
- blood glucose calibration - liquid
- low
3
TRUEPLUS LANCETS 26G lancets
3
TRUECONTROL GLUCOSE
CONTR - blood glucose
calibration - liquid
TRUEPLUS LANCETS 28G lancets
3
3
TRUEPLUS LANCETS 28G SUPE
- lancets
3
TRUEDRAW LANCING DEVICE lancet devices
3
TRUEPLUS LANCETS 30G lancets
3
TRUEPLUS INSULIN SYRINGE/ insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
TRUEPLUS LANCETS 30G ULTR
- lancets
3
TRUEPLUS LANCETS 33G lancets
3
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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Specialty
Quantity Limits
"Smart" PA
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Drug Name
Drug Tier
2015
233
TRUEPLUS LANCETS 33G MICR
- lancets
3
TRUEPLUS SAFETY LANCETS 2
- lancets
3
TRUERESULT BLOOD GLUCOSE
- blood glucose monitoring kit w/
device
ULTICARE INSULIN SYRINGE/ insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
2
3
ULTICARE INSULIN SYRINGE/ insulin syringe/needle u-100 0.3
ml 30 x 1/2"
2
TRUETEST GLUCOSE CONTROL
- blood glucose calibration - liquid
3
ULTICARE INSULIN SYRINGE/ insulin syringe/needle u-100 1/2
ml 31 x 5/16"
TRUETRACK BLOOD GLUCOSE
M - blood glucose monitoring kit
w/ device
3
ULTICARE INSULIN SYRINGE/ insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
TRUETRACK SMART SYSTEM blood glucose monitoring kit w/
device
3
ULTICARE INSULIN SYRINGE/ insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
TRUE2GO BLOOD GLUCOSE
MON - blood glucose monitoring
kit w/ device
3
ULTICARE INSULIN SYRINGE/ insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
ULTI-LANCE AUTO-ADJUST DE lancet devices
3
2
ULTI-LANCE AUTOMATIC/ CLE lancet devices
3
ULTICARE INSULIN SYRINGE/ insulin syringe/needle u-100 1/2
ml 30 x 1/2"
2
ULTI-LANCE MINI ADJUSTABL lancet devices
3
ULTICARE INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
28 x 1/2"
2
ULTICARE INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
29 x 1/2"
2
ULTICARE INSULIN SAFETY S insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
ULTICARE INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
30 x 5/16"
2
ULTICARE INSULIN SAFETY S insulin syringe/needle u-100 1 ml
29 x 1/2"
2
ULTICARE INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
30 x 1/2"
2
ULTICARE INSULIN SYRINGE insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
ULTICARE INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
31 x 5/16"
2
ULTICARE INSULIN SYRINGE insulin syringe/needle u-100 1 ml
31 x 5/16"
2
ULTICARE INSULIN SYRINGE/ insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
ULTICARE INSULIN SYRINGE insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
ULTICARE MICRO PEN NEEDLE
- insulin pen needle 32 g x 4 mm
(5/32")
2
ULTICARE INSULIN SYRINGE/ insulin syringe/needle u-100 0.3
ml 29 x 1/2"
234
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
ULTICARE MINI PEN NEEDLES insulin pen needle 31 g x 6 mm
(1/4")
2
ULTILET INSULIN SYRINGE/S insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
ULTICARE ORIGINAL PEN NEE insulin pen needle 29 g x 12 mm
(1/2")
2
ULTILET INSULIN SYRINGE/S insulin syringe/needle u-100 1 ml
30 x 5/16"
2
ULTICARE PEN NEEDLES/29G
- insulin pen needle 29 g x 12.7
mm
2
ULTILET INSULIN SYRINGE/S insulin syringe/needle u-100 1 ml
31 x 5/16"
2
ULTICARE SHORT PEN NEEDLE
- insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
ULTILET INSULIN SYRINGE/S insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
ULTICARE THIN LANCETS 30G lancets
3
2
ULTIGUARD INSULIN SYRINGE insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
ULTILET INSULIN SYRINGE/0 insulin syringe/needle u-100 0.3
ml 30 x 7/16"
2
ULTIGUARD INSULIN SYRINGE insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
ULTILET INSULIN SYRINGE/0 insulin syringe/needle u-100 1/2
ml 29 x 7/16"
2
ULTIGUARD INSULIN SYRINGE insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
ULTILET INSULIN SYRINGE/0 insulin syringe/needle u-100 1/2
ml 30 x 7/16"
2
ULTIGUARD INSULIN SYRINGE insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
ULTILET INSULIN SYRINGE/0 insulin syringe/needle u-100 0.3
ml 29 x 7/16"
2
ULTIGUARD INSULIN SYRINGE insulin syringe/needle u-100 1 ml
29 x 1/2"
2
ULTILET INSULIN SYRINGE/1 insulin syringe/needle u-100 1 ml
29 x 7/16"
2
ULTIGUARD INSULIN SYRINGE insulin syringe/needle u-100 1 ml
30 x 5/16"
2
ULTILET INSULIN SYRINGE/1 insulin syringe/needle u-100 1 ml
30 x 7/16"
ULTILET LANCETS - lancets
3
ULTILET LANCETS 33G - lancets
3
ULTILET BASIC LANCETS 30G lancets
3
ULTILET OPERATING DEVICE lancet devices
3
ULTILET CLASSIC LANCETS lancets
3
2
ULTILET INSULIN SYRINGE/S insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
ULTILET PEN NEEDLE 32GX4M
- insulin pen needle 32 g x 4 mm
(5/32")
ULTILET SAFETY LANCETS 23 lancets
3
ULTILET INSULIN SYRINGE/S insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
ULTILET SHORT PEN NEEDLES
- insulin pen needle 31 g x 5 mm
(3/16")
2
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
235
ULTILET SHORT PEN NEEDLES
- insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
ULTRA-COMFORT INSULIN SYR
- insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
ULTILET ULTI-LANCE ADJ DE lancet devices
3
2
ULTRA COMFORT INSULIN SYR
- insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
ULTRA-COMFORT INSULIN SYR
- insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
ULTRA COMFORT INSULIN SYR
- insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
ULTRA-COMFORT INSULIN SYR
- insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
ULTRA COMFORT INSULIN SYR
- insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
ULTRA-COMFORT INSULIN SYR
- insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
ULTRA COMFORT INSULIN SYR
- insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
ULTRA-COMFORT INSULIN SYR
- insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
ULTRA COMFORT INSULIN SYR
- insulin syringe/needle u-100 1/2
ml 30 x 1/2"
2
ULTRA-COMFORT INSULIN SYR
- insulin syringe/needle u-100 1
ml 28 x 1/2"
2
ULTRA COMFORT INSULIN SYR
- insulin syringe/needle u-100 1
ml 29 x 1/2"
2
ULTRA-COMFORT INSULIN SYR
- insulin syringe/needle u-100 1
ml 29 x 1/2"
2
ULTRA COMFORT INSULIN SYR
- insulin syringe/needle u-100 1
ml 30 x 1/2"
2
ULTRA-COMFORT INSULIN SYR
- insulin syringe/needle u-100 1
ml 30 x 5/16"
2
ULTRA COMFORT INSULIN SYR
- insulin syringe/needle u-100 1
ml 31 x 5/16"
2
ULTRA-COMFORT INSULIN SYR
- insulin syringe/needle u-100 1
ml 31 x 5/16"
2
ULTRA INSULIN SYRINGE/U-1 insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
ULTRA-COMFORT INSULIN SYR
- insulin syringe/needle u-100 0.3
ml 31 x 5/16"
ULTRA-THIN II AUTO LANCET lancets
3
ULTRA THIN LANCETS 28G lancets
3
2
ULTRA THIN LANCETS 30G lancets
3
ULTRA-THIN II INSULIN SYR insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
ULTRA TRAK PRO BLOOD GLUC
- blood glucose monitoring kit w/
device
3
ULTRA-THIN II INSULIN SYR insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
ULTRA-COMFORT INSULIN SYR
- insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
ULTRA-THIN II INSULIN SYR insulin syringe/needle u-100 1/2
ml 31 x 5/16"
236
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
ULTRA-THIN II INSULIN SYR insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
UNIFINE PENTIPS PLUS 29GX insulin pen needle 29 g x 12 mm
(1/2")
2
ULTRA-THIN II INSULIN SYR insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
UNIFINE PENTIPS PLUS 31GX insulin pen needle 31 g x 5 mm
(3/16")
2
ULTRA-THIN II INSULIN SYR insulin syringe/needle u-100 1 ml
29 x 1/2"
2
UNIFINE PENTIPS PLUS 31GX insulin pen needle 31 g x 6 mm
(1/4")
2
ULTRA-THIN II INSULIN SYR insulin syringe/needle u-100 1 ml
30 x 5/16"
2
UNIFINE PENTIPS PLUS 31GX insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
ULTRA-THIN II INSULIN SYR insulin syringe/needle u-100 1 ml
31 x 5/16"
2
UNIFINE PENTIPS PLUS 32GX insulin pen needle 32 g x 4 mm
(5/32")
2
ULTRA-THIN II INSULIN SYR insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
UNIFINE PENTIPS 29GX12MM insulin pen needle 29 g x 12 mm
(1/2")
2
ULTRA-THIN II LANCETS 28G lancets
3
2
ULTRA-THIN II LANCETS 30G lancets
3
UNIFINE PENTIPS 31G X 3/1 insulin pen needle 31 g x 5 mm
(3/16")
2
ULTRA-THIN II MINI PEN NE insulin pen needle 31 g x 5 mm
(3/16")
2
UNIFINE PENTIPS 31G X 6MM insulin pen needle 31 g x 6 mm
(1/4")
2
ULTRA-THIN II PEN NEEDLES insulin pen needle 29 g x 12.7
mm
2
UNIFINE PENTIPS 31G X 8MM insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
ULTRA-THIN II PEN NEEDLES insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
UNIFINE PENTIPS 31GX5MM insulin pen needle 31 g x 5 mm
(3/16")
2
ULTRA-THIN II SAFETY AUTO lancets
3
UNIFINE PENTIPS 31GX6MM insulin pen needle 31 g x 6 mm
(1/4")
ULTRATRAK PRO CONTROL
SOL - blood glucose calibration liquid
3
UNIFINE PENTIPS 31GX8MM insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
3
ULTRATRAK PRO NORMAL
CONT - blood glucose calibration
- liquid - normal
3
ULTRATRAK ULTIMATE
CONTRO - blood glucose
calibration - liquid
UNIFINE PENTIPS 32GX4MM insulin pen needle 32 g x 4 mm
(5/32")
2
UNILET COMFORTOUCH
LANCET - lancets
3
UNILET EXCELITE - lancets
3
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
237
VALUE PLUS LANCETS STANDA
- lancets
3
3
VALUE PLUS LANCETS SUPER lancets
3
UNILET GP 28 ULTRA THIN lancets
3
VALUE PLUS LANCETS THIN 2 lancets
3
UNILET LANCET - lancets
3
3
UNILET SUPERLITE LANCET lancets
3
VALUE PLUS LANCING DEVICE lancet devices
3
UNISTIK 3 GENTLE - lancets
3
VALUMARK LANCET SUPER THI
- lancets
3
VALUMARK LANCET ULTRA THI
- lancets
3
UNISTRIP CONTROL SOLUTION
- blood glucose calibration - liquid
- high
2
UNISTRIP CONTROL SOLUTION
- blood glucose calibration - liquid
- low
3
VALUMARK PEN NEEDLES 29GX
- insulin pen needle 29 g x 12
mm (1/2")
2
UNIVERSAL 1 LANCETS THIN lancets
3
VALUMARK PEN NEEDLES 31G
- insulin pen needle 31 g x 6 mm
(1/4")
3
VALUMARK PEN NEEDLES 31G
- insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
UNIVERSAL 1 LANCETS ULTRA lancets
V-R MONOJECT INSULIN SYRI insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
VALVED HOLDING CHAMBER spacer/aerosol-holding chambers
- device
3
V-R MONOJECT INSULIN SYRI insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
VANISHPOINT INSULIN SYRIN insulin syringe/needle u-100 1/2
ml 30 x 1/2"
2
V-R MONOJECT INSULIN SYRI insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
VANISHPOINT INSULIN SYRIN insulin syringe/needle u-100 1 ml
29 x 1/2"
2
V-R MONOJECT INSULIN SYRI insulin syringe/needle u-100 1 ml
28 x 1/2"
2
VICTORY CONTROL LEVEL 1/2 blood glucose calibration - liquid
3
2
VIDA MIA AUTOLET LANCING lancet devices
3
V-R MONOJECT INSULIN SYRI insulin syringe/needle u-100 1 ml
29 x 1/2"
2
VALUE HEALTH INSULIN SYRI insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
VIDA MIA UNIFINE PENTIPS insulin pen needle 29 g x 12 mm
(1/2")
2
VALUE HEALTH INSULIN SYRI insulin syringe/needle u-100 1 ml
29 x 1/2"
2
VIDA MIA UNIFINE PENTIPS insulin pen needle 31 g x 6 mm
(1/4")
238
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
UNILET G.P. SUPERLITE LAN lancets
Drug Name
Drug Tier
3
Specialty
UNILET G.P. LANCET - lancets
Quantity Limits
3
"Smart" PA
UNILET EXCELITE II - lancets
Prior Authorization
Drug Name
Drug Tier
2015
VIDA MIA UNIFINE PENTIPS insulin pen needle 32 g x 4 mm
(5/32")
2
WAVESENSE AMP - blood
glucose monitoring kit w/ device
3
VIDA MIA UNILET LANCETS S lancets
WAVESENSE KEYNOTE - blood
glucose monitoring kit w/ device
3
3
VIDA MIA UNILET LANCETS U lancets
WD MEDIC INSULIN SYRINGE/ insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
3
VIDA MIA UNIPFINE PENTIPS insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
WD MEDIC INSULIN SYRINGE/ insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
VITALET PRO LANCETS - lancets
3
2
VITALET PRO PLUS LANCETS lancets
3
WD MEDIC INSULIN SYRINGE/ insulin syringe/needle u-100 1/2
ml 29 x 1/2"
VOCAL POINT GLUCOSE CONTR
- blood glucose calibration - liquid
- high
3
WD MEDIC INSULIN SYRINGE/ insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
VOCAL POINT GLUCOSE CONTR
- blood glucose calibration - liquid
- low
3
WD MEDIC INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
29 x 1/2"
2
VORTEX VALVED HOLDING
CHA - spacer/aerosol-holding
chambers - device
3
WD MEDIC INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
30 x 5/16"
2
VP INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
WEGMANS UNIFINE PENTIPS P
- insulin pen needle 31 g x 5 mm
(3/16")
2
W&F LANCETS COLORED 21G lancets
3
2
W&F LANCETS 26G - lancets
3
WEGMANS UNIFINE PENTIPS P
- insulin pen needle 31 g x 6 mm
(1/4")
3
WEGMANS UNIFINE PENTIPS P
- insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
WALGREENS ADVANCED
TRAVEL - lancets
WALGREENS COMFORT
ASSURED - lancets
3
2
WALGREENS LANCETS - lancets
3
WEGMANS UNIFINE PENTIPS P
- insulin pen needle 32 g x 4 mm
(5/32")
WIDE-SEAL SILICONE DIAPHR diaphragm wide seal 60 mm
A
WIDE-SEAL SILICONE DIAPHR diaphragm wide seal 65 mm
A
WIDE-SEAL SILICONE DIAPHR diaphragm wide seal 70 mm
A
WIDE-SEAL SILICONE DIAPHR diaphragm wide seal 75 mm
A
WALGREENS LANCING DEVICE - 3
lancet devices
3
WALGREENS THIN LANCETS lancets
WALGREENS ULTRA THIN LANC 3
- lancets
3
WATCHHALER - spacer/aerosolholding chambers - device
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
239
WIDE-SEAL SILICONE DIAPHR diaphragm wide seal 80 mm
A
ANHYDROUS CREAM BASE anhydrous cream base
WIDE-SEAL SILICONE DIAPHR diaphragm wide seal 85 mm
A
WIDE-SEAL SILICONE DIAPHR diaphragm wide seal 90 mm
A
WIDE-SEAL SILICONE DIAPHR diaphragm wide seal 95 mm
A
XPRES CONTROL SOLUTION NO
- blood glucose calibration - liquid
- normal
3
1ST CHOICE LANCETS SUPER lancets
3
1ST CHOICE LANCETS THIN lancets
3
APOTHEDERM - transdermal base 3
cream
CAPS 0 CLEAR DELAYED RELE - 1
non gelatin capsules (empty)
CAPSULE #0 CLEAR/LOCKING/ - 1
non gelatin capsules (empty)
CAPSULE CONI-SNAP #0 CLEA - 1
non gelatin capsules (empty)
CAPSULE CONI-SNAP #1 CLEA - 1
non gelatin capsules (empty)
CAPSULE CONI-SNAP #3 CLEA - 1
non gelatin capsules (empty)
1
COLD CREAM - cold cream
1ST CHOICE LANCETS ULTRA lancets
3
1ST CHOICE PEN NEEDLES 31 insulin pen needle 31 g x 6 mm
(1/4")
2
1ST CHOICE PEN NEEDLES 31 insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
1ST TIER UNIFINE PENTIPS insulin pen needle 29 g x 12 mm
(1/2")
2
1ST TIER UNIFINE PENTIPS insulin pen needle 31 g x 5 mm
(3/16")
2
1ST TIER UNIFINE PENTIPS insulin pen needle 31 g x 6 mm
(1/4")
1
FLAVOR BLEND - oral vehicles
3
FLAVOR PLUS - oral vehicles
3
FLAVOR SWEET - oral vehicles
3
FLAVOR SWEET-SF - oral
vehicles
3
KRISGEL 100 - krisgel 100 gel
3
lanolin
1
LANOLIN - lanolin anhydrous oil
1
LANOLIN ANHYDROUS - lanolin
anhydrous
1
2
LECITHIN ORGANOGEL premium lecithin organogel base
gel
1
1ST TIER UNIFINE PENTIPS insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
ORA-BLEND - oral vehicles
3
ORA-BLEND SF - oral vehicles
3
3
2
ORA-PLUS - oral vehicles
1ST TIER UNIFINE PENTIPS insulin pen needle 32 g x 4 mm
(5/32")
ORA-SWEET - oral vehicles
3
ORA-SWEET SF - oral vehicles
3
1ST TIER UNILET COMFORTOU - 3
lancets
ORAL MIX FLAVORED SUSPEND
- oral vehicles
3
PHARMACEUTICAL ADJUVANTS
ORAL MIX SF - oral vehicles
3
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
Specialty
Quantity Limits
"Smart" PA
3
EMPTY CAPSULE SIZE 1 VEGE non gelatin capsules (empty)
240
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
PCCA COBASE #1 - cobase #1
ointment base
3
PCCA POLYPEG BASE polyethylene glycol ointment
3
PCCA SWEET-SF - oral vehicles
3
PCCA SYRUP VEHICLE - oral
vehicles
3
PCCA-PLUS - oral vehicles
3
PEG-8 DISTEARATE BASE L polyethylene glycol ointment
Specialty
3
Quantity Limits
PCCA ACACIA SYRUP BASE acacia syrup
"Smart" PA
1
Prior Authorization
ORAL SYRUP SF - oral vehicles
Drug Name
Drug Tier
1
Specialty
ORAL SYRUP FLAVORED VEHIC
- oral vehicles
Quantity Limits
1
"Smart" PA
ORAL SUSPEND - oral vehicles
Prior Authorization
Drug Name
Drug Tier
2015
VEGETABLE CAPSULE #1 WHIT - 1
non gelatin capsules (empty)
VEGETABLE CAPSULE #2 WHIT - 1
non gelatin capsules (empty)
VEGETABLE CAPSULE #3 WHIT - 1
non gelatin capsules (empty)
VEGETABLE CAPSULE #4 WHIT - 1
non gelatin capsules (empty)
3
VERSAFREE - oral vehicles
VERSAPLUS - oral vehicles
3
YELLOW PETROLATUM petrolatum ointment
1
ASSORTED CLASSES
1
1
sodium polystyrene sulfonate
powder (Kayexalate)
3
•
PETROLATUM YELLOW petrolatum ointment
1
ASTAGRAF XL - tacrolimus cap sr
24hr 0.5 mg
3
•
PLACEBO #00 - placebo - cap
1
ASTAGRAF XL - tacrolimus cap sr
24hr 1 mg
PLO GEL - MEDIFLO KIT premium lecithin organogel base
kit
3
ASTAGRAF XL - tacrolimus cap sr
24hr 5 mg
3
•
AZASAN - azathioprine tab 75 mg
3
PLO GEL - MEDIFLO PRE-MIX premium lecithin organogel base
gel
3
3
CELLCEPT - mycophenolate
mofetil cap 250 mg
3
PLO20 BASE - premium lecithin
organogel base gel
•
1
CELLCEPT - mycophenolate
mofetil tab 500 mg
3
POLYETHYLENE GLYCOL 8000 polyethylene glycol 8000 oint
•
1
CELLCEPT - mycophenolate
mofetil for oral susp 200 mg/ml
2
PURIFIED WATER - distilled water
•
SALINE/PHENOL - saline w/
phenol inj
1
CUPRIMINE - penicillamine cap
250 mg
3
SYRPALTA - oral vehicles
3
•
1
cyclosporine cap 100 mg
(Sandimmune)
1
VEGETABLE CAPSULE #0 GREE
- non gelatin capsules (empty)
cyclosporine cap 25 mg
(Sandimmune)
1
•
CYCLOSPORINE MODIFIED cyclosporine modified cap 50 mg
1
•
VEGETABLE CAPSULE #0 WHIT - 1
non gelatin capsules (empty)
VEGETABLE CAPSULE #00 WHI - 1
non gelatin capsules (empty)
AZASAN - azathioprine tab 100 mg 3
1
azathioprine tab 50 mg (Imuran)
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
241
2
REVLIMID - lenalidomide caps 2.5
mg
2
•
• •
REVLIMID - lenalidomide cap 5 mg 2
2
REVLIMID - lenalidomide cap 10
mg
2
REVLIMID - lenalidomide cap 15
mg
2
REVLIMID - lenalidomide cap 20
mg
2
REVLIMID - lenalidomide cap 25
mg
1
ringer's solution for irrigation
•
•
• •
• •
•
• •
•
• •
•
• •
•
RAPAMUNE - sirolimus tab 1 mg
cyclosporine modified cap
25 mg (Neoral)
1
•
cyclosporine modified oral soln
100 mg/ml (Neoral)
1
•
DEPEN TITRATABS penicillamine tab 250 mg
3
IMURAN - azathioprine tab 50 mg
3
KAYEXALATE - sodium
polystyrene sulfonate powder
3
lactated ringer's for irrigation
1
mycophenolate mofetil cap
250 mg (Cellcept)
1
•
mycophenolate mofetil for oral
susp 200 mg/ml (Cellcept)
1
•
mycophenolate mofetil tab
500 mg (Cellcept)
1
•
mycophenolate sodium tab dr
180 mg (mycophenolic acid
equiv) (Myfortic)
1
•
mycophenolate sodium tab dr
360 mg (mycophenolic acid
equiv) (Myfortic)
1
•
MYFORTIC - mycophenolate
sodium tab dr 180 mg
(mycophenolic acid equiv)
3
MYFORTIC - mycophenolate
sodium tab dr 360 mg
(mycophenolic acid equiv)
3
NEORAL - cyclosporine modified
cap 25 mg
3
•
NEORAL - cyclosporine modified
cap 100 mg
3
•
NEORAL - cyclosporine modified
oral soln 100 mg/ml
3
•
PROGRAF - tacrolimus cap 0.5 mg 3
3
PROGRAF - tacrolimus cap 1 mg
•
•
•
•
PROGRAF - tacrolimus cap 5 mg
3
RAPAMUNE - sirolimus tab 0.5 mg
3
242
Specialty
RAPAMUNE - sirolimus oral soln 1
mg/ml
1
•
Quantity Limits
3
cyclosporine modified cap
100 mg (Neoral)
•
"Smart" PA
RAPAMUNE - sirolimus tab 2 mg
Drug Name
Drug Name
Prior Authorization
Drug Tier
3
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Tier
2015
•
•
•
SANDIMMUNE - cyclosporine cap
25 mg
3
•
SANDIMMUNE - cyclosporine cap
100 mg
3
•
SANDIMMUNE - cyclosporine oral
soln 100 mg/ml
3
•
sirolimus tab 0.5 mg (Rapamune)
1
sirolimus tab 1 mg (Rapamune)
1
sirolimus tab 2 mg (Rapamune)
1
•
•
•
sodium polystyrene sulfonate
oral susp 15 gm/60ml (Sps)
1
sodium polystyrene sulfonate
rectal susp 30 gm/120ml
1
SPS - sodium polystyrene
sulfonate oral susp 15 gm/60ml
3
SYPRINE - trientine hcl cap 250
mg
3
tacrolimus cap 0.5 mg (Prograf)
1
tacrolimus cap 1 mg (Prograf)
1
tacrolimus cap 5 mg (Prograf)
1
THALOMID - thalidomide cap 50
mg
2
•
• •
•
•
•
•
• •
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
•
• •
THALOMID - thalidomide cap 150
mg
2
•
• •
THALOMID - thalidomide cap 200
mg
2
•
• •
ZORTRESS - everolimus tab 0.25
mg
3
•
ZORTRESS - everolimus tab 0.5
mg
3
•
ZORTRESS - everolimus tab 0.75
mg
3
•
Specialty
2
Quantity Limits
Prior Authorization
THALOMID - thalidomide cap 100
mg
Drug Name
"Smart" PA
Drug Tier
2015
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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2015
INDEX
1ST CHOICE LANCETS SUPER - lancets .................... 240
1ST CHOICE LANCETS THIN - lancets ........................ 240
1ST CHOICE LANCETS ULTRA - lancets .....................240
1ST CHOICE PEN NEEDLES 31 - insulin pen needle 31 g
x 6 mm (1/4").................................................................240
1ST CHOICE PEN NEEDLES 31 - insulin pen needle 31 g
x 8 mm (1/3" or 5/16")...................................................240
1ST TIER UNIFINE PENTIPS - insulin pen needle 29 g x
12 mm (1/2")..................................................................240
1ST TIER UNIFINE PENTIPS - insulin pen needle 31 g x
5 mm (3/16")..................................................................240
1ST TIER UNIFINE PENTIPS - insulin pen needle 31 g x
6 mm (1/4")....................................................................240
1ST TIER UNIFINE PENTIPS - insulin pen needle 31 g x
8 mm (1/3" or 5/16")......................................................240
1ST TIER UNIFINE PENTIPS - insulin pen needle 32 g x
4 mm (5/32")..................................................................240
1ST TIER UNILET COMFORTOU - lancets ...................240
8-MOP - methoxsalen cap 10 mg................................... 183
A
A.A.G.C. KIT IN TERODERM - amantad-amitript-gabacycloben cream 8-4-10-4% (cmpd kit) ..........................165
A1C NOW - blood glucose monitoring kit w/ device ....... 192
abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg (Trizivir).................................................8
abacavir sulfate tab 300 mg (base equiv) (Ziagen).........8
ABILIFY - aripiprazole im inj 9.75 mg/1.3ml (7.5 mg/
ml).................................................................................... 94
ABILIFY - aripiprazole oral solution 1 mg/ml.....................94
ABILIFY - aripiprazole tab 10 mg......................................94
ABILIFY - aripiprazole tab 15 mg......................................94
ABILIFY - aripiprazole tab 20 mg......................................94
ABILIFY - aripiprazole tab 2 mg........................................94
ABILIFY - aripiprazole tab 30 mg......................................94
ABILIFY - aripiprazole tab 5 mg........................................94
ABILIFY DISCMELT - aripiprazole orally disintegrating tab
10 mg...............................................................................94
ABILIFY DISCMELT - aripiprazole orally disintegrating tab
15 mg...............................................................................94
ABILIFY MAINTENA - aripiprazole im for extended release
susp 300 mg....................................................................94
ABILIFY MAINTENA - aripiprazole im for extended release
susp 400 mg....................................................................94
ABSORICA - isotretinoin cap 10 mg............................... 165
ABSORICA - isotretinoin cap 20 mg............................... 165
ABSORICA - isotretinoin cap 25 mg............................... 165
ABSORICA - isotretinoin cap 30 mg............................... 165
ABSORICA - isotretinoin cap 35 mg............................... 165
ABSORICA - isotretinoin cap 40 mg............................... 165
ABSTRAL - fentanyl citrate sl tab 100 mcg (base
equiv)............................................................................. 108
244
ABSTRAL - fentanyl citrate sl tab 200 mcg (base
equiv)............................................................................. 108
ABSTRAL - fentanyl citrate sl tab 300 mcg (base
equiv)............................................................................. 108
ABSTRAL - fentanyl citrate sl tab 400 mcg (base
equiv)............................................................................. 108
ABSTRAL - fentanyl citrate sl tab 600 mcg (base
equiv)............................................................................. 108
ABSTRAL - fentanyl citrate sl tab 800 mcg (base
equiv)............................................................................. 108
acamprosate calcium tab delayed release 333 mg
(Campral)...................................................................... 103
ACANYA - clindamycin phosphate-benzoyl peroxide gel
1.2-2.5%.........................................................................165
acarbose tab 100 mg (Precose)..................................... 28
acarbose tab 25 mg (Precose)....................................... 28
acarbose tab 50 mg (Precose)....................................... 28
ACCOLATE - zafirlukast tab 10 mg.................................. 70
ACCOLATE - zafirlukast tab 20 mg.................................. 70
ACCU-CHEK ACTIVE GLUCOSE - blood glucose
calibration - liquid ......................................................... 188
ACCU-CHEK ACTIVE STRIPS - glucose blood test
strip................................................................................ 183
ACCU-CHEK AVIVA - blood glucose calibration - liquid
....................................................................................... 188
ACCU-CHEK AVIVA - glucose blood test strip............... 183
ACCU-CHEK AVIVA PLUS - blood glucose monitoring kit
w/ device ...................................................................... 188
ACCU-CHEK AVIVA PLUS - glucose blood test strip..... 183
ACCU-CHEK COMFORT CURVE C - blood glucose
calibration - liquid ......................................................... 188
ACCU-CHEK COMFORT CURVE L - blood glucose
calibration - liquid ......................................................... 189
ACCU-CHEK COMFORT CURVE T - glucose blood test
strip................................................................................ 183
ACCU-CHEK COMPACT BLUE CO - blood glucose
calibration - liquid ......................................................... 189
ACCU-CHEK COMPACT PLUS CA - blood glucose
monitoring kit ................................................................ 189
ACCU-CHEK COMPACT PLUS CL - blood glucose
calibration - liquid ......................................................... 189
ACCU-CHEK COMPACT PLUS - glucose blood test
strip................................................................................ 183
ACCU-CHEK COMPACT STRIPS - glucose blood test
strip................................................................................ 183
ACCU-CHEK COMPACT TEST DR - glucose blood test
strip................................................................................ 183
ACCU-CHEK FASTCLIX LANCET - lancets .................. 189
ACCU-CHEK INSTANT GLUCOSE - blood glucose
calibration - liquid ......................................................... 189
ACCU-CHEK INSTANT GLUCOSE - blood glucose
calibration - liquid ......................................................... 189
ACCU-CHEK MULTICLIX LANCE - lancets ...................189
ACCU-CHEK MULTICLIX LANCE - lancets ...................189
ACCU-CHEK NANO SMARTVIEW - blood glucose
monitoring kit w/ device ................................................189
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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ACCU-CHEK SAFE-T-PRO LANC - lancets .................. 189
ACCU-CHEK SAFE-T-PRO LANC - lancets .................. 189
ACCU-CHEK SAFE-T-PRO PLUS - lancets .................. 189
ACCU-CHEK SAFE-T-PRO PLUS - lancets .................. 189
ACCU-CHEK SMARTVIEW CONTR - blood glucose
calibration - liquid ......................................................... 189
ACCU-CHEK SMARTVIEW STRIP - glucose blood test
strip................................................................................ 183
ACCU-CHEK SOFTCLIX LANCET - lancet devices .......189
ACCU-CHEK SOFTCLIX LANCET - lancets ..................189
ACCU-CHEK SOFTCLIX LANCET - lancets ..................189
ACCU-CHEK SOFT TOUCH LANC - lancets ................ 189
ACCU-CHEK SOFT TOUCH LANC - lancets ................ 189
ACCU-CHEK VOICEMATE - blood glucose monitoring kit
w/ device ...................................................................... 189
ACCUNEB - albuterol sulfate soln nebu 0.63 mg/3ml
(base equiv).....................................................................70
ACCUNEB - albuterol sulfate soln nebu 1.25 mg/3ml
(base equiv).....................................................................70
ACCUPRIL - quinapril hcl tab 10 mg................................ 48
ACCUPRIL - quinapril hcl tab 20 mg................................ 48
ACCUPRIL - quinapril hcl tab 40 mg................................ 48
ACCUPRIL - quinapril hcl tab 5 mg.................................. 48
ACCURETIC - quinapril-hydrochlorothiazide tab 10-12.5
mg.................................................................................... 48
ACCURETIC - quinapril-hydrochlorothiazide tab 20-12.5
mg.................................................................................... 48
ACCURETIC - quinapril-hydrochlorothiazide tab 20-25
mg.................................................................................... 48
ACCUTREND GLUCOSE CONTROL - blood glucose
calibration - liquid ......................................................... 189
ACCUTREND GLUCOSE - glucose blood test strip........183
acebutolol hcl cap 200 mg (Sectral)..............................42
acebutolol hcl cap 400 mg (Sectral)..............................42
ACEON - perindopril erbumine tab 4 mg.......................... 48
ACEON - perindopril erbumine tab 8 mg.......................... 48
ACETAMINOPHEN/CAFFEINE/DI - acetaminophencaffeine-dihydrocodeine tab 712.8-60-32 mg................ 108
acetaminophen-isometheptene-caffeine tab 325-65-20
mg (Prodrin)................................................................. 121
acetaminophen-isometheptene-dichloral cap
325-65-100 mg.............................................................. 121
acetaminophen-salicylamide-phenyltoloxamine cap
300-200-20mg............................................................... 106
acetaminophen w/ codeine soln 120-12 mg/5ml.........108
acetaminophen w/ codeine tab 300-15 mg (Tylenol/
codeine)........................................................................ 108
acetaminophen w/ codeine tab 300-30 mg (Tylenol/
codeine #3)................................................................... 108
acetaminophen w/ codeine tab 300-60 mg (Tylenol/
codeine #4)...................................................................108
ACETAZOLAMIDE - acetazolamide tab 125 mg...............57
acetazolamide cap sr 12hr 500 mg (Diamox)................57
acetazolamide sodium for inj 500 mg........................... 57
acetazolamide tab 250 mg..............................................57
ACETIC ACID/ALUMINUM ACET - acetic acid 2% in
aluminum acetate otic soln............................................161
acetic acid irrigation soln 0.25%................................... 85
acetic acid otic soln 2%............................................... 161
acetylcysteine cap 600 mg........................................... 148
acetylcysteine inhal soln 10%........................................65
acetylcysteine inhal soln 20%........................................65
ACIPHEX - rabeprazole sodium ec tab 20 mg..................75
ACIPHEX SPRINKLE - rabeprazole sodium capsule
sprinkle dr 10 mg............................................................ 75
ACIPHEX SPRINKLE - rabeprazole sodium capsule
sprinkle dr 5 mg.............................................................. 75
acitretin cap 10 mg (Soriatane)....................................165
acitretin cap 17.5 mg (Soriatane).................................165
acitretin cap 25 mg (Soriatane)....................................165
ACLOVATE - alclometasone dipropionate cream
0.05%.............................................................................165
ACTEMRA - tocilizumab subcutaneous soln prefilled
syringe 162 mg/0.9ml.................................................... 117
ACTICLATE - doxycycline hyclate tab 150 mg................... 4
ACTICLATE - doxycycline hyclate tab 75 mg..................... 4
ACTIGALL - ursodiol cap 300 mg.....................................80
ACTI-LANCE LANCETS 28G - lancets ..........................189
ACTI-LANCE LITE SAFETY LA - lancets ...................... 189
ACTI-LANCE SPECIAL SAFETY - lancets .................... 189
ACTI-LANCE UNIVERSAL SAFE - lancets ....................189
ACTIMMUNE - interferon gamma-1b inj 100 mcg/0.5ml
(2000000 unit/0.5ml)........................................................15
ACTIQ - fentanyl citrate lollipop 1200 mcg......................108
ACTIQ - fentanyl citrate lollipop 1600 mcg......................108
ACTIQ - fentanyl citrate lollipop 200 mcg........................108
ACTIQ - fentanyl citrate lollipop 400 mcg........................108
ACTIQ - fentanyl citrate lollipop 600 mcg........................108
ACTIQ - fentanyl citrate lollipop 800 mcg........................108
ACTIVE-CYCLOBENZAPRINE KI - cyclobenzaprine hcl td
cream 5% (compound kit) ............................................ 132
ACTIVE FE - fe carbonyl-fa-b complex-a-c-d-e-min tab
75-1.25 mg ................................................................... 150
ACTIVE-KETOPROFEN KIT - ketoprofen cream 5%
(compound kit) ..............................................................165
ACTIVELLA - estradiol & norethindrone acetate tab
0.5-0.1 mg....................................................................... 22
ACTIVELLA - estradiol & norethindrone acetate tab 1-0.5
mg.................................................................................... 22
ACTIVE OB - prenatal w/o a w/fe cbn-fa-dha cap 20-1-320
mg .................................................................................134
ACTIVE-PAC/GABAPENTIN - gabapentin oral cap 300
mg & lidocaine-menthol gel ther pk............................... 103
ACTIVE-PREP KIT I - flurbiprofen-cyclobenzaprine cream
(cmpd kit) ..................................................................... 165
ACTIVE-PREP KIT III - ketoprofen-lidocaine-gabapentin
cream (cmpd kit) .......................................................... 166
ACTIVE-PREP KIT II - ketoprofen-baclofen-gabapentin
cream (cmpd kit) .......................................................... 166
ACTIVE-PREP KIT IV - tramadol-gabapentin-mentholcamphor cream (cmpd kit) ........................................... 166
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2015
ACTIVE-PREP KIT V - itraconazole-phenytoin sodium
cream (cmpd kit) .......................................................... 166
ACTIVE-TRAMADOL KIT - tramadol hcl cream 8%
(compound kit) ..............................................................166
ACTONEL - risedronate sodium tab 150 mg.................... 36
ACTONEL - risedronate sodium tab 30 mg...................... 36
ACTONEL - risedronate sodium tab 35 mg...................... 36
ACTONEL - risedronate sodium tab 5 mg........................ 36
ACTOPLUS MET - pioglitazone hcl-metformin hcl tab
15-500 mg....................................................................... 28
ACTOPLUS MET - pioglitazone hcl-metformin hcl tab
15-850 mg....................................................................... 28
ACTOPLUS MET XR - pioglitazone hcl-metformin hcl tab
sr 24hr 15-1000 mg.........................................................28
ACTOPLUS MET XR - pioglitazone hcl-metformin hcl tab
sr 24hr 30-1000 mg.........................................................28
ACTOS - pioglitazone hcl tab 15 mg (base equiv)............ 28
ACTOS - pioglitazone hcl tab 30 mg (base equiv)............ 28
ACTOS - pioglitazone hcl tab 45 mg (base equiv)............ 28
ACT TOTAL CARE DRY MOUTH - sodium fluoride rinse
0.02%.............................................................................162
ACULAR - ketorolac tromethamine ophth soln 0.5%.......156
ACULAR LS - ketorolac tromethamine ophth soln
0.4%...............................................................................156
ACURA BLOOD GLUCOSE MONIT - blood glucose
monitoring kit w/ device ................................................189
ACURA BLOOD GLUCOSE TEST - glucose blood test
strip................................................................................ 183
ACURA CONTROL SOLUTION HI - blood glucose
calibration - liquid - high ...............................................189
ACURA CONTROL SOLUTION LO - blood glucose
calibration - liquid - low ................................................ 189
ACURA CONTROL SOLUTION NO - blood glucose
calibration - liquid - normal ...........................................189
ACURA PLUS BLOOD GLUCOSE - blood glucose
monitoring kit w/ device ................................................189
ACUVAIL - ketorolac tromethamine ophth soln
0.45%.............................................................................156
acyclovir cap 200 mg (Zovirax)........................................8
acyclovir oint 5% (Zovirax)...........................................166
acyclovir susp 200 mg/5ml (Zovirax).............................. 8
acyclovir tab 400 mg (Zovirax)........................................ 8
acyclovir tab 800 mg (Zovirax)........................................ 8
ACZONE - dapsone gel 5%............................................ 166
ADALAT CC - nifedipine tab sr 24hr 30 mg...................... 44
ADALAT CC - nifedipine tab sr 24hr 60 mg...................... 44
ADALAT CC - nifedipine tab sr 24hr 90 mg...................... 44
adapalene cream 0.1% (Differin).................................. 166
adapalene gel 0.1% (Differin)....................................... 166
adapalene gel 0.3% (Differin)....................................... 166
ADAZIN - benzo-capsaicin-lido-methyl salicylate cream
2-0.035-2-10%............................................................... 166
ADCIRCA - tadalafil tab 20 mg (pah)................................62
ADDERALL - amphetamine-dextroamphetamine tab 10
mg.................................................................................... 99
246
ADDERALL - amphetamine-dextroamphetamine tab 12.5
mg.................................................................................... 99
ADDERALL - amphetamine-dextroamphetamine tab 15
mg.................................................................................... 99
ADDERALL - amphetamine-dextroamphetamine tab 20
mg.................................................................................... 99
ADDERALL - amphetamine-dextroamphetamine tab 30
mg.................................................................................... 99
ADDERALL - amphetamine-dextroamphetamine tab 5
mg.................................................................................... 99
ADDERALL - amphetamine-dextroamphetamine tab 7.5
mg.................................................................................... 99
ADDERALL XR - amphetamine-dextroamphetamine cap
sr 24hr 10 mg..................................................................99
ADDERALL XR - amphetamine-dextroamphetamine cap
sr 24hr 15 mg..................................................................99
ADDERALL XR - amphetamine-dextroamphetamine cap
sr 24hr 20 mg..................................................................99
ADDERALL XR - amphetamine-dextroamphetamine cap
sr 24hr 25 mg..................................................................99
ADDERALL XR - amphetamine-dextroamphetamine cap
sr 24hr 30 mg..................................................................99
ADDERALL XR - amphetamine-dextroamphetamine cap
sr 24hr 5 mg....................................................................99
adefovir dipivoxil tab 10 mg (Hepsera)........................... 8
ADEMPAS - riociguat tab 0.5 mg..................................... 62
ADEMPAS - riociguat tab 1.5 mg..................................... 62
ADEMPAS - riociguat tab 1 mg........................................ 62
ADEMPAS - riociguat tab 2.5 mg..................................... 62
ADEMPAS - riociguat tab 2 mg........................................ 62
ADJUSTABLE LANCING DEVICE - lancet devices ....... 189
ADOXA - doxycycline monohydrate cap 150 mg................ 4
ADOXA - doxycycline monohydrate tab 100 mg................. 4
ADOXA - doxycycline monohydrate tab 50 mg................... 4
ADOXA - doxycycline monohydrate tab 75 mg................... 4
ADOXA PAK 1/100 - doxycycline monohydrate tab 100
mg...................................................................................... 4
ADOXA PAK 1/150 - doxycycline monohydrate tab 150
mg...................................................................................... 4
ADOXA PAK 2/100 - doxycycline monohydrate tab 100
mg...................................................................................... 4
ADRENACLICK - epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000)..........................................................58
ADRENACLICK - epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)............................................................58
ADRENAL C FORMULA - bioflavonoid products tab ..... 134
ADULT ASPIRIN LOW STRENGT - aspirin dispersible tab
81 mg.............................................................................106
ADVAIR DISKUS - fluticasone-salmeterol aer powder ba
100-50 mcg/dose............................................................. 70
ADVAIR DISKUS - fluticasone-salmeterol aer powder ba
250-50 mcg/dose............................................................. 70
ADVAIR DISKUS - fluticasone-salmeterol aer powder ba
500-50 mcg/dose............................................................. 70
ADVAIR HFA - fluticasone-salmeterol inhal aerosol 115-21
mcg/act............................................................................ 70
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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ADVAIR HFA - fluticasone-salmeterol inhal aerosol 230-21
mcg/act............................................................................ 70
ADVAIR HFA - fluticasone-salmeterol inhal aerosol 45-21
mcg/act............................................................................ 70
ADVANCED AM/PM - multiple vitamins w/ calcium therapy
pack .............................................................................. 134
ADVANCE INTUITION BLOOD G - blood glucose
monitoring kit w/ device ................................................189
ADVANCE INTUITION CONTROL - blood glucose
calibration - liquid - normal ...........................................189
ADVANCE INTUITION TEST ST - glucose blood test
strip................................................................................ 183
ADVANCE MICRO-DRAW CONTRO - blood glucose
calibration - liquid ......................................................... 190
ADVANCE MICRO-DRAW NORMAL - blood glucose
calibration - liquid ......................................................... 190
ADVANCE MICRO-DRAW TEST S - glucose blood test
strip................................................................................ 183
ADVICOR - niacin-lovastatin tab sr 24hr 1000-20 mg....... 59
ADVICOR - niacin-lovastatin tab sr 24hr 1000-40 mg....... 59
ADVICOR - niacin-lovastatin tab sr 24hr 500-20 mg.........59
ADVICOR - niacin-lovastatin tab sr 24hr 750-20 mg.........59
ADVOCATE BLOOD GLUCOSE MO - blood glucose
monitoring kit w/ device ................................................190
ADVOCATE CONTROL SOLUTION - blood glucose
calibration - liquid - high ...............................................190
ADVOCATE CONTROL SOLUTION - blood glucose
calibration - liquid - low ................................................ 190
ADVOCATE INSULIN PEN NEED - insulin pen needle 31
g x 5 mm (3/16")........................................................... 190
ADVOCATE INSULIN PEN NEED - insulin pen needle 31
g x 8 mm (1/3" or 5/16")................................................190
ADVOCATE INSULIN SYRINGE/ - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................190
ADVOCATE INSULIN SYRINGE/ - insulin syringe/needle
u-100 0.3 ml 30 x 5/16".................................................190
ADVOCATE INSULIN SYRINGE/ - insulin syringe/needle
u-100 0.3 ml 31 x 5/16".................................................190
ADVOCATE INSULIN SYRINGE/ - insulin syringe/needle
u-100 1/2 ml 29 x 1/2"...................................................190
ADVOCATE INSULIN SYRINGE/ - insulin syringe/needle
u-100 1/2 ml 30 x 5/16".................................................190
ADVOCATE INSULIN SYRINGE/ - insulin syringe/needle
u-100 1/2 ml 31 x 5/16".................................................190
ADVOCATE INSULIN SYRINGE/ - insulin syringe/needle
u-100 1 ml 29 x 1/2"......................................................190
ADVOCATE INSULIN SYRINGE/ - insulin syringe/needle
u-100 1 ml 30 x 5/16"....................................................190
ADVOCATE INSULIN SYRINGE/ - insulin syringe/needle
u-100 1 ml 31 x 5/16"....................................................190
ADVOCATE LANCETS - lancets ................................... 190
ADVOCATE LANCING DEVICE - lancet devices .......... 190
ADVOCATE REDI-CODE/TALKIN - blood glucose
monitoring kit w/ device ................................................190
ADVOCATE REDI-CODE+/ TALK - blood glucose
monitoring kit w/ device ................................................190
ADVOCATE REDI-CODE+ CONTR - blood glucose
calibration - liquid - high ...............................................190
ADVOCATE REDI-CODE+ CONTR - blood glucose
calibration - liquid - low ................................................ 190
ADVOCATE REDI-CODE+ TEST - glucose blood test
strip................................................................................ 184
ADVOCATE REDI-CODE - glucose blood test strip........183
ADVOCATE SAFETY LANCETS - lancets .................... 190
ADVOCATE TEST STRIPS - glucose blood test strip.....184
AEROCHAMBER/FLOWSIGNAL - spacer/aerosol-holding
chambers - device ........................................................191
AEROCHAMBER MINI AEROSOL - spacer/aerosolholding chambers - device ........................................... 190
AEROCHAMBER MV - spacer/aerosol-holding chambers device ........................................................................... 190
AEROCHAMBER PLUS/MASK - spacer/aerosol-holding
chambers - device ........................................................191
AEROCHAMBER PLUS/SMALL MA - spacer/aerosolholding chambers - device ........................................... 191
AEROCHAMBER PLUS FLOW-VU/ - spacer/aerosolholding chambers - device ........................................... 190
AEROCHAMBER PLUS FLOW VU - spacer/aerosolholding chambers - device ........................................... 190
AEROCHAMBER PLUS FLOW-VU - spacer/aerosolholding chambers - device ........................................... 190
AEROCHAMBER PLUS - spacer/aerosol-holding
chambers - device ........................................................190
AEROCHAMBER Z-STAT PLUS/F - spacer/aerosolholding chambers - device ........................................... 191
AEROCHAMBER Z-STAT PLUS/L - spacer/aerosolholding chambers - device ........................................... 191
AEROCHAMBER Z-STAT PLUS/M - spacer/aerosolholding chambers - device ........................................... 191
AEROCHAMBER Z-STAT PLUS/S - spacer/aerosolholding chambers - device ........................................... 191
AEROCHAMBER Z-STAT PLUS V - spacer/aerosolholding chambers - device ........................................... 191
AEROHIST - chlorpheniramine-methscopolamine tab sr
12hr 8-2.5 mg.................................................................. 63
AEROSPAN - flunisolide hfa inhal aerosol 80 mcg/act......70
AFINITOR DISPERZ - everolimus tab for oral susp 2
mg.................................................................................... 15
AFINITOR DISPERZ - everolimus tab for oral susp 3
mg.................................................................................... 15
AFINITOR DISPERZ - everolimus tab for oral susp 5
mg.................................................................................... 15
AFINITOR - everolimus tab 10 mg....................................15
AFINITOR - everolimus tab 2.5 mg...................................15
AFINITOR - everolimus tab 5 mg..................................... 15
AFINITOR - everolimus tab 7.5 mg...................................15
AF LANCETS SUPER THIN - lancets ........................... 191
AGAMATRIX AMP NO CODE TES - glucose blood test
strip................................................................................ 184
AGAMATRIX CONTROL HIGH - blood glucose calibration
- liquid - high ................................................................ 191
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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2015
AGAMATRIX CONTROL NORMAL - blood glucose
calibration - liquid ......................................................... 191
AGAMATRIX CONTROL NORMAL - blood glucose
calibration - liquid - normal ...........................................191
AGAMATRIX JAZZ - blood glucose monitoring kit w/
device ........................................................................... 191
AGAMATRIX JAZZ TEST STRIP - glucose blood test
strip................................................................................ 184
AGAMATRIX KEYNOTE TEST ST - glucose blood test
strip................................................................................ 184
AGAMATRIX PRESTO - blood glucose monitoring kit w/
device ........................................................................... 191
AGAMATRIX PRESTO TEST STR - glucose blood test
strip................................................................................ 184
AGAMATRIX ULTRA-THIN LANC - lancets ...................191
AGGRENOX - aspirin-dipyridamole cap sr 12hr 25-200
mg.................................................................................. 156
AGRYLIN - anagrelide hcl cap 0.5 mg............................156
AIF #2 DRUG PREPARATION - flurbiprofen-gabapentcycloben-lido-dexameth cr (cmp kit) .............................166
AIF #3 DRUG PREPARATION K - flurbiprofen-baclofencycloben-lido cream (cmp kit) ...................................... 166
AKNE-MYCIN - erythromycin oint 2%.............................166
AKTEN - lidocaine hcl ophth gel 3.5%............................ 156
AKYNZEO - netupitant-palonosetron cap 300-0.5 mg.......78
ALAGESIC LQ - butalbital-acetaminophen-caffeine soln
50-325-40 mg/15ml........................................................107
ALAHIST AC - phenylephrine w/ codeine liqd 7.5-10
mg/5ml............................................................................. 65
ALAHIST DHC - phenylephrine-dihydrocodeine liqd 7.5-3
mg/5ml............................................................................. 65
ALA QUIN - clioquinol-hc cream 3-0.5%.........................166
ALA SCALP - hydrocortisone lotion 2%.......................... 166
ALBATUSSIN NN - phenyleph-dm-pyril-pot guai-sod cit-cit
acid liquid ....................................................................... 65
ALBATUSSIN - phenylephrine-carbetapentane-gg cap
10-25-400 mg.................................................................. 65
ALBENZA - albendazole tab 200 mg................................ 13
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)..........70
albuterol sulfate soln nebu 0.5% (5 mg/ml).................. 70
albuterol sulfate soln nebu 0.63 mg/3ml (base
equiv).............................................................................. 70
albuterol sulfate soln nebu 1.25 mg/3ml (base
equiv).............................................................................. 70
albuterol sulfate syrup 2 mg/5ml................................... 70
albuterol sulfate tab 2 mg.............................................. 70
albuterol sulfate tab 4 mg.............................................. 70
albuterol sulfate tab sr 12hr 4 mg (Vospire er).............70
albuterol sulfate tab sr 12hr 8 mg (Vospire er).............70
ALCAINE - proparacaine hcl ophth soln 0.5%................ 156
alclometasone dipropionate cream 0.05%
(Aclovate)......................................................................166
alclometasone dipropionate oint 0.05%...................... 166
ALCORTIN A - iodoquinol-hydrocortisone-aloe
polysaccharide gel 1-2-1% ........................................... 166
248
ALDACTAZIDE - spironolactone & hydrochlorothiazide tab
25-25 mg......................................................................... 57
ALDACTAZIDE - spironolactone & hydrochlorothiazide tab
50-50 mg......................................................................... 57
ALDACTONE - spironolactone tab 100 mg.......................57
ALDACTONE - spironolactone tab 25 mg.........................57
ALDACTONE - spironolactone tab 50 mg.........................57
ALDARA - imiquimod cream 5%.....................................166
ALENDRONATE SODIUM - alendronate sodium oral soln
70 mg/75ml......................................................................36
ALENDRONATE SODIUM - alendronate sodium tab 40
mg.................................................................................... 36
alendronate sodium tab 10 mg...................................... 36
alendronate sodium tab 35 mg...................................... 36
alendronate sodium tab 5 mg........................................ 36
alendronate sodium tab 70 mg (Fosamax)................... 36
ALFERON N - interferon alfa-n3 inj 5000000 unit/ml........ 15
alfuzosin hcl tab sr 24hr 10 mg (Uroxatral).................. 85
ALINIA - nitazoxanide for susp 100 mg/5ml......................13
ALINIA - nitazoxanide tab 500 mg.................................... 13
ALKERAN - melphalan tab 2 mg...................................... 15
ALLFEN CD - guaifenesin-codeine tab 400-10 mg........... 65
ALLFEN CDX - guaifenesin-codeine liquid 200-20
mg/5ml............................................................................. 65
ALLFEN CDX - guaifenesin-codeine tab 400-20 mg.........65
allopurinol tab 100 mg (Zyloprim)............................... 123
allopurinol tab 300 mg (Zyloprim)............................... 123
ALOCRIL - nedocromil sodium ophth soln 2%................156
ALODOX CONVENIENCE KIT - doxycycline hyclate tab
20 mg w/ eyelid cleansers kit ...........................................4
ALOMIDE - lodoxamide tromethamine ophth soln
0.1%...............................................................................156
ALOQUIN - iodoquinol-aloe polysaccharides gel 1.25-1%
....................................................................................... 166
ALORA - estradiol td patch biweekly 0.025 mg/24hr.........22
ALORA - estradiol td patch biweekly 0.05 mg/24hr...........22
ALORA - estradiol td patch biweekly 0.075 mg/24hr.........22
ALORA - estradiol td patch biweekly 0.1 mg/24hr.............22
ALPAIN - phenyltoloxamine-acetaminophen tab 60-500
mg.................................................................................. 107
ALPHAGAN P - brimonidine tartrate ophth soln 0.1%.....156
ALPHAGAN P - brimonidine tartrate ophth soln
0.15%.............................................................................156
ALPRAZOLAM INTENSOL - alprazolam conc 1 mg/
ml..................................................................................... 86
alprazolam orally disintegrating tab 0.25 mg
(Niravam)........................................................................ 86
alprazolam orally disintegrating tab 0.5 mg................. 86
alprazolam orally disintegrating tab 1 mg.................... 86
alprazolam orally disintegrating tab 2 mg.................... 86
alprazolam tab 0.25 mg (Xanax).................................... 87
alprazolam tab 0.5 mg (Xanax)...................................... 87
alprazolam tab 1 mg (Xanax)......................................... 87
alprazolam tab 2 mg (Xanax)......................................... 87
alprazolam tab sr 24hr 0.5 mg (Xanax xr)..................... 86
alprazolam tab sr 24hr 1 mg (Xanax xr)........................ 86
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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alprazolam tab sr 24hr 2 mg (Xanax xr)........................ 86
alprazolam tab sr 24hr 3 mg (Xanax xr)........................ 87
ALREX - loteprednol etabonate ophth susp 0.2%........... 156
ALSUMA - sumatriptan succinate solution auto-injector 6
mg/0.5ml........................................................................ 121
ALTABAX - retapamulin oint 1%.....................................166
ALTACE - ramipril cap 1.25 mg........................................ 48
ALTACE - ramipril cap 10 mg........................................... 48
ALTACE - ramipril cap 2.5 mg.......................................... 48
ALTACE - ramipril cap 5 mg.............................................48
ALTERNATE SITE LANCING DE - lancet devices ........ 191
ALTOPREV - lovastatin tab sr 24hr 20 mg....................... 59
ALTOPREV - lovastatin tab sr 24hr 40 mg....................... 59
ALTOPREV - lovastatin tab sr 24hr 60 mg....................... 59
aluminum chloride soln 20% (Drysol)......................... 166
ALUVEA - urea cream 39%............................................ 166
ALVESCO - ciclesonide inhal aerosol 160 mcg/act...........71
ALVESCO - ciclesonide inhal aerosol 80 mcg/act.............71
ALZ-NAC - l-methylfolate-methylcobalamin-acetylcyst tab
6-2-600 mg ................................................................... 148
AMANTADINE HCL - amantadine hcl tab 100 mg.......... 129
amantadine hcl cap 100 mg......................................... 129
amantadine hcl syrup 50 mg/5ml.................................129
AMARYL - glimepiride tab 1 mg....................................... 28
AMARYL - glimepiride tab 2 mg....................................... 28
AMARYL - glimepiride tab 4 mg....................................... 28
AMBIEN CR - zolpidem tartrate tab cr 12.5 mg................ 98
AMBIEN CR - zolpidem tartrate tab cr 6.25 mg................ 98
AMBIEN - zolpidem tartrate tab 10 mg............................. 98
AMBIEN - zolpidem tartrate tab 5 mg............................... 98
AMBIFED CD - pseudoephedrine w/ cod-gg tab 30-10-400
mg.................................................................................... 65
AMBIFED CDX - pseudoephedrine w/ cod-gg tab
30-20-400 mg.................................................................. 65
AMBIFED-G CD - pseudoephedrine w/ cod-gg tab
20-10-400 mg.................................................................. 65
AMBIFED-G CDX - pseudoephedrine w/ cod-gg tab
20-20-400 mg.................................................................. 65
AMCINONIDE - amcinonide cream 0.1%........................166
AMCINONIDE - amcinonide lotion 0.1%......................... 166
AMCINONIDE - amcinonide oint 0.1%............................166
amcinonide cream 0.1%............................................... 166
AMERGE - naratriptan hcl tab 1 mg (base equiv)........... 121
AMERGE - naratriptan hcl tab 2.5 mg (base equiv)........ 121
AMETHYST - levonorgestrel-ethinyl estradiol (continuous)
tab 90-20 mcg................................................................. 24
AMICAR - aminocaproic acid syrup 25%........................ 155
AMICAR - aminocaproic acid tab 1000 mg..................... 155
AMICAR - aminocaproic acid tab 500 mg....................... 155
amikacin sulfate inj 1 gm/4ml (250 mg/ml)..................... 6
amikacin sulfate inj 500 mg/2ml (250 mg/ml)..................6
amiloride & hydrochlorothiazide tab 5-50 mg...............57
amiloride hcl tab 5 mg....................................................57
AMINOBENZOATE POTASSIUM - potassium
aminobenzoate packet 2 gm......................................... 133
AMINOCAPROIC ACID - aminocaproic acid tab 1000
mg.................................................................................. 155
aminocaproic acid syrup 25% (Amicar)...................... 155
aminocaproic acid tab 500 mg (Amicar)..................... 155
amiodarone hcl tab 100 mg........................................... 47
amiodarone hcl tab 200 mg (Cordarone)...................... 47
amiodarone hcl tab 400 mg........................................... 47
AMITIZA - lubiprostone cap 24 mcg................................. 80
AMITIZA - lubiprostone cap 8 mcg................................... 80
amitriptyline hcl tab 100 mg...........................................88
amitriptyline hcl tab 10 mg............................................ 88
amitriptyline hcl tab 150 mg...........................................88
amitriptyline hcl tab 25 mg............................................ 88
amitriptyline hcl tab 50 mg............................................ 88
amitriptyline hcl tab 75 mg............................................ 88
amlodipine besylate-atorvastatin calcium tab 10-10 mg
(Caduet).......................................................................... 62
amlodipine besylate-atorvastatin calcium tab 10-20 mg
(Caduet).......................................................................... 62
amlodipine besylate-atorvastatin calcium tab 10-40 mg
(Caduet).......................................................................... 62
amlodipine besylate-atorvastatin calcium tab 10-80 mg
(Caduet).......................................................................... 62
amlodipine besylate-atorvastatin calcium tab 2.5-10
mg (Caduet)....................................................................62
amlodipine besylate-atorvastatin calcium tab 2.5-20
mg (Caduet)....................................................................62
amlodipine besylate-atorvastatin calcium tab 2.5-40
mg (Caduet)....................................................................62
amlodipine besylate-atorvastatin calcium tab 5-10 mg
(Caduet).......................................................................... 62
amlodipine besylate-atorvastatin calcium tab 5-20 mg
(Caduet).......................................................................... 62
amlodipine besylate-atorvastatin calcium tab 5-40 mg
(Caduet).......................................................................... 62
amlodipine besylate-atorvastatin calcium tab 5-80 mg
(Caduet).......................................................................... 62
amlodipine besylate-benazepril hcl cap 10-20 mg
(Lotrel).............................................................................48
amlodipine besylate-benazepril hcl cap 10-40 mg
(Lotrel).............................................................................48
amlodipine besylate-benazepril hcl cap 2.5-10 mg
(Lotrel).............................................................................48
amlodipine besylate-benazepril hcl cap 5-10 mg
(Lotrel).............................................................................48
amlodipine besylate-benazepril hcl cap 5-20 mg
(Lotrel).............................................................................48
amlodipine besylate-benazepril hcl cap 5-40 mg
(Lotrel).............................................................................48
amlodipine besylate tab 10 mg (Norvasc).....................44
amlodipine besylate tab 2.5 mg (Norvasc)....................44
amlodipine besylate tab 5 mg (Norvasc)...................... 44
amlodipine besylate-valsartan tab 10-160 mg
(Exforge)......................................................................... 48
amlodipine besylate-valsartan tab 10-320 mg
(Exforge)......................................................................... 48
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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amlodipine besylate-valsartan tab 5-160 mg
(Exforge)......................................................................... 49
amlodipine besylate-valsartan tab 5-320 mg
(Exforge)......................................................................... 49
amlodipine-valsartan-hydrochlorothiazide tab
10-160-12.5 mg (Exforge hct)....................................... 49
amlodipine-valsartan-hydrochlorothiazide tab
10-160-25 mg (Exforge hct).......................................... 49
amlodipine-valsartan-hydrochlorothiazide tab
10-320-25 mg (Exforge hct).......................................... 49
amlodipine-valsartan-hydrochlorothiazide tab
5-160-12.5 mg (Exforge hct)......................................... 49
amlodipine-valsartan-hydrochlorothiazide tab 5-160-25
mg (Exforge hct)............................................................49
AMOXAPINE - amoxapine tab 100 mg............................. 88
AMOXAPINE - amoxapine tab 150 mg............................. 88
AMOXAPINE - amoxapine tab 25 mg...............................88
AMOXAPINE - amoxapine tab 50 mg...............................88
amoxicillin (trihydrate) cap 250 mg................................. 1
amoxicillin (trihydrate) cap 500 mg................................. 1
amoxicillin (trihydrate) for susp 125 mg/5ml.................. 1
amoxicillin (trihydrate) for susp 200 mg/5ml.................. 1
amoxicillin (trihydrate) for susp 250 mg/5ml.................. 1
amoxicillin (trihydrate) for susp 400 mg/5ml.................. 1
amoxicillin (trihydrate) tab 500 mg..................................1
amoxicillin (trihydrate) tab 875 mg..................................1
amoxicillin & k clavulanate chew tab 200-28.5 mg.........1
amoxicillin & k clavulanate chew tab 400-57 mg............1
amoxicillin & k clavulanate for susp 200-28.5
mg/5ml.............................................................................. 1
amoxicillin & k clavulanate for susp 250-62.5 mg/5ml
(Augmentin)......................................................................1
amoxicillin & k clavulanate for susp 400-57 mg/5ml...... 1
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml
(Augmentin es-600)......................................................... 1
amoxicillin & k clavulanate tab 250-125 mg................... 1
amoxicillin & k clavulanate tab 500-125 mg
(Augmentin)......................................................................1
amoxicillin & k clavulanate tab 875-125 mg
(Augmentin)......................................................................1
amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg
(Augmentin xr)................................................................. 1
AMOXICILLIN - amoxicillin (trihydrate) chew tab 125
mg...................................................................................... 1
AMOXICILLIN - amoxicillin (trihydrate) chew tab 250
mg...................................................................................... 1
amoxicillin cap-clarithro tab-lansopraz cap dr therapy
pack (Prevpac)............................................................... 75
AMOXICILLIN ER - amoxicillin (trihydrate) tab sr 24hr 775
mg...................................................................................... 1
amphetamine-dextroamphetamine cap sr 24hr 10 mg
(Adderall xr)................................................................... 99
amphetamine-dextroamphetamine cap sr 24hr 15 mg
(Adderall xr)................................................................... 99
amphetamine-dextroamphetamine cap sr 24hr 20 mg
(Adderall xr)................................................................... 99
250
amphetamine-dextroamphetamine cap sr 24hr 25 mg
(Adderall xr)................................................................... 99
amphetamine-dextroamphetamine cap sr 24hr 30 mg
(Adderall xr)................................................................. 100
amphetamine-dextroamphetamine cap sr 24hr 5 mg
(Adderall xr)................................................................. 100
amphetamine-dextroamphetamine tab 10 mg
(Adderall)...................................................................... 100
amphetamine-dextroamphetamine tab 12.5 mg
(Adderall)...................................................................... 100
amphetamine-dextroamphetamine tab 15 mg
(Adderall)...................................................................... 100
amphetamine-dextroamphetamine tab 20 mg
(Adderall)...................................................................... 100
amphetamine-dextroamphetamine tab 30 mg
(Adderall)...................................................................... 100
amphetamine-dextroamphetamine tab 5 mg
(Adderall)...................................................................... 100
amphetamine-dextroamphetamine tab 7.5 mg
(Adderall)...................................................................... 100
AMPICILLIN - ampicillin for susp 125 mg/5ml.....................1
AMPICILLIN - ampicillin for susp 250 mg/5ml.....................1
ampicillin cap 250 mg.......................................................1
ampicillin cap 500 mg.......................................................1
AMPYRA - dalfampridine tab sr 12hr 10 mg................... 103
AMRIX - cyclobenzaprine hcl cap sr 24hr 15 mg............ 132
AMRIX - cyclobenzaprine hcl cap sr 24hr 30 mg............ 132
AMTURNIDE - aliskiren-amlodipine-hydrochlorothiazide
tab 150-5-12.5 mg........................................................... 49
AMTURNIDE - aliskiren-amlodipine-hydrochlorothiazide
tab 300-10-12.5 mg......................................................... 49
AMTURNIDE - aliskiren-amlodipine-hydrochlorothiazide
tab 300-10-25 mg............................................................ 49
AMTURNIDE - aliskiren-amlodipine-hydrochlorothiazide
tab 300-5-12.5 mg........................................................... 49
AMTURNIDE - aliskiren-amlodipine-hydrochlorothiazide
tab 300-5-25 mg.............................................................. 49
ANACAINE - benzocaine oint 10%................................. 166
ANADROL-50 - oxymetholone tab 50 mg......................... 21
ANAFRANIL - clomipramine hcl cap 25 mg...................... 88
ANAFRANIL - clomipramine hcl cap 50 mg...................... 88
ANAFRANIL - clomipramine hcl cap 75 mg...................... 88
anagrelide hcl cap 0.5 mg (Agrylin).............................156
anagrelide hcl cap 1 mg............................................... 156
ANALPRAM ADVANCED - hc-pramoxine cr & diet
manage prod tab & cleans wipe kit............................... 164
ANALPRAM E - hc-pramoxine emol cream 2.5-1% &
pramoxine wipe 1% kit.................................................. 164
ANALPRAM-HC - hydrocortisone acetate w/ pramoxine
rectal cream 1-1%......................................................... 164
ANALPRAM-HC - hydrocortisone acetate w/ pramoxine
rectal cream 2.5-1%...................................................... 164
ANALPRAM-HC - hydrocortisone acetate w/ pramoxine
rectal lotn 2.5-1%.......................................................... 164
ANALPRAM-HC SINGLES - hydrocortisone acetate w/
pramoxine rectal cream 1-1%....................................... 164
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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ANALPRAM-HC SINGLES - hydrocortisone acetate w/
pramoxine rectal cream 2.5-1%.................................... 164
ANAPROX DS - naproxen sodium tab 550 mg............... 118
ANAPROX - naproxen sodium tab 275 mg.....................117
ANASPAZ - hyoscyamine sulfate tab disp 0.125 mg........ 75
anastrozole tab 1 mg (Arimidex)................................... 15
ANCOBON - flucytosine cap 250 mg..................................7
ANCOBON - flucytosine cap 500 mg..................................7
ANDRODERM - testosterone td patch 24hr 2 mg/24hr..... 21
ANDRODERM - testosterone td patch 24hr 4 mg/24hr..... 21
ANDROGEL PUMP - testosterone td gel 12.5 mg/act
(1%)................................................................................. 21
ANDROGEL PUMP - testosterone td gel 20.25 mg/act
(1.62%)............................................................................ 21
ANDROGEL - testosterone td gel 20.25 mg/1.25gm
(1.62%)............................................................................ 21
ANDROGEL - testosterone td gel 25 mg/2.5gm (1%)....... 21
ANDROGEL - testosterone td gel 40.5 mg/2.5gm
(1.62%)............................................................................ 21
ANDROGEL - testosterone td gel 50 mg/5gm (1%).......... 21
ANDROID - methyltestosterone cap 10 mg...................... 21
ANDROXY - fluoxymesterone tab 10 mg..........................21
ANGELIQ - drospirenone-estradiol tab 0.25-0.5 mg......... 22
ANGELIQ - drospirenone-estradiol tab 0.5-1 mg.............. 22
ANHYDROUS CREAM BASE - anhydrous cream
base............................................................................... 240
ANIMI-3/VITAMIN D - folic acid-b6-b12-d-omega 3phytosterols cap 1 mg ..................................................150
ANIMI-3 - folic acid-b6-b12-d-omega 3-phytosterols cap 1
mg .................................................................................150
ANIMI-3 - folic acid-vit b6-vit b12-omega 3-phytosterols
cap 1 mg ...................................................................... 150
ANORO ELLIPTA - umeclidinium-vilanterol aero powd ba
62.5-25 mcg/inh............................................................... 71
ANTABUSE - disulfiram tab 250 mg............................... 103
ANTABUSE - disulfiram tab 500 mg............................... 103
ANTARA - fenofibrate micronized cap 130 mg................. 59
ANTARA - fenofibrate micronized cap 30 mg................... 59
ANTARA - fenofibrate micronized cap 43 mg................... 59
ANTARA - fenofibrate micronized cap 90 mg................... 59
ANTIPYRINE/BENZOCAINE - antipyrine-benzocaine otic
soln 55-14 mg/ml (5.5-1.4%)......................................... 161
antipyrine-benzocaine otic soln 54-14 mg/ml
(5.4-1.4%)...................................................................... 161
antipyrine-benzocaine otic soln 55-14 mg/ml
(5.5-1.4%)...................................................................... 161
antipyrine-benzocaine-polycosanol otic sol
5.4-1.4-0.0097% (Treagan otic)................................... 161
ANTI-STICK INSULIN SYRING - insulin syringe/needle
u-100 1/2 ml 28 x 1/2"...................................................191
ANTI-STICK INSULIN SYRING - insulin syringe/needle
u-100 1/2 ml 29 x 1/2"...................................................191
ANTI-STICK INSULIN SYRING - insulin syringe/needle
u-100 1 ml 29 x 1/2"......................................................191
ANTIVERT - meclizine hcl tab 12.5 mg............................ 78
ANTIVERT - meclizine hcl tab 25 mg............................... 79
ANTIVERT - meclizine hcl tab 50 mg............................... 79
ANUSOL-HC - hydrocortisone acetate suppos 25
mg.................................................................................. 164
ANUSOL-HC - hydrocortisone rectal cream 2.5%...........164
ANZEMET - dolasetron mesylate tab 100 mg...................79
ANZEMET - dolasetron mesylate tab 50 mg.....................79
APEXICON E - diflorasone diacetate emollient base
cream 0.05%................................................................. 166
APIDRA - insulin glulisine inj 100 unit/ml.......................... 32
APIDRA SOLOSTAR - insulin glulisine soln pen-injector inj
100 unit/ml....................................................................... 32
APLENZIN - bupropion hbr tab sr 24hr 174 mg................ 88
APLENZIN - bupropion hbr tab sr 24hr 348 mg................ 88
APLENZIN - bupropion hbr tab sr 24hr 522 mg................ 88
APOKYN - apomorphine hydrochloride inj 10 mg/ml.......129
APOP - sulfacetamide sodium in bakuchiol vehicle gel
10%................................................................................166
APOTHEDERM - transdermal base cream .................... 240
APPBUTAMONE - bupropion hcl tab 75 mg & dietary
management cap pack.................................................... 88
APPBUTAMONE-D - bupropion hcl tab 75 mg & dietary
management cap pack.................................................... 88
APPFORMIN-D - metformin hcl tab 500 mg & dietary
management cap pack.................................................... 28
APPFORMIN - metformin hcl tab 500 mg & dietary
management cap pack.................................................... 28
apraclonidine hcl ophth soln 0.5% (base equivalent)
(Iopidine).......................................................................156
APRISO - mesalamine cap sr 24hr 0.375 gm................... 80
APTIOM - eslicarbazepine acetate tab 200 mg...............123
APTIOM - eslicarbazepine acetate tab 400 mg...............123
APTIOM - eslicarbazepine acetate tab 600 mg...............123
APTIOM - eslicarbazepine acetate tab 800 mg...............123
APTIVUS - tipranavir cap 250 mg.......................................8
APTIVUS - tipranavir oral soln 100 mg/ml.......................... 8
AP-ZEL - multiple vitamins w/ minerals tab ....................134
AQUA LANCE ADJUSTABLE LAN - lancet devices ...... 191
ARALEN - chloroquine phosphate tab 500 mg................. 13
ARANESP ALBUMIN FREE - darbepoetin alfapolysorbate 80 soln inj 100 mcg/0.5ml.......................... 150
ARANESP ALBUMIN FREE - darbepoetin alfapolysorbate 80 soln inj 100 mcg/ml............................... 150
ARANESP ALBUMIN FREE - darbepoetin alfapolysorbate 80 soln inj 150 mcg/0.3ml.......................... 150
ARANESP ALBUMIN FREE - darbepoetin alfapolysorbate 80 soln inj 150 mcg/0.75ml........................ 150
ARANESP ALBUMIN FREE - darbepoetin alfapolysorbate 80 soln inj 200 mcg/0.4ml.......................... 150
ARANESP ALBUMIN FREE - darbepoetin alfapolysorbate 80 soln inj 200 mcg/ml............................... 150
ARANESP ALBUMIN FREE - darbepoetin alfapolysorbate 80 soln inj 25 mcg/0.42ml.......................... 150
ARANESP ALBUMIN FREE - darbepoetin alfapolysorbate 80 soln inj 25 mcg/ml.................................150
ARANESP ALBUMIN FREE - darbepoetin alfapolysorbate 80 soln inj 300 mcg/0.6ml.......................... 150
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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ARANESP ALBUMIN FREE - darbepoetin alfapolysorbate 80 soln inj 300 mcg/ml............................... 150
ARANESP ALBUMIN FREE - darbepoetin alfapolysorbate 80 soln inj 40 mcg/0.4ml............................ 150
ARANESP ALBUMIN FREE - darbepoetin alfapolysorbate 80 soln inj 40 mcg/ml.................................150
ARANESP ALBUMIN FREE - darbepoetin alfapolysorbate 80 soln inj 500 mcg/ml............................... 150
ARANESP ALBUMIN FREE - darbepoetin alfapolysorbate 80 soln inj 60 mcg/0.3ml............................ 150
ARANESP ALBUMIN FREE - darbepoetin alfapolysorbate 80 soln inj 60 mcg/ml.................................150
ARAVA - leflunomide tab 10 mg..................................... 118
ARAVA - leflunomide tab 20 mg..................................... 118
ARCALYST - rilonacept for inj 220 mg........................... 118
ARCAPTA NEOHALER - indacaterol maleate inhal
powder cap 75 mcg (base equiv).................................... 71
ARICEPT - donepezil hydrochloride tab 10 mg...............103
ARICEPT - donepezil hydrochloride tab 23 mg...............103
ARICEPT - donepezil hydrochloride tab 5 mg.................103
ARICEPT ODT - donepezil hydrochloride orally
disintegrating tab 10 mg................................................ 103
ARICEPT ODT - donepezil hydrochloride orally
disintegrating tab 5 mg..................................................103
ARIMIDEX - anastrozole tab 1 mg....................................15
ARIXTRA - fondaparinux sodium inj 10 mg/0.8ml........... 154
ARIXTRA - fondaparinux sodium inj 2.5 mg/0.5ml.......... 154
ARIXTRA - fondaparinux sodium inj 5 mg/0.4ml............. 154
ARIXTRA - fondaparinux sodium inj 7.5 mg/0.6ml.......... 154
ARMOUR THYROID - thyroid tab 120 mg (2 grain).......... 33
ARMOUR THYROID - thyroid tab 15 mg (1/4 grain)......... 33
ARMOUR THYROID - thyroid tab 180 mg (3 grain).......... 33
ARMOUR THYROID - thyroid tab 240 mg (4 grain).......... 33
ARMOUR THYROID - thyroid tab 300 mg (5 grain).......... 33
ARMOUR THYROID - thyroid tab 30 mg (1/2 grain)......... 33
ARMOUR THYROID - thyroid tab 60 mg (1 grain)............ 33
ARMOUR THYROID - thyroid tab 90 mg (1 1/2 grain)...... 33
AROMASIN - exemestane tab 25 mg............................... 15
ARTHROTEC 50 - diclofenac w/ misoprostol tab delayed
release 50-0.2 mg......................................................... 118
ARTHROTEC 75 - diclofenac w/ misoprostol tab delayed
release 75-0.2 mg......................................................... 118
ARZOL SILVER NITRATE APP - silver nitrate-potassium
nitrate applicator 75-25%...............................................166
ASACOL HD - mesalamine tab delayed release 800
mg.................................................................................... 80
ASACOL - mesalamine tab delayed release 400 mg........ 80
ASCENSIA AUTODISC LOW AND - blood glucose
calibration - liquid ......................................................... 191
ASCENSIA AUTODISC NORMAL - blood glucose
calibration - liquid - normal ...........................................191
ASCENSIA AUTODISC TEST ST - glucose blood test
disk.................................................................................184
ASCORBIC ACID - ascorbic acid oral granules.............. 133
ASMANEX 14 METERED DOSES - mometasone furoate
inhal powd 220 mcg/inh (breath activated)......................71
252
ASMANEX 60 METERED DOSES - mometasone furoate
inhal powd 220 mcg/inh (breath activated)......................71
ASMANEX HFA - mometasone furoate inhal aerosol
suspension 100 mcg/act..................................................71
ASMANEX HFA - mometasone furoate inhal aerosol
suspension 200 mcg/act..................................................71
ASMANEX TWISTHALER 120 ME - mometasone furoate
inhal powd 220 mcg/inh (breath activated)......................71
ASMANEX TWISTHALER 14 MET - mometasone furoate
inhal powd 220 mcg/inh (breath activated)......................71
ASMANEX TWISTHALER 30 ME - mometasone furoate
inhal powd 220 mcg/inh (breath activated)......................71
ASMANEX TWISTHALER 30 MET - mometasone furoate
inhal powd 110 mcg/inh (breath activated)......................71
ASMANEX TWISTHALER 60 MET - mometasone furoate
inhal powd 220 mcg/inh (breath activated)......................71
ASMANEX TWISTHALER 7 METE - mometasone furoate
inhal powd 110 mcg/inh (breath activated)......................71
ASPIRIN - aspirin tab 81 mg.......................................... 107
ASPIRIN-CAFFEINE-DIHYDROC - aspirin-caffeinedihydrocodeine cap 356.4-30-16 mg............................. 108
aspirin chew tab 81 mg................................................ 107
ASPIRIN LOW DOSE - aspirin tab 81 mg...................... 107
aspirin tab 81 mg.......................................................... 107
aspirin tab delayed release 81 mg...............................107
ASSURE 3 CONTROL LEVEL 1/ - blood glucose
calibration - liquid ......................................................... 192
ASSURE 3 TEST STRIPS - glucose blood test strip.......184
ASSURE 4 CONTROL LEVEL 1/ - blood glucose
calibration - liquid ......................................................... 192
ASSURE 4 TEST STRIPS - glucose blood test strip.......184
ASSURE COMFORT LANCETS UL - lancets ................191
ASSURE DOSE NORMAL/HIGH C - blood glucose
calibration - liquid ......................................................... 191
ASSURE DOSE NORMAL CONTRO - blood glucose
calibration - liquid - normal ...........................................191
ASSURE HAEMOLANCE PLUS HI - lancets .................191
ASSURE HAEMOLANCE PLUS LO - lancets ................191
ASSURE HAEMOLANCE PLUS MI - lancets ................ 191
ASSURE HAEMOLANCE PLUS NO - lancets ............... 191
ASSURE HAEMOLANCE PLUS PE - lancets ................191
ASSURE ID INSULIN SAFETY - insulin syringe/needle
u-100 1/2 ml 29 x 1/2"...................................................191
ASSURE ID INSULIN SAFETY - insulin syringe/needle
u-100 1 ml 29 x 1/2"......................................................191
ASSURE II CHECK STRIP - glucose blood test strip......184
ASSURE II CONTROL LEVEL 1 - blood glucose
calibration - liquid ......................................................... 191
ASSURE II - glucose blood test strip.............................. 184
ASSURE II TEST STRIPS - glucose blood test strip.......184
ASSURE LANCE LANCETS - lancets ........................... 192
ASSURE LANCETS - lancets ........................................ 192
ASSURE PLATINUM TEST STRI - glucose blood test
strip................................................................................ 184
ASSURE PRISM CONTROL LEV - blood glucose
calibration - liquid ......................................................... 192
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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ASSURE PRISM MULTI TEST S - glucose blood test
strip................................................................................ 184
ASSURE PRO CONTROL LEVEL - blood glucose
calibration - liquid ......................................................... 192
ASSURE PRO TEST STRIPS - glucose blood test
strip................................................................................ 184
ASTAGRAF XL - tacrolimus cap sr 24hr 0.5 mg............. 241
ASTAGRAF XL - tacrolimus cap sr 24hr 1 mg................ 241
ASTAGRAF XL - tacrolimus cap sr 24hr 5 mg................ 241
ASTELIN - azelastine hcl nasal spray 137 mcg/spray (1
mg/ml).............................................................................. 64
ASTEPRO - azelastine hcl nasal spray 0.15% (205.5 mcg/
spray)............................................................................... 64
ASTRINGYN - ferric subsulfate soln 259 mg/gm............ 155
ATABEX EC - prenatal vit w/ dss-iron carbonyl-fa tab dr
29-1 mg ........................................................................ 134
ATABEX PRENATAL - prenatal vit w/ iron carbonyl-fa tab
65-1 mg ........................................................................ 134
ATACAND - candesartan cilexetil tab 16 mg.................... 49
ATACAND - candesartan cilexetil tab 32 mg.................... 49
ATACAND - candesartan cilexetil tab 4 mg...................... 49
ATACAND - candesartan cilexetil tab 8 mg...................... 49
ATACAND HCT - candesartan cilexetilhydrochlorothiazide tab 16-12.5 mg................................ 49
ATACAND HCT - candesartan cilexetilhydrochlorothiazide tab 32-12.5 mg................................ 49
ATACAND HCT - candesartan cilexetilhydrochlorothiazide tab 32-25 mg................................... 49
ATELVIA - risedronate sodium tab delayed release 35
mg.................................................................................... 36
atenolol & chlorthalidone tab 100-25 mg (Tenoretic
100)..................................................................................49
atenolol & chlorthalidone tab 50-25 mg (Tenoretic
50)....................................................................................49
atenolol tab 100 mg (Tenormin).....................................42
atenolol tab 25 mg (Tenormin).......................................42
atenolol tab 50 mg (Tenormin).......................................42
ATIVAN - lorazepam tab 0.5 mg.......................................87
ATIVAN - lorazepam tab 1 mg..........................................87
ATIVAN - lorazepam tab 2 mg..........................................87
AT LAST CONTROL SOLUTION - blood glucose
calibration - liquid ......................................................... 192
AT LAST LANCETS - lancets ........................................ 192
AT LAST TEST STRIPS - glucose blood test strip..........184
atorvastatin calcium tab 10 mg (base equivalent)
(Lipitor)........................................................................... 59
atorvastatin calcium tab 20 mg (base equivalent)
(Lipitor)........................................................................... 59
atorvastatin calcium tab 40 mg (base equivalent)
(Lipitor)........................................................................... 59
atorvastatin calcium tab 80 mg (base equivalent)
(Lipitor)........................................................................... 59
atovaquone-proguanil hcl tab 250-100 mg
(Malarone).......................................................................13
atovaquone-proguanil hcl tab 62.5-25 mg
(Malarone).......................................................................13
atovaquone susp 750 mg/5ml (Mepron)........................13
ATRALIN - tretinoin gel 0.05%........................................166
ATRIPLA - efavirenz-emtricitabine-tenofovir df tab
600-200-300 mg................................................................ 8
ATROPEN - atropine sulfate im inj device 0.25
mg/0.3ml.......................................................................... 75
ATROPEN - atropine sulfate im inj device 0.5
mg/0.7ml.......................................................................... 75
ATROPEN - atropine sulfate im inj device 1 mg/0.7ml...... 75
ATROPEN - atropine sulfate im inj device 2 mg/0.7ml...... 75
ATROPINE SULFATE - atropine sulfate ophth oint
1%..................................................................................156
atropine sulfate ophth soln 1% (Isopto atropine)....... 156
ATROVENT HFA - ipratropium bromide hfa inhal aerosol
17 mcg/act....................................................................... 71
ATROVENT - ipratropium bromide nasal soln 0.03% (21
mcg/spray)....................................................................... 64
ATROVENT - ipratropium bromide nasal soln 0.06% (42
mcg/spray)....................................................................... 64
AUBAGIO - teriflunomide tab 14 mg...............................103
AUBAGIO - teriflunomide tab 7 mg.................................103
AUGMENTIN - amoxicillin & k clavulanate chew tab
200-28.5 mg...................................................................... 1
AUGMENTIN - amoxicillin & k clavulanate for susp
125-31.25 mg/5ml..............................................................1
AUGMENTIN - amoxicillin & k clavulanate for susp
250-62.5 mg/5ml................................................................1
AUGMENTIN - amoxicillin & k clavulanate tab 500-125
mg...................................................................................... 1
AUGMENTIN - amoxicillin & k clavulanate tab 875-125
mg...................................................................................... 1
AUGMENTIN ES-600 - amoxicillin & k clavulanate for
susp 600-42.9 mg/5ml.......................................................1
AUGMENTIN XR - amoxicillin & k clavulanate tab sr 12hr
1000-62.5 mg.................................................................... 1
AURALGAN - antipyrine-benzocaine otic soln 55-14 mg/ml
(5.5-1.4%)...................................................................... 161
AURORA LANCET SUPER THIN - lancets ................... 192
AURORA LANCET THIN 23G - lancets .........................192
AURORA PEN NEEDLES 29GX12 - insulin pen needle 29
g x 12 mm (1/2")........................................................... 192
AURORA PEN NEEDLES 31G X - insulin pen needle 31 g
x 6 mm (1/4").................................................................192
AURORA PEN NEEDLES 31G X - insulin pen needle 31 g
x 8 mm (1/3" or 5/16")...................................................192
AURORA UNIFINE PENTIPS/32 - insulin pen needle 32 g
x 4 mm (5/32")...............................................................192
AURORA UNIFINE PENTIPS/MI - insulin pen needle 31 g
x 5 mm (3/16")...............................................................192
AURYXIA - ferric citrate tab 1 gm (210 mg ferric iron)...... 80
AUTO-LANCET - lancet devices ....................................192
AUTO-LANCET MINI - lancet devices ........................... 192
AUTOLET IMPRESSION - lancet devices ..................... 192
AUTOLET IMPRESSION LANCIN - lancet devices ....... 192
AUTOLET MINI - lancet devices ....................................192
AUTOPEN - injection device for insulin...........................192
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2015
AUTOPEN - injection device for insulin...........................192
AUVI-Q - epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000)..........................................................58
AUVI-Q - epinephrine solution auto-injector 0.3 mg/0.3ml
(1:1000)............................................................................58
AVAILNEX - carbocysteine chew tab 750 mg................. 148
AVALIDE - irbesartan-hydrochlorothiazide tab 150-12.5
mg.................................................................................... 49
AVALIDE - irbesartan-hydrochlorothiazide tab 300-12.5
mg.................................................................................... 49
AVANDAMET - rosiglitazone maleate-metformin hcl tab
2-1000 mg....................................................................... 28
AVANDAMET - rosiglitazone maleate-metformin hcl tab
2-500 mg......................................................................... 28
AVANDAMET - rosiglitazone maleate-metformin hcl tab
4-1000 mg....................................................................... 28
AVANDAMET - rosiglitazone maleate-metformin hcl tab
4-500 mg......................................................................... 28
AVANDARYL - rosiglitazone maleate-glimepiride tab 4-1
mg.................................................................................... 28
AVANDARYL - rosiglitazone maleate-glimepiride tab 4-2
mg.................................................................................... 28
AVANDARYL - rosiglitazone maleate-glimepiride tab 4-4
mg.................................................................................... 28
AVANDARYL - rosiglitazone maleate-glimepiride tab 8-2
mg.................................................................................... 28
AVANDARYL - rosiglitazone maleate-glimepiride tab 8-4
mg.................................................................................... 28
AVANDIA - rosiglitazone maleate tab 2 mg (base
equiv)............................................................................... 28
AVANDIA - rosiglitazone maleate tab 4 mg (base
equiv)............................................................................... 28
AVANDIA - rosiglitazone maleate tab 8 mg (base
equiv)............................................................................... 28
AVAPRO - irbesartan tab 150 mg.....................................49
AVAPRO - irbesartan tab 300 mg.....................................49
AVAPRO - irbesartan tab 75 mg.......................................49
AVAR-E LS - sulfacetamide sodium w/ sulfur cream
10-2%.............................................................................166
AVAR LS CLEANSER - sulfacetamide sodium w/ sulfur
cleanser 10-2%..............................................................166
AVAR LS - sulfacetamide sodium w/ sulfur cleansing pad
10-2%.............................................................................166
AVAR - sulfacetamide sodium w/ sulfur cleansing pad
9.5-5%............................................................................166
AVC - sulfanilamide vaginal cream 15%........................... 84
AVELOX ABC PACK - moxifloxacin hcl tab 400 mg (base
equiv)................................................................................. 6
AVELOX - moxifloxacin hcl tab 400 mg (base equiv)..........6
AVIDOXY DK - doxycycline tab 100 mg & suncreen & sal
acid wash 2% kit............................................................... 4
AVINZA - morphine sulfate beads cap sr 24hr 120
mg.................................................................................. 109
AVINZA - morphine sulfate beads cap sr 24hr 30 mg..... 108
AVINZA - morphine sulfate beads cap sr 24hr 45 mg..... 108
AVINZA - morphine sulfate beads cap sr 24hr 60 mg..... 109
254
AVINZA - morphine sulfate beads cap sr 24hr 75 mg..... 109
AVINZA - morphine sulfate beads cap sr 24hr 90 mg..... 109
AVODART - dutasteride cap 0.5 mg.................................85
AVONEX - interferon beta-1a for im inj kit 30mcg
(33mcg(6.6 mu)/vial)......................................................103
AVONEX - interferon beta-1a im inj kit 30 mcg/0.5ml......103
AVONEX PEN - interferon beta-1a im inj kit 30
mcg/0.5ml...................................................................... 103
AXERT - almotriptan malate tab 12.5 mg....................... 121
AXERT - almotriptan malate tab 6.25 mg....................... 121
AXID - nizatidine cap 150 mg........................................... 75
AXID - nizatidine cap 300 mg........................................... 75
AXID - nizatidine oral soln 15 mg/ml.................................75
AXIRON - testosterone td soln 30 mg/act......................... 21
AYGESTIN - norethindrone acetate tab 5 mg................... 27
AZACTAM - aztreonam for inj 1 gm..................................13
AZACTAM - aztreonam for inj 2 gm..................................13
AZASAN - azathioprine tab 100 mg................................241
AZASAN - azathioprine tab 75 mg..................................241
AZASITE - azithromycin ophth soln 1%.......................... 156
azathioprine tab 50 mg (Imuran)..................................241
azelastine hcl nasal spray 0.15% (205.5 mcg/spray)
(Astepro)......................................................................... 64
azelastine hcl nasal spray 137 mcg/spray (1 mg/
ml)....................................................................................64
azelastine hcl ophth soln 0.05% (Optivar).................. 156
AZELEX - azelaic acid cream 20%................................. 166
AZILECT - rasagiline mesylate tab 0.5 mg (base
equiv)............................................................................. 129
AZILECT - rasagiline mesylate tab 1 mg (base
equiv)............................................................................. 129
AZITHROMYCIN - azithromycin powd pack for susp 1
gm...................................................................................... 3
azithromycin for susp 100 mg/5ml (Zithromax)..............3
azithromycin for susp 200 mg/5ml (Zithromax)..............3
azithromycin tab 250 mg (Zithromax)............................. 3
azithromycin tab 500 mg (Zithromax)............................. 3
azithromycin tab 600 mg (Zithromax)............................. 3
AZOPT - brinzolamide ophth susp 1%............................157
AZOR - amlodipine besylate-olmesartan medoxomil tab
10-20 mg......................................................................... 49
AZOR - amlodipine besylate-olmesartan medoxomil tab
10-40 mg......................................................................... 49
AZOR - amlodipine besylate-olmesartan medoxomil tab
5-20 mg........................................................................... 49
AZOR - amlodipine besylate-olmesartan medoxomil tab
5-40 mg........................................................................... 49
aztreonam for inj 1 gm (Azactam)................................. 13
aztreonam for inj 2 gm (Azactam)................................. 13
AZULFIDINE EN-TABS - sulfasalazine tab delayed
release 500 mg................................................................81
AZULFIDINE - sulfasalazine tab 500 mg.......................... 81
B
B-6 FOLIC ACID - cobalamine combination cap ............ 150
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
2015
BABY DDROPS - cholecalciferol drops 400 unit/0.03ml
(per drop).......................................................................133
BACITRACIN - bacitracin ophth oint 500 unit/gm............157
bacitracin-polymyxin b ophth oint...............................157
bacitracin-polymyxin-neomycin-hc ophth oint 1%.....157
baclofen tab 10 mg....................................................... 132
baclofen tab 20 mg....................................................... 132
BACMIN - multiple vitamins w/ minerals tab .................. 134
BACTRIM DS - sulfamethoxazole-trimethoprim tab
800-160 mg..................................................................... 13
BACTRIM - sulfamethoxazole-trimethoprim tab 400-80
mg.................................................................................... 13
BACTROBAN - mupirocin calcium cream 2%.................166
BACTROBAN - mupirocin oint 2%.................................. 166
BACTROBAN NASAL - mupirocin calcium nasal oint
2%....................................................................................64
BAL-CARE DHA ESSENTIAL - prenat w/fe poly-na feredfa tab 27-1 & omega cap dr 374mg.............................. 135
BAL-CARE DHA - prenat w/fe poly-na fered-fa tab 27-1 &
omega cap dr 430mg.................................................... 134
balsalazide disodium cap 750 mg (Colazal)..................81
BANZEL - rufinamide susp 40 mg/ml..............................123
BANZEL - rufinamide tab 200 mg................................... 123
BANZEL - rufinamide tab 400 mg................................... 123
BARACLUDE - entecavir oral soln 0.05 mg/ml................... 9
BARACLUDE - entecavir tab 0.5 mg.................................. 9
BARACLUDE - entecavir tab 1 mg..................................... 9
BAYER BREEZE 2 BLOOD GLUC - blood glucose
monitoring kit w/ device ................................................192
BAYER BREEZE 2 HIGH CONTR - blood glucose
calibration - liquid - high ...............................................192
BAYER BREEZE 2 LOW CONTRO - blood glucose
calibration - liquid - low ................................................ 192
BAYER BREEZE 2 NORMAL CON - blood glucose
calibration - liquid - normal ...........................................192
BAYER BREEZE 2 TEST DISC - glucose blood test
disk.................................................................................184
BAYER CONTOUR BLOOD GLUCO - blood glucose
monitoring kit w/ device ................................................192
BAYER CONTOUR BLOOD GLUCO - glucose blood test
strip................................................................................ 184
BAYER CONTOUR HIGH CONTRO - blood glucose
calibration - liquid - high ...............................................192
BAYER CONTOUR LINK BLOOD - blood glucose
monitoring kit w/ device ................................................192
BAYER CONTOUR LOW CONTROL - blood glucose
calibration - liquid - low ................................................ 193
BAYER CONTOUR NEXT BLOOD - blood glucose
monitoring kit w/ device ................................................193
BAYER CONTOUR NEXT BLOOD - glucose blood test
strip................................................................................ 184
BAYER CONTOUR NEXT CONTRO - blood glucose
calibration - liquid - low ................................................ 193
BAYER CONTOUR NEXT CONTRO - blood glucose
calibration - liquid - normal ...........................................193
BAYER CONTOUR NEXT EZ BLO - blood glucose
monitoring kit w/ device ................................................193
BAYER CONTOUR NEXT LINK B - blood glucose
monitoring kit w/ device ................................................193
BAYER CONTOUR NEXT USB BL - blood glucose
monitoring kit w/ device ................................................193
BAYER CONTOUR NORMAL CONT - blood glucose
calibration - liquid - normal ...........................................193
BAYER CONTOUR USB BLOOD G - blood glucose
monitoring kit w/ device ................................................193
BAYER MICROLET 2 LANCING - lancet devices ..........193
BAYER MICROLET LANCETS - lancets ....................... 193
BCG VACCINE - bcg vaccine inj...................................... 15
b-complex w/ c & folic acid cap 1 mg
(Nephrocaps)................................................................134
b-complex w/ c & folic acid tab................................... 134
b-complex w/ c & folic acid tab 1 mg (Nephro-vite
rx).................................................................................. 134
b-complex w/ c & folic acid tab 5 mg.......................... 134
b-complex w/ c-biotin-minerals & folic acid tab 5 mg
(Diatx zn)...................................................................... 134
BD AUTOSHIELD 29G X 1/2" - insulin pen needle 29 g x
12 mm (1/2")..................................................................193
BD AUTOSHIELD 29G X 3/16" - insulin pen needle 29 g x
5 mm (3/16")..................................................................193
BD AUTOSHIELD 29G X 5/16" - insulin pen needle 29 g x
8 mm (5/16")..................................................................193
BD AUTOSHIELD DUO 30G X 3 - insulin pen needle 30 g
x 5 mm (3/16")...............................................................193
BD INSULIN SYRINGE/DETACH - insulin syringe/needle
u-100 1 ml 25 x 1"........................................................ 194
BD INSULIN SYRINGE/DETACH - insulin syringe/needle
u-100 1 ml 25 x 5/8"......................................................194
BD INSULIN SYRINGE/DETACH - insulin syringe/needle
u-100 1 ml 26 x 1/2"......................................................194
BD INSULIN SYRINGE/U-100/ - insulin syringe/needle
u-100 1/2 ml 30 x 1/2"...................................................194
BD INSULIN SYRINGE/U-100/ - insulin syringe/needle
u-100 1 ml 27 x 1/2"......................................................194
BD INSULIN SYRINGE/U-100/ - insulin syringe/needle
u-100 1 ml 28 x 1/2"......................................................194
BD INSULIN SYRINGE/U-100/ - insulin syringe/needle
u-100 2 ml 27.5 x 5/8"...................................................194
BD INSULIN SYRINGE/U-100/ - insulin syringe/needle
u-100 2 ml 29 x 1/2"......................................................194
BD INSULIN SYRINGE LUER-L - insulin syringe (disp)
u-100 1 ml..................................................................... 193
BD INSULIN SYRINGE MICROF - insulin syringe/needle
u-100 0.3 ml 28 x 1/2"...................................................193
BD INSULIN SYRINGE MICROF - insulin syringe/needle
u-100 1/2 ml 28 x 1/2"...................................................193
BD INSULIN SYRINGE MICROF - insulin syringe/needle
u-100 1 ml 27 x 5/8"......................................................193
BD INSULIN SYRINGE MICROF - insulin syringe/needle
u-100 1 ml 28 x 1/2"......................................................193
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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B-D INSULIN SYRINGE MICRO - insulin syringe/needle
u-100 1 ml 28 x 1/2"......................................................192
BD INSULIN SYRINGE SAFETY - insulin syringe/needle
u-100 0.3 ml 31 x 5/16".................................................193
BD INSULIN SYRINGE SAFETY - insulin syringe/needle
u-100 1/2 ml 29 x 1/2"...................................................193
BD INSULIN SYRINGE SAFETY - insulin syringe/needle
u-100 1 ml 29 x 1/2"......................................................193
BD INSULIN SYRINGE SLIP T - insulin syringe (disp)
u-100 1 ml..................................................................... 193
BD INSULIN SYRINGE U-40/1 - insulin syringe/needle
u-40 1 ml 25 x 5/8"....................................................... 193
BD INSULIN SYRINGE ULTRAF - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................193
BD INSULIN SYRINGE ULTRAF - insulin syringe/needle
u-100 0.3 ml 30 x 1/2"...................................................193
BD INSULIN SYRINGE ULTRAF - insulin syringe/needle
u-100 0.3 ml 31 x 15/64"...............................................194
BD INSULIN SYRINGE ULTRAF - insulin syringe/needle
u-100 0.3 ml 31 x 5/16".................................................194
BD INSULIN SYRINGE ULTRAF - insulin syringe/needle
u-100 1/2 ml 29 x 1/2"...................................................194
BD INSULIN SYRINGE ULTRAF - insulin syringe/needle
u-100 1/2 ml 30 x 1/2"...................................................194
BD INSULIN SYRINGE ULTRAF - insulin syringe/needle
u-100 1/2 ml 31 x 15/64"...............................................194
BD INSULIN SYRINGE ULTRAF - insulin syringe/needle
u-100 1/2 ml 31 x 5/16".................................................194
BD INSULIN SYRINGE ULTRAF - insulin syringe/needle
u-100 1 ml 29 x 1/2"......................................................194
BD INSULIN SYRINGE ULTRAF - insulin syringe/needle
u-100 1 ml 30 x 1/2"......................................................194
BD INSULIN SYRINGE ULTRAF - insulin syringe/needle
u-100 1 ml 31 x 15/64"..................................................194
BD INSULIN SYRINGE ULTRAF - insulin syringe/needle
u-100 1 ml 31 x 5/16"....................................................194
B-D INSULIN SYRINGE ULTRA - insulin syringe/needle
u-100 0.3 ml 30 x 1/2"...................................................192
B-D INSULIN SYRINGE ULTRA - insulin syringe/needle
u-100 0.3 ml 31 x 5/16".................................................192
B-D INSULIN SYRINGE ULTRA - insulin syringe/needle
u-100 1 ml 31 x 5/16"....................................................192
BD INTEGRA INSULIN SYRING - insulin syringe/needle
u-100 1 ml 29 x 1/2"......................................................194
BD INTEGRA SYRINGE/RETRAC - insulin syringe/needle
u-100 1 ml 25 x 1"........................................................ 194
BD LANCET DEVICE - lancet devices .......................... 194
BD LANCET ULTRAFINE 30G - lancets ........................194
BD LANCET ULTRAFINE 33G - lancets ........................194
BD LATITUDE DIABETES MANA - blood glucose
monitoring kit w/ device ................................................194
BD LO-DOSE INSULIN SYRIN - insulin syringe/needle
u-100 1/2 ml 28 x 1/2"...................................................193
BD LOGIC BLOOD GLUCOSE MO - blood glucose
monitoring kit w/ device ................................................194
BD MICROTAINER LANCETS - lancets ........................194
256
BD PEN - injection device for insulin.............................. 194
BD PEN MINI - injection device for insulin...................... 194
BD PEN NEEDLE/MINI/ULTRAF - insulin pen needle 31 g
x 5 mm (3/16")...............................................................194
BD PEN NEEDLE/NANO/ULTRA - insulin pen needle 32 g
x 4 mm (5/32")...............................................................194
BD PEN NEEDLE/SHORT/ULTRA - insulin pen needle 31
g x 8 mm (1/3" or 5/16")................................................195
BD PEN NEEDLE/ULTRAFINE/2 - insulin pen needle 29 g
x 12.7 mm..................................................................... 195
BD PEN NEEDLES SHORT/ULTR - insulin pen needle 31
g x 8 mm (1/3" or 5/16")................................................195
BD SAFETYGLIDE INSULIN SY - insulin syringe/needle
u-100 1/2 ml 30 x 5/16".................................................195
BD SAFETY-LOK INSULIN SYR - insulin syringe/needle
u-100 1 ml 29 x 1/2"......................................................195
BD TEST STRIPS - glucose blood test strip................... 184
BD ULTRA FINE LANCETS - lancets ............................195
BECONASE AQ - beclomethasone dipropionate monohyd
nasal susp 42 mcg/spray................................................ 64
BELLADONNA & OPIUM - belladonna alkaloids & opium
suppos 16.2-30 mg..........................................................75
BELLADONNA ALKALOIDS & OP - belladonna alkaloids
& opium suppos 16.2-60 mg........................................... 75
belladonna alkaloids-phenobarbital elixir 16.2 mg/5ml
(Donnatal)....................................................................... 75
BELSOMRA - suvorexant tab 10 mg................................ 98
BELSOMRA - suvorexant tab 15 mg................................ 98
BELSOMRA - suvorexant tab 20 mg................................ 98
BELSOMRA - suvorexant tab 5 mg.................................. 98
benazepril & hydrochlorothiazide tab 10-12.5 mg
(Lotensin hct)................................................................. 49
benazepril & hydrochlorothiazide tab 20-12.5 mg
(Lotensin hct)................................................................. 49
benazepril & hydrochlorothiazide tab 20-25 mg
(Lotensin hct)................................................................. 50
benazepril & hydrochlorothiazide tab 5-6.25 mg..........50
benazepril hcl tab 10 mg (Lotensin).............................. 50
benazepril hcl tab 20 mg (Lotensin).............................. 50
benazepril hcl tab 40 mg (Lotensin).............................. 50
benazepril hcl tab 5 mg.................................................. 50
BENICAR HCT - olmesartan medoxomilhydrochlorothiazide tab 20-12.5 mg................................ 50
BENICAR HCT - olmesartan medoxomilhydrochlorothiazide tab 40-12.5 mg................................ 50
BENICAR HCT - olmesartan medoxomilhydrochlorothiazide tab 40-25 mg................................... 50
BENICAR - olmesartan medoxomil tab 20 mg.................. 50
BENICAR - olmesartan medoxomil tab 40 mg.................. 50
BENICAR - olmesartan medoxomil tab 5 mg.................... 50
BENSAL HP - salicylic acid & benzoic acid oint 3-6%.....167
BENTYL - dicyclomine hcl cap 10 mg.............................. 75
BENTYL - dicyclomine hcl inj 10 mg/ml............................ 75
BENTYL - dicyclomine hcl oral soln 10 mg/5ml................ 75
BENTYL - dicyclomine hcl tab 20 mg............................... 75
BENZAC AC WASH - benzoyl peroxide liq 5%...............167
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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BENZACLIN - clindamycin phosphate-benzoyl peroxide
gel 1-5%........................................................................ 167
BENZACLIN WITH PUMP - clindamycin phosphatebenzoyl peroxide gel 1-5%............................................ 167
BENZAC W WASH - benzoyl peroxide liq 5%................ 167
BENZALKONIUM CHLORIDE - benzalkonium chloride
soln................................................................................ 183
BENZALKONIUM CHLORIDE - benzalkonium chloride
soln 17%........................................................................183
BENZALKONIUM CHLORIDE - benzalkonium chloride
soln 50%........................................................................183
BENZAMYCIN - benzoyl peroxide-erythromycin gel
5-3%...............................................................................167
BENZAMYCINPAK - benzoyl peroxide-erythromycin gel
pack 5-3%......................................................................167
BENZEFOAM - benzoyl peroxide foam 5.3%................. 167
BENZEFOAMULTRA - benzoyl peroxide foam 9.8%...... 167
BENZIQ - benzoyl peroxide gel 5.25 %.......................... 167
BENZIQ LS - benzoyl peroxide gel 2.75%...................... 167
benzocaine dental soln 20%........................................ 162
BENZOIN COMPOUND TINCTURE - benzoin compound
tincture........................................................................... 167
BENZOIN TINCTURE - benzoin tincture.........................167
benzonatate cap 100 mg (Tessalon perles).................. 65
benzonatate cap 200 mg................................................ 65
benzoyl peroxide cleanser 4.25%................................ 167
benzoyl peroxide cloth 3%........................................... 167
benzoyl peroxide cloth 6%........................................... 167
benzoyl peroxide cloth 9%........................................... 167
benzoyl peroxide creamy wash 4% & cleanser lotion
kit...................................................................................167
benzoyl peroxide creamy wash 8% &benzoyl peroxide
bar 5% kit (Bpo creamy wash comp).........................167
benzoyl peroxide creamy wash 8% & cleanser lotion
kit...................................................................................167
benzoyl peroxide-erythromycin gel 5-3%
(Benzamycin)................................................................167
benzoyl peroxide foam 5.3% (Benzefoam)..................167
benzoyl peroxide foam 9.8% (Benzefoamultra).......... 167
benzoyl peroxide gel 10%............................................ 167
benzoyl peroxide gel 5%.............................................. 167
benzoyl peroxide liq 10%............................................. 167
benzoyl peroxide liq 2.5%............................................ 167
benzoyl peroxide liq 5.25%.......................................... 167
benzoyl peroxide liq 7%............................................... 167
benzoyl peroxide lotion 3%..........................................167
benzoyl peroxide lotion 6%..........................................167
benzoyl peroxide lotion 9%..........................................167
benzoyl peroxide pad 3%............................................. 167
benzoyl peroxide pad 6%............................................. 167
benzoyl peroxide pad 9%............................................. 167
benztropine mesylate inj 1 mg/ml (Cogentin)............. 129
benztropine mesylate tab 0.5 mg.................................129
benztropine mesylate tab 1 mg................................... 129
benztropine mesylate tab 2 mg................................... 129
BEPREVE - bepotastine besilate ophth soln 1.5%..........157
BESIVANCE - besifloxacin hcl ophth susp 0.6% (base
equiv)............................................................................. 157
BETADINE OPHTHALMIC PREP - povidone-iodine ophth
soln 5%..........................................................................157
BETAGAN C CAP QD - levobunolol hcl ophth soln
0.5%...............................................................................157
BETAGAN - levobunolol hcl ophth soln 0.5%................. 157
betamethasone dipropionate augmented cream 0.05%
(Diprolene af)............................................................... 167
betamethasone dipropionate augmented gel
0.05%.............................................................................167
betamethasone dipropionate augmented lotion 0.05%
(Diprolene).................................................................... 167
betamethasone dipropionate augmented oint 0.05%
(Diprolene).................................................................... 167
betamethasone dipropionate cream 0.05%.................167
betamethasone dipropionate lotion 0.05%................. 167
betamethasone dipropionate oint 0.05%.....................167
betamethasone valerate aerosol foam 0.12%
(Luxiq)........................................................................... 168
BETAMETHASONE VALERATE - betamethasone
valerate oint 0.1%..........................................................168
betamethasone valerate cream 0.1%...........................168
betamethasone valerate lotion 0.1%........................... 168
betamethasone valerate oint 0.1%...............................168
BETAPACE AF - sotalol hcl (afib/afl) tab 120 mg............. 42
BETAPACE AF - sotalol hcl (afib/afl) tab 160 mg............. 42
BETAPACE AF - sotalol hcl (afib/afl) tab 80 mg............... 42
BETAPACE - sotalol hcl tab 120 mg................................ 42
BETAPACE - sotalol hcl tab 160 mg................................ 42
BETAPACE - sotalol hcl tab 80 mg.................................. 42
BETASERON - interferon beta-1b for inj kit 0.3 mg........ 103
betaxolol hcl ophth soln 0.5%..................................... 157
betaxolol hcl tab 10 mg (Kerlone)................................. 42
betaxolol hcl tab 20 mg (Kerlone)................................. 42
bethanechol chloride tab 10 mg (Urecholine)...............83
bethanechol chloride tab 25 mg (Urecholine)...............83
bethanechol chloride tab 50 mg (Urecholine)...............83
bethanechol chloride tab 5 mg (Urecholine)................ 83
BETHKIS - tobramycin nebu soln 300 mg/4ml....................6
BETIMOL - timolol ophth soln 0.25%..............................157
BETIMOL - timolol ophth soln 0.5%................................157
BETOPTIC-S - betaxolol hcl ophth susp 0.25%.............. 157
BEYAZ - drospirenone-ethinyl estrad-levomefolate tab
3-0.02-0.451 mg.............................................................. 24
BG STAR BLOOD GLUCOSE TES - glucose blood test
strip................................................................................ 184
BIAXIN - clarithromycin for susp 250 mg/5ml..................... 3
BIAXIN - clarithromycin tab 250 mg....................................3
BIAXIN - clarithromycin tab 500 mg....................................3
BIAXIN XL - clarithromycin tab sr 24hr 500 mg.................. 3
BIAXIN XL PAC - clarithromycin tab sr 24hr 500 mg.......... 3
bicalutamide tab 50 mg (Casodex)................................ 15
BIDIL - isosorbide dinitrate-hydralazine hcl tab 20-37.5
mg.................................................................................... 62
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BIFERARX - polysacch fe cmplx-fe heme poly-fa-b12 tab
22-6-1-0.025 mg............................................................ 150
BILTRICIDE - praziquantel tab 600 mg.............................13
BINOSTO - alendronate sodium effervescent tab 70
mg.................................................................................... 36
BIOREGESIC - phenyltoloxamine-acetaminophen tab
50-650 mg..................................................................... 107
BIOSCANNER GLUCOSE TEST S - glucose blood test
strip................................................................................ 184
BIO-STATIN - nystatin cap 1000000 unit............................7
BIO-STATIN - nystatin cap 500000 unit..............................7
bisoprolol & hydrochlorothiazide tab 10-6.25 mg
(Ziac)............................................................................... 50
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg
(Ziac)............................................................................... 50
bisoprolol & hydrochlorothiazide tab 5-6.25 mg
(Ziac)............................................................................... 50
bisoprolol fumarate tab 10 mg (Zebeta)........................42
bisoprolol fumarate tab 5 mg (Zebeta)..........................42
BLEPH-10 - sulfacetamide sodium ophth soln 10%........ 157
BLEPHAMIDE LIQUIFILM - sulfacetamide sodiumprednisolone ophth susp 10-0.2%................................. 157
BLEPHAMIDE S.O.P. - sulfacetamide sodiumprednisolone ophth oint 10-0.2%...................................157
BLEPHAMIDE - sulfacetamide sodium-prednisolone ophth
susp 10-0.2%.................................................................157
BLOOD GLUCOSE MONITORING - blood glucose
monitoring kit w/ device ................................................195
BLOOD GLUCOSE SYSTEM PAK - blood glucose
monitoring kit w/ device ................................................195
BLOOD GLUCOSE TEST STRIPS - glucose blood test
strip................................................................................ 184
BL TEST STRIP - glucose blood test strip...................... 184
B-NEXA - prenatal w/ calcium-vit b6-fa-ginger tab 1.22 mg
....................................................................................... 134
B-NEXA - prenatal w/ calcium-vit b6-fa-ginger tab 1.2 mg
....................................................................................... 134
BONIVA - ibandronate sodium tab 150 mg (base
equivalent)....................................................................... 36
BORIC ACID - boric acid granules..................................168
BOSULIF - bosutinib tab 100 mg......................................15
BOSULIF - bosutinib tab 500 mg......................................15
BP FOLINATAL PLUS B - prenatal w/ calcium carbonateb6-b12-fa tab 1 mg ...................................................... 135
BP MULTINATAL PLUS - prenatal w/o a vit w/ fe
fumarate-fa tab 30-1 mg .............................................. 135
BP MULTINATAL PLUS - prenatal w/o a vit w/ fe fum-fa
tab chew 40-1 mg ........................................................ 135
BPO 3% FOAMING CLOTHS - benzoyl peroxide cloth
3%..................................................................................168
BPO 6% FOAMING CLOTHS - benzoyl peroxide cloth
6%..................................................................................168
BPO 9% FOAMING CLOTHS - benzoyl peroxide cloth
9%..................................................................................168
BPO - benzoyl peroxide gel 4%......................................168
BPO - benzoyl peroxide gel 8%......................................168
258
BP VIT 3 - folic acid-vit b6-vit b12-omega 3-phytosterols
cap 1 mg ...................................................................... 151
BRAVELLE - urofollitropin purified for inj 75 unit...............36
BREATHERITE COLLAPSIBLE - spacer/aerosol-holding
chambers - device ........................................................195
BREATHERITE RIGID SPACER - spacer/aerosol-holding
chambers - device ........................................................195
BREATHERITE - spacer/aerosol-holding chambers device ........................................................................... 195
BREATHERITE W/LARGE MASK - spacer/aerosolholding chambers - device ........................................... 195
BREATHERITE W/MEDIUM MASK - spacer/aerosolholding chambers - device ........................................... 195
BREATHERITE W/SMALL MASK - spacer/aerosol-holding
chambers - device ........................................................195
BREO ELLIPTA - fluticasone furoate-vilanterol aero powd
ba 100-25 mcg/inh...........................................................71
BREVICON-28 - norethindrone & ethinyl estradiol tab 0.5
mg-35 mcg.......................................................................25
BRILINTA - ticagrelor tab 90 mg.....................................156
brimonidine tartrate ophth soln 0.15% (Alphagan
p)....................................................................................157
brimonidine tartrate ophth soln 0.2%..........................157
BRINTELLIX - vortioxetine hbr tab 10 mg (base equiv).....88
BRINTELLIX - vortioxetine hbr tab 20 mg (base equiv).....88
BRINTELLIX - vortioxetine hbr tab 5 mg (base equiv).......88
BRISDELLE - paroxetine mesylate cap 7.5 mg (base
equiv)............................................................................. 103
BROMDAY - bromfenac sodium ophth soln 0.09% (base
equiv) (once-daily)......................................................... 157
bromfenac sodium ophth soln 0.09% (base equiv)
(once-daily)...................................................................157
bromfenac sodium ophth soln 0.09% (base
equivalent).................................................................... 157
bromocriptine mesylate cap 5 mg (Parlodel)..............129
bromocriptine mesylate tab 2.5 mg.............................129
brompheniramine & pseudoephedrine tab sr 12hr 6-45
mg....................................................................................65
brompheniramine maleate tab sr 12hr 6 mg.................63
BROMPHENIRAMINE TANNATE - brompheniramine
tannate chew tab 12 mg..................................................63
BRONCOMAR-1 - theophylline-pse-gg elixir 150-30-150
mg/15ml........................................................................... 71
BRONCOPECTOL - phenyleph-chlorphen w/ dm-gg syrup
5-2-5-75 mg/5ml.............................................................. 65
BRONDIL - dyphylline-guaifenesin liqd 100-100
mg/15ml........................................................................... 71
BROVANA - arformoterol tartrate soln nebu 15 mcg/2ml
(base equiv).....................................................................71
budesonide cap sr 24hr 3 mg (Entocort ec)................. 19
budesonide inhalation susp 0.25 mg/2ml
(Pulmicort)...................................................................... 71
budesonide inhalation susp 0.5 mg/2ml
(Pulmicort)...................................................................... 71
budesonide nasal susp 32 mcg/act (Rhinocort
aqua)............................................................................... 64
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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BULLSEYE MINI SAFETY LANC - lancets .................... 195
BULLSEYE SAFETY LANCETS - lancets ......................195
bumetanide tab 0.5 mg................................................... 57
bumetanide tab 1 mg...................................................... 57
bumetanide tab 2 mg...................................................... 57
BUNAVAIL - buprenorphine-naloxone buccal film 2.1-0.3
mg (base equiv).............................................................109
BUNAVAIL - buprenorphine-naloxone buccal film 4.2-0.7
mg (base equiv).............................................................109
BUNAVAIL - buprenorphine-naloxone buccal film 6.3-1 mg
(base equiv)................................................................... 109
BUPAP - butalbital-acetaminophen tab 50-300 mg......... 107
BUPAP - butalbital-acetaminophen tab 50-650 mg......... 107
BUPHENYL - sodium phenylbutyrate oral powder 3 gm/
teaspoonful...................................................................... 36
BUPHENYL - sodium phenylbutyrate tab 500 mg.............36
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base
equiv)............................................................................ 109
buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base
equiv)............................................................................ 109
buprenorphine hcl sl tab 2 mg (base equiv)............... 109
buprenorphine hcl sl tab 8 mg (base equiv)............... 109
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg
(Zyban).......................................................................... 103
bupropion hcl tab 100 mg (Wellbutrin)......................... 89
bupropion hcl tab 75 mg (Wellbutrin)........................... 89
bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr)........ 88
bupropion hcl tab sr 12hr 150 mg (Wellbutrin sr)........ 88
bupropion hcl tab sr 12hr 200 mg (Wellbutrin sr)........ 88
bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl).........88
bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl).........88
BUSPIRONE HCL - buspirone hcl tab 7.5 mg.................. 87
buspirone hcl tab 10 mg................................................ 87
buspirone hcl tab 15 mg................................................ 87
buspirone hcl tab 30 mg................................................ 87
buspirone hcl tab 5 mg.................................................. 87
buspirone hcl tab 7.5 mg............................................... 87
BUTAL/ASA/CAFF - butalbital-aspirin-caffeine tab
50-325-40 mg................................................................ 107
BUTALBITAL/ASPIRIN/CAFFEI - butalbital-aspirincaffeine tab 50-325-40 mg............................................ 107
butalbital-acetaminophen-caffeine cap 50-300-40 mg
(Fioricet)........................................................................107
butalbital-acetaminophen-caffeine cap 50-325-40
mg..................................................................................107
butalbital-acetaminophen-caffeine cap 50-500-40
mg..................................................................................107
butalbital-acetaminophen-caffeine tab 50-325-40 mg
(Esgic)........................................................................... 107
butalbital-acetaminophen-caffeine tab 50-500-40
mg..................................................................................107
butalbital-acetaminophen-caff w/ cod cap 50-300-40-30
mg (Fioricet/codeine).................................................. 109
butalbital-acetaminophen-caff w/ cod cap 50-325-40-30
mg..................................................................................109
butalbital-acetaminophen tab 50-325 mg.................... 107
butalbital-acetaminophen tab 50-650 mg.................... 107
butalbital-aspirin-caffeine cap 50-325-40 mg
(Fiorinal)........................................................................107
butalbital-aspirin-caffeine tab 50-325-40 mg...............107
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg
(Fiorinal/codeine #3)....................................................109
butamben-tetracaine-benzocaine aerosol spray
2-2-14%......................................................................... 168
BUTISOL SODIUM - butabarbital sodium elixir 30
mg/5ml............................................................................. 98
BUTISOL SODIUM - butabarbital sodium tab 30 mg........ 98
BUTISOL SODIUM - butabarbital sodium tab 50 mg........ 98
butorphanol tartrate inj 1 mg/ml.................................. 109
butorphanol tartrate inj 2 mg/ml.................................. 109
butorphanol tartrate nasal soln 10 mg/ml...................109
BUTRANS - buprenorphine td patch weekly 10 mcg/
hr....................................................................................109
BUTRANS - buprenorphine td patch weekly 15 mcg/
hr....................................................................................109
BUTRANS - buprenorphine td patch weekly 20 mcg/
hr....................................................................................109
BUTRANS - buprenorphine td patch weekly 5 mcg/
hr....................................................................................109
BUTRANS - buprenorphine td patch weekly 7.5 mcg/
hr....................................................................................109
BYDUREON - exenatide extended release for inj susp 2
mg.................................................................................... 28
BYDUREON - exenatide extended release for susp peninjector 2 mg....................................................................28
BYETTA - exenatide soln pen-injector 10 mcg/0.04ml...... 29
BYETTA - exenatide soln pen-injector 5 mcg/0.02ml........ 29
BYSTOLIC - nebivolol hcl tab 10 mg (base
equivalent)....................................................................... 42
BYSTOLIC - nebivolol hcl tab 2.5 mg (base
equivalent)....................................................................... 42
BYSTOLIC - nebivolol hcl tab 20 mg (base
equivalent)....................................................................... 42
BYSTOLIC - nebivolol hcl tab 5 mg (base equivalent)...... 42
C
cabergoline tab 0.5 mg................................................... 36
CADUET - amlodipine besylate-atorvastatin calcium tab
10-10 mg......................................................................... 62
CADUET - amlodipine besylate-atorvastatin calcium tab
10-20 mg......................................................................... 62
CADUET - amlodipine besylate-atorvastatin calcium tab
10-40 mg......................................................................... 62
CADUET - amlodipine besylate-atorvastatin calcium tab
10-80 mg......................................................................... 63
CADUET - amlodipine besylate-atorvastatin calcium tab
2.5-10 mg........................................................................ 62
CADUET - amlodipine besylate-atorvastatin calcium tab
2.5-20 mg........................................................................ 62
CADUET - amlodipine besylate-atorvastatin calcium tab
2.5-40 mg........................................................................ 62
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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CADUET - amlodipine besylate-atorvastatin calcium tab
5-10 mg........................................................................... 62
CADUET - amlodipine besylate-atorvastatin calcium tab
5-20 mg........................................................................... 62
CADUET - amlodipine besylate-atorvastatin calcium tab
5-40 mg........................................................................... 62
CADUET - amlodipine besylate-atorvastatin calcium tab
5-80 mg........................................................................... 62
CAFCIT - caffeine citrate oral soln 60 mg/3ml (10 mg/ml
base equiv).................................................................... 100
CAFERGOT - ergotamine w/ caffeine tab 1-100 mg....... 121
caffeine citrate oral soln 60 mg/3ml (10 mg/ml base
equiv) (Cafcit)...............................................................100
CALAFOL RX - fa-hydroxocobalamin-policosanol-vit b6-vit
d-ca tab ........................................................................ 148
CALAN SR - verapamil hcl tab cr 120 mg........................ 44
CALAN SR - verapamil hcl tab cr 180 mg........................ 44
CALAN SR - verapamil hcl tab cr 240 mg........................ 44
CALAN - verapamil hcl tab 120 mg.................................. 44
CALAN - verapamil hcl tab 80 mg.................................... 44
CALCIFOL - ca carb-folic acid-vit d-b6-b12-boron-mag
wafer 1342-1.6 mg........................................................ 146
calcipotriene-betamethasone dipropionate oint
0.005-0.064% (Taclonex)............................................. 168
calcipotriene cream 0.005% (Dovonex)....................... 168
calcipotriene oint 0.005%............................................. 168
calcipotriene soln 0.005% (50 mcg/ml)........................168
calcitonin (salmon) nasal soln 200 unit/act
(Miacalcin)...................................................................... 36
CALCITRIOL - calcitriol oint 3 mcg/gm........................... 168
calcitriol cap 0.25 mcg (Rocaltrol).................................36
calcitriol cap 0.5 mcg (Rocaltrol)...................................36
calcitriol oral soln 1 mcg/ml (Rocaltrol)........................36
calcium acetate (phosphate binder) cap 667 mg (169
mg ca) (Phoslo)............................................................. 81
calcium acetate (phosphate binder) tab 667 mg
(Eliphos)..........................................................................81
CALCIUM-FOLIC ACID PLUS D - ca carb-folic acid-vit db6-b12-boron-mag wafer 1342-1 mg.............................146
CALCIUM PNV - prenatal w/o vit a w/ fe fum-fa-omega 3
cap 28-1-250 mg .......................................................... 135
CAMBIA - diclofenac potassium packet 50 mg............... 121
CAMPRAL - acamprosate calcium tab delayed release
333 mg...........................................................................103
CANASA - mesalamine suppos 1000 mg......................... 81
candesartan cilexetil-hydrochlorothiazide tab 16-12.5
mg (Atacand hct)........................................................... 50
candesartan cilexetil-hydrochlorothiazide tab 32-12.5
mg (Atacand hct)........................................................... 50
candesartan cilexetil-hydrochlorothiazide tab 32-25
mg (Atacand hct)........................................................... 50
candesartan cilexetil tab 16 mg (Atacand)....................50
candesartan cilexetil tab 32 mg (Atacand)....................50
candesartan cilexetil tab 4 mg (Atacand)......................50
candesartan cilexetil tab 8 mg (Atacand)......................50
CANTIL - mepenzolate bromide tab 25 mg.......................75
260
CAPCOF - phenylephrine-chlorphen w/ codeine syrup
5-2-10 mg/5ml................................................................. 65
capecitabine tab 150 mg (Xeloda)................................. 15
capecitabine tab 500 mg (Xeloda)................................. 15
CAPEX - fluocinolone acetonide shampoo 0.01%.......... 168
CAPITAL/CODEINE - acetaminophen w/ codeine susp
120-12 mg/5ml...............................................................109
CAPRELSA - vandetanib tab 100 mg............................... 15
CAPRELSA - vandetanib tab 300 mg............................... 15
CAPS 0 CLEAR DELAYED RELE - non gelatin capsules
(empty) ......................................................................... 240
CAPSULE #0 CLEAR/LOCKING/ - non gelatin capsules
(empty) ......................................................................... 240
CAPSULE CONI-SNAP #0 CLEA - non gelatin capsules
(empty) ......................................................................... 240
CAPSULE CONI-SNAP #1 CLEA - non gelatin capsules
(empty) ......................................................................... 240
CAPSULE CONI-SNAP #3 CLEA - non gelatin capsules
(empty) ......................................................................... 240
CAPTOPRIL/HYDROCHLOROTHIA - captopril &
hydrochlorothiazide tab 25-15 mg................................... 50
CAPTOPRIL/HYDROCHLOROTHIA - captopril &
hydrochlorothiazide tab 25-25 mg................................... 50
CAPTOPRIL/HYDROCHLOROTHIA - captopril &
hydrochlorothiazide tab 50-15 mg................................... 50
CAPTOPRIL/HYDROCHLOROTHIA - captopril &
hydrochlorothiazide tab 50-25 mg................................... 50
captopril tab 100 mg....................................................... 50
captopril tab 12.5 mg...................................................... 50
captopril tab 25 mg......................................................... 50
captopril tab 50 mg......................................................... 50
CARAC - fluorouracil cream 0.5%...................................168
CARAFATE - sucralfate susp 1 gm/10ml..........................75
CARAFATE - sucralfate tab 1 gm.....................................75
CARBAGLU - carglumic acid tab 200 mg......................... 36
carbamazepine cap sr 12hr 100 mg (Carbatrol)..........124
carbamazepine cap sr 12hr 200 mg (Carbatrol)..........124
carbamazepine cap sr 12hr 300 mg (Carbatrol)..........124
carbamazepine chew tab 100 mg................................ 124
carbamazepine susp 100 mg/5ml (Tegretol)............... 124
carbamazepine tab 200 mg (Tegretol)......................... 124
carbamazepine tab sr 12hr 200 mg (Tegretol-xr)........124
carbamazepine tab sr 12hr 400 mg (Tegretol-xr)........124
CARBAPHEN 12 PED - phenyleph-chlorphencarbetapentane susp 2.5-1.25-7.5 mg/ml........................ 65
CARBAPHEN 12 - phenyleph-chlorphen-carbetapentane
liqd 10-4-27.5 mg/5ml......................................................65
CARBATROL - carbamazepine cap sr 12hr 100 mg....... 124
CARBATROL - carbamazepine cap sr 12hr 200 mg....... 124
CARBATROL - carbamazepine cap sr 12hr 300 mg....... 124
CARBIDOPA/LEVODOPA/ENTACA - carbidopalevodopa-entacapone tabs 12.5-50-200 mg.................. 129
CARBIDOPA/LEVODOPA/ENTACA - carbidopalevodopa-entacapone tabs 18.75-75-200 mg................ 129
CARBIDOPA/LEVODOPA/ENTACA - carbidopalevodopa-entacapone tabs 25-100-200 mg................... 129
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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CARBIDOPA/LEVODOPA/ENTACA - carbidopalevodopa-entacapone tabs 31.25-125-200 mg.............. 129
CARBIDOPA/LEVODOPA/ENTACA - carbidopalevodopa-entacapone tabs 37.5-150-200 mg................ 129
CARBIDOPA/LEVODOPA/ENTACA - carbidopalevodopa-entacapone tabs 50-200-200 mg................... 129
carbidopa & levodopa orally disintegrating tab 10-100
mg..................................................................................129
carbidopa & levodopa orally disintegrating tab 25-100
mg..................................................................................129
carbidopa & levodopa orally disintegrating tab 25-250
mg..................................................................................129
carbidopa & levodopa tab 10-100 mg (Sinemet).........129
carbidopa & levodopa tab 25-100 mg (Sinemet).........129
carbidopa & levodopa tab 25-250 mg (Sinemet).........129
carbidopa & levodopa tab cr 25-100 mg (Sinemet
cr).................................................................................. 129
carbidopa & levodopa tab cr 50-200 mg (Sinemet
cr).................................................................................. 129
carbidopa tab 25 mg (Lodosyn)...................................129
carbinoxamine maleate soln 4 mg/5ml..........................63
carbinoxamine maleate tab 4 mg...................................63
carbonyl iron susp 15 mg/1.25ml (elemental iron)..... 151
CARDENE SR - nicardipine hcl cap sr 12hr 30 mg...........44
CARDENE SR - nicardipine hcl cap sr 12hr 45 mg...........44
CARDENE SR - nicardipine hcl cap sr 12hr 60 mg...........44
CARDIOCOM LANCING DEVICE - lancet devices ........ 195
CARDIOTEK-RX - folic acid-b12-b6-arginine-black pepper
tab .................................................................................148
CARDIOVID PLUS - dha-epa-vit b6-b12-folic acid cap
240-360-20-0.5-0.8 mg.................................................. 148
CARDIZEM CD - diltiazem hcl coated beads cap sr 24hr
120 mg.............................................................................44
CARDIZEM CD - diltiazem hcl coated beads cap sr 24hr
180 mg.............................................................................44
CARDIZEM CD - diltiazem hcl coated beads cap sr 24hr
240 mg.............................................................................45
CARDIZEM CD - diltiazem hcl coated beads cap sr 24hr
300 mg.............................................................................45
CARDIZEM CD - diltiazem hcl coated beads cap sr 24hr
360 mg.............................................................................45
CARDIZEM - diltiazem hcl tab 120 mg............................. 44
CARDIZEM - diltiazem hcl tab 30 mg............................... 44
CARDIZEM - diltiazem hcl tab 60 mg............................... 44
CARDIZEM - diltiazem hcl tab 90 mg............................... 44
CARDIZEM LA - diltiazem hcl coated beads tab sr 24hr
120 mg.............................................................................45
CARDIZEM LA - diltiazem hcl coated beads tab sr 24hr
180 mg.............................................................................45
CARDIZEM LA - diltiazem hcl coated beads tab sr 24hr
240 mg.............................................................................45
CARDIZEM LA - diltiazem hcl coated beads tab sr 24hr
300 mg.............................................................................45
CARDIZEM LA - diltiazem hcl coated beads tab sr 24hr
360 mg.............................................................................45
CARDIZEM LA - diltiazem hcl coated beads tab sr 24hr
420 mg.............................................................................45
CARDURA - doxazosin mesylate tab 1 mg.......................50
CARDURA - doxazosin mesylate tab 2 mg.......................50
CARDURA - doxazosin mesylate tab 4 mg.......................50
CARDURA - doxazosin mesylate tab 8 mg.......................50
CARDURA XL - doxazosin mesylate tab sr 24 hr 4 mg
(base equiv).....................................................................85
CARDURA XL - doxazosin mesylate tab sr 24 hr 8 mg
(base equiv).....................................................................85
CAREFINE PEN NEEDLE 32GX4 - insulin pen needle 32
g x 4 mm (5/32")........................................................... 195
CAREFINE PEN NEEDLES 29GX - insulin pen needle 29
g x 12 mm (1/2")........................................................... 195
CAREFINE PEN NEEDLES 30GX - insulin pen needle 30
g x 8 mm (1/3" or 5/16")................................................195
CAREFINE PEN NEEDLES 31GX - insulin pen needle 31
g x 6 mm (1/4")............................................................. 195
CAREFINE PEN NEEDLES 31GX - insulin pen needle 31
g x 8 mm (1/3" or 5/16")................................................195
CAREFINE PEN NEEDLES 32GX - insulin pen needle 32
g x 5 mm (1/5" or 3/16")................................................195
CAREFINE PEN NEEDLES 32GX - insulin pen needle 32
g x 6 mm (1/4")............................................................. 195
CAREONE ADVANCED LANCING - lancet devices ...... 195
CAREONE BLOOD GLUCOSE MON - blood glucose
monitoring kit w/ device ................................................195
CAREONE BLOOD GLUCOSE TES - glucose blood test
strip................................................................................ 184
CAREONE LANCET THIN - lancets .............................. 195
CAREONE LANCET ULTRA THIN - lancets ..................195
CAREONE ULTIGUARD INSULIN - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................195
CAREONE ULTIGUARD INSULIN - insulin syringe/needle
u-100 0.3 ml 30 x 5/16".................................................195
CAREONE ULTIGUARD INSULIN - insulin syringe/needle
u-100 1/2 ml 29 x 1/2"...................................................196
CAREONE ULTIGUARD INSULIN - insulin syringe/needle
u-100 1/2 ml 30 x 5/16".................................................196
CAREONE ULTIGUARD INSULIN - insulin syringe/needle
u-100 1 ml 29 x 1/2"......................................................196
CAREONE ULTIGUARD INSULIN - insulin syringe/needle
u-100 1 ml 30 x 5/16"....................................................196
CAREONE UNIFINE PENTIPS 2 - insulin pen needle 29 g
x 12 mm (1/2")...............................................................196
CAREONE UNIFINE PENTIPS 3 - insulin pen needle 31 g
x 5 mm (3/16")...............................................................196
CAREONE UNIFINE PENTIPS 3 - insulin pen needle 31 g
x 6 mm (1/4").................................................................196
CAREONE UNIFINE PENTIPS 3 - insulin pen needle 31 g
x 8 mm (1/3" or 5/16")...................................................196
CAREONE UNIFINE PENTIPS P - insulin pen needle 29 g
x 12 mm (1/2")...............................................................196
CAREONE UNIFINE PENTIPS P - insulin pen needle 31 g
x 5 mm (3/16")...............................................................196
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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CAREONE UNIFINE PENTIPS P - insulin pen needle 31 g
x 6 mm (1/4").................................................................196
CAREONE UNIFINE PENTIPS P - insulin pen needle 31 g
x 8 mm (1/3" or 5/16")...................................................196
CAREONE UNIFINE PENTIPS P - insulin pen needle 32 g
x 4 mm (5/32")...............................................................196
CARESENS CONTROL A SOLUTI - blood glucose
calibration - liquid ......................................................... 196
CARESENS N BLOOD GLUCOSE - glucose blood test
strip................................................................................ 184
CARISOPRODOL - carisoprodol tab 250 mg..................132
carisoprodol tab 350 mg (Soma)................................. 132
carisoprodol w/ aspirin & codeine tab 200-325-16
mg..................................................................................132
carisoprodol w/ aspirin tab 200-325 mg...................... 132
CARMOL-HC - urea-hc acetate cream 1%..................... 168
CARNITOR - levocarnitine oral soln 1 gm/10ml (10%)......36
CARNITOR - levocarnitine tab 330 mg............................. 36
CARNITOR SF - levocarnitine oral soln 1 gm/10ml
(10%)............................................................................... 36
carteolol hcl ophth soln 1%......................................... 157
carvedilol tab 12.5 mg (Coreg).......................................42
carvedilol tab 25 mg (Coreg)..........................................42
carvedilol tab 3.125 mg (Coreg).....................................42
carvedilol tab 6.25 mg (Coreg).......................................42
CASCARA SAGRADA - cascara sagrada fl ext 1 gm/
ml..................................................................................... 74
CASODEX - bicalutamide tab 50 mg................................ 15
CATAFLAM - diclofenac potassium tab 50 mg............... 118
CATAPRES - clonidine hcl tab 0.1 mg..............................50
CATAPRES - clonidine hcl tab 0.2 mg..............................51
CATAPRES - clonidine hcl tab 0.3 mg..............................51
CATAPRES-TTS-1 - clonidine hcl td patch weekly 0.1
mg/24hr............................................................................51
CATAPRES-TTS-2 - clonidine hcl td patch weekly 0.2
mg/24hr............................................................................51
CATAPRES-TTS-3 - clonidine hcl td patch weekly 0.3
mg/24hr............................................................................51
CAVAN-ALPHA KIT - prenat w/fe poly-na fered-fa tab 27-1
& omega cap dr 300mg.................................................135
CAVAN-EC SOD DHA - prenatal w/ sod feredetate-fa tab
30-1 & omega 3 cap dr................................................. 135
CAYSTON - aztreonam lysine for inhal soln 75 mg (base
equivalent)....................................................................... 14
CEDAX - ceftibuten cap 400 mg.........................................2
CEDAX - ceftibuten for susp 180 mg/5ml........................... 2
CEDAX - ceftibuten for susp 90 mg/5ml............................. 2
CEENU - lomustine cap 100 mg.......................................15
CEENU - lomustine cap 10 mg.........................................15
CEENU - lomustine cap 40 mg.........................................15
cefaclor cap 250 mg......................................................... 2
cefaclor cap 500 mg......................................................... 2
CEFACLOR - cefaclor for susp 125 mg/5ml....................... 2
CEFACLOR - cefaclor for susp 250 mg/5ml....................... 2
CEFACLOR - cefaclor for susp 375 mg/5ml....................... 2
262
CEFACLOR ER - cefaclor monohydrate tab sr 12hr 500
mg...................................................................................... 2
cefadroxil cap 500 mg...................................................... 2
cefadroxil for susp 250 mg/5ml....................................... 2
cefadroxil for susp 500 mg/5ml....................................... 2
cefadroxil tab 1 gm........................................................... 2
cefazolin sodium for inj 1 gm.......................................... 2
cefazolin sodium for inj 500 mg...................................... 2
cefdinir cap 300 mg.......................................................... 2
cefdinir for susp 125 mg/5ml........................................... 2
cefdinir for susp 250 mg/5ml........................................... 2
CEFDITOREN PIVOXIL - cefditoren pivoxil tab 200 mg
(base equivalent)............................................................... 2
CEFDITOREN PIVOXIL - cefditoren pivoxil tab 400 mg
(base equivalent)............................................................... 2
cefpodoxime proxetil for susp 100 mg/5ml.................... 2
cefpodoxime proxetil for susp 50 mg/5ml...................... 2
cefpodoxime proxetil tab 100 mg.................................... 2
cefpodoxime proxetil tab 200 mg.................................... 2
cefprozil for susp 125 mg/5ml......................................... 2
cefprozil for susp 250 mg/5ml......................................... 2
cefprozil tab 250 mg......................................................... 2
cefprozil tab 500 mg......................................................... 2
CEFTIBUTEN - ceftibuten cap 400 mg...............................2
CEFTIBUTEN - ceftibuten for susp 180 mg/5ml................. 2
CEFTIN - cefuroxime axetil for susp 125 mg/5ml................2
CEFTIN - cefuroxime axetil for susp 250 mg/5ml................2
CEFTIN - cefuroxime axetil tab 250 mg..............................2
CEFTIN - cefuroxime axetil tab 500 mg..............................2
cefuroxime axetil for susp 125 mg/5ml (Ceftin)..............2
cefuroxime axetil tab 250 mg (Ceftin)............................. 2
cefuroxime axetil tab 500 mg (Ceftin)............................. 2
CELEBREX - celecoxib cap 100 mg...............................118
CELEBREX - celecoxib cap 200 mg...............................118
CELEBREX - celecoxib cap 400 mg...............................118
CELEBREX - celecoxib cap 50 mg.................................118
celecoxib cap 100 mg (Celebrex).................................118
celecoxib cap 200 mg (Celebrex).................................118
celecoxib cap 400 mg (Celebrex).................................118
celecoxib cap 50 mg (Celebrex).................................. 118
CELEXA - citalopram hydrobromide tab 10 mg (base
equiv)............................................................................... 89
CELEXA - citalopram hydrobromide tab 20 mg (base
equiv)............................................................................... 89
CELEXA - citalopram hydrobromide tab 40 mg (base
equiv)............................................................................... 89
CELLCEPT - mycophenolate mofetil cap 250 mg........... 241
CELLCEPT - mycophenolate mofetil for oral susp 200 mg/
ml................................................................................... 241
CELLCEPT - mycophenolate mofetil tab 500 mg............241
CELONTIN - methsuximide cap 300 mg.........................124
CEM-UREA - urea soln 45%...........................................168
CENESTIN - estrogens, conjugated synthetic a tab 0.3
mg.................................................................................... 22
CENESTIN - estrogens, conjugated synthetic a tab 0.45
mg.................................................................................... 22
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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CENESTIN - estrogens, conjugated synthetic a tab 0.625
mg.................................................................................... 22
CENESTIN - estrogens, conjugated synthetic a tab 0.9
mg.................................................................................... 22
CENESTIN - estrogens, conjugated synthetic a tab 1.25
mg.................................................................................... 22
CENFOL - folic acid-vitamin b6-vitamin b12 tab 2.3-24.5-2
mg.................................................................................. 151
CENTANY AT - mupirocin oint kit 2%.............................168
CENTANY - mupirocin oint 2%....................................... 168
CENTRATEX - ferrous fumarate-fa-b complex-c-zn-mgmn-cu cap 106-1 mg .................................................... 151
cephalexin cap 250 mg (Keflex).......................................2
cephalexin cap 500 mg (Keflex).......................................2
cephalexin cap 750 mg (Keflex).......................................2
CEPHALEXIN - cephalexin tab 250 mg..............................2
CEPHALEXIN - cephalexin tab 500 mg..............................2
cephalexin for susp 125 mg/5ml......................................2
cephalexin for susp 250 mg/5ml......................................2
CERDELGA - eliglustat tartrate cap 84 mg (base
equivalent)..................................................................... 151
CEREFOLIN - l-methylfolate w/ vit b12-vit b6-vit b2 tab
6-1-50-5 mg ..................................................................148
CEREFOLIN NAC - l-methylfolate-algae-b12-acetylcyst
tab 6-90.314-2-600mg .................................................. 148
CEREFOLIN NAC - l-methylfolate-methylcobalaminacetylcyst tab 6-2-600 mg ............................................ 148
CERVIDIL - dinoprostone vaginal inserts 10 mg...............36
CESAMET - nabilone cap 1 mg........................................79
CETACAINE - butamben-tetracaine-benzocaine aerosol
spray 2-2-14%............................................................... 168
cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)...................63
CETRAXAL - ciprofloxacin hcl otic soln 0.2% (base
equivalent)..................................................................... 161
CETROTIDE - cetrorelix acetate for inj kit 0.25 mg...........36
CETROTIDE - cetrorelix acetate for inj kit 3 mg................36
cevimeline hcl cap 30 mg (Evoxac)............................. 162
CHANTIX CONTINUING MONTH - varenicline tartrate tab
1 mg (base equiv)......................................................... 104
CHANTIX STARTING MONTH PA - varenicline tartrate
tab 0.5 mg x 11 & tab 1 mg x 42 pack.......................... 104
CHANTIX - varenicline tartrate tab 0.5 mg (base
equiv)............................................................................. 103
CHANTIX - varenicline tartrate tab 0.5 mg x 11 & tab 1 mg
x 42 pack.......................................................................104
CHANTIX - varenicline tartrate tab 1 mg (base
equiv)............................................................................. 103
CHEMET - succimer cap 100 mg................................... 183
CHENODAL - chenodiol tab 250 mg................................ 81
CHLORDIAZEPOXIDE/AMITRIPT - chlordiazepoxideamitriptyline tab 10-25 mg............................................. 104
CHLORDIAZEPOXIDE/AMITRIPT - chlordiazepoxideamitriptyline tab 5-12.5 mg............................................ 104
chlordiazepoxide hcl cap 10 mg.................................... 87
chlordiazepoxide hcl cap 25 mg.................................... 87
chlordiazepoxide hcl cap 5 mg......................................87
CHLORHEXIDINE DIGLUCONATE - chlorhexidine
gluconate soln 20%....................................................... 183
CHLORHEXIDINE GLUCONATE - chlorhexidine
gluconate soln 20%....................................................... 183
chlorhexidine gluconate soln 0.12% (Peridex)........... 162
chloroquine phosphate tab 250 mg...............................13
chloroquine phosphate tab 500 mg (Aralen)................ 13
CHLOROTHIAZIDE - chlorothiazide tab 250 mg.............. 57
chlorothiazide tab 250 mg.............................................. 57
chlorothiazide tab 500 mg.............................................. 57
chlorpheniramine w/ codeine liquid 2-10 mg/5ml.........65
chlorpromazine hcl tab 100 mg..................................... 94
chlorpromazine hcl tab 10 mg....................................... 94
chlorpromazine hcl tab 200 mg..................................... 94
chlorpromazine hcl tab 25 mg....................................... 94
chlorpromazine hcl tab 50 mg....................................... 94
CHLORPROPAMIDE - chlorpropamide tab 100 mg......... 29
CHLORPROPAMIDE - chlorpropamide tab 250 mg......... 29
CHLORTHALIDONE - chlorthalidone tab 100 mg.............57
CHLORTHALIDONE - chlorthalidone tab 25 mg...............57
CHLORTHALIDONE - chlorthalidone tab 50 mg...............57
chlorzoxazone tab 500 mg (Parafon forte dsc)...........132
CHOICE DM FORA G20 TEST S - glucose blood test
strip................................................................................ 184
CHOICE-OB+DHA - prenatal mv w/fe poly-fa chw 29-1 mg
& dha cap 250 mg pak .................................................135
cholecalciferol cap 1000 unit....................................... 133
cholecalciferol chew tab 1000 unit.............................. 133
cholecalciferol chew tab 400 unit................................ 133
cholecalciferol drops 400 unit/0.03ml (per drop)........133
cholecalciferol drops 5000 unit/ml (1000
unit/0.2ml)..................................................................... 133
cholecalciferol oral liquid 400 unit/ml......................... 133
cholecalciferol tab 1000 unit........................................ 133
cholecalciferol tab 400 unit.......................................... 133
cholestyramine light powder 4 gm/dose (Questran
light)................................................................................ 59
cholestyramine light powder packets 4 gm..................59
cholestyramine powder 4 gm/dose (Questran)............ 59
cholestyramine powder packets 4 gm (Questran)........59
choline & magnesium salicylates liq 500 mg/5ml.......107
choline & magnesium salicylates tab 1000 mg.......... 107
choline & magnesium salicylates tab 500 mg............ 107
choline & magnesium salicylates tab 750 mg............ 107
choline fenofibrate cap dr 135 mg (fenofibric acid
equiv) (Trilipix)............................................................... 59
choline fenofibrate cap dr 45 mg (fenofibric acid
equiv) (Trilipix)............................................................... 59
CHOLINE MAGNESIUM TRISALI - choline & magnesium
salicylates tab 1000 mg.................................................107
chorionic gonadotropin for inj 10000 unit.................... 37
CIALIS - tadalafil tab 5 mg................................................63
CICLODAN CREAM KIT - ciclopirox olamine cream 0.77%
(base equiv) & cleanser kit............................................168
CICLODAN SOLUTION KIT - ciclopirox solution kit
8%..................................................................................168
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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ciclopirox gel 0.77%......................................................168
ciclopirox olamine cream 0.77% (base equiv)............ 168
ciclopirox olamine susp 0.77% (base equiv).............. 168
ciclopirox shampoo 1% (Loprox shampoo)................168
ciclopirox solution 8% (Penlac Nail Lacquer).............168
ciclopirox solution kit 8% (Ciclodan solution ki)........168
CICLOPIROX TOPICAL SOLUTI - ciclopirox solution 8%
& vitamin e 5% topical kit..............................................168
CIFEREX - folic acid-cholecalciferol cap 1 mg-3775
unit................................................................................. 151
cilostazol tab 100 mg (Pletal).......................................156
cilostazol tab 50 mg (Pletal).........................................156
CILOXAN - ciprofloxacin hcl ophth oint 0.3%..................157
CILOXAN - ciprofloxacin hcl ophth soln 0.3%................. 157
cimetidine hcl soln 300 mg/5ml..................................... 75
cimetidine tab 200 mg.................................................... 75
cimetidine tab 300 mg.................................................... 75
cimetidine tab 400 mg.................................................... 75
cimetidine tab 800 mg.................................................... 75
CIMZIA - certolizumab pegol for inj kit 2 x 200 mg............81
CIMZIA - certolizumab pegol inj kit 2 x 200 mg/ml............ 81
CIMZIA STARTER KIT - certolizumab pegol inj kit 6 x 200
mg/ml............................................................................... 81
CIPRO - ciprofloxacin for oral susp 250 mg/5ml (5%) (5
gm/100ml).......................................................................... 6
CIPRO - ciprofloxacin for oral susp 500 mg/5ml (10%) (10
gm/100ml).......................................................................... 6
CIPRO - ciprofloxacin hcl tab 250 mg (base equiv)............ 6
CIPRO - ciprofloxacin hcl tab 500 mg (base equiv)............ 6
CIPRODEX - ciprofloxacin-dexamethasone otic susp
0.3-0.1%.........................................................................161
CIPROFLOXACIN - ciprofloxacin hcl otic soln 0.2% (base
equivalent)..................................................................... 161
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000
mg(base eq) (Cipro xr)....................................................6
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg
(base eq) (Cipro xr)......................................................... 6
ciprofloxacin for oral susp 250 mg/5ml (5%) (5
gm/100ml) (Cipro)............................................................ 6
ciprofloxacin for oral susp 500 mg/5ml (10%) (10
gm/100ml) (Cipro)............................................................ 6
ciprofloxacin hcl ophth soln 0.3% (Ciloxan)............... 157
ciprofloxacin hcl tab 100 mg (base equiv)......................6
ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)......... 6
ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)......... 6
ciprofloxacin hcl tab 750 mg (base equiv)......................6
CIPRO HC - ciprofloxacin-hydrocortisone otic susp
0.2-1%............................................................................161
CIPRO XR - ciprofloxacin-ciprofloxacin hcl tab sr 24hr
1000 mg(base eq)............................................................. 6
CIPRO XR - ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500
mg (base eq)..................................................................... 6
citalopram hydrobromide oral soln 10 mg/5ml.............89
citalopram hydrobromide tab 10 mg (base equiv)
(Celexa)........................................................................... 89
264
citalopram hydrobromide tab 20 mg (base equiv)
(Celexa)........................................................................... 89
citalopram hydrobromide tab 40 mg (base equiv)
(Celexa)........................................................................... 89
CITRANATAL 90 DHA - prenat w/o a w/fecbn-fegl-dss-fa
tab 90 &dha cap 300mg pak......................................... 135
CITRANATAL ASSURE - prenat w/o a w/fecbn-fegl-dss-fa
tab & dha cap 300 mg pack.......................................... 135
CITRANATAL B-CALM - prenat w/o a w/fecbn-feglu-fa tab
20-1 mg & vit b6 tab pak...............................................135
CITRANATAL B-CALM - prenat w/o a w/ fe cbnyl-fa tab
20-1 mg & vit b6 tab pak...............................................135
CITRANATAL DHA - prenat w/o a w/fecbn-fegl-dss-fa tab
& dha cap 250 mg pack................................................ 135
CITRANATAL HARMONY - prenatal w/o a w/fe cbn-dssfa-dha cap 29-1-265 mg ...............................................135
CITRANATAL HARMONY - prenatal w/o vit a w/ fe cbndss-fa-dha cap 30-1-260 mg ........................................ 135
CITRANATAL HARMONY - prenat w/o a w/fe fum-fe cbndss-fa-dha cap 27-1-260 mg ........................................ 135
CITRANATAL RX - prenatal w/o a w/ fe carbonyl-fe glucdss-fa tab 27-1mg ........................................................ 135
CITROLITH - potassium & sodium citrates tab 50-950
mg.................................................................................... 85
CLARAVIS - isotretinoin cap 30 mg................................168
CLARIFOAM EF - sulfacetamide sodium w/ sulfur foam
10-5%.............................................................................168
CLARINEX-D 12 HOUR - desloratadine &
pseudoephedrine tab sr 12hr 2.5-120 mg....................... 65
CLARINEX-D 24 HOUR - desloratadine &
pseudoephedrine tab sr 24hr 5-240 mg.......................... 65
CLARINEX - desloratadine syrup 0.5 mg/ml..................... 63
CLARINEX - desloratadine tab 5 mg................................ 63
CLARINEX REDITABS - desloratadine tab orally
disintegrating 2.5 mg....................................................... 63
CLARINEX REDITABS - desloratadine tab orally
disintegrating 5 mg.......................................................... 63
clarithromycin for susp 125 mg/5ml................................3
clarithromycin for susp 250 mg/5ml (Biaxin)..................3
clarithromycin tab 250 mg (Biaxin)................................. 3
clarithromycin tab 500 mg (Biaxin)................................. 3
clarithromycin tab sr 24hr 500 mg (Biaxin xl pac)..........3
CLEANLET LANCETS 28G - lancets .............................196
CLEMASTINE FUMARATE - clemastine fumarate syrup
0.67 mg/5ml (0.5 mg/5ml base eq)................................. 63
clemastine fumarate tab 2.68 mg...................................63
CLEOCIN - clindamycin hcl cap 150 mg...........................14
CLEOCIN - clindamycin hcl cap 300 mg...........................14
CLEOCIN - clindamycin hcl cap 75 mg.............................14
CLEOCIN - clindamycin phosphate vaginal cream 2%..... 84
CLEOCIN - clindamycin phosphate vaginal suppos 100
mg.................................................................................... 84
CLEOCIN PEDIATRIC GRANULE - clindamycin palmitate
hcl for soln 75 mg/5ml (base equiv)................................ 14
CLEOCIN-T - clindamycin phosphate gel 1%................. 168
CLEOCIN-T - clindamycin phosphate lotion 1%..............168
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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CLEOCIN-T - clindamycin phosphate soln 1%............... 168
CLEOCIN-T - clindamycin phosphate swab 1%..............168
CLEVER CHEK AUTO-CODE TES - glucose blood test
strip................................................................................ 184
CLEVER CHEK AUTO-CODE VOI - glucose blood test
strip................................................................................ 184
CLEVER CHEK BLOOD GLUCOSE - blood glucose
monitoring kit w/ device ................................................196
CLEVER CHEK LANCETS ULTRA - lancets ................. 196
CLEVER CHEK TEST STRIPS - glucose blood test
strip................................................................................ 184
CLEVER CHOICE AUTO-CODE P - glucose blood test
strip................................................................................ 184
CLEVER CHOICE COMFORT EZ - insulin pen needle 31
g x 5 mm (3/16")........................................................... 197
CLEVER CHOICE COMFORT EZ - insulin pen needle 31
g x 6 mm (1/4")............................................................. 197
CLEVER CHOICE COMFORT EZ - insulin pen needle 31
g x 8 mm (1/3" or 5/16")................................................197
CLEVER CHOICE COMFORT EZ - insulin pen needle 32
g x 4 mm (5/32")........................................................... 197
CLEVER CHOICE COMFORT EZ - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................196
CLEVER CHOICE COMFORT EZ - insulin syringe/needle
u-100 0.3 ml 30 x 1/2"...................................................196
CLEVER CHOICE COMFORT EZ - insulin syringe/needle
u-100 0.3 ml 30 x 5/16".................................................196
CLEVER CHOICE COMFORT EZ - insulin syringe/needle
u-100 0.3 ml 31 x 5/16".................................................197
CLEVER CHOICE COMFORT EZ - insulin syringe/needle
u-100 1/2 ml 28 x 1/2"...................................................196
CLEVER CHOICE COMFORT EZ - insulin syringe/needle
u-100 1/2 ml 29 x 1/2"...................................................196
CLEVER CHOICE COMFORT EZ - insulin syringe/needle
u-100 1/2 ml 30 x 1/2"...................................................196
CLEVER CHOICE COMFORT EZ - insulin syringe/needle
u-100 1/2 ml 30 x 5/16".................................................196
CLEVER CHOICE COMFORT EZ - insulin syringe/needle
u-100 1/2 ml 31 x 5/16".................................................196
CLEVER CHOICE COMFORT EZ - insulin syringe/needle
u-100 1 ml 28 x 1/2"......................................................196
CLEVER CHOICE COMFORT EZ - insulin syringe/needle
u-100 1 ml 29 x 1/2"......................................................196
CLEVER CHOICE COMFORT EZ - insulin syringe/needle
u-100 1 ml 30 x 1/2"......................................................197
CLEVER CHOICE COMFORT EZ - insulin syringe/needle
u-100 1 ml 30 x 5/16"....................................................196
CLEVER CHOICE COMFORT EZ - insulin syringe/needle
u-100 1 ml 31 x 5/16"....................................................197
CLEVER CHOICE GLUCOSE CON - blood glucose
calibration - liquid - high ...............................................197
CLEVER CHOICE GLUCOSE CON - blood glucose
calibration - liquid - low ................................................ 197
CLEVER CHOICE MICRO BLOOD - blood glucose
monitoring kit w/ device ................................................197
CLEVER CHOICE MICRO TEST - glucose blood test
strip................................................................................ 184
CLICKFINE PEN NEEDLE 32GX - insulin pen needle 32 g
x 4 mm (5/32")...............................................................197
CLICKFINE PEN NEEDLES/31G - insulin pen needle 31 g
x 6 mm (1/4").................................................................197
CLICKFINE PEN NEEDLES/31G - insulin pen needle 31 g
x 8 mm (1/3" or 5/16")...................................................197
CLICKFINE PEN NEEDLE UNIV - insulin pen needle 31 g
x 6 mm (1/4").................................................................197
CLICKFINE PEN NEEDLE UNIV - insulin pen needle 31 g
x 8 mm (1/3" or 5/16")...................................................197
CLICKFINE UNIVERSAL PEN N - insulin pen needle 31 g
x 6 mm (1/4").................................................................197
CLICKFINE UNIVERSAL PEN N - insulin pen needle 31 g
x 8 mm (1/3" or 5/16")...................................................197
clidinium & chlordiazepoxide cap 2.5-5 mg
(Librax)............................................................................75
CLIMARA - estradiol td patch weekly 0.025 mg/24hr........ 22
CLIMARA - estradiol td patch weekly 0.0375 mg/24hr
(37.5 mcg/24hr)............................................................... 22
CLIMARA - estradiol td patch weekly 0.05 mg/24hr..........22
CLIMARA - estradiol td patch weekly 0.06 mg/24hr..........22
CLIMARA - estradiol td patch weekly 0.075 mg/24hr........ 22
CLIMARA - estradiol td patch weekly 0.1 mg/24hr............22
CLIMARA PRO - estradiol-levonorgestrel td patch weekly
0.045-0.015 mg/day.........................................................22
CLINDACIN ETZ - clindamycin phosphate swab 1% &
cleanser kit.................................................................... 168
CLINDACIN PAC - clindamycin phosphate swab 1% &
cleanser kit.................................................................... 168
CLINDAGEL - clindamycin phosphate gel 1%................ 169
clindamycin hcl cap 150 mg (Cleocin).......................... 14
clindamycin hcl cap 300 mg (Cleocin).......................... 14
clindamycin hcl cap 75 mg (Cleocin)............................ 14
clindamycin palmitate hcl for soln 75 mg/5ml (base
equiv) (Cleocin pediatric gr).........................................14
clindamycin phosphate-benzoyl peroxide gel 1-5%
(Benzaclin)....................................................................169
clindamycin phosphate foam 1% (Evoclin).................169
clindamycin phosphate gel 1% (Cleocin-t)................. 169
clindamycin phosphate lotion 1% (Cleocin-t).............169
clindamycin phosphate soln 1% (Cleocin-t)............... 169
clindamycin phosphate swab 1% (Cleocin-t)..............169
clindamycin phosphate vaginal cream 2%
(Cleocin)..........................................................................84
clindamycin phosph-benzoyl peroxide (refrig) gel 1.2
(1)-5% (Duac)................................................................169
CLINDESSE - clindamycin phosphate (one dose) vaginal
cream 2%........................................................................ 84
clobetasol propionate cream 0.05% (Temovate)........ 169
clobetasol propionate emollient base cream 0.05%
(Temovate e)................................................................ 169
clobetasol propionate emulsion foam 0.05% (Oluxe)....................................................................................169
clobetasol propionate foam 0.05% (Olux)................... 169
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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clobetasol propionate gel 0.05% (Temovate)..............169
clobetasol propionate lotion 0.05% (Clobex)..............169
clobetasol propionate oint 0.05% (Temovate)............ 169
clobetasol propionate shampoo 0.05% (Clobex)........169
clobetasol propionate soln 0.05% (Temovate)........... 169
CLOBEX - clobetasol propionate lotion 0.05%................169
CLOBEX - clobetasol propionate shampoo 0.05%..........169
CLOBEX - clobetasol propionate spray 0.05%............... 169
CLOCORTOLONE PIVALATE - clocortolone pivalate
cream 0.1%................................................................... 169
CLOCORTOLONE PIVALATE PUM - clocortolone pivalate
cream 0.1%................................................................... 169
CLODAN KIT - clobetasol propionate shampoo 0.05% &
cleanser kit.................................................................... 169
CLODERM - clocortolone pivalate cream 0.1%.............. 169
CLODERM PUMP - clocortolone pivalate cream
0.1%...............................................................................169
CLOMID - clomiphene citrate tab 50 mg...........................37
clomiphene citrate tab 50 mg........................................ 37
clomipramine hcl cap 25 mg (Anafranil)....................... 89
clomipramine hcl cap 50 mg (Anafranil)....................... 89
clomipramine hcl cap 75 mg (Anafranil)....................... 89
clonazepam orally disintegrating tab 0.125 mg..........124
clonazepam orally disintegrating tab 0.25 mg............124
clonazepam orally disintegrating tab 0.5 mg..............124
clonazepam orally disintegrating tab 1 mg.................124
clonazepam orally disintegrating tab 2 mg.................124
clonazepam tab 0.5 mg (Klonopin)..............................124
clonazepam tab 1 mg (Klonopin).................................124
clonazepam tab 2 mg (Klonopin).................................124
clonidine hcl tab 0.1 mg (Catapres).............................. 51
clonidine hcl tab 0.2 mg (Catapres).............................. 51
clonidine hcl tab 0.3 mg (Catapres).............................. 51
clonidine hcl tab sr 12hr 0.1 mg (Kapvay).................. 100
clonidine hcl td patch weekly 0.1 mg/24hr (Cataprestts-1)................................................................................ 51
clonidine hcl td patch weekly 0.2 mg/24hr (Cataprestts-2)................................................................................ 51
clonidine hcl td patch weekly 0.3 mg/24hr (Cataprestts-3)................................................................................ 51
clopidogrel bisulfate tab 300 mg (base equiv)
(Plavix).......................................................................... 156
clopidogrel bisulfate tab 75 mg (base equiv)
(Plavix).......................................................................... 156
clorazepate dipotassium tab 15 mg (Tranxene t)......... 87
clorazepate dipotassium tab 3.75 mg (Tranxene t)...... 87
clorazepate dipotassium tab 7.5 mg (Tranxene t)........ 87
CLORPRES - clonidine & chlorthalidone tab 0.1-15
mg.................................................................................... 51
CLORPRES - clonidine & chlorthalidone tab 0.2-15
mg.................................................................................... 51
CLORPRES - clonidine & chlorthalidone tab 0.3-15
mg.................................................................................... 51
CLOSERCARE - lancet devices .................................... 197
clotrimazole cream 1%................................................. 169
clotrimazole soln 1%.....................................................169
266
clotrimazole troche 10 mg............................................162
clotrimazole w/ betamethasone cream 1-0.05%
(Lotrisone).................................................................... 169
clotrimazole w/ betamethasone lotion 1-0.05%.......... 169
CLOZAPINE ODT - clozapine orally disintegrating tab 100
mg.................................................................................... 94
CLOZAPINE ODT - clozapine orally disintegrating tab 12.5
mg.................................................................................... 94
CLOZAPINE ODT - clozapine orally disintegrating tab 25
mg.................................................................................... 94
clozapine tab 100 mg (Clozaril)..................................... 94
clozapine tab 200 mg......................................................94
clozapine tab 25 mg (Clozaril)....................................... 94
clozapine tab 50 mg........................................................94
CLOZARIL - clozapine tab 100 mg................................... 94
CLOZARIL - clozapine tab 25 mg.....................................94
C-NATE DHA - prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg ................................................................. 135
CNL8 NAIL KIT - ciclopirox soln 8% & lacquer removal
pads kit.......................................................................... 169
COAGUCHEK LANCETS - lancets ................................197
COAGUCHEK LANCETS - lancets ................................197
COAL TAR - coal tar soln 20%.......................................169
COARTEM - artemether-lumefantrine tab 20-120 mg....... 13
COCA COLA SYRUP - phosphorated carbohydrate w/
caffeine syrup.................................................................. 79
CODAR AR - chlorpheniramine w/ codeine liquid 2-8
mg/5ml............................................................................. 66
CODAR D - pseudoephedrine w/ codeine liquid 30-8
mg/5ml............................................................................. 66
CODEINE SULFATE - codeine sulfate oral soln 30
mg/5ml........................................................................... 109
CODEINE SULFATE - codeine sulfate tab 15 mg...........109
codeine sulfate tab 30 mg............................................ 109
codeine sulfate tab 60 mg............................................ 109
COGENTIN - benztropine mesylate inj 1 mg/ml..............129
COLAZAL - balsalazide disodium cap 750 mg..................81
colchicine w/ probenecid tab 0.5-500 mg....................123
COLCRYS - colchicine tab 0.6 mg..................................123
COLD CREAM - cold cream........................................... 240
COLESTID - colestipol hcl granule packets 5 gm............. 59
COLESTID - colestipol hcl granules 5 gm.........................59
COLESTID - colestipol hcl tab 1 gm................................. 59
COLESTID FLAVORED - colestipol hcl granule packets 5
gm.................................................................................... 59
COLESTID FLAVORED - colestipol hcl granules 5 gm.....59
colestipol hcl granule packets 5 gm (Colestid
flavored)..........................................................................59
colestipol hcl granules 5 gm (Colestid flavored)..........59
colestipol hcl tab 1 gm (Colestid)..................................59
COLGATE DRY MOUTH RELIEF - sodium fluoride
mouthwash 2.1 mg/10ml............................................... 162
COLY-MYCIN S - neomycin-colistin-hc-thonzonium otic
susp 3.3-3-10-0.5 mg/ml................................................161
COLYTE-FLAVOR PACKS - peg 3350-kcl-na bicarb-naclna sulfate for soln 227.1 gm............................................74
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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COLYTE-FLAVOR PACKS - peg 3350-kcl-na bicarb-naclna sulfate for soln 240 gm.............................................. 74
COMBIGAN - brimonidine tartrate-timolol maleate ophth
soln 0.2-0.5%.................................................................157
COMBIPATCH - estradiol-norethindrone ace td pttw
0.05-0.14 mg/day.............................................................23
COMBIPATCH - estradiol-norethindrone ace td pttw
0.05-0.25 mg/day.............................................................23
COMBIVENT - ipratropium-albuterol aerosol 18-103 mcg/
act (20-120mcg/act).........................................................71
COMBIVENT RESPIMAT - ipratropium-albuterol inhal
aerosol soln 20-100 mcg/act........................................... 71
COMBIVIR - lamivudine-zidovudine tab 150-300 mg..........9
COMETRIQ - cabozantinib s-malate cap 3 x 20 mg (60 mg
dose) kit........................................................................... 15
COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 1 x 20
mg (100 dose) kit............................................................ 15
COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 3 x 20
mg (140 dose) kit............................................................ 16
COMFORT ASSURED LANCETS M - lancets ...............197
COMFORT ASSURED LANCETS S - lancets ............... 197
COMFORT LANCETS - lancets .....................................197
COMPAZINE - prochlorperazine maleate tab 10 mg........ 94
COMPAZINE - prochlorperazine maleate tab 5 mg.......... 94
COMPLERA - emtricitabine-rilpivirine-tenofovir df tab
200-25-300 mg.................................................................. 9
COMPLETE NATAL DHA - prenat-fe bis-fe prot succ-fa-ca
tab & omega 3 cap 250 pk............................................135
COMPLETENATE - prenatal vit w/ fe fumarate-fa chew
tab 29-1 mg ..................................................................135
COMTAN - entacapone tab 200 mg............................... 129
CO-NATAL FA - prenatal vit w/ fe fumarate-fa tab 29-1 mg
....................................................................................... 135
CONCEPT DHA - prenatal w/fe fum-fe poly -fa-omega 3
cap 53.5-38-1 mg ......................................................... 135
CONCEPT OB - prenatal w/o a w/fe fum-fe poly-fa cap
130-92.4-1 mg .............................................................. 135
CONCERTA - methylphenidate hcl tab sa osm 18
mg.................................................................................. 100
CONCERTA - methylphenidate hcl tab sa osm 27
mg.................................................................................. 100
CONCERTA - methylphenidate hcl tab sa osm 36
mg.................................................................................. 100
CONCERTA - methylphenidate hcl tab sa osm 54
mg.................................................................................. 100
CONDYLOX - podofilox gel 0.5%................................... 169
CONDYLOX - podofilox soln 0.5%..................................169
CONTROL AST - glucose blood test strip.......................184
CONTROL BLOOD GLUCOSE MON - blood glucose
monitoring kit w/ device ................................................197
CONTROL SOLUTION NORMAL - blood glucose
calibration - liquid - normal ...........................................197
CONTROL TEST STRIPS - glucose blood test strip....... 184
CONZIP - tramadol hcl cap sr 24hr biphasic release 100
mg.................................................................................. 109
CONZIP - tramadol hcl cap sr 24hr biphasic release 200
mg.................................................................................. 109
CONZIP - tramadol hcl cap sr 24hr biphasic release 300
mg.................................................................................. 109
COPAXONE - glatiramer acetate inj kit 20 mg/ml........... 104
COPAXONE - glatiramer acetate soln prefilled syringe 40
mg/ml............................................................................. 104
COPEGUS - ribavirin tab 200 mg....................................... 9
CORDARONE - amiodarone hcl tab 200 mg.................... 47
CORDRAN - flurandrenolide cream 0.05%..................... 169
CORDRAN - flurandrenolide lotion 0.05%...................... 169
CORDRAN - flurandrenolide oint 0.05%......................... 169
CORDRAN TAPE - flurandrenolide tape 4 mcg/sqcm.....169
COREG - carvedilol tab 12.5 mg...................................... 42
COREG - carvedilol tab 25 mg......................................... 42
COREG - carvedilol tab 3.125 mg.................................... 42
COREG - carvedilol tab 6.25 mg...................................... 42
COREG CR - carvedilol phosphate cap sr 24hr 10 mg..... 42
COREG CR - carvedilol phosphate cap sr 24hr 20 mg..... 42
COREG CR - carvedilol phosphate cap sr 24hr 40 mg..... 42
COREG CR - carvedilol phosphate cap sr 24hr 80 mg..... 42
CORGARD - nadolol tab 20 mg........................................42
CORGARD - nadolol tab 40 mg........................................42
CORGARD - nadolol tab 80 mg........................................42
CORTANE-B AQUEOUS - pramoxine-hc-chloroxylenol
aqueous otic soln 10-10-1 mg/ml.................................. 161
CORTANE-B - hydrocortisone-pramoxine-chloroxylenol lot
10-10-1mg/ml.................................................................169
CORTANE-B-OTIC - pramoxine-hc-chloroxylenol otic soln
10-10-1 mg/ml............................................................... 161
CORTEF - hydrocortisone tab 10 mg............................... 19
CORTEF - hydrocortisone tab 20 mg............................... 19
CORTEF - hydrocortisone tab 5 mg................................. 19
CORTENEMA - hydrocortisone enema 100 mg/60ml..... 164
CORTIFOAM - hydrocortisone acetate rectal foam 90 mg/
dose............................................................................... 164
CORTISONE ACETATE - cortisone acetate tab 25
mg.................................................................................... 19
CORTISPORIN - bacitracin-polymyxin-neomycin hc oint
1%..................................................................................169
CORTISPORIN - neomycin-polymyxin-hc cream
0.5%...............................................................................169
CORTISPORIN - neomycin-polymyxin-hc otic soln
1%..................................................................................161
CORTISPORIN-TC - neomycin-colistin-hc-thonzonium otic
susp 3.3-3-10-0.5 mg/ml................................................161
CORVITE 150 - iron combination tab ............................ 151
CORVITE 150 - iron-folic acid-vit c-vit b6-vit b12-zinc tab
150-1.25 mg.................................................................. 151
CORVITE FE - iron combination tab ..............................151
CORVITE - multiple vitamins w/ minerals & fa tab 1.25
mg.................................................................................. 135
CORZIDE - nadolol & bendroflumethiazide tab 40-5
mg.................................................................................... 51
CORZIDE - nadolol & bendroflumethiazide tab 80-5
mg.................................................................................... 51
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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COSOPT - dorzolamide hcl-timolol maleate ophth soln
22.3-6.8 mg/ml...............................................................157
COSOPT PF - dorzolamide hcl-timolol maleate ophth sol
22.3-6.8 mg/ml pf.......................................................... 157
COTAB A - chlorpheniramine w/ codeine tab 4-10 mg......66
COTAB AX - chlorpheniramine w/ codeine tab 4-20
mg.................................................................................... 66
COTABFLU - codeine-chlorpheniramine-acetaminophen
tab 20-4-500 mg.............................................................. 66
COUMADIN - warfarin sodium tab 10 mg....................... 154
COUMADIN - warfarin sodium tab 1 mg......................... 154
COUMADIN - warfarin sodium tab 2.5 mg...................... 154
COUMADIN - warfarin sodium tab 2 mg......................... 154
COUMADIN - warfarin sodium tab 3 mg......................... 154
COUMADIN - warfarin sodium tab 4 mg......................... 154
COUMADIN - warfarin sodium tab 5 mg......................... 154
COUMADIN - warfarin sodium tab 6 mg......................... 154
COUMADIN - warfarin sodium tab 7.5 mg...................... 154
COVERA-HS - verapamil hcl tab sr 24hr (controlled onset)
180 mg.............................................................................45
COVERA-HS - verapamil hcl tab sr 24hr (controlled onset)
240 mg.............................................................................45
COZAAR - losartan potassium tab 100 mg.......................51
COZAAR - losartan potassium tab 25 mg.........................51
COZAAR - losartan potassium tab 50 mg.........................51
CPB WC - pseudoephedrine-bromphen-codeine liq
10-1.3-6.3 mg/5ml............................................................66
CREON - pancrelipase (lip-prot-amyl) dr cap
12000-38000-60000 unit..................................................80
CREON - pancrelipase (lip-prot-amyl) dr cap
24000-76000-120000 unit................................................80
CREON - pancrelipase (lip-prot-amyl) dr cap
3000-9500-15000 unit......................................................79
CREON - pancrelipase (lip-prot-amyl) dr cap
36000-114000-180000 unit..............................................80
CREON - pancrelipase (lip-prot-amyl) dr cap
6000-19000-30000 unit....................................................79
CRESTOR - rosuvastatin calcium tab 10 mg.................... 60
CRESTOR - rosuvastatin calcium tab 20 mg.................... 60
CRESTOR - rosuvastatin calcium tab 40 mg.................... 60
CRESTOR - rosuvastatin calcium tab 5 mg......................59
CRESYLATE - cresyl acetate otic soln 25%................... 161
CRINONE - progesterone vaginal gel 4%.........................84
CRINONE - progesterone vaginal gel 8%.........................84
CRIXIVAN - indinavir sulfate cap 200 mg........................... 9
CRIXIVAN - indinavir sulfate cap 400 mg........................... 9
CRNATAL - prenatal mv w/fecbn-fegl-dss-fa tab & dha cap
275 mg pack..................................................................135
CROMOLYN SODIUM - cromolyn sodium soln nebu 20
mg/2ml............................................................................. 71
cromolyn sodium ophth soln 4%.................................157
cromolyn sodium oral conc 100 mg/5ml
(Gastrocrom).................................................................. 81
cromolyn sodium soln nebu 20 mg/2ml........................71
CUPRIMINE - penicillamine cap 250 mg........................ 241
CUTIVATE - fluticasone propionate cream 0.05%.......... 170
268
CUTIVATE - fluticasone propionate lotion 0.05%............170
CUTIVATE - fluticasone propionate oint 0.005%............ 170
CUVPOSA - glycopyrrolate oral soln 1 mg/5ml.................75
CVS ADVANCED GLUCOSE METE - blood glucose
monitoring kit w/ device ................................................197
CVS ADVANCED GLUCOSE METE - glucose blood test
strip................................................................................ 184
CVS BLOOD GLUCOSE STRIPS - glucose blood test
strip................................................................................ 184
CVS INSULIN SYRINGE/0.3ML - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................197
CVS INSULIN SYRINGE/0.3ML - insulin syringe/needle
u-100 0.3 ml 30 x 1/2"...................................................197
CVS INSULIN SYRINGE/0.5ML - insulin syringe/needle
u-100 1/2 ml 29 x 1/2"...................................................197
CVS INSULIN SYRINGE/0.5ML - insulin syringe/needle
u-100 1/2 ml 30 x 1/2"...................................................197
CVS INSULIN SYRINGE/1ML/2 - insulin syringe/needle
u-100 1 ml 29 x 1/2"......................................................197
CVS LANCETS 21G - lancets ....................................... 198
CVS LANCETS MICRO THIN 33 - lancets .................... 198
CVS LANCETS ORIGINAL - lancets ............................. 198
CVS LANCETS THIN 26G - lancets .............................. 198
CVS LANCETS THIN - lancets ......................................198
CVS LANCETS ULTRA THIN 30 - lancets .................... 198
CVS LANCING DEVICE - lancet devices ...................... 198
CVS ULTRA THIN LANCETS - lancets ......................... 198
CVS VITAMIN D3 - cholecalciferol cap 400 unit............. 133
CYANIDE ANTIDOTE PKG - cyanide antidote kit...........183
CYANOCOBALAMIN/LEVOMEFOLA - l-methylfolate w/ vit
b6-vit b12 tab 1.13-25-2 mg .........................................148
CYCLESSA - desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mg-mg........................ 25
CYCLOBENZAPRINE COMFORT P - cyclobenzaprine hcl
tab 10 mg & liniment topical gel kit............................... 132
cyclobenzaprine hcl tab 10 mg.................................... 132
cyclobenzaprine hcl tab 5 mg......................................132
cyclobenzaprine hcl tab 7.5 mg (Fexmid)................... 132
CYCLOGYL - cyclopentolate hcl ophth soln 0.5%.......... 157
CYCLOGYL - cyclopentolate hcl ophth soln 1%............. 157
CYCLOGYL - cyclopentolate hcl ophth soln 2%............. 157
CYCLOMYDRIL - cyclopentolate w/ phenylephrine ophth
soln 0.2-1%....................................................................157
cyclopentolate hcl ophth soln 1% (Cyclogyl)............. 157
cyclopentolate hcl ophth soln 2% (Cyclogyl)............. 157
CYCLOPHOSPHAMIDE - cyclophosphamide cap 25
mg.................................................................................... 16
CYCLOPHOSPHAMIDE - cyclophosphamide cap 50
mg.................................................................................... 16
CYCLOPHOSPHAMIDE - cyclophosphamide tab 25
mg.................................................................................... 16
CYCLOPHOSPHAMIDE - cyclophosphamide tab 50
mg.................................................................................... 16
CYCLOSERINE - cycloserine cap 250 mg......................... 7
CYCLOSET - bromocriptine mesylate tab 0.8 mg (base
equivalent)....................................................................... 29
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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cyclosporine cap 100 mg (Sandimmune)....................241
cyclosporine cap 25 mg (Sandimmune)......................241
cyclosporine modified cap 100 mg (Neoral)............... 242
cyclosporine modified cap 25 mg (Neoral)................. 242
CYCLOSPORINE MODIFIED - cyclosporine modified cap
50 mg.............................................................................241
cyclosporine modified oral soln 100 mg/ml
(Neoral)......................................................................... 242
CYMBALTA - duloxetine hcl enteric coated pellets cap 20
mg.................................................................................... 89
CYMBALTA - duloxetine hcl enteric coated pellets cap 30
mg.................................................................................... 89
CYMBALTA - duloxetine hcl enteric coated pellets cap 60
mg.................................................................................... 89
cyproheptadine hcl syrup 2 mg/5ml..............................63
cyproheptadine hcl tab 4 mg......................................... 63
CYSTADANE - betaine powder for oral solution .............. 37
CYSTAGON - cysteamine bitartrate cap 150 mg.............. 85
CYSTAGON - cysteamine bitartrate cap 50 mg................85
CYSTARAN - cysteamine hcl ophth soln 0.44% (base
equivalent)..................................................................... 157
CYTOMEL - liothyronine sodium tab 25 mcg.................... 33
CYTOMEL - liothyronine sodium tab 50 mcg.................... 34
CYTOMEL - liothyronine sodium tab 5 mcg......................33
CYTOTEC - misoprostol tab 100 mcg.............................. 75
CYTOTEC - misoprostol tab 200 mcg.............................. 75
CYTRA-3 - pot & sod citrates w/ cit ac syrup 550-500-334
mg/5ml............................................................................. 85
D
D.H.E. 45 - dihydroergotamine mesylate inj 1 mg/ml...... 121
D3 - cholecalciferol cap 400 unit.....................................134
DALIRESP - roflumilast tab 500 mcg................................71
danazol cap 100 mg........................................................ 21
danazol cap 200 mg........................................................ 21
danazol cap 50 mg..........................................................21
DANTRIUM - dantrolene sodium cap 100 mg.................132
DANTRIUM - dantrolene sodium cap 25 mg...................132
DANTRIUM - dantrolene sodium cap 50 mg...................132
dantrolene sodium cap 25 mg (Dantrium).................. 132
dantrolene sodium cap 50 mg (Dantrium).................. 132
DANTROLENE SODIUM - dantrolene sodium cap 100
mg.................................................................................. 132
DAPSONE - dapsone tab 100 mg.................................... 14
DAPSONE - dapsone tab 25 mg...................................... 14
DAPTACEL - diph, acellular pert & tet tox inj 15 lf-10
mcg-5 lf/0.5ml.................................................................. 15
DARAPRIM - pyrimethamine tab 25 mg........................... 13
DAYPRO - oxaprozin tab 600 mg................................... 118
DAYTRANA - methylphenidate td patch 10 mg/9hr........ 100
DAYTRANA - methylphenidate td patch 15 mg/9hr........ 100
DAYTRANA - methylphenidate td patch 20 mg/9hr........ 100
DAYTRANA - methylphenidate td patch 30 mg/9hr........ 100
DDAVP - desmopressin acetate inj 4 mcg/ml................... 37
DDAVP - desmopressin acetate nasal soln 0.01%
(refrigerated).................................................................... 37
DDAVP - desmopressin acetate nasal spray soln
0.01%...............................................................................37
DDAVP - desmopressin acetate tab 0.1 mg..................... 37
DDAVP - desmopressin acetate tab 0.2 mg..................... 37
DDROPS - cholecalciferol drops 1000 unit/0.03ml (per
drop)...............................................................................133
DEBACTEROL - sulfuric acid-sulfonated phenolics soln
30-50%...........................................................................162
DECARA - cholecalciferol cap 25000 unit.......................133
DECON-A - brompheniramine & phenylephrine elixir 2-5
mg/5ml............................................................................. 66
DECON-G - phenylephrine-brompheniramine-guaifenesin
liqd 2-1-40 mg/ml.............................................................66
DELESTROGEN - estradiol valerate im in oil 10 mg/
ml..................................................................................... 23
DELESTROGEN - estradiol valerate im in oil 20 mg/
ml..................................................................................... 23
DELESTROGEN - estradiol valerate im in oil 40 mg/
ml..................................................................................... 23
DELOS - benzoyl peroxide lotion 3.5%...........................170
DELZICOL - mesalamine cap dr 400 mg..........................81
DEMADEX - torsemide tab 100 mg.................................. 57
DEMADEX - torsemide tab 10 mg.................................... 57
DEMADEX - torsemide tab 20 mg.................................... 57
DEMADEX - torsemide tab 5 mg...................................... 57
demeclocycline hcl tab 150 mg....................................... 4
demeclocycline hcl tab 300 mg....................................... 4
DEMEROL - meperidine hcl tab 100 mg.........................109
DEMEROL - meperidine hcl tab 50 mg...........................109
DEMSER - metyrosine cap 250 mg.................................. 51
DENAVIR - penciclovir cream 1%...................................170
DENDRACIN NEURODENDRAXCIN - capsaicin-mentholmethyl salicylate lotion 0.025-10-30%........................... 170
DEPAKENE - valproate sodium syrup 250 mg/5ml (base
equiv)............................................................................. 124
DEPAKENE - valproic acid cap 250 mg......................... 124
DEPAKOTE - divalproex sodium tab delayed release 125
mg.................................................................................. 124
DEPAKOTE - divalproex sodium tab delayed release 250
mg.................................................................................. 124
DEPAKOTE - divalproex sodium tab delayed release 500
mg.................................................................................. 124
DEPAKOTE ER - divalproex sodium tab sr 24 hr 250
mg.................................................................................. 124
DEPAKOTE ER - divalproex sodium tab sr 24 hr 500
mg.................................................................................. 124
DEPAKOTE SPRINKLES - divalproex sodium cap sprinkle
125 mg...........................................................................124
DEPEN TITRATABS - penicillamine tab 250 mg............ 242
DEPLIN 15 - l-methylfolate-algae cap 15-90.314 mg ..... 148
DEPLIN 7.5 - l-methylfolate-algae cap 7.5-90.314 mg
....................................................................................... 148
DEPLIN - l-methylfolate tab 15 mg ................................ 148
DEPLIN - l-methylfolate tab 7.5 mg ............................... 148
DEPO-ESTRADIOL - estradiol cypionate im in oil 5 mg/
ml..................................................................................... 23
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DEPO-PROVERA CONTRACEPTIV medroxyprogesterone acetate im susp 150 mg/ml.......... 25
DEPO-PROVERA - medroxyprogesterone acetate im susp
400 mg/ml........................................................................16
DEPO-SUBQ PROVERA 104 - medroxyprogesterone
acetate subcutaneous susp 104 mg/0.65ml.................... 25
DEPO-TESTOSTERONE - testosterone cypionate im in oil
100 mg/ml........................................................................21
DEPO-TESTOSTERONE - testosterone cypionate im in oil
200 mg/ml........................................................................21
DEPRIZINE FUSEPAQ - ranitidine hcl for oral susp 22.4
mg/ml (compound kit) .....................................................75
DERMA-SMOOTHE/FS BODY - fluocinolone acetonide oil
0.01% (body oil)............................................................ 170
DERMA-SMOOTHE/FS BODY OIL - fluocinolone
acetonide oil 0.01% (body oil)....................................... 170
DERMA-SMOOTHE/FS SCALP - fluocinolone acetonide
oil 0.01% (scalp oil)....................................................... 170
DERMA-SMOOTHE/FS SCALP OI - fluocinolone
acetonide oil 0.01% (scalp oil)...................................... 170
DERMASORB AF - clioquinol-hc cream 3-0.5% &
emollient liqd kit.............................................................170
DERMASORB HC - hydrocortisone lot 2% & cleanser liq
kit................................................................................... 170
DERMASORB TA - triamcinolone cream 0.1% & emollient
cream kit........................................................................ 170
DERMATOP - prednicarbate cream 0.1%.......................170
DERMATOP - prednicarbate oint 0.1%...........................170
DERMOTIC - fluocinolone acetonide (otic) oil 0.01%......161
desipramine hcl tab 100 mg (Norpramin)......................89
desipramine hcl tab 10 mg (Norpramin)....................... 89
desipramine hcl tab 150 mg (Norpramin)......................89
desipramine hcl tab 25 mg (Norpramin)....................... 89
desipramine hcl tab 50 mg (Norpramin)....................... 89
desipramine hcl tab 75 mg (Norpramin)....................... 89
desloratadine tab 5 mg (Clarinex)................................. 63
desloratadine tab orally disintegrating 2.5 mg
(Clarinex reditabs)......................................................... 63
desloratadine tab orally disintegrating 5 mg (Clarinex
reditabs)..........................................................................63
desmopressin acetate inj 4 mcg/ml (Ddavp)................ 37
desmopressin acetate nasal soln 0.01% (refrigerated)
(Ddavp)............................................................................37
desmopressin acetate nasal spray soln 0.01%
(Ddavp)............................................................................37
desmopressin acetate nasal spray soln 0.01%
(refrigerated)...................................................................37
desmopressin acetate tab 0.1 mg (Ddavp)................... 37
desmopressin acetate tab 0.2 mg (Ddavp)................... 37
DESOGEN - desogestrel & ethinyl estradiol tab 0.15
mg-30 mcg.......................................................................25
desogest-eth estrad & eth estrad tab 0.15-0.02/0.01
mg(21/5) (Mircette).........................................................25
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mg-mg
(Cyclessa)....................................................................... 25
270
desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg
(Desogen)....................................................................... 25
DESONATE - desonide gel 0.05%..................................170
desonide cream 0.05% (Desowen)...............................170
desonide lotion 0.05% (Desowen)............................... 170
desonide oint 0.05% (Desowen).................................. 170
DESOWEN CREAM/CETAPHIL LO - desonide cream
0.05% w/ moisturizing lotion kit..................................... 170
DESOWEN - desonide cream 0.05%..............................170
DESOWEN - desonide lotion 0.05%............................... 170
DESOWEN - desonide oint 0.05%..................................170
DESOWEN LOTION/CETAPHIL C - desonide lotion
0.05% w/ moisturizing cream kit....................................170
DESOWEN OINTMENT/CETAPHIL - desonide ointment
0.05% w/ moisturizing lotion kit..................................... 170
desoximetasone cream 0.25% (Topicort)....................170
DESOXIMETASONE - desoximetasone cream
0.05%.............................................................................170
DESOXIMETASONE - desoximetasone oint 0.05%........170
desoximetasone gel 0.05% (Topicort)......................... 170
desoximetasone oint 0.25% (Topicort)........................170
DESOXYN - methamphetamine hcl tab 5 mg................. 100
DESPEC-EXP - pseudoephedrine-dihydrocodeine-gg
syrup 15-7.5-100 mg/5ml.................................................66
DESPEC-PDC - phenylephrine-chlorphen-dihydrocodeine
liqd 7.5-2.5-3 mg/5ml.......................................................66
DESVENLAFAXINE ER - desvenlafaxine fumarate tab sr
24hr 100 mg (base equiv)............................................... 89
DESVENLAFAXINE ER - desvenlafaxine fumarate tab sr
24hr 50 mg (base equiv)................................................. 89
DESVENLAFAXINE ER - desvenlafaxine tab sr 24hr 100
mg.................................................................................... 89
DESVENLAFAXINE ER - desvenlafaxine tab sr 24hr 50
mg.................................................................................... 89
DETROL LA - tolterodine tartrate cap sr 24hr 2 mg.......... 83
DETROL LA - tolterodine tartrate cap sr 24hr 4 mg.......... 83
DETROL - tolterodine tartrate tab 1 mg............................ 83
DETROL - tolterodine tartrate tab 2 mg............................ 83
DEXAMETHASONE - dexamethasone soln 0.5
mg/5ml............................................................................. 19
DEXAMETHASONE - dexamethasone tab 1 mg.............. 19
DEXAMETHASONE - dexamethasone tab 2 mg.............. 19
dexamethasone elixir 0.5 mg/5ml.................................. 19
DEXAMETHASONE INTENSOL - dexamethasone conc 1
mg/ml............................................................................... 19
dexamethasone sodium phosphate ophth soln
0.1%...............................................................................157
dexamethasone tab 0.5 mg............................................ 19
dexamethasone tab 0.75 mg.......................................... 19
dexamethasone tab 1.5 mg............................................ 19
dexamethasone tab 4 mg............................................... 19
dexamethasone tab 6 mg............................................... 19
DEXCHLORPHENIRAMINE MALEA dexchlorpheniramine maleate syrup 2 mg/5ml................ 63
DEXEDRINE - dextroamphetamine sulfate cap sr 24hr 10
mg.................................................................................. 100
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DEXEDRINE - dextroamphetamine sulfate cap sr 24hr 15
mg.................................................................................. 100
DEXEDRINE - dextroamphetamine sulfate cap sr 24hr 5
mg.................................................................................. 100
DEXILANT - dexlansoprazole cap delayed release 30
mg.................................................................................... 76
DEXILANT - dexlansoprazole cap delayed release 60
mg.................................................................................... 76
dexmethylphenidate hcl cap sr 24 hr 15 mg (Focalin
xr).................................................................................. 100
dexmethylphenidate hcl cap sr 24 hr 30 mg (Focalin
xr).................................................................................. 100
dexmethylphenidate hcl cap sr 24 hr 40 mg (Focalin
xr).................................................................................. 100
dexmethylphenidate hcl cap sr 24 hr 5 mg (Focalin
xr).................................................................................. 100
dexmethylphenidate hcl tab 10 mg (Focalin)..............100
dexmethylphenidate hcl tab 2.5 mg (Focalin).............100
dexmethylphenidate hcl tab 5 mg (Focalin)................100
DEXPAK 10 DAY - dexamethasone tab 1.5 mg taper
pack................................................................................. 19
DEXPAK 13 DAY - dexamethasone tab 1.5 mg taper
pack................................................................................. 19
DEXPAK 6 DAY - dexamethasone tab 1.5 mg taper
pack................................................................................. 20
DEXPANTHENOL - dexpanthenol inj 250 mg/ml.............. 81
dextroamphetamine sulfate cap sr 24hr 10 mg
(Dexedrine)................................................................... 100
dextroamphetamine sulfate cap sr 24hr 15 mg
(Dexedrine)................................................................... 100
dextroamphetamine sulfate cap sr 24hr 5 mg
(Dexedrine)................................................................... 100
dextroamphetamine sulfate oral solution 5 mg/5ml
(Procentra)....................................................................100
dextroamphetamine sulfate tab 10 mg........................100
dextroamphetamine sulfate tab 5 mg..........................101
DEXTROMETHORPHAN HBR/CHLO - phenylephrinechlorphen-dm liquid 1.75-0.75-2.75 mg/ml...................... 66
DEX-TUSS - guaifenesin-codeine liquid 300-10
mg/5ml............................................................................. 66
DIABETA - glyburide tab 1.25 mg.....................................29
DIABETA - glyburide tab 2.5 mg.......................................29
DIABETA - glyburide tab 5 mg..........................................29
DIALYVITE/ZINC - b-complex w/ c-zn & folic acid tab 1
mg.................................................................................. 135
DIALYVITE 3000 - b-complex w/ c-biotin-e-minerals & folic
acid tab 3 mg................................................................ 135
DIALYVITE 5000 - b-complex w/ c-biotin-e-minerals & folic
acid tab 5 mg................................................................ 135
DIALYVITE SUPREME D - multiple vitamins w/ minerals &
fa tab 3 mg.................................................................... 135
DIAMOX - acetazolamide cap sr 12hr 500 mg..................57
DIASTAR EASY TEST II LANC - lancets ...................... 198
DIASTAR EASY TEST LANCETS - lancets ...................198
DIASTAT ACUDIAL - diazepam rectal gel delivery system
10 mg.............................................................................124
DIASTAT ACUDIAL - diazepam rectal gel delivery system
20 mg.............................................................................124
DIASTAT PEDIATRIC - diazepam rectal gel delivery
system 2.5 mg............................................................... 124
DIATRUE GLUCOSE CONTROL S - blood glucose
calibration - liquid - high ...............................................198
DIATRUE GLUCOSE CONTROL S - blood glucose
calibration - liquid - low ................................................ 198
DIATRUE GLUCOSE CONTROL S - blood glucose
calibration - liquid - normal ...........................................198
DIATRUE PLUS BLOOD GLUCOS - glucose blood test
strip................................................................................ 184
DIATX ZN - b-complex w/ c-biotin-minerals & folic acid tab
5 mg...............................................................................136
DIAZEPAM - diazepam im inj device 10 mg/2ml...............87
DIAZEPAM - diazepam inj 5 mg/ml.................................. 87
DIAZEPAM - diazepam rectal gel delivery system 10
mg.................................................................................. 124
DIAZEPAM - diazepam rectal gel delivery system 2.5
mg.................................................................................. 124
DIAZEPAM - diazepam rectal gel delivery system 20
mg.................................................................................. 124
DIAZEPAM - diazepam soln 1 mg/ml............................... 87
DIAZEPAM INTENSOL - diazepam conc 5 mg/ml............ 87
diazepam tab 10 mg (Valium).........................................87
diazepam tab 2 mg (Valium)...........................................87
diazepam tab 5 mg (Valium)...........................................87
DIBENZYLINE - phenoxybenzamine hcl cap 10 mg......... 51
DICLEGIS - doxylamine-pyridoxine tab delayed release
10-10 mg......................................................................... 79
diclofenac potassium tab 50 mg (Cataflam)............... 118
diclofenac sodium (actinic keratoses) gel 3%
(Solaraze)......................................................................170
diclofenac sodium ophth soln 0.1%............................ 158
diclofenac sodium soln 1.5% (Pennsaid)....................170
diclofenac sodium tab delayed release 25 mg........... 118
diclofenac sodium tab delayed release 50 mg........... 118
diclofenac sodium tab delayed release 75 mg........... 118
diclofenac sodium tab sr 24hr 100 mg (Voltarenxr).................................................................................. 118
diclofenac w/ misoprostol tab delayed release 50-0.2
mg (Arthrotec 50)........................................................ 118
diclofenac w/ misoprostol tab delayed release 75-0.2
mg (Arthrotec 75)........................................................ 118
dicloxacillin sodium cap 250 mg..................................... 1
dicloxacillin sodium cap 500 mg..................................... 1
DICOPANOL FUSEPAQ - diphenhydramine hcl for oral
susp 5 mg/ml (compound kit) .........................................63
dicyclomine hcl cap 10 mg (Bentyl).............................. 76
DICYCLOMINE HCL - dicyclomine hcl oral soln 10
mg/5ml............................................................................. 76
dicyclomine hcl tab 20 mg (Bentyl)...............................76
didanosine delayed release capsule 125 mg (Videx
ec)......................................................................................9
didanosine delayed release capsule 200 mg (Videx
ec)......................................................................................9
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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didanosine delayed release capsule 250 mg (Videx
ec)......................................................................................9
didanosine delayed release capsule 400 mg (Videx
ec)......................................................................................9
DIDGET - blood glucose monitoring kit w/ device .......... 198
DIDRONEL - etidronate disodium tab 400 mg.................. 37
DIFFERIN - adapalene cream 0.1%............................... 170
DIFFERIN - adapalene gel 0.1%.................................... 170
DIFFERIN - adapalene gel 0.3%.................................... 170
DIFFERIN - adapalene lotion 0.1%.................................170
DIFICID - fidaxomicin tab 200 mg.......................................3
DIFLORASONE DIACETATE - diflorasone diacetate
cream 0.05%................................................................. 170
diflorasone diacetate oint 0.05%................................. 170
DIFLUCAN - fluconazole for susp 10 mg/ml....................... 7
DIFLUCAN - fluconazole for susp 40 mg/ml....................... 7
DIFLUCAN - fluconazole tab 100 mg..................................7
DIFLUCAN - fluconazole tab 150 mg..................................7
DIFLUCAN - fluconazole tab 200 mg..................................7
DIFLUCAN - fluconazole tab 50 mg....................................7
diflunisal tab 500 mg.................................................... 107
DIGEX NF - hyoscyamine-phenyltoloxamine cap
0.0625-15 mg.................................................................. 76
DIGOXIN - digoxin oral soln 0.05 mg/ml...........................41
digoxin tab 125 mcg (0.125 mg) (Lanoxin)....................41
digoxin tab 250 mcg (0.25 mg) (Lanoxin)......................41
DIHYDROERGOTAMINE MESYLAT - dihydroergotamine
mesylate nasal spray 4 mg/ml.......................................121
dihydroergotamine mesylate inj 1 mg/ml (D.h.e.
45)..................................................................................121
DILACOR XR - diltiazem hcl cap sr 24hr 240 mg............. 45
DILANTIN-125 - phenytoin susp 125 mg/5ml..................124
DILANTIN INFATABS - phenytoin chew tab 50 mg........ 124
DILANTIN - phenytoin sodium extended cap 100 mg..... 124
DILANTIN - phenytoin sodium extended cap 30 mg....... 124
DILANTIN - phenytoin susp 125 mg/5ml.........................124
DILATRATE SR - isosorbide dinitrate cap cr 40 mg..........41
DILAUDID - hydromorphone hcl liqd 1 mg/ml................. 109
DILAUDID - hydromorphone hcl tab 2 mg...................... 109
DILAUDID - hydromorphone hcl tab 4 mg...................... 109
DILAUDID - hydromorphone hcl tab 8 mg...................... 109
diltiazem hcl cap sr 12hr 120 mg...................................45
diltiazem hcl cap sr 12hr 60 mg.................................... 45
diltiazem hcl cap sr 12hr 90 mg.................................... 45
diltiazem hcl cap sr 24hr 120 mg...................................45
diltiazem hcl cap sr 24hr 180 mg...................................45
diltiazem hcl cap sr 24hr 240 mg...................................45
diltiazem hcl coated beads cap sr 24hr 120 mg
(Cardizem cd)................................................................. 45
diltiazem hcl coated beads cap sr 24hr 180 mg
(Cardizem cd)................................................................. 45
diltiazem hcl coated beads cap sr 24hr 240 mg
(Cardizem cd)................................................................. 45
diltiazem hcl coated beads cap sr 24hr 300 mg
(Cardizem cd)................................................................. 45
272
diltiazem hcl coated beads cap sr 24hr 360 mg
(Cardizem cd)................................................................. 45
diltiazem hcl coated beads tab sr 24hr 180 mg
(Cardizem la).................................................................. 45
diltiazem hcl coated beads tab sr 24hr 240 mg
(Cardizem la).................................................................. 45
diltiazem hcl coated beads tab sr 24hr 300 mg
(Cardizem la).................................................................. 45
diltiazem hcl coated beads tab sr 24hr 360 mg
(Cardizem la).................................................................. 45
diltiazem hcl coated beads tab sr 24hr 420 mg
(Cardizem la).................................................................. 45
diltiazem hcl extended release beads cap sr 24hr 120
mg (Tiazac).....................................................................45
diltiazem hcl extended release beads cap sr 24hr 180
mg (Tiazac).....................................................................45
diltiazem hcl extended release beads cap sr 24hr 240
mg (Tiazac).....................................................................45
diltiazem hcl extended release beads cap sr 24hr 300
mg (Tiazac).....................................................................45
diltiazem hcl extended release beads cap sr 24hr 360
mg (Tiazac).....................................................................45
diltiazem hcl extended release beads cap sr 24hr 420
mg (Tiazac).....................................................................45
diltiazem hcl tab 120 mg (Cardizem)............................. 45
diltiazem hcl tab 30 mg (Cardizem)............................... 45
diltiazem hcl tab 60 mg (Cardizem)............................... 45
diltiazem hcl tab 90 mg.................................................. 45
dimenhydrinate tab 50 mg............................................. 79
DIOVAN HCT - valsartan-hydrochlorothiazide tab
160-12.5 mg.................................................................... 51
DIOVAN HCT - valsartan-hydrochlorothiazide tab 160-25
mg.................................................................................... 51
DIOVAN HCT - valsartan-hydrochlorothiazide tab
320-12.5 mg.................................................................... 51
DIOVAN HCT - valsartan-hydrochlorothiazide tab 320-25
mg.................................................................................... 51
DIOVAN HCT - valsartan-hydrochlorothiazide tab 80-12.5
mg.................................................................................... 51
DIOVAN - valsartan tab 160 mg....................................... 51
DIOVAN - valsartan tab 320 mg....................................... 51
DIOVAN - valsartan tab 40 mg......................................... 51
DIOVAN - valsartan tab 80 mg......................................... 51
DIPENTUM - olsalazine sodium cap 250 mg.................... 81
diphenhydramine hcl cap 25 mg................................... 63
diphenhydramine hcl cap 50 mg................................... 63
diphenhydramine hcl elixir 12.5 mg/5ml....................... 64
diphenhydramine hcl inj 50 mg/ml................................ 64
DIPHENOXYLATE/ATROPINE - diphenoxylate w/
atropine liq 2.5-0.025 mg/5ml..........................................74
diphenoxylate w/ atropine tab 2.5-0.025 mg
(Lomotil)..........................................................................74
DIPHTHERIA/TETANUS TOXOID - diphtheria-tetanus tox
adsorbed (dt) im inj 25-5 unit/0.5ml.................................15
DIPROLENE AF - betamethasone dipropionate
augmented cream 0.05%.............................................. 171
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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DIPROLENE - betamethasone dipropionate augmented
lotion 0.05%...................................................................170
DIPROLENE - betamethasone dipropionate augmented
oint 0.05%......................................................................171
dipyridamole tab 25 mg (Persantine).......................... 156
dipyridamole tab 50 mg (Persantine).......................... 156
dipyridamole tab 75 mg (Persantine).......................... 156
DISALCID - salsalate tab 500 mg................................... 107
DISALCID - salsalate tab 750 mg................................... 107
disopyramide phosphate cap 100 mg (Norpace)..........47
disopyramide phosphate cap 150 mg (Norpace)..........47
disulfiram tab 250 mg (Antabuse)............................... 104
disulfiram tab 500 mg (Antabuse)............................... 104
DITROPAN XL - oxybutynin chloride tab sr 24hr 10
mg.................................................................................... 83
DITROPAN XL - oxybutynin chloride tab sr 24hr 15
mg.................................................................................... 83
DITROPAN XL - oxybutynin chloride tab sr 24hr 5 mg......83
DIURIL - chlorothiazide susp 250 mg/5ml.........................57
divalproex sodium cap sprinkle 125 mg (Depakote
sprinkles)...................................................................... 124
divalproex sodium tab delayed release 125 mg
(Depakote).................................................................... 125
divalproex sodium tab delayed release 250 mg
(Depakote).................................................................... 125
divalproex sodium tab delayed release 500 mg
(Depakote).................................................................... 125
divalproex sodium tab sr 24 hr 250 mg (Depakote
er).................................................................................. 125
divalproex sodium tab sr 24 hr 500 mg (Depakote
er).................................................................................. 125
DIVIGEL - estradiol td gel 0.25 mg/0.25gm (0.1%)........... 23
DIVIGEL - estradiol td gel 0.5 mg/0.5gm (0.1%)............... 23
DIVIGEL - estradiol td gel 1 mg/gm (0.1%).......................23
DIVISTA - folic acid-vit b6-vit b12-omega 3-biotin-cr cap 1
mg .................................................................................151
DOLGIC PLUS - butalbital-acetaminophen-caffeine tab
50-750-40 mg................................................................ 107
DOLOGESIC - phenyltoloxamine-acetaminophen liquid
30-500 mg/15ml.............................................................107
DOLOPHINE HCL - methadone hcl tab 5 mg................. 109
DOLOPHINE - methadone hcl tab 10 mg....................... 109
DONATUSS DC - phenylephrine-dihydrocodeine-gg syrup
7.5-7.5-50 mg/5ml............................................................66
donepezil hydrochloride orally disintegrating tab 10
mg (Aricept odt)...........................................................104
donepezil hydrochloride orally disintegrating tab 5
mg..................................................................................104
donepezil hydrochloride tab 10 mg (Aricept)............. 104
donepezil hydrochloride tab 23 mg (Aricept)............. 104
donepezil hydrochloride tab 5 mg (Aricept)............... 104
DONNATAL EXTENTABS - pb-hyoscy-atrop-scopol tab cr
48.6-0.3111-0.0582-0.0195 mg....................................... 76
DONNATAL - pb-hyoscy-atrop-scopol elix
16.2-0.1037-0.0194-0.0065 mg/5ml................................ 76
DONNATAL - pb-hyoscy-atrop-scopol tab
16.2-0.1037-0.0194-0.0065 mg....................................... 76
DORAL - quazepam tab 15 mg........................................ 98
DORYX - doxycycline hyclate tab delayed release 150
mg...................................................................................... 4
DORYX - doxycycline hyclate tab delayed release 200
mg...................................................................................... 4
dorzolamide hcl ophth soln 2% (Trusopt)...................158
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8
mg/ml (Cosopt)............................................................ 158
DOVONEX - calcipotriene cream 0.005%.......................171
doxazosin mesylate tab 1 mg (Cardura)....................... 51
doxazosin mesylate tab 2 mg (Cardura)....................... 51
doxazosin mesylate tab 4 mg (Cardura)....................... 51
doxazosin mesylate tab 8 mg (Cardura)....................... 51
doxepin hcl cap 100 mg................................................. 89
doxepin hcl cap 10 mg................................................... 89
doxepin hcl cap 150 mg................................................. 89
doxepin hcl cap 25 mg................................................... 89
doxepin hcl cap 50 mg................................................... 89
doxepin hcl conc 10 mg/ml............................................ 89
DOXEPIN HCL - doxepin hcl cap 75 mg.......................... 89
doxercalciferol cap 0.5 mcg (Hectorol)......................... 37
doxercalciferol cap 1 mcg (Hectorol)............................ 37
doxercalciferol cap 2.5 mcg (Hectorol)......................... 37
DOXYCYCLINE - doxycycline (rosacea) cap delayed
release 40 mg................................................................171
doxycycline hyclate cap 100 mg (Vibramycin)............... 4
doxycycline hyclate cap 50 mg....................................... 4
doxycycline hyclate tab 100 mg...................................... 4
doxycycline hyclate tab 20 mg........................................ 4
doxycycline hyclate tab delayed release 100 mg........... 4
doxycycline hyclate tab delayed release 150 mg
(Doryx).............................................................................. 4
doxycycline hyclate tab delayed release 75 mg............. 4
doxycycline monohydrate cap 100 mg (Monodox)........ 4
doxycycline monohydrate cap 150 mg (Adoxa)............. 4
doxycycline monohydrate cap 50 mg............................. 4
doxycycline monohydrate cap 75 mg (Monodox).......... 4
doxycycline monohydrate for susp 25 mg/5ml
(Vibramycin)..................................................................... 4
doxycycline monohydrate tab 100 mg (Adoxa pak
1/100).................................................................................4
doxycycline monohydrate tab 150 mg (Adoxa pak
1/150).................................................................................5
doxycycline monohydrate tab 50 mg (Adoxa)................ 5
doxycycline monohydrate tab 75 mg (Adoxa)................ 5
DOXYTEX - doxylamine succinate liquid 2.5 mg/2.5ml.....64
DRISDOL - ergocalciferol cap 50000 unit....................... 133
DRITHO-CREME HP - anthralin cream 1%.................... 171
dronabinol cap 10 mg (Marinol).....................................79
dronabinol cap 2.5 mg (Marinol)....................................79
dronabinol cap 5 mg (Marinol).......................................79
DROPLET LANCETS ULTRA THI - lancets ...................198
DROPLET LANCING DEVICE - lancet devices ............. 198
drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz)..... 25
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drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin
28)....................................................................................25
DROXIA - hydroxyurea cap 200 mg............................... 151
DROXIA - hydroxyurea cap 300 mg............................... 151
DROXIA - hydroxyurea cap 400 mg............................... 151
DRUG MART ADJUSTABLE LANC - lancet devices ..... 198
DRUG MART LANCETS THIN - lancets ........................198
DRUG MART LANCETS ULTRA T - lancets ................. 198
DRUG MART ON-THE-GO LANCE - lancets ................ 198
DRUG MART ULTRA COMFORT I - insulin syringe/
needle u-100 0.3 ml 29 x 1/2"....................................... 198
DRUG MART ULTRA COMFORT I - insulin syringe/
needle u-100 0.3 ml 30 x 5/16"..................................... 198
DRUG MART ULTRA COMFORT I - insulin syringe/
needle u-100 0.3 ml 31 x 5/16"..................................... 198
DRUG MART ULTRA COMFORT I - insulin syringe/
needle u-100 1/2 ml 30 x 5/16"..................................... 198
DRUG MART ULTRA COMFORT I - insulin syringe/
needle u-100 1/2 ml 31 x 5/16"..................................... 198
DRUG MART ULTRA COMFORT I - insulin syringe/
needle u-100 1 ml 29 x 1/2"..........................................198
DRUG MART ULTRA COMFORT I - insulin syringe/
needle u-100 1 ml 30 x 5/16"........................................ 198
DRUG MART UNIFINE PENTIPS - insulin pen needle 29
g x 12 mm (1/2")........................................................... 198
DRUG MART UNIFINE PENTIPS - insulin pen needle 31
g x 5 mm (3/16")........................................................... 198
DRUG MART UNIFINE PENTIPS - insulin pen needle 31
g x 6 mm (1/4")............................................................. 198
DRUG MART UNIFINE PENTIPS - insulin pen needle 31
g x 8 mm (1/3" or 5/16")................................................198
DRUG MART UNIFINE PENTIPS - insulin pen needle 32
g x 4 mm (5/32")........................................................... 198
DRUG MART UNILET LANCETS - lancets ................... 198
DRYSOL - aluminum chloride soln 20%......................... 171
DUAC - clindamycin phosph-benzoyl peroxide (refrig) gel
1.2 (1)-5%......................................................................171
DUANE READE LANCET ALTERN - lancets ................ 198
DUANE READE LANCET SUPER - lancets .................. 199
DUANE READE LANCET ULTRA - lancets ...................199
DUANE READE UNIFINE PENTI - insulin pen needle 29 g
x 12 mm (1/2")...............................................................199
DUANE READE UNIFINE PENTI - insulin pen needle 31 g
x 6 mm (1/4").................................................................199
DUANE READE UNIFINE PENTI - insulin pen needle 31 g
x 8 mm (1/3" or 5/16")...................................................199
DUAVEE - conjugated estrogens-bazedoxifene tab
0.45-20 mg...................................................................... 23
DUETACT - pioglitazone hcl-glimepiride tab 30-2 mg....... 29
DUETACT - pioglitazone hcl-glimepiride tab 30-4 mg....... 29
DUET DHA 400EC - prenat w/fe poly-na fered-fa tab 25-1
& omega cap dr 400mg.................................................136
DUET DHA 400 - prenat w/fe poly-na fered-fa tab 25-1 &
omega cap 400 mg....................................................... 136
DUET DHA 430EC - prenat w/fe poly-na fered-fa tab 25-1
& omega cap dr 430mg.................................................136
274
DUET DHA 430 - prenat w/fe poly-na fered-fa tab 25-1 &
omega cap 430 mg....................................................... 136
DUET DHA BALANCED - prenat w/fe poly-na fered-fa tab
24-1 & omega cap 272 mg............................................136
DUET DHA BALANCED - prenat w/fe poly-na fered-fa tab
25-1 & omega cap 267 mg............................................136
DUET DHA BALANCED - prenat w/fe poly-na fered-fa tab
26-1 & omega cap 278 mg............................................136
DUET DHA BALANCED - prenat w/fe poly-na fered-fa tab
27-1 & omega cap dr 380mg........................................ 136
DUET DHA EC - prenat w/fe poly-na fered-fa tab 25-1 &
omega cap dr 400mg.................................................... 136
DUET DHA EC - prenat w/fe poly-na fered-fa tab 25-1 &
omega cap dr 430mg.................................................... 136
DUET DHA - prenat w/fe poly-na fered-fa tab 25-1 &
omega cap 400 mg....................................................... 136
DUET DHA - prenat w/fe poly-na fered-fa tab 25-1 &
omega cap 430 mg....................................................... 136
DUEXIS - ibuprofen-famotidine tab 800-26.6 mg............ 118
DULERA - mometasone furoate-formoterol fumarate
aerosol 100-5 mcg/act..................................................... 71
DULERA - mometasone furoate-formoterol fumarate
aerosol 200-5 mcg/act..................................................... 71
duloxetine hcl enteric coated pellets cap 20 mg
(Cymbalta)...................................................................... 89
duloxetine hcl enteric coated pellets cap 30 mg
(Cymbalta)...................................................................... 89
duloxetine hcl enteric coated pellets cap 60 mg
(Cymbalta)...................................................................... 89
DUO-CARE CONTROL SOLUTION - blood glucose
calibration - liquid ......................................................... 199
DUO-CARE TEST STRIPS - glucose blood test strip..... 184
DUONEB - ipratropium-albuterol nebu soln 0.5-2.5(3)
mg/3ml............................................................................. 71
DURACHOL - folic acid-cholecalciferol cap 1 mg-3775
unit................................................................................. 151
DURAGESIC - fentanyl td patch 72hr 100 mcg/hr.......... 110
DURAGESIC - fentanyl td patch 72hr 12 mcg/hr............ 109
DURAGESIC - fentanyl td patch 72hr 25 mcg/hr............ 110
DURAGESIC - fentanyl td patch 72hr 50 mcg/hr............ 110
DURAGESIC - fentanyl td patch 72hr 75 mcg/hr............ 110
DUREZOL - difluprednate ophth emulsion 0.05%...........158
DUTOPROL - metoprolol & hydrochlorothiazide tab sr
24hr 100-12.5 mg............................................................ 51
DUTOPROL - metoprolol & hydrochlorothiazide tab sr
24hr 25-12.5 mg.............................................................. 51
DUTOPROL - metoprolol & hydrochlorothiazide tab sr
24hr 50-12.5 mg.............................................................. 51
D-VI-SOL - cholecalciferol oral liquid 400 unit/ml............ 133
DYAZIDE - triamterene & hydrochlorothiazide cap 37.5-25
mg.................................................................................... 57
DYMISTA - azelastine hcl-fluticasone prop nasal spray
137-50 mcg/act................................................................ 64
DYNACIN - minocycline hcl tab 100 mg............................. 5
DYNACIN - minocycline hcl tab 50 mg............................... 5
DYNACIN - minocycline hcl tab 75 mg............................... 5
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DYNACIRC CR - isradipine tab sr 24hr 10 mg................. 46
DYNACIRC CR - isradipine tab sr 24hr 5 mg................... 45
dyphylline-guaifenesin liqd 100-100 mg/5ml................ 71
dyphylline-guaifenesin tab 200-400 mg........................ 72
DYRENIUM - triamterene cap 100 mg..............................57
DYRENIUM - triamterene cap 50 mg................................57
E
E.E.S. 400 - erythromycin ethylsuccinate tab 400 mg.........3
E.E.S. GRANULES - erythromycin ethylsuccinate for susp
200 mg/5ml........................................................................3
EASIVENT/MASK-LARGE - spacer/aerosol-holding
chambers - device ........................................................199
EASIVENT/MASK-MEDIUM - spacer/aerosol-holding
chambers - device ........................................................199
EASIVENT/MASK-SMALL - spacer/aerosol-holding
chambers - device ........................................................199
EASIVENT - spacer/aerosol-holding chambers - device
....................................................................................... 199
EASY COMFORT INSULIN SYRI - insulin syringe/needle
u-100 0.3 ml 30 x 5/16".................................................199
EASY COMFORT INSULIN SYRI - insulin syringe/needle
u-100 1/2 ml 30 x 1/2"...................................................199
EASY COMFORT INSULIN SYRI - insulin syringe/needle
u-100 1/2 ml 30 x 5/16".................................................199
EASY COMFORT INSULIN SYRI - insulin syringe/needle
u-100 1 ml 30 x 1/2"......................................................199
EASY COMFORT INSULIN SYRI - insulin syringe/needle
u-100 1 ml 30 x 5/16"....................................................199
EASY COMFORT LANCETS - lancets .......................... 199
EASY COMFORT PEN NEEDLES - insulin pen needle 31
g x 5 mm (3/16")........................................................... 199
EASY COMFORT PEN NEEDLES - insulin pen needle 31
g x 8 mm (1/3" or 5/16")................................................199
EASY COMFORT PEN NEEDLES - insulin pen needle 32
g x 4 mm (5/32")........................................................... 199
EASYGLUCO CONTROL SOLUTIO - blood glucose
calibration - liquid - high ...............................................201
EASYGLUCO CONTROL SOLUTIO - blood glucose
calibration - liquid - low ................................................ 201
EASYGLUCO CONTROL SOLUTIO - blood glucose
calibration - liquid - normal ...........................................201
EASYGLUCO - glucose blood test strip..........................185
EASYMAX 15 LEVEL 1 GLUCOS - blood glucose
calibration - liquid ......................................................... 202
EASYMAX 15 LEVEL 2 GLUCOS - blood glucose
calibration - liquid ......................................................... 202
EASYMAX 15 TEST STRIPS - glucose blood test
strip................................................................................ 185
EASYMAX CONTROL SOLUTION - blood glucose
calibration - liquid - high ...............................................201
EASYMAX CONTROL SOLUTION - blood glucose
calibration - liquid - low ................................................ 202
EASYMAX CONTROL SOLUTION - blood glucose
calibration - liquid - normal ...........................................202
EASYMAX L BLOOD GLUCOSE S - blood glucose
monitoring kit w/ device ................................................202
EASYMAX N BLOOD GLUCOSE S - blood glucose
monitoring kit w/ device ................................................202
EASYMAX NG SELF-MONITORIN - blood glucose
monitoring kit w/ device ................................................202
EASYMAX TEST STRIPS - glucose blood test strip....... 185
EASYMAX V2 SELF-MONITORIN - blood glucose
monitoring kit w/ device ................................................202
EASYMAX V BLOOD GLUCOSE S - blood glucose
monitoring kit w/ device ................................................202
EASY MINI LANCING DEVICE - lancet devices ............ 199
EASY PLUS BLOOD GLUCOSE M - blood glucose
monitoring kit w/ device ................................................199
EASYPLUS BLOOD GLUCOSE TE - glucose blood test
strip................................................................................ 185
EASY PLUS BLOOD GLUCOSE T - glucose blood test
strip................................................................................ 184
EASY PLUS CONTROL SOLUTIO - blood glucose
calibration - liquid - high ...............................................199
EASY PLUS CONTROL SOLUTIO - blood glucose
calibration - liquid - low ................................................ 200
EASY PLUS CONTROL SOLUTIO - blood glucose
calibration - liquid - normal ...........................................199
EASY PLUS II BLOOD GLUCOS - glucose blood test
strip................................................................................ 184
EASY PLUS II CONTROL SOLU - blood glucose
calibration - liquid - high ...............................................200
EASY PLUS II CONTROL SOLU - blood glucose
calibration - liquid - low ................................................ 200
EASYPLUS R13N SELF-MONITO - blood glucose
monitoring kit w/ device ................................................202
EASYPLUS V SELF-MONITORIN - blood glucose
monitoring kit w/ device ................................................202
EASYPRO BLOOD GLUCOSE MON - blood glucose
monitoring kit w/ device ................................................202
EASYPRO BLOOD GLUCOSE TES - glucose blood test
strip................................................................................ 185
EASYPRO PLUS - blood glucose monitoring kit w/ device
....................................................................................... 202
EASYPRO PLUS - glucose blood test strip.................... 185
EASY STEP BLOOD GLUCOSE M - blood glucose
monitoring kit w/ device ................................................200
EASY STEP CONTROL SOLUTIO - blood glucose
calibration - liquid - high ...............................................200
EASY STEP CONTROL SOLUTIO - blood glucose
calibration - liquid - low ................................................ 200
EASY STEP CONTROL SOLUTIO - blood glucose
calibration - liquid - normal ...........................................200
EASY STEP TEST STRIPS - glucose blood test strip.....185
EASY TALK BLOOD GLUCOSE M - blood glucose
monitoring kit w/ device ................................................200
EASY TALK BLOOD GLUCOSE T - glucose blood test
strip................................................................................ 185
EASY TALK CONTROL SOLUTIO - blood glucose
calibration - liquid - high ...............................................200
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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EASY TALK CONTROL SOLUTIO - blood glucose
calibration - liquid - low ................................................ 200
EASY TALK CONTROL SOLUTIO - blood glucose
calibration - liquid - normal ...........................................200
EASYTEST II LANCETS - lancets ................................. 202
EASYTEST LANCETS - lancets .................................... 202
EASY TOUCH 32GX5MM - insulin pen needle 32 g x 5
mm (1/5" or 3/16")......................................................... 201
EASY TOUCH 32GX6MM - insulin pen needle 32 g x 6
mm (1/4")....................................................................... 201
EASY TOUCH CONTROL SOLUTI - blood glucose
calibration - liquid ......................................................... 200
EASY TOUCH GLUCOSE MONITO - blood glucose
monitoring kit w/ device ................................................200
EASY TOUCH GLUCOSE TEST S - glucose blood test
strip................................................................................ 185
EASY TOUCH HEALTHPRO CONT - blood glucose
calibration - liquid ......................................................... 200
EASY TOUCH HEALTHPRO GLUC - blood glucose
monitoring kit w/ device ................................................200
EASY TOUCH HEALTHPRO GLUC - glucose blood test
strip................................................................................ 185
EASY TOUCH INSULIN SYRING - insulin syringe/needle
u-100 0.3 ml 30 x 1/2"...................................................200
EASY TOUCH INSULIN SYRING - insulin syringe/needle
u-100 0.3 ml 30 x 5/16".................................................200
EASY TOUCH INSULIN SYRING - insulin syringe/needle
u-100 0.3 ml 31 x 5/16".................................................201
EASY TOUCH INSULIN SYRING - insulin syringe/needle
u-100 1/2 ml 27 x 1/2"...................................................200
EASY TOUCH INSULIN SYRING - insulin syringe/needle
u-100 1/2 ml 28 x 1/2"...................................................200
EASY TOUCH INSULIN SYRING - insulin syringe/needle
u-100 1/2 ml 29 x 1/2"...................................................200
EASY TOUCH INSULIN SYRING - insulin syringe/needle
u-100 1/2 ml 30 x 1/2"...................................................200
EASY TOUCH INSULIN SYRING - insulin syringe/needle
u-100 1/2 ml 30 x 5/16".................................................200
EASY TOUCH INSULIN SYRING - insulin syringe/needle
u-100 1/2 ml 31 x 5/16".................................................200
EASY TOUCH INSULIN SYRING - insulin syringe/needle
u-100 1 ml 27 x 1/2"......................................................200
EASY TOUCH INSULIN SYRING - insulin syringe/needle
u-100 1 ml 28 x 1/2"......................................................200
EASY TOUCH INSULIN SYRING - insulin syringe/needle
u-100 1 ml 29 x 1/2"......................................................200
EASY TOUCH INSULIN SYRING - insulin syringe/needle
u-100 1 ml 30 x 1/2"......................................................200
EASY TOUCH INSULIN SYRING - insulin syringe/needle
u-100 1 ml 30 x 5/16"....................................................200
EASY TOUCH INSULIN SYRING - insulin syringe/needle
u-100 1 ml 31 x 5/16"....................................................201
EASY TOUCH LANCETS 21G/PR - lancets .................. 201
EASY TOUCH LANCETS 23G/PR - lancets .................. 201
EASY TOUCH LANCETS 26G/PR - lancets .................. 201
EASY TOUCH LANCETS 28G/PR - lancets .................. 201
276
EASY TOUCH LANCETS 28G/TW - lancets ................. 201
EASY TOUCH LANCETS 30G/PR - lancets .................. 201
EASY TOUCH LANCETS 30G/TW - lancets ................. 201
EASY TOUCH LANCETS 32G/PR - lancets .................. 201
EASY TOUCH LANCETS 32G/TW - lancets ................. 201
EASY TOUCH LANCETS 33G/TW - lancets ................. 201
EASY TOUCH LANCETS - lancets ............................... 201
EASY TOUCH LANCING DEVICE - lancet devices ....... 201
EASY TOUCH PEN NEEDLES/31 - insulin pen needle 31
g x 5 mm (3/16")........................................................... 201
EASY TOUCH PEN NEEDLES 29 - insulin pen needle 29
g x 12 mm (1/2")........................................................... 201
EASY TOUCH PEN NEEDLES 31 - insulin pen needle 31
g x 6 mm (1/4")............................................................. 201
EASY TOUCH PEN NEEDLES 31 - insulin pen needle 31
g x 8 mm (1/3" or 5/16")................................................201
EASY TOUCH PEN NEEDLES 32 - insulin pen needle 32
g x 4 mm (5/32")........................................................... 201
EASY TOUCH PEN NEEDLES 32 - insulin pen needle 32
g x 5 mm (1/5" or 3/16")................................................201
EASY TOUCH PEN NEEDLES 32 - insulin pen needle 32
g x 6 mm (1/4")............................................................. 201
EASY TOUCH SAFETY LANCETS - lancets .................201
EASY TRAK BLOOD GLUCOSE M - blood glucose
monitoring kit w/ device ................................................201
EASY TRAK BLOOD GLUCOSE T - glucose blood test
strip................................................................................ 185
EASY TRAK GLUCOSE CONTROL - blood glucose
calibration - liquid - high ...............................................201
EASY TRAK GLUCOSE CONTROL - blood glucose
calibration - liquid - low ................................................ 201
EASY TRAK GLUCOSE CONTROL - blood glucose
calibration - liquid - normal ...........................................201
EASY TWIST & CAP LANCETS - lancets...................... 201
ECLIPSE BLOOD GLUCOSE MON - blood glucose
monitoring kit w/ device ................................................202
ECLIPSE HIGH CONTROL - blood glucose calibration liquid - high ...................................................................202
ECLIPSE LOW CONTROL - blood glucose calibration liquid - low .................................................................... 202
ECLIPSE NORMAL CONTROL - blood glucose calibration
- liquid - normal ............................................................ 202
ECLIPSE TEST STRIPS - glucose blood test strip......... 185
EC-NAPROSYN - naproxen tab ec 375 mg.................... 118
EC-NAPROSYN - naproxen tab ec 500 mg.................... 118
econazole nitrate cream 1%......................................... 171
ECOZA - econazole nitrate foam 1%..............................171
EDARBI - azilsartan medoxomil tab 40 mg.......................51
EDARBI - azilsartan medoxomil tab 80 mg.......................52
EDARBYCLOR - azilsartan medoxomil-chlorthalidone tab
40-12.5 mg...................................................................... 52
EDARBYCLOR - azilsartan medoxomil-chlorthalidone tab
40-25 mg......................................................................... 52
ED CHLORPED - chlorpheniramine tannate susp 2 mg/
ml..................................................................................... 64
ED-CHLOR-TAN - chlorpheniramine tannate tab 8 mg.....64
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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ED CYTE F - ferrous fumarate-folic acid-docusate sodium
tab 324-1-50 mg............................................................ 151
EDECRIN - ethacrynic acid tab 25 mg..............................57
EDLUAR - zolpidem tartrate sl tab 10 mg.........................98
EDLUAR - zolpidem tartrate sl tab 5 mg...........................98
EDURANT - rilpivirine hcl tab 25 mg (base equivalent).......9
EFFER-K - potassium bicarbonate-citric acid effer tab 10
meq................................................................................ 146
EFFER-K - potassium bicarbonate-citric acid effer tab 20
meq................................................................................ 146
EFFEXOR XR - venlafaxine hcl cap sr 24hr 150 mg (base
equivalent)....................................................................... 89
EFFEXOR XR - venlafaxine hcl cap sr 24hr 37.5 mg (base
equivalent)....................................................................... 89
EFFEXOR XR - venlafaxine hcl cap sr 24hr 75 mg (base
equivalent)....................................................................... 89
EFFIENT - prasugrel hcl tab 10 mg (base equiv)............156
EFFIENT - prasugrel hcl tab 5 mg (base equiv)..............156
EFUDEX - fluorouracil cream 5%................................... 171
EGRIFTA - tesamorelin acetate for inj 1 mg (base
equiv)............................................................................... 37
EGRIFTA - tesamorelin acetate for inj 2 mg (base
equiv)............................................................................... 37
ELDEPRYL - selegiline hcl cap 5 mg..............................129
ELEMENT AUTOCODE SYSTEM - blood glucose
monitoring kit w/ device ................................................202
ELEMENT COMPACT CONTROL S - blood glucose
calibration - liquid ......................................................... 202
ELEMENT COMPACT TEST STRI - glucose blood test
strip................................................................................ 185
ELEMENT HIGH CONTROL - blood glucose calibration liquid - high ...................................................................202
ELEMENT LOW CONTROL - blood glucose calibration liquid - low .................................................................... 202
ELEMENT NORMAL CONTROL - blood glucose
calibration - liquid - normal ...........................................202
ELEMENT PLUS CONTROL SOLU - blood glucose
calibration - liquid - high ...............................................202
ELEMENT PLUS CONTROL SOLU - blood glucose
calibration - liquid - low ................................................ 202
ELEMENT PLUS CONTROL SOLU - blood glucose
calibration - liquid - normal ...........................................202
ELEMENT PLUS TEST STRIPS - glucose blood test
strip................................................................................ 185
ELEMENT TEST STRIPS - glucose blood test strip....... 185
ELENZAPATCH - lidocaine-menthol patch 4-1%............171
ELESTAT - epinastine hcl ophth soln 0.05%.................. 158
ELESTRIN - estradiol gel 0.06% (0.52 mg/0.87 gm
metered-dose pump)....................................................... 23
ELIDEL - pimecrolimus cream 1%.................................. 171
ELIGARD - leuprolide acetate (3 month) for subcutaneous
inj kit 22.5mg................................................................... 16
ELIGARD - leuprolide acetate (4 month) for subcutaneous
inj kit 30 mg.....................................................................16
ELIGARD - leuprolide acetate (6 month) for subcutaneous
inj kit 45 mg.....................................................................16
ELIGARD - leuprolide acetate for subcutaneous inj kit 7.5
mg.................................................................................... 16
ELIMITE - permethrin cream 5%.................................... 171
ELIPHOS - calcium acetate (phosphate binder) tab 667
mg.................................................................................... 81
ELIQUIS - apixaban tab 2.5 mg......................................154
ELIQUIS - apixaban tab 5 mg.........................................154
ELITE-OB - prenatal vit w/ iron carbonyl-fa tab 50-1.25 mg
....................................................................................... 136
ELITE-THIN INSULIN SYRING - insulin syringe/needle
u-100 0.3 ml 31 x 5/16".................................................203
ELITE-THIN INSULIN SYRING - insulin syringe/needle
u-100 1/2 ml 28 x 1/2"...................................................202
ELITE-THIN INSULIN SYRING - insulin syringe/needle
u-100 1/2 ml 28 x 5/16".................................................202
ELITE-THIN INSULIN SYRING - insulin syringe/needle
u-100 1/2 ml 29 x 1/2"...................................................203
ELITE-THIN INSULIN SYRING - insulin syringe/needle
u-100 1/2 ml 29 x 5/16".................................................203
ELITE-THIN INSULIN SYRING - insulin syringe/needle
u-100 1/2 ml 30 x 5/16".................................................203
ELITE-THIN INSULIN SYRING - insulin syringe/needle
u-100 1/2 ml 31 x 5/16".................................................202
ELITE-THIN INSULIN SYRING - insulin syringe/needle
u-100 1 ml 28 x 1/2"......................................................203
ELITE-THIN INSULIN SYRING - insulin syringe/needle
u-100 1 ml 28 x 5/16"....................................................203
ELITE-THIN INSULIN SYRING - insulin syringe/needle
u-100 1 ml 29 x 1/2"......................................................203
ELITE-THIN INSULIN SYRING - insulin syringe/needle
u-100 1 ml 29 x 5/16"....................................................203
ELITE-THIN INSULIN SYRING - insulin syringe/needle
u-100 1 ml 30 x 5/16"....................................................203
ELITE-THIN INSULIN SYRING - insulin syringe/needle
u-100 1 ml 31 x 5/16"....................................................203
ELIXOPHYLLIN - theophylline elixir 80 mg/15ml.............. 72
ELLA - ulipristal acetate tab 30 mg...................................25
ELMIRON - pentosan polysulfate sodium caps 100
mg.................................................................................... 85
ELOCON - mometasone furoate cream 0.1%.................171
ELOCON - mometasone furoate oint 0.1%..................... 171
ELOCON - mometasone furoate solution 0.1%
(lotion)............................................................................ 171
EMADINE - emedastine difumarate ophth soln 0.05%
(base equiv)...................................................................158
EMBRACE BLOOD GLUCOSE TES - glucose blood test
strip................................................................................ 185
EMBRACE CONTROL SOLUTION - blood glucose
calibration - liquid - low ................................................ 203
EMBRACE EVO BLOOD GLUCOSE - blood glucose
monitoring kit w/ device ................................................203
EMBRACE EVO BLOOD GLUCOSE - glucose blood test
strip................................................................................ 185
EMBRACE LANCETS ULTRA THI - lancets ..................203
EMBRACE PRO BLOOD GLUCOSE - glucose blood test
strip................................................................................ 185
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EMBRACE PRO GLUCOSE CONTR - blood glucose
calibration - liquid ......................................................... 203
EMCYT - estramustine phosphate sodium cap 140
mg.................................................................................... 16
EMEND - aprepitant capsule 125 mg............................... 79
EMEND - aprepitant capsule 40 mg................................. 79
EMEND - aprepitant capsule 80 mg................................. 79
EMEND - aprepitant capsule therapy pack 80 & 125
mg.................................................................................... 79
EMLA - lidocaine-prilocaine cream 2.5-2.5%.................. 171
EMPTY CAPSULE SIZE 1 VEGE - non gelatin capsules
(empty) ......................................................................... 240
EMSAM - selegiline td patch 24hr 12 mg/24hr..................90
EMSAM - selegiline td patch 24hr 6 mg/24hr....................89
EMSAM - selegiline td patch 24hr 9 mg/24hr....................90
EMTRIVA - emtricitabine caps 200 mg...............................9
EMTRIVA - emtricitabine soln 10 mg/ml............................. 9
ENABLEX - darifenacin hydrobromide tab sr 24hr 15 mg
(base equiv).....................................................................83
ENABLEX - darifenacin hydrobromide tab sr 24hr 7.5 mg
(base equiv).....................................................................83
enalapril maleate & hydrochlorothiazide tab 10-25 mg
(Vaseretic).......................................................................52
enalapril maleate & hydrochlorothiazide tab 5-12.5
mg....................................................................................52
enalapril maleate tab 10 mg (Vasotec).......................... 52
enalapril maleate tab 2.5 mg (Vasotec)......................... 52
enalapril maleate tab 20 mg (Vasotec).......................... 52
enalapril maleate tab 5 mg (Vasotec)............................ 52
ENBREL - etanercept for subcutaneous inj kit 25 mg..... 118
ENBREL - etanercept subcutaneous soln prefilled syringe
25 mg/0.5ml...................................................................118
ENBREL - etanercept subcutaneous soln prefilled syringe
50 mg/ml........................................................................118
ENBREL SURECLICK - etanercept subcutaneous solution
auto-injector 50 mg/ml................................................... 118
ENCARE - nonoxynol-9 vaginal suppos 100 mg...............84
ENDACOF-DC - pseudoephedrine w/ codeine liquid 30-10
mg/5ml............................................................................. 66
ENDOMETRIN - progesterone vaginal insert 100 mg....... 84
ENJUVIA - estrogens, conjugated synthetic b tab 0.3
mg.................................................................................... 23
ENJUVIA - estrogens, conjugated synthetic b tab 0.45
mg.................................................................................... 23
ENJUVIA - estrogens, conjugated synthetic b tab 0.625
mg.................................................................................... 23
ENJUVIA - estrogens, conjugated synthetic b tab 0.9
mg.................................................................................... 23
ENJUVIA - estrogens, conjugated synthetic b tab 1.25
mg.................................................................................... 23
ENOVARX-AMITRIPTYLINE - amitriptyline hcl cream 2%
kit (compounding kit)..................................................... 188
ENOVARX-BACLOFEN - baclofen cream 1% (compound
kit) .................................................................................171
ENOVARX-CYCLOBENZAPRINE H - cyclobenzaprine hcl
td cream 20 mg/gm (compound kit) ............................. 132
278
ENOVARX-IBUPROFEN - ibuprofen cream 10%
(compounding kit) .........................................................171
ENOVARX-LIDOCAINE HCL - lidocaine hcl cream 10%
(compound kit) ..............................................................171
ENOVARX-LIDOCAINE HCL - lidocaine hcl cream 5%
(compound kit) ..............................................................171
ENOVARX-NAPROXEN - naproxen cream 10%
(compound kit) ..............................................................171
ENOVARX-TRAMADOL - tramadol hcl cream 5%
(compound kit) ..............................................................171
enoxaparin sodium inj 100 mg/ml (Lovenox)..............154
enoxaparin sodium inj 120 mg/0.8ml (Lovenox).........154
enoxaparin sodium inj 150 mg/ml (Lovenox)..............154
enoxaparin sodium inj 300 mg/3ml (Lovenox)............154
enoxaparin sodium inj 30 mg/0.3ml (Lovenox)...........154
enoxaparin sodium inj 40 mg/0.4ml (Lovenox)...........154
enoxaparin sodium inj 60 mg/0.6ml (Lovenox)...........154
enoxaparin sodium inj 80 mg/0.8ml (Lovenox)...........154
entacapone tab 200 mg (Comtan)................................130
entecavir tab 0.5 mg (Baraclude).....................................9
entecavir tab 1 mg (Baraclude)........................................9
ENTERAGAM - serum-derived bovine immunoglob/protein
isolate 5 gm packet....................................................... 148
ENTEREG - alvimopan cap 12 mg................................... 81
ENTOCORT EC - budesonide cap sr 24hr 3 mg.............. 20
ENVISION AUTOCODE - blood glucose monitoring kit w/
device ........................................................................... 203
ENVISION AUTOCODE TEST ST - glucose blood test
strip................................................................................ 185
ENVISION CONTROL HIGH - blood glucose calibration liquid - high ...................................................................203
ENVISION CONTROL LOW - blood glucose calibration liquid - low .................................................................... 203
ENVISION CONTROL NORMAL - blood glucose
calibration - liquid - normal ...........................................203
EPANED - enalapril maleate for oral soln 1 mg/ml........... 52
EPIDUO - adapalene-benzoyl peroxide gel 0.1-2.5%..... 171
EPIFOAM - pramoxine-hc aerosol foam 1-1%................ 171
epinastine hcl ophth soln 0.05% (Elestat)...................158
EPINEPHRINE - epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000)..........................................................58
EPINEPHRINE - epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)............................................................59
EPIPEN 2-PAK - epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)............................................................59
EPIPEN-JR 2-PAK - epinephrine solution auto-injector
0.15 mg/0.3ml (1:2000)................................................... 59
EPIVIR HBV - lamivudine oral soln 5 mg/ml....................... 9
EPIVIR HBV - lamivudine tab 100 mg................................ 9
EPIVIR - lamivudine oral soln 10 mg/ml............................. 9
EPIVIR - lamivudine tab 150 mg.........................................9
EPIVIR - lamivudine tab 300 mg.........................................9
eplerenone tab 25 mg (Inspra).......................................52
eplerenone tab 50 mg (Inspra).......................................52
EPOGEN - epoetin alfa inj 10000 unit/ml........................151
EPOGEN - epoetin alfa inj 20000 unit/ml........................151
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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EPOGEN - epoetin alfa inj 2000 unit/ml..........................151
EPOGEN - epoetin alfa inj 3000 unit/ml..........................151
EPOGEN - epoetin alfa inj 4000 unit/ml..........................151
eprosartan mesylate tab 600 mg (Teveten)...................52
EPZICOM - abacavir sulfate-lamivudine tab 600-300
mg...................................................................................... 9
EQL COLOR LANCETS 21G - lancets .......................... 203
EQL COLOR LANCETS MICRO T - lancets .................. 203
EQL INSULIN SYRINGE/0.3ML - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................203
EQL INSULIN SYRINGE/0.3ML - insulin syringe/needle
u-100 0.3 ml 30 x 5/16".................................................203
EQL INSULIN SYRINGE/0.3ML - insulin syringe/needle
u-100 0.3 ml 31 x 5/16".................................................203
EQL INSULIN SYRINGE/0.5ML - insulin syringe/needle
u-100 1/2 ml 29 x 1/2"...................................................203
EQL INSULIN SYRINGE/0.5ML - insulin syringe/needle
u-100 1/2 ml 30 x 5/16".................................................203
EQL INSULIN SYRINGE/0.5ML - insulin syringe/needle
u-100 1/2 ml 31 x 5/16".................................................203
EQL INSULIN SYRINGE/1ML/2 - insulin syringe/needle
u-100 1 ml 29 x 1/2"......................................................204
EQL INSULIN SYRINGE/1ML/3 - insulin syringe/needle
u-100 1 ml 30 x 5/16"....................................................204
EQL INSULIN SYRINGE/1ML/3 - insulin syringe/needle
u-100 1 ml 31 x 5/16"....................................................204
EQL INSULIN SYRINGE/U-100 - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................203
EQL INSULIN SYRINGE/U-100 - insulin syringe/needle
u-100 1/2 ml 29 x 1/2"...................................................203
EQL INSULIN SYRINGE/U-100 - insulin syringe/needle
u-100 1 ml 29 x 1/2"......................................................203
EQL SHORT PEN NEEDLES 31G - insulin pen needle 31
g x 8 mm (1/3" or 5/16")................................................204
EQL SUPER THIN LANCETS 30 - lancets .................... 204
EQL THIN LANCETS 26G - lancets .............................. 204
EQL TRUE2GO BLOOD GLUCOSE - blood glucose
monitoring kit w/ device ................................................204
EQL TRUETEST BLOOD GLUCOS - glucose blood test
strip................................................................................ 185
EQL TRUETRACK TEST - glucose blood test strip........ 185
EQL ULTRA COMFORT INSULIN - insulin syringe/needle
u-100 0.3 ml 31 x 5/16".................................................204
EQL ULTRA COMFORT INSULIN - insulin syringe/needle
u-100 1 ml 30 x 5/16"....................................................204
EQL ULTRA SHORT PEN NEEDL - insulin pen needle 31
g x 6 mm (1/4")............................................................. 204
EQUAGESIC - meprobamate-aspirin tab 200-325
mg.................................................................................. 107
EQUETRO - carbamazepine (antipsychotic) cap sr 12hr
100 mg.............................................................................94
EQUETRO - carbamazepine (antipsychotic) cap sr 12hr
200 mg.............................................................................94
EQUETRO - carbamazepine (antipsychotic) cap sr 12hr
300 mg.............................................................................94
ergocalciferol cap 50000 unit (Drisdol)....................... 134
ergoloid mesylates tab 1 mg........................................104
ERGOMAR - ergotamine tartrate sl tab 2 mg................. 121
ERIVEDGE - vismodegib cap 150 mg.............................. 16
ERTACZO - sertaconazole nitrate cream 2%................. 171
ERYGEL - erythromycin gel 2%......................................171
ERYPED 200 - erythromycin ethylsuccinate for susp 200
mg/5ml............................................................................... 3
ERYPED 400 - erythromycin ethylsuccinate for susp 400
mg/5ml............................................................................... 3
ERY-TAB - erythromycin tab delayed release 250 mg........ 3
ERY-TAB - erythromycin tab delayed release 333 mg........ 3
ERY-TAB - erythromycin tab delayed release 500 mg........ 3
ERYTHROCIN STEARATE - erythromycin stearate tab
250 mg...............................................................................3
ERYTHROMYCIN BASE - erythromycin tab 250 mg.......... 3
ERYTHROMYCIN BASE - erythromycin tab 500 mg.......... 3
ERYTHROMYCIN - erythromycin gel 2%....................... 171
ERYTHROMYCIN - erythromycin w/ delayed release
particles cap 250 mg......................................................... 3
ERYTHROMYCIN ETHYLSUCCINA - erythromycin
ethylsuccinate tab 400 mg................................................ 3
erythromycin gel 2% (Erygel).......................................171
erythromycin ophth oint 5 mg/gm............................... 158
erythromycin pads 2%..................................................171
erythromycin soln 2%...................................................171
ERYTHROMYCIN STEARATE - erythromycin stearate tab
250 mg...............................................................................3
erythromycin-sulfisoxazole for susp 200-600
mg/5ml............................................................................ 14
erythromycin w/ delayed release particles cap 250
mg......................................................................................4
ESBRIET - pirfenidone cap 267 mg..................................74
ESCAVITE D - pediatric multiple vitamins w/ fl-fe chew tab
0.25-6 mg ..................................................................... 136
ESCAVITE LQ - pediatric multiple vitamins w/ fl-fe drops
0.25-6 mg/ml ................................................................ 136
ESCAVITE - pediatric multiple vitamins w/ fl-fe chew tab
0.25-7.5 mg .................................................................. 136
escitalopram oxalate soln 5 mg/5ml (base equiv)
(Lexapro).........................................................................90
escitalopram oxalate tab 10 mg (base equiv)
(Lexapro).........................................................................90
escitalopram oxalate tab 20 mg (base equiv)
(Lexapro).........................................................................90
escitalopram oxalate tab 5 mg (base equiv)
(Lexapro).........................................................................90
ESGIC - butalbital-acetaminophen-caffeine cap 50-325-40
mg.................................................................................. 107
ESGIC - butalbital-acetaminophen-caffeine tab 50-325-40
mg.................................................................................. 107
ESGIC-PLUS - butalbital-acetaminophen-caffeine cap
50-500-40 mg................................................................ 107
ESGIC-PLUS - butalbital-acetaminophen-caffeine tab
50-500-40 mg................................................................ 107
ESOMEPRAZOLE STRONTIUM - esomeprazole
strontium cap delayed release 24.65 mg........................ 76
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ESOMEPRAZOLE STRONTIUM - esomeprazole
strontium cap delayed release 49.3 mg.......................... 76
estazolam tab 1 mg.........................................................98
estazolam tab 2 mg.........................................................98
esterified estrogens & methyltestosterone tab
0.625-1.25 mg................................................................. 23
esterified estrogens & methyltestosterone tab 1.25-2.5
mg....................................................................................23
ESTRACE - estradiol tab 0.5 mg...................................... 23
ESTRACE - estradiol tab 1 mg......................................... 23
ESTRACE - estradiol tab 2 mg......................................... 23
ESTRACE - estradiol vaginal cream 0.1 mg/gm............... 84
estradiol & norethindrone acetate tab 0.5-0.1 mg
(Activella)........................................................................23
estradiol & norethindrone acetate tab 1-0.5 mg
(Activella)........................................................................23
estradiol tab 0.5 mg (Estrace)........................................23
estradiol tab 1 mg (Estrace)...........................................23
estradiol tab 2 mg (Estrace)...........................................23
estradiol td patch weekly 0.025 mg/24hr (Climara)...... 23
estradiol td patch weekly 0.0375 mg/24hr (37.5
mcg/24hr) (Climara)....................................................... 23
estradiol td patch weekly 0.05 mg/24hr (Climara)........ 23
estradiol td patch weekly 0.06 mg/24hr (Climara)........ 23
estradiol td patch weekly 0.075 mg/24hr (Climara)...... 23
estradiol td patch weekly 0.1 mg/24hr (Climara).......... 23
estradiol valerate im in oil 10 mg/ml............................. 23
estradiol valerate im in oil 20 mg/ml (Delestrogen)......23
estradiol valerate im in oil 40 mg/ml (Delestrogen)......23
ESTRASORB - estradiol transdermal emulsion 4.35
mg/1.74gm....................................................................... 23
ESTRING - estradiol vaginal ring 2 mg (7.5
mcg/24hrs)....................................................................... 84
ESTROGEL - estradiol gel 0.06% (0.75 mg/1.25 gm
metered-dose pump)....................................................... 23
ESTROPIPATE - estropipate tab 3 mg............................. 23
estropipate tab 0.75 mg..................................................23
estropipate tab 1.5 mg....................................................23
ESTROSTEP FE - norethindrone ac-ethinyl estrad-fe tab
1-20/1-30/1-35 mg-mcg................................................... 25
eszopiclone tab 1 mg (Lunesta).................................... 98
eszopiclone tab 2 mg (Lunesta).................................... 98
eszopiclone tab 3 mg (Lunesta).................................... 98
ethambutol hcl tab 100 mg (Myambutol)........................ 7
ethambutol hcl tab 400 mg (Myambutol)........................ 7
ethosuximide cap 250 mg (Zarontin)...........................125
ethosuximide soln 250 mg/5ml (Zarontin).................. 125
ETHYL CHLORIDE/FINE PINPO - ethyl chloride aerosol
spray.............................................................................. 171
ETHYL CHLORIDE/FINE STREA - ethyl chloride aerosol
spray.............................................................................. 171
ETHYL CHLORIDE/MEDIUM JET - ethyl chloride aerosol
spray.............................................................................. 171
ETHYL CHLORIDE/MEDIUM STR - ethyl chloride aerosol
spray.............................................................................. 171
280
ETHYL CHLORIDE/MIST - ethyl chloride aerosol
spray.............................................................................. 171
ETHYL CHLORIDE - ethyl chloride aerosol spray.......... 171
ethynodiol diacetate & ethinyl estradiol tab 1 mg-35
mcg..................................................................................25
ETIDRONATE DISODIUM - etidronate disodium tab 200
mg.................................................................................... 37
ETIDRONATE DISODIUM - etidronate disodium tab 400
mg.................................................................................... 37
etodolac cap 200 mg.....................................................118
etodolac cap 300 mg.....................................................118
etodolac tab 400 mg..................................................... 118
etodolac tab 500 mg..................................................... 118
etodolac tab sr 24hr 400 mg........................................ 118
etodolac tab sr 24hr 500 mg........................................ 118
etodolac tab sr 24hr 600 mg........................................ 118
ETOPOSIDE - etoposide cap 50 mg................................ 16
EURAX - crotamiton cream 10%.................................... 171
EURAX - crotamiton lotion 10%......................................171
EVAMIST - estradiol transdermal spray 1.53 mg/spray.....24
EVENCARE + BLOOD GLUCOSE - glucose blood test
strip................................................................................ 185
EVENCARE BLOOD GLUCOSE TE - glucose blood test
strip................................................................................ 185
EVENCARE CONTROL SOLUTION - blood glucose
calibration - liquid ......................................................... 204
EVENCARE G2 GLUCOSE CONTR - blood glucose
calibration - liquid ......................................................... 204
EVENCARE G2 TEST STRIPS - glucose blood test
strip................................................................................ 185
EVENCARE G3 GLUCOSE CONTR - blood glucose
calibration - liquid ......................................................... 204
EVENCARE G3 TEST STRIPS - glucose blood test
strip................................................................................ 185
EVISTA - raloxifene hcl tab 60 mg....................................37
EVOCLIN - clindamycin phosphate foam 1%..................171
EVOLUTION AUTOCODE - glucose blood test strip.......185
EVOLUTION CONTROL SOLUTIO - blood glucose
calibration - liquid - normal ...........................................204
EVOXAC - cevimeline hcl cap 30 mg............................. 162
EVZIO - naloxone hcl solution auto-injector 0.4
mg/0.4ml........................................................................ 183
EXACTECH R-S-G TEST STRIP - glucose blood test
strip................................................................................ 185
EXACTECH TEST STRIPS - glucose blood test strip..... 185
EXACTUSS - phenylephrine w/ dm-gg liqd 10-28-388
mg/5ml............................................................................. 66
EXALGO - hydromorphone hcl tab er 24hr deter 12
mg.................................................................................. 110
EXALGO - hydromorphone hcl tab er 24hr deter 16
mg.................................................................................. 110
EXALGO - hydromorphone hcl tab er 24hr deter 32
mg.................................................................................. 110
EXALGO - hydromorphone hcl tab er 24hr deter 8
mg.................................................................................. 110
EXELDERM - sulconazole nitrate cream 1%.................. 172
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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EXELDERM - sulconazole nitrate solution 1%................ 172
EXEL INSULIN PEN NEEDLES - insulin pen needle 29 g
x 12 mm (1/2")...............................................................204
EXEL INSULIN PEN NEEDLES - insulin pen needle 31 g
x 6 mm (1/4").................................................................204
EXEL INSULIN PEN NEEDLES - insulin pen needle 31 g
x 8 mm (1/3" or 5/16")...................................................204
EXEL INSULIN SYRINGE/0.3M - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................204
EXEL INSULIN SYRINGE/0.3M - insulin syringe/needle
u-100 0.3 ml 30 x 5/16".................................................204
EXEL INSULIN SYRINGE/0.5M - insulin syringe/needle
u-100 1/2 ml 28 x 1/2"...................................................204
EXEL INSULIN SYRINGE/0.5M - insulin syringe/needle
u-100 1/2 ml 29 x 1/2"...................................................204
EXEL INSULIN SYRINGE/0.5M - insulin syringe/needle
u-100 1/2 ml 30 x 5/16".................................................204
EXEL INSULIN SYRINGE/1ML/ - insulin syringe/needle
u-100 1 ml 28 x 1/2"......................................................204
EXEL INSULIN SYRINGE/1ML/ - insulin syringe/needle
u-100 1 ml 29 x 1/2"......................................................204
EXEL INSULIN SYRINGE/1ML/ - insulin syringe/needle
u-100 1 ml 30 x 5/16"....................................................204
EXELON - rivastigmine tartrate cap 1.5 mg.................... 104
EXELON - rivastigmine tartrate cap 3 mg....................... 104
EXELON - rivastigmine tartrate cap 4.5 mg.................... 104
EXELON - rivastigmine tartrate cap 6 mg....................... 104
EXELON - rivastigmine tartrate soln 2 mg/ml..................104
EXELON - rivastigmine td patch 24hr 13.3 mg/24hr....... 104
EXELON - rivastigmine td patch 24hr 4.6 mg/24hr......... 104
EXELON - rivastigmine td patch 24hr 9.5 mg/24hr......... 104
exemestane tab 25 mg (Aromasin)................................16
EXFORGE - amlodipine besylate-valsartan tab 10-160
mg.................................................................................... 52
EXFORGE - amlodipine besylate-valsartan tab 10-320
mg.................................................................................... 52
EXFORGE - amlodipine besylate-valsartan tab 5-160
mg.................................................................................... 52
EXFORGE - amlodipine besylate-valsartan tab 5-320
mg.................................................................................... 52
EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 10-160-12.5 mg......................... 52
EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 10-160-25 mg............................ 52
EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 10-320-25 mg............................ 52
EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 5-160-12.5 mg........................... 52
EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 5-160-25 mg.............................. 52
EXJADE - deferasirox tab for oral susp 125 mg..............183
EXJADE - deferasirox tab for oral susp 250 mg..............183
EXJADE - deferasirox tab for oral susp 500 mg..............183
EXTAVIA - interferon beta-1b for inj kit 0.3 mg............... 104
EXTINA - ketoconazole foam 2%................................... 172
EXTRA-VIRT PLUS DHA - prenatal w/o vit a w/ fe fumdoc-fa-dha cap 29-1.25-350 mg ................................... 136
E-Z JECT LANCETS 21G - lancets ............................... 199
E-Z JECT LANCETS COLOR - lancets ......................... 199
E-Z JECT LANCETS - lancets .......................................199
E-ZJECT LANCETS MICRO-THI - lancets .................... 199
E-Z JECT LANCETS SUPER TH - lancets .................... 199
E-Z JECT LANCETS THIN 26G - lancets ...................... 199
EZ-LETS LANCETS 21G - lancets ................................ 204
EZ-LETS LANCETS 23G - lancets ................................ 204
EZ-LETS LANCETS 26G SUPER - lancets ................... 204
EZ-LETS LANCETS 28G ULTRA - lancets ....................204
EZ-LETS LANCETS 30G - lancets ................................ 204
EZ SMART BLOOD GLUCOSE LA - lancets ................. 204
EZ SMART BLOOD GLUCOSE TE - glucose blood test
strip................................................................................ 185
EZ SMART PLUS BLOOD GLUCO - glucose blood test
strip................................................................................ 185
E-Z SPACER - spacer/aerosol-holding chambers - device
....................................................................................... 199
E-Z SPACER THE BODY GUARD - spacer/aerosolholding chambers - device ........................................... 199
F
FA-8 - folic acid cap 0.8 mg............................................151
FABIOR - tazarotene (acne) foam 0.1%......................... 172
FACTIVE - gemifloxacin mesylate tab 320 mg (base
equiv)................................................................................. 6
FALESSA - levomefolate glucosamine tab 1 mg (folate
equivalent)..................................................................... 148
FALESSA - levonorgest-eth estrad tab 0.1 mg-20 mcg &
fa tab 1 mg kit................................................................. 25
famciclovir tab 125 mg (Famvir)...................................... 9
famciclovir tab 250 mg (Famvir)...................................... 9
famciclovir tab 500 mg (Famvir)...................................... 9
famotidine for susp 40 mg/5ml (Pepcid)....................... 76
famotidine tab 20 mg (Pepcid).......................................76
famotidine tab 40 mg (Pepcid).......................................76
FAMVIR - famciclovir tab 125 mg....................................... 9
FAMVIR - famciclovir tab 250 mg....................................... 9
FAMVIR - famciclovir tab 500 mg....................................... 9
FANAPT - iloperidone tab 10 mg......................................94
FANAPT - iloperidone tab 12 mg......................................94
FANAPT - iloperidone tab 1 mg........................................94
FANAPT - iloperidone tab 2 mg........................................94
FANAPT - iloperidone tab 4 mg........................................94
FANAPT - iloperidone tab 6 mg........................................94
FANAPT - iloperidone tab 8 mg........................................94
FANAPT TITRATION PACK - iloperidone tab 1 mg & 2 mg
& 4 mg & 6 mg titration pak............................................ 94
FARESTON - toremifene citrate tab 60 mg (base
equivalent)....................................................................... 16
FARXIGA - dapagliflozin propanediol tab 10 mg (base
equivalent)....................................................................... 29
FARXIGA - dapagliflozin propanediol tab 5 mg (base
equivalent)....................................................................... 29
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FASTTAKE COMPACT MONITORI - blood glucose
monitoring kit w/ device ................................................205
FASTTAKE TEST STRIPS - glucose blood test strip...... 185
FAZACLO - clozapine orally disintegrating tab 100 mg.....94
FAZACLO - clozapine orally disintegrating tab 12.5
mg.................................................................................... 94
FAZACLO - clozapine orally disintegrating tab 150 mg.....94
FAZACLO - clozapine orally disintegrating tab 200 mg.....95
FAZACLO - clozapine orally disintegrating tab 25 mg.......94
FBL KIT - flurbiprofen-baclofen-lidocaine cream 15-4-5%
(cmpd kit) ..................................................................... 172
FC2 FEMALE CONDOM - condoms - female ................ 205
FC FEMALE CONDOM - condoms - female .................. 205
FE 90 PLUS - fe carbonyl-fe gluconate-fa-vit b12-vit c-dss
tab 90-1 mg ..................................................................151
fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1
mg..................................................................................151
fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240
mg..................................................................................151
fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu
cap (Tandem plus).......................................................150
felbamate susp 600 mg/5ml (Felbatol)........................ 125
felbamate tab 400 mg (Felbatol).................................. 125
felbamate tab 600 mg (Felbatol).................................. 125
FELBATOL - felbamate susp 600 mg/5ml...................... 125
FELBATOL - felbamate tab 400 mg................................125
FELBATOL - felbamate tab 600 mg................................125
FELDENE - piroxicam cap 10 mg................................... 118
FELDENE - piroxicam cap 20 mg................................... 118
felodipine tab sr 24hr 10 mg.......................................... 46
felodipine tab sr 24hr 2.5 mg......................................... 46
felodipine tab sr 24hr 5 mg............................................46
FEMARA - letrozole tab 2.5 mg........................................ 16
FEMCAP - cervical cap 22 mm.......................................205
FEMCAP - cervical cap 26 mm.......................................205
FEMCAP - cervical cap 30 mm.......................................205
FEMCON FE - norethindrone & ethinyl estradiol-fe chew
tab 0.4 mg-35 mcg.......................................................... 25
FEMHRT 1/5 - norethindrone acetate-ethinyl estradiol tab
1 mg-5 mcg..................................................................... 24
FEMHRT LOW DOSE - norethindrone acetate-ethinyl
estradiol tab 0.5 mg-2.5 mcg...........................................24
FEM PH - acetic acid-oxyquinoline vaginal gel
0.9-0.025%.......................................................................84
FEMRING - estradiol acetate vaginal ring 0.05
mg/24hr............................................................................84
FEMRING - estradiol acetate vaginal ring 0.1 mg/24hr..... 84
FEMTRACE - estradiol acetate tab 0.45 mg.....................24
FEMTRACE - estradiol acetate tab 0.9 mg.......................24
FENOFIBRATE - fenofibrate cap 150 mg......................... 60
FENOFIBRATE - fenofibrate cap 50 mg........................... 60
fenofibrate micronized cap 130 mg............................... 60
fenofibrate micronized cap 134 mg (Lofibra)................60
fenofibrate micronized cap 200 mg (Lofibra)................60
fenofibrate micronized cap 43 mg................................. 60
fenofibrate micronized cap 67 mg (Lofibra)..................60
282
fenofibrate tab 145 mg (Tricor)...................................... 60
fenofibrate tab 160 mg (Lofibra).................................... 60
fenofibrate tab 48 mg (Tricor)........................................ 60
fenofibrate tab 54 mg (Lofibra)...................................... 60
FENOFIBRIC ACID - fenofibric acid tab 105 mg...............60
FENOFIBRIC ACID - fenofibric acid tab 35 mg.................60
FENOGLIDE - fenofibrate tab 120 mg.............................. 60
FENOGLIDE - fenofibrate tab 40 mg................................ 60
FENOPROFEN CALCIUM - fenoprofen calcium cap 400
mg.................................................................................. 118
FENOPROFEN CALCIUM - fenoprofen calcium tab 600
mg.................................................................................. 118
fentanyl citrate lollipop 1200 mcg (Actiq)................... 110
fentanyl citrate lollipop 1600 mcg (Actiq)................... 110
fentanyl citrate lollipop 200 mcg (Actiq)..................... 110
fentanyl citrate lollipop 400 mcg (Actiq)..................... 110
fentanyl citrate lollipop 600 mcg (Actiq)..................... 110
fentanyl citrate lollipop 800 mcg (Actiq)..................... 110
fentanyl td patch 72hr 100 mcg/hr (Duragesic).......... 110
fentanyl td patch 72hr 12 mcg/hr (Duragesic)............ 110
fentanyl td patch 72hr 25 mcg/hr (Duragesic)............ 110
fentanyl td patch 72hr 50 mcg/hr (Duragesic)............ 110
fentanyl td patch 72hr 75 mcg/hr (Duragesic)............ 110
FENTORA - fentanyl citrate buccal tab 100 mcg (base
equiv)............................................................................. 110
FENTORA - fentanyl citrate buccal tab 200 mcg (base
equiv)............................................................................. 110
FENTORA - fentanyl citrate buccal tab 400 mcg (base
equiv)............................................................................. 110
FENTORA - fentanyl citrate buccal tab 600 mcg (base
equiv)............................................................................. 110
FENTORA - fentanyl citrate buccal tab 800 mcg (base
equiv)............................................................................. 110
FER-IN-SOL - ferrous sulfate soln 75 mg/ml (15 mg/ml
elemental fe).................................................................. 151
FERIVA 21/7 - fe asparto gly-b12-fa-c-dss-succinic acidzn tab 75-1 mg .............................................................151
FERIVAFA - iron-c-fa-b12-biotin-copper-docusate cap
110-1 mg ...................................................................... 151
FERIVA - fe bisglycin-fe carbonyl-c-fa-b12-biotin-dss cap
75-1 mg ........................................................................ 151
FERRALET 90 - fe carbonyl-fe gluconate-fa-vit b12-vit cdss tab 90-1 mg ........................................................... 151
FERRAPLUS 90 - iron-folic acid-vit b12-vit c-docusate sod
tab 90-1 mg ..................................................................151
FERRETTS CHEWABLE IRON - carbonyl iron chew tab
18 mg (elemental iron).................................................. 151
FERREX 150 FORTE PLUS - fe asp gly-fe polysacchsucc ac-c-threon ac-b12-fa cap ....................................151
FERREX 28 - fe asparto gly-fe fum-b12-fa-c-succinic ac
tab ther pack ................................................................ 151
FERRIPROX - deferiprone tab 500 mg...........................183
FERRO-PLEX HEMATINIC - fe fum-dss-vit c-vit e-vit b12if-fa tab 115-1 mg .........................................................151
FERROTRIN - iron w/ b12-vit c-fa-ifc cap
36-0.015-75-0.5-240 mg................................................ 151
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab
106-1 mg ......................................................................150
ferrous fumarate-folic acid tab 324-1 mg.................... 152
ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental
fe)...................................................................................152
FERROUS SULFATE - ferrous sulfate liquid 220 mg/5ml
(44 mg/5ml elemental fe)...............................................152
FERROUS SULFATE - ferrous sulfate syrup 300 mg/5ml
(60 mg/5ml elemental fe)...............................................152
ferrous sulfate soln 75 mg/ml (15 mg/ml elemental
fe)...................................................................................152
ferrous sulfate-vit c-folic acid tab cr 105-500-0.8
mg..................................................................................152
FETZIMA - levomilnacipran hcl cap sr 24hr 120 mg (base
equivalent)....................................................................... 90
FETZIMA - levomilnacipran hcl cap sr 24hr 20 mg (base
equivalent)....................................................................... 90
FETZIMA - levomilnacipran hcl cap sr 24hr 40 mg (base
equivalent)....................................................................... 90
FETZIMA - levomilnacipran hcl cap sr 24hr 80 mg (base
equivalent)....................................................................... 90
FETZIMA TITRATION PACK - levomilnacipran hcl cap sr
24hr 20 & 40 mg therapy pack........................................90
FEXMID - cyclobenzaprine hcl tab 7.5 mg......................132
fexofenadine hcl tab 60 mg............................................64
FIBRICOR - fenofibric acid tab 105 mg............................ 60
FIBRICOR - fenofibric acid tab 35 mg.............................. 60
FIFTY50 CONTROL SOLUTION - blood glucose
calibration - liquid ......................................................... 205
FIFTY50 GLUCOSE METER 2.0 - blood glucose
monitoring kit w/ device ................................................205
FIFTY50 GLUCOSE TEST STRI - glucose blood test
strip................................................................................ 185
FIFTY50 LANCING DEVICE - lancet devices ................ 205
FIFTY50 PEN NEEDLES 31G X - insulin pen needle 31 g
x 5 mm (3/16")...............................................................205
FIFTY50 PEN NEEDLES 31G X - insulin pen needle 31 g
x 8 mm (1/3" or 5/16")...................................................205
FIFTY50 SAFETY SEAL LANCE - lancets .................... 205
FIFTY50 SUPERIOR COMFORT - insulin syringe/needle
u-100 0.3 ml 31 x 5/16".................................................205
FIFTY50 SUPERIOR COMFORT - insulin syringe/needle
u-100 1/2 ml 31 x 5/16".................................................205
FIFTY50 SUPERIOR COMFORT - insulin syringe/needle
u-100 1 ml 31 x 5/16"....................................................205
FINACEA - azelaic acid gel 15%.................................... 172
FINACEA PLUS - azelaic acid gel 15% w/cleanser &
moisturizing lotion kit..................................................... 172
finasteride tab 5 mg (Proscar)....................................... 85
FINE 30 - lancets ...........................................................205
FINGERSTIX LANCETS - lancets ................................. 205
FIORICET/CODEINE - butalbital-acetaminophen-caff w/
cod cap 50-300-40-30 mg............................................. 110
FIORICET/CODEINE - butalbital-acetaminophen-caff w/
cod cap 50-325-40-30 mg............................................. 110
FIORICET - butalbital-acetaminophen-caffeine cap
50-300-40 mg................................................................ 107
FIORICET - butalbital-acetaminophen-caffeine tab
50-325-40 mg................................................................ 108
FIORINAL/CODEINE #3 - butalbital-aspirin-caff w/
codeine cap 50-325-40-30 mg...................................... 110
FIORINAL - butalbital-aspirin-caffeine cap 50-325-40
mg.................................................................................. 108
FIRAZYR - icatibant acetate inj 30 mg/3ml (base
equivalent)..................................................................... 156
FIRST-BXN MOUTHWASH - diphenhydramine-lidocainenystatin susp ................................................................ 162
FIRST-DUKES MOUTHWASH - diphenhydraminehydrocortisone-nystatin susp ........................................162
FIRST-HYDROCORTISONE - hydrocortisone gel
10%................................................................................172
FIRST-LANSOPRAZOLE - lansoprazole susp 3 mg/ml
(compound kit) ................................................................76
FIRST-MARYS MOUTHWASH - diphenhydraminehydrocortisone-nystatin-tetracycline susp .....................162
FIRST-MOUTHWASH BLM - diphenhyd-lidocaine-al
hydroxide-mg hydroxide-simeth susp ...........................162
FIRST-OMEPRAZOLE - omeprazole susp 2 mg/ml
(compound kit) ................................................................76
FIRST-PROGESTERONE VGS 10 - progesterone vaginal
suppository 100 mg......................................................... 84
FIRST-PROGESTERONE VGS 20 - progesterone vaginal
suppository 200 mg......................................................... 84
FIRST-PROGESTERONE VGS 25 - progesterone vaginal
suppository 25 mg........................................................... 84
FIRST-PROGESTERONE VGS 40 - progesterone vaginal
suppository 400 mg......................................................... 84
FIRST-PROGESTERONE VGS 50 - progesterone vaginal
suppository 50 mg........................................................... 84
FIRST-TESTOSTERONE MC COM - testosterone
propionate td cream 2%.................................................. 21
FIRST-TESTOSTERONE - testosterone propionate td
ointment 2%.....................................................................21
FIRST-VANCOMYCIN 25 - vancomycin hcl oral soln 25
mg/ml (compound kit) .....................................................14
FIRST-VANCOMYCIN 50 - vancomycin hcl oral soln 50
mg/ml (compound kit) .....................................................14
FLAGYL ER - metronidazole tab sr 24hr 750 mg..............14
FLAGYL - metronidazole cap 375 mg...............................14
FLAGYL - metronidazole tab 250 mg............................... 14
FLAGYL - metronidazole tab 500 mg............................... 14
FLAREX - fluorometholone acetate ophth susp 0.1%..... 158
FLAVOR BLEND - oral vehicles .................................... 240
FLAVOR PLUS - oral vehicles .......................................240
FLAVOR SWEET - oral vehicles ....................................240
FLAVOR SWEET-SF - oral vehicles .............................. 240
flavoxate hcl tab 100 mg................................................ 83
flaxseed oil-evening primrose-bilberry cap
1000-500-40 mg (Tears again hydrate)...................... 148
flecainide acetate tab 100 mg........................................ 47
flecainide acetate tab 150 mg........................................ 47
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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flecainide acetate tab 50 mg.......................................... 47
FLECTOR - diclofenac epolamine patch 1.3%................172
FLEXERIL - cyclobenzaprine hcl tab 10 mg................... 132
FLEXERIL - cyclobenzaprine hcl tab 5 mg..................... 132
FLOMAX - tamsulosin hcl cap 0.4 mg.............................. 85
FLONASE - fluticasone propionate nasal susp 50 mcg/
act.................................................................................... 64
FLO-PRED - prednisolone acetate oral susp 16.7 mg/5ml
(15 mg/5ml base)............................................................ 20
FLORICAL - sodium fluoride w/ calcium carb cap 8.3-364
mg.................................................................................. 146
FLORICAL - sodium fluoride w/ calcium carb tab 8.3-364
mg.................................................................................. 146
FLORIVA - ped multiple vitamins & minerals w/ fl chew tab
0.5 mg............................................................................136
FLORIVA - ped multiple vitamins & minerals w/ fl chew tab
1 mg...............................................................................136
FLORIVA - sodium fluoride-vitamin d liqd drops 0.25 mg/
ml-400 unit/ml................................................................ 146
FLOVENT DISKUS - fluticasone propionate aer pow ba
100 mcg/blister................................................................ 72
FLOVENT DISKUS - fluticasone propionate aer pow ba
250 mcg/blister................................................................ 72
FLOVENT DISKUS - fluticasone propionate aer pow ba 50
mcg/blister........................................................................72
FLOVENT HFA - fluticasone propionate hfa inhal aer 110
mcg/act (125/valve)......................................................... 72
FLOVENT HFA - fluticasone propionate hfa inhal aer 220
mcg/act (250/valve)......................................................... 72
FLOVENT HFA - fluticasone propionate hfa inhal aero 44
mcg/act (50/valve)........................................................... 72
fluconazole for susp 10 mg/ml (Diflucan)....................... 8
fluconazole for susp 40 mg/ml (Diflucan)....................... 8
fluconazole tab 100 mg (Diflucan)................................... 8
fluconazole tab 150 mg (Diflucan)................................... 8
fluconazole tab 200 mg (Diflucan)................................... 8
fluconazole tab 50 mg (Diflucan).....................................8
flucytosine cap 250 mg (Ancobon)..................................8
flucytosine cap 500 mg (Ancobon)..................................8
fludrocortisone acetate tab 0.1 mg................................20
FLUMADINE - rimantadine hydrochloride tab 100 mg........ 9
FLUNISOLIDE - flunisolide nasal soln 25 mcg/act
(0.025%).......................................................................... 64
FLUNISOLIDE - flunisolide nasal soln 29 mcg/act
(0.025%).......................................................................... 64
flunisolide nasal soln 25 mcg/act (0.025%)
(Flunisolide)....................................................................64
fluocinolone acetonide (otic) oil 0.01%
(Dermotic)..................................................................... 162
fluocinolone acetonide cream 0.01%.......................... 172
fluocinolone acetonide cream 0.025% (Synalar)........ 172
fluocinolone acetonide oil 0.01% (body oil) (Dermasmoothe/fs bod)...........................................................172
fluocinolone acetonide oil 0.01% (scalp oil) (Dermasmoothe/fs sca)........................................................... 172
fluocinolone acetonide oint 0.025% (Synalar)............ 172
284
fluocinolone acetonide soln 0.01% (Synalar)............. 172
fluocinonide cream 0.05%............................................ 172
fluocinonide cream 0.1% (Vanos)................................ 172
fluocinonide emulsified base cream 0.05%................ 172
fluocinonide gel 0.05%................................................. 172
fluocinonide oint 0.05%................................................ 172
fluocinonide soln 0.05%............................................... 172
FLUORABON - sodium fluoride soln 0.25 mg/0.6ml (from
0.55 mg/0.6ml naf)........................................................ 146
FLUOR-A-DAY - sodium fluoride-xylitol chew tab 0.55
(0.25 mg f)-236.79 mg...................................................146
FLUOR-A-DAY - sodium fluoride-xylitol chew tab 1.1 (0.5
mg f)-236.79 mg............................................................ 146
FLUOR-A-DAY - sodium fluoride-xylitol chew tab 2.2 (1
mg f)-236.79 mg............................................................ 146
FLUORIDEX DAILY DEFENSE S - sodium fluoridepotassium nitrate gel 1.1-5%.........................................162
fluorometholone ophth susp 0.1% (Fml liquifilm)...... 158
FLUOROPLEX - fluorouracil cream 1%.......................... 172
fluorouracil cream 5% (Efudex)................................... 172
FLUOROURACIL - fluorouracil cream 0.5%................... 172
fluorouracil soln 2%......................................................172
fluorouracil soln 5%......................................................172
fluoxetine hcl (pmdd) cap 10 mg................................. 104
fluoxetine hcl (pmdd) cap 20 mg................................. 104
fluoxetine hcl cap 10 mg (Prozac)................................. 90
fluoxetine hcl cap 20 mg (Prozac)................................. 90
fluoxetine hcl cap 40 mg (Prozac)................................. 90
fluoxetine hcl cap delayed release 90 mg (Prozac
weekly)............................................................................ 90
FLUOXETINE HCL - fluoxetine hcl tab 60 mg.................. 90
fluoxetine hcl solution 20 mg/5ml................................. 90
fluoxetine hcl tab 10 mg.................................................90
fluoxetine hcl tab 20 mg.................................................90
fluphenazine decanoate inj 25 mg/ml............................95
FLUPHENAZINE HCL - fluphenazine hcl elixir 2.5
mg/5ml............................................................................. 95
FLUPHENAZINE HCL - fluphenazine hcl inj 2.5 mg/ml.....95
FLUPHENAZINE HCL - fluphenazine hcl oral conc 5 mg/
ml..................................................................................... 95
fluphenazine hcl tab 10 mg............................................ 95
fluphenazine hcl tab 1 mg..............................................95
fluphenazine hcl tab 2.5 mg........................................... 95
fluphenazine hcl tab 5 mg..............................................95
FLURA-DROPS - sodium fluoride soln 0.25 mg/drop f
(from 0.55 mg/drop naf)................................................ 146
flurazepam hcl cap 15 mg.............................................. 98
flurazepam hcl cap 30 mg.............................................. 98
FLURAZEPAM HCL - flurazepam hcl cap 15 mg..............98
FLURAZEPAM HCL - flurazepam hcl cap 30 mg..............98
flurbiprofen sodium ophth soln 0.03% (Ocufen)........ 158
flurbiprofen tab 100 mg................................................ 118
flurbiprofen tab 50 mg.................................................. 118
flutamide cap 125 mg..................................................... 16
fluticasone propionate cream 0.05% (Cutivate)..........172
fluticasone propionate lotion 0.05% (Cutivate).......... 172
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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fluticasone propionate nasal susp 50 mcg/act
(Flonase)......................................................................... 64
fluticasone propionate oint 0.005% (Cutivate)............172
fluvastatin sodium cap 20 mg (Lescol)......................... 60
fluvastatin sodium cap 40 mg (Lescol)......................... 60
fluvoxamine maleate cap sr 24hr 100 mg (Luvox
cr).................................................................................... 90
fluvoxamine maleate cap sr 24hr 150 mg (Luvox
cr).................................................................................... 90
fluvoxamine maleate tab 100 mg................................... 90
fluvoxamine maleate tab 25 mg.....................................90
fluvoxamine maleate tab 50 mg.....................................90
FML - fluorometholone ophth oint 0.1%.......................... 158
FML FORTE - fluorometholone ophth susp 0.25%......... 158
FML LIQUIFILM - fluorometholone ophth susp 0.1%...... 158
FOCALGIN-B - prenatal w/ calcium-vit b6-fa-ginger tab
1.22 mg ........................................................................ 136
FOCALIN - dexmethylphenidate hcl tab 10 mg...............101
FOCALIN - dexmethylphenidate hcl tab 2.5 mg.............. 101
FOCALIN - dexmethylphenidate hcl tab 5 mg.................101
FOCALIN XR - dexmethylphenidate hcl cap sr 24 hr 10
mg.................................................................................. 101
FOCALIN XR - dexmethylphenidate hcl cap sr 24 hr 15
mg.................................................................................. 101
FOCALIN XR - dexmethylphenidate hcl cap sr 24 hr 20
mg.................................................................................. 101
FOCALIN XR - dexmethylphenidate hcl cap sr 24 hr 25
mg.................................................................................. 101
FOCALIN XR - dexmethylphenidate hcl cap sr 24 hr 30
mg.................................................................................. 101
FOCALIN XR - dexmethylphenidate hcl cap sr 24 hr 35
mg.................................................................................. 101
FOCALIN XR - dexmethylphenidate hcl cap sr 24 hr 40
mg.................................................................................. 101
FOCALIN XR - dexmethylphenidate hcl cap sr 24 hr 5
mg.................................................................................. 101
FOLBECAL - prenatal w/ calcium carbonate-b6-b12-fa tab
1 mg ............................................................................. 136
FOLBEE AR - folic acid-b12-b6-arginine-black pepper tab
....................................................................................... 148
FOLBIC RF - l-methylfolate w/ vit b6-vit b12 tab 1.13-25-2
mg .................................................................................148
FOLCAL DHA - prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 27-1.25-300 mg ..................................................... 136
FOLCAPS OMEGA 3 - prenatal vit w/ fe cbn-fe asp glycfa-omega 3 cap 27-1mg ...............................................136
FOLET DHA - prenat w/fecbn-bisg-methylf-dss tab dr &
dha cap pak...................................................................136
FOLET ONE - prenat w/o a w/fecbn-bisg-methylf-dss-dha
cap 38-1-225 mg .......................................................... 136
FOLGARD OS - multiple vit w/ min & calcium-folic acid tab
500-1.1 mg.................................................................... 136
FOLGARD RX - folic acid-vitamin b6-vitamin b12 tab
2.2-25-1 mg................................................................... 152
folic acid-pyridoxine-cyanocobalamin tab 2.5-25-2
mg..................................................................................148
folic acid tab 1 mg........................................................ 152
folic acid tab 400 mcg.................................................. 152
folic acid tab 800 mcg.................................................. 152
folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5
mg..................................................................................152
folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg
(Folgard rx)...................................................................152
folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg...... 152
folic acid-vit b6-vit b12-omega 3-phytosterols cap 1
mg ................................................................................ 150
FOLIVANE-F - fe fum-fe poly-fa-c-b3 cap
62.5-62.5-1-40-3mg(125 mg fe) ................................... 152
FOLIVANE-OB - prenatal w/o a w/fe fum-fe poly-fa cap
130-92.4-1 mg .............................................................. 136
FOLIVANE-PLUS - fe fum-iron polysacch complex-fa-b
complex-c-biotin cap .................................................... 152
FOLIVANE-PRX DHA NF - prenatal w/o vit a w/fe fumdss-fa-dha cap 30-1.24-265 mg ................................... 136
FOLLISTIM AQ - follitropin beta inj 150 unit/0.5ml............ 37
FOLLISTIM AQ - follitropin beta inj 300 unit/0.36ml.......... 37
FOLLISTIM AQ - follitropin beta inj 600 unit/0.72ml.......... 37
FOLLISTIM AQ - follitropin beta inj 75 unit/0.5ml..............37
FOLLISTIM AQ - follitropin beta inj 900 unit/1.08ml.......... 37
FOLPACE RX - folic acid-hydroxocobal-vit b6-vit e-mag
tab 2.05 mg-425 mcg.................................................... 152
FOLTANX - l-methylfolate w/ vit b6-vit b12 tab 3-35-2 mg
....................................................................................... 148
FOLTANX RF - l-methylfolate-algae-vit b12-b6 cap
3-90.314-2-35 mg .........................................................148
FOLTRATE - cobalamine combination tab .....................152
FOLTX - folic acid-pyridoxine-cyanocobalamin tab
2.5-25-2 mg................................................................... 148
FOLTX - l-methylfolate w/ vit b6-vit b12 tab 1.13-25-2 mg
....................................................................................... 148
fondaparinux sodium inj 10 mg/0.8ml (Arixtra).......... 154
fondaparinux sodium inj 2.5 mg/0.5ml (Arixtra)......... 154
fondaparinux sodium inj 5 mg/0.4ml (Arixtra)............ 154
fondaparinux sodium inj 7.5 mg/0.6ml (Arixtra)......... 154
FORACARE GD40 - glucose blood test strip.................. 186
FORACARE GDH CONTROL SOLU - blood glucose
calibration - liquid - high ...............................................205
FORACARE GDH CONTROL SOLU - blood glucose
calibration - liquid - low ................................................ 205
FORACARE GDH CONTROL SOLU - blood glucose
calibration - liquid - normal ...........................................205
FORACARE PREMIUM V10 TEST - glucose blood test
strip................................................................................ 186
FORACARE TEST N GO TEST S - glucose blood test
strip................................................................................ 186
FORA CONTROL SOLUTION HIG - blood glucose
calibration - liquid - high ...............................................205
FORA CONTROL SOLUTION LOW - blood glucose
calibration - liquid - low ................................................ 205
FORA CONTROL SOLUTION NOR - blood glucose
calibration - liquid - normal ...........................................205
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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FORA D10 BLOOD GLUCOSE TE - glucose blood test
strip................................................................................ 185
FORA D15C BLOOD GLUCOSE T - glucose blood test
strip................................................................................ 185
FORA D15G BLOOD GLUCOSE T - glucose blood test
strip................................................................................ 185
FORA D15Z BLOOD GLUCOSE T - glucose blood test
strip................................................................................ 185
FORA D20 BLOOD GLUCOSE TE - glucose blood test
strip................................................................................ 185
FORADIL AEROLIZER - formoterol fumarate inhal cap 12
mcg.................................................................................. 72
FORA G20 BLOOD GLUCOSE MO - blood glucose
monitoring kit w/ device ................................................205
FORA G20 BLOOD GLUCOSE TE - glucose blood test
strip................................................................................ 186
FORA G30A BLOOD GLUCOSE T - glucose blood test
strip................................................................................ 186
FORA G71A BLOOD GLUCOSE M - blood glucose
monitoring kit w/ device ................................................205
FORA G71A BLOOD GLUCOSE T - glucose blood test
strip................................................................................ 186
FORA G90 BLOOD GLUCOSE TE - glucose blood test
strip................................................................................ 186
FORA GD20 TEST STRIPS - glucose blood test
strip................................................................................ 185
FORA GD50 BLOOD GLUCOSE T - glucose blood test
strip................................................................................ 186
FORA LANCETS - lancets .............................................205
FORA LANCING DEVICE - lancet devices .................... 205
FORA TEST N' GO BLOOD GLU - glucose blood test
strip................................................................................ 186
FORA V10 BLOOD GLUCOSE TE - glucose blood test
strip................................................................................ 186
FORA V12 BLOOD GLUCOSE TE - glucose blood test
strip................................................................................ 186
FORA V20 BLOOD GLUCOSE TE - glucose blood test
strip................................................................................ 186
FORA V22 BLOOD GLUCOSE MO - blood glucose
monitoring kit w/ device ................................................205
FORA V22 BLOOD GLUCOSE TE - glucose blood test
strip................................................................................ 186
FORA V30A BLOOD GLUCOSE M - blood glucose
monitoring kit w/ device ................................................205
FORA V30A BLOOD GLUCOSE T - glucose blood test
strip................................................................................ 186
FORFIVO XL - bupropion hcl tab sr 24hr 450 mg............. 90
FORMALDEHYDE - formaldehyde solution 37%............ 183
formaldehyde solution 10%..........................................183
FORMA-RAY - formaldehyde solution 20%.................... 183
FORTAMET - metformin hcl tab sr 24hr osmotic 1000
mg.................................................................................... 29
FORTAMET - metformin hcl tab sr 24hr osmotic 500
mg.................................................................................... 29
FORTAVIT - multiple vitamins w/ minerals cap ..............137
286
FORTEO - teriparatide (recombinant) inj 600
mcg/2.4ml........................................................................ 37
FORTESTA - testosterone td gel 10mg/act (2%).............. 21
FORTICAL - calcitonin (salmon) nasal soln 200 unit/
act.................................................................................... 37
FORTISCARE BLOOD GLUCOSE - glucose blood test
strip................................................................................ 186
FORTISCARE CONTROL SOLUTI - blood glucose
calibration - liquid - high ...............................................205
FORTISCARE CONTROL SOLUTI - blood glucose
calibration - liquid - low ................................................ 205
FORTISCARE CONTROL SOLUTI - blood glucose
calibration - liquid - normal ...........................................205
FORTISCARE SELF-MONITORIN - blood glucose
monitoring kit w/ device ................................................205
FOSAMAX - alendronate sodium tab 70 mg.....................37
FOSAMAX PLUS D - alendronate sodium-cholecalciferol
tab 70-2800 mg-unit........................................................ 37
FOSAMAX PLUS D - alendronate sodium-cholecalciferol
tab 70-5600 mg-unit........................................................ 37
fosinopril sodium & hydrochlorothiazide tab 10-12.5
mg....................................................................................52
fosinopril sodium & hydrochlorothiazide tab 20-12.5
mg....................................................................................52
fosinopril sodium tab 10 mg.......................................... 52
fosinopril sodium tab 20 mg.......................................... 52
fosinopril sodium tab 40 mg.......................................... 52
FOSRENOL - lanthanum carbonate chew tab 1000
mg.................................................................................... 81
FOSRENOL - lanthanum carbonate chew tab 500 mg......81
FOSRENOL - lanthanum carbonate chew tab 750 mg......81
FOSTEUM - genistein-zinc amino acid chelate-vitamin d
cap ................................................................................148
FRAGMIN - dalteparin sodium inj 10000 unit/ml............. 154
FRAGMIN - dalteparin sodium inj 12500 unit/0.5ml........ 155
FRAGMIN - dalteparin sodium inj 15000 unit/0.6ml........ 155
FRAGMIN - dalteparin sodium inj 18000 unit/0.72ml...... 155
FRAGMIN - dalteparin sodium inj 25000 unit/ml............. 155
FRAGMIN - dalteparin sodium inj 2500 unit/0.2ml.......... 154
FRAGMIN - dalteparin sodium inj 5000 unit/0.2ml.......... 155
FRAGMIN - dalteparin sodium inj 7500 unit/0.3ml.......... 155
FREDS PHARMACY AUTOLET LA - lancet devices ..... 206
FREDS PHARMACY UNIFINE PE - insulin pen needle 31
g x 5 mm (3/16")........................................................... 206
FREDS PHARMACY UNIFINE PE - insulin pen needle 31
g x 8 mm (1/3" or 5/16")................................................206
FREDS PHARMACY UNIFINE PE - insulin pen needle 32
g x 4 mm (5/32")........................................................... 206
FREDS PHARMACY UNILET LAN - lancets ................. 206
FREESTYLE CONTROL SOLUTIO - blood glucose
calibration - liquid ......................................................... 206
FREESTYLE FREEDOM - blood glucose monitoring kit w/
device ........................................................................... 206
FREESTYLE FREEDOM LITE - blood glucose monitoring
kit w/ device ................................................................. 206
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
2015
FREESTYLE INSULINX BLOOD - blood glucose
monitoring kit w/ device ................................................206
FREESTYLE INSULINX BLOOD - glucose blood test
strip................................................................................ 186
FREESTYLE LANCETS - lancets .................................. 206
FREESTYLE LITE TEST STRIP - glucose blood test
strip................................................................................ 186
FREESTYLE PRECISION INSUL - insulin syringe/needle
u-100 1/2 ml 30 x 5/16".................................................206
FREESTYLE PRECISION INSUL - insulin syringe/needle
u-100 1/2 ml 31 x 5/16".................................................206
FREESTYLE PRECISION INSUL - insulin syringe/needle
u-100 1 ml 30 x 5/16"....................................................206
FREESTYLE PRECISION INSUL - insulin syringe/needle
u-100 1 ml 31 x 5/16"....................................................206
FREESTYLE SIDEKICK II VAL - blood glucose monitoring
kit w/ device ................................................................. 206
FREESTYLE TEST STRIPS - glucose blood test
strip................................................................................ 186
FREESTYLE UNISTICK II LAN - lancets .......................206
FROVA - frovatriptan succinate tab 2.5 mg (base
equivalent)..................................................................... 122
FULYZAQ - crofelemer tab delayed release 125 mg........ 74
FURADANTIN - nitrofurantoin susp 25 mg/5ml.................82
FUROSEMIDE - furosemide oral soln 8 mg/ml................. 57
furosemide oral soln 10 mg/ml...................................... 57
furosemide tab 20 mg (Lasix)........................................ 57
furosemide tab 40 mg (Lasix)........................................ 57
furosemide tab 80 mg (Lasix)........................................ 57
FUSION PLUS - fe fum-iron poly cmplx-fa-b cmplx-cbiotin-probiotic cap ....................................................... 152
FUZEON - enfuvirtide for inj 90 mg.................................... 9
FYCOMPA - perampanel tab 10 mg............................... 125
FYCOMPA - perampanel tab 12 mg............................... 125
FYCOMPA - perampanel tab 2 mg................................. 125
FYCOMPA - perampanel tab 4 mg................................. 125
FYCOMPA - perampanel tab 6 mg................................. 125
FYCOMPA - perampanel tab 8 mg................................. 125
G
gabapentin cap 100 mg (Neurontin)............................ 125
gabapentin cap 300 mg (Neurontin)............................ 125
gabapentin cap 400 mg (Neurontin)............................ 125
gabapentin oral soln 250 mg/5ml (Neurontin)............ 125
gabapentin tab 600 mg (Neurontin).............................125
gabapentin tab 800 mg (Neurontin).............................125
GABAVALE-5 - diazepam tab 5 mg & dietary management
cap pack.......................................................................... 87
GABAZOLAMINE-0.5 - alprazolam tab 0.5 mg & dietary
management cap pack.................................................... 87
GABAZOLAMINE - alprazolam tab 0.25 mg & dietary
management cap pack.................................................... 87
GABAZOLPIDEM-5 - zolpidem tab 5 mg & dietary
management cap pack.................................................... 98
GABITIDINE - ranitidine hcl tab 150 mg & dietary
management cap pack.................................................... 76
GABITRIL - tiagabine hcl tab 12 mg............................... 125
GABITRIL - tiagabine hcl tab 16 mg............................... 125
GABITRIL - tiagabine hcl tab 2 mg................................. 125
GABITRIL - tiagabine hcl tab 4 mg................................. 125
GABOXETINE - fluoxetine hcl cap 10 mg & dietary
management cap pack.................................................... 90
galantamine hydrobromide cap sr 24hr 16 mg
(Razadyne er)............................................................... 104
galantamine hydrobromide cap sr 24hr 24 mg
(Razadyne er)............................................................... 104
galantamine hydrobromide cap sr 24hr 8 mg
(Razadyne er)............................................................... 104
galantamine hydrobromide oral soln 4 mg/ml
(Razadyne)....................................................................104
galantamine hydrobromide tab 12 mg (Razadyne).....104
galantamine hydrobromide tab 4 mg (Razadyne).......104
galantamine hydrobromide tab 8 mg (Razadyne).......104
GALZIN - zinc acetate cap 25 mg (elemental zinc)......... 146
GALZIN - zinc acetate cap 50 mg (elemental zinc)......... 146
GANIRELIX ACETATE - ganirelix acetate inj 250
mcg/0.5ml........................................................................ 37
GARAMYCIN - gentamicin sulfate ophth soln 0.3%........ 158
GASTRINEX NF - hyoscyamine-phenyltoloxamine cap
0.0625-15 mg.................................................................. 76
GASTROCROM - cromolyn sodium oral conc 100
mg/5ml............................................................................. 81
gatifloxacin ophth soln 0.5% (Zymaxid)......................158
GATTEX - teduglutide (rdna) for inj kit 5 mg.....................81
GE100 BLOOD GLUCOSE MONIT - blood glucose
monitoring kit w/ device ................................................206
GE100 BLOOD GLUCOSE TEST - glucose blood test
strip................................................................................ 186
GE100 CONTROL SOLUTION NO - blood glucose
calibration - liquid - normal ...........................................206
GEBAUERS PAIN EASE - pentafluoropropanetetrafluoroethane aero spray......................................... 172
GEBAUERS SPRAY AND STRETC - pentafluoropropanetetrafluoroethane aero spray......................................... 172
GELCLAIR - povidone-sodium hyaluronate-glycyrrhetinic
acid gel .........................................................................162
GELFILM OP - gelatin adsorbable ophth film..................158
GEL-KAM ORAL CARE RINSE - stannous fluoride conc
0.63%.............................................................................162
GEL-KAM - stannous fluoride gel 0.4%.......................... 162
GELNIQUE - oxybutynin chloride td gel 10%....................83
GELNIQUE - oxybutynin td gel 3% (28 mg/act metereddose pump)......................................................................83
GELX - oral wound care products - gel ..........................162
gemfibrozil tab 600 mg (Lopid)......................................60
GENERESS FE - norethindrone & ethinyl estradiol-fe
chew tab 0.8 mg-25 mcg.................................................25
GENOTROPIN MINIQUICK - somatropin for inj 0.2
mg.................................................................................... 37
GENOTROPIN MINIQUICK - somatropin for inj 0.4
mg.................................................................................... 37
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GENOTROPIN MINIQUICK - somatropin for inj 0.6
mg.................................................................................... 38
GENOTROPIN MINIQUICK - somatropin for inj 0.8
mg.................................................................................... 38
GENOTROPIN MINIQUICK - somatropin for inj 1.2
mg.................................................................................... 38
GENOTROPIN MINIQUICK - somatropin for inj 1.4
mg.................................................................................... 38
GENOTROPIN MINIQUICK - somatropin for inj 1.6
mg.................................................................................... 38
GENOTROPIN MINIQUICK - somatropin for inj 1.8
mg.................................................................................... 38
GENOTROPIN MINIQUICK - somatropin for inj 1 mg.......38
GENOTROPIN MINIQUICK - somatropin for inj 2 mg.......38
GENOTROPIN - somatropin for inj 12 mg (13.8 mg
overfill)............................................................................. 37
GENOTROPIN - somatropin for subcutaneous inj 5
mg.................................................................................... 37
GENTAMICIN SULFATE - gentamicin sulfate cream
0.1%...............................................................................172
GENTAMICIN SULFATE - gentamicin sulfate oint
0.1%...............................................................................172
gentamicin sulfate inj 10 mg/ml.......................................6
gentamicin sulfate inj 40 mg/ml.......................................6
gentamicin sulfate ophth oint 0.3%.............................158
gentamicin sulfate ophth soln 0.3% (Garamycin).......158
GENTLE-LET GP LANCETS - lancets ...........................206
GENTLE-LET LANCETS GENERA - lancets .................206
GENTLE-LET LANCETS SAFETY - lancets .................. 206
GEODON - ziprasidone hcl cap 20 mg............................. 95
GEODON - ziprasidone hcl cap 40 mg............................. 95
GEODON - ziprasidone hcl cap 60 mg............................. 95
GEODON - ziprasidone hcl cap 80 mg............................. 95
GEODON - ziprasidone mesylate for inj 20 mg (base
equivalent)....................................................................... 95
GESTICARE DHA - prenatal w/fe fum-fa tab dr 27-1 mg &
dha cap 250 mg pack .................................................. 137
GHT BLOOD GLUCOSE MONITO - blood glucose
monitoring kit w/ device ................................................206
GHT TEST STRIPS - glucose blood test strip.................186
GIAZO - balsalazide disodium tab 1.1 gm........................ 81
GILENYA - fingolimod hcl cap 0.5 mg (base equiv)........ 104
GILOTRIF - afatinib dimaleate tab 20 mg (base
equivalent)....................................................................... 16
GILOTRIF - afatinib dimaleate tab 30 mg (base
equivalent)....................................................................... 16
GILOTRIF - afatinib dimaleate tab 40 mg (base
equivalent)....................................................................... 16
GILPHEX TR - phenylephrine-guaifenesin tab 10-388
mg.................................................................................... 66
GILTUSS PED-C - phenylephrine w/ codeine-gg liquid
2.5-3-50 mg/ml................................................................ 66
GILTUSS - phenylephrine w/ dm-gg liqd 10-28-388
mg/5ml............................................................................. 66
GILTUSS TR - phenylephrine w/ dm-gg cap 7-14-288
mg.................................................................................... 66
288
GILTUSS TR - phenylephrine w/ dm-gg tab 10-28-388
mg.................................................................................... 66
GILTUSS TR - phenylephrine w/ dm-gg tab sr 12hr
20-30-600 mg.................................................................. 66
GLEEVEC - imatinib mesylate tab 100 mg (base
equivalent)....................................................................... 16
GLEEVEC - imatinib mesylate tab 400 mg (base
equivalent)....................................................................... 16
glimepiride tab 1 mg (Amaryl)....................................... 29
glimepiride tab 2 mg (Amaryl)....................................... 29
glimepiride tab 4 mg (Amaryl)....................................... 29
glipizide-metformin hcl tab 2.5-250 mg......................... 29
glipizide-metformin hcl tab 2.5-500 mg......................... 29
glipizide-metformin hcl tab 5-500 mg............................ 29
glipizide tab 10 mg (Glucotrol)...................................... 29
glipizide tab 5 mg (Glucotrol)........................................ 29
glipizide tab sr 24hr 10 mg (Glucotrol xl)......................29
glipizide tab sr 24hr 2.5 mg (Glucotrol xl).....................29
glipizide tab sr 24hr 5 mg (Glucotrol xl)....................... 29
GLOBAL EASE INJECT PEN NE - insulin pen needle 29 g
x 12 mm (1/2")...............................................................206
GLOBAL EASE INJECT PEN NE - insulin pen needle 31 g
x 5 mm (3/16")...............................................................206
GLOBAL EASE INJECT PEN NE - insulin pen needle 31 g
x 8 mm (1/3" or 5/16")...................................................206
GLOBAL EASE INJECT PEN NE - insulin pen needle 32 g
x 4 mm (5/32")...............................................................206
GLOBAL INJECT EASE INSULI - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................206
GLOBAL INJECT EASE INSULI - insulin syringe/needle
u-100 0.3 ml 30 x 1/2"...................................................206
GLOBAL INJECT EASE INSULI - insulin syringe/needle
u-100 0.3 ml 30 x 5/16".................................................206
GLOBAL INJECT EASE INSULI - insulin syringe/needle
u-100 0.3 ml 31 x 5/16".................................................207
GLOBAL INJECT EASE INSULI - insulin syringe/needle
u-100 1/2 ml 28 x 1/2"...................................................206
GLOBAL INJECT EASE INSULI - insulin syringe/needle
u-100 1/2 ml 29 x 1/2"...................................................207
GLOBAL INJECT EASE INSULI - insulin syringe/needle
u-100 1/2 ml 30 x 1/2"...................................................207
GLOBAL INJECT EASE INSULI - insulin syringe/needle
u-100 1/2 ml 30 x 5/16".................................................207
GLOBAL INJECT EASE INSULI - insulin syringe/needle
u-100 1/2 ml 31 x 5/16".................................................206
GLOBAL INJECT EASE INSULI - insulin syringe/needle
u-100 1 ml 28 x 1/2"......................................................207
GLOBAL INJECT EASE INSULI - insulin syringe/needle
u-100 1 ml 29 x 1/2"......................................................207
GLOBAL INJECT EASE INSULI - insulin syringe/needle
u-100 1 ml 30 x 1/2"......................................................207
GLOBAL INJECT EASE INSULI - insulin syringe/needle
u-100 1 ml 30 x 5/16"....................................................207
GLOBAL INJECT EASE INSULI - insulin syringe/needle
u-100 1 ml 31 x 5/16"....................................................207
GLOBAL INJECT EASE LANCET - lancets ................... 207
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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GLOBAL LANCING DEVICE - lancet devices ................207
GLUCAGEN - glucagon hcl (rdna) for inj 1 mg (base
equiv)............................................................................... 29
GLUCAGEN HYPOKIT - glucagon hcl (rdna) for inj 1 mg
(base equiv).....................................................................29
GLUCAGON EMERGENCY KIT - glucagon (rdna) for inj
kit 1 mg............................................................................29
GLUCOCARD 01 BLOOD GLUCOS - blood glucose
monitoring kit w/ device ................................................207
GLUCOCARD 01 CONTROL SOLU - blood glucose
calibration - liquid ......................................................... 207
GLUCOCARD 01 CONTROL SOLU - blood glucose
calibration - liquid - normal ...........................................207
GLUCOCARD 01-MINI BLOOD G - blood glucose
monitoring kit w/ device ................................................207
GLUCOCARD 01 SENSOR - glucose blood test strip.....186
GLUCOCARD 01 TEST STRIPS - glucose blood test
strip................................................................................ 186
GLUCOCARD EXPRESSION AUDI - blood glucose
monitoring kit w/ device ................................................207
GLUCOCARD EXPRESSION BLOO - glucose blood test
strip................................................................................ 186
GLUCOCARD EXPRESSION CONT - blood glucose
calibration - liquid ......................................................... 207
GLUCOCARD SHINE - blood glucose monitoring kit w/
device ........................................................................... 207
GLUCOCARD SHINE CONTROL S - blood glucose
calibration - liquid ......................................................... 207
GLUCOCARD SHINE TEST STRI - glucose blood test
strip................................................................................ 186
GLUCOCARD VITAL BLOOD GLU - blood glucose
monitoring kit w/ device ................................................207
GLUCOCARD VITAL TEST STRI - glucose blood test
strip................................................................................ 186
GLUCOCARD X-METER - blood glucose monitoring kit w/
device ........................................................................... 207
GLUCOCARD X-METER CONTROL - blood glucose
calibration - liquid - normal ...........................................207
GLUCOCARD X-SENSOR - glucose blood test strip...... 186
GLUCOCOM BLOOD GLUCOSE MO - blood glucose
monitoring kit w/ device ................................................207
GLUCOCOM HIGH CONTROL - blood glucose calibration
- liquid - high ................................................................ 207
GLUCOCOM LANCETS 28G - lancets .......................... 207
GLUCOCOM LANCETS 30G - lancets .......................... 207
GLUCOCOM LANCETS 33G - lancets .......................... 207
GLUCOCOM NORMAL CONTROL - blood glucose
calibration - liquid - normal ...........................................207
GLUCOCOM TEST STRIPS - glucose blood test
strip................................................................................ 186
GLUCOLAB HIGH CONTROL - blood glucose calibration liquid - high ...................................................................207
GLUCOLAB LOW CONTROL - blood glucose calibration liquid - low .................................................................... 207
GLUCOLAB NORMAL CONTROL - blood glucose
calibration - liquid - normal ...........................................208
GLUCOLAB TEST STRIPS - glucose blood test strip..... 186
GLUCOLET 2 AUTOMATIC LANC - lancet devices .......208
GLUCONAVII BLOOD GLUCOSE - blood glucose
monitoring kit w/ device ................................................208
GLUCONAVII BLOOD GLUCOSE - glucose blood test
strip................................................................................ 186
GLUCO PERFECT 3 TEST STRI - glucose blood test
strip................................................................................ 186
GLUCOPHAGE - metformin hcl tab 1000 mg................... 29
GLUCOPHAGE - metformin hcl tab 500 mg..................... 29
GLUCOPHAGE - metformin hcl tab 850 mg..................... 29
GLUCOPHAGE XR - metformin hcl tab sr 24hr 500
mg.................................................................................... 29
GLUCOPHAGE XR - metformin hcl tab sr 24hr 750
mg.................................................................................... 29
GLUCOPRO INSULIN SYRINGE/ - insulin syringe/needle
u-100 0.3 ml 30 x 1/2"...................................................208
GLUCOPRO INSULIN SYRINGE/ - insulin syringe/needle
u-100 0.3 ml 30 x 5/16".................................................208
GLUCOPRO INSULIN SYRINGE/ - insulin syringe/needle
u-100 0.3 ml 31 x 5/16".................................................208
GLUCOPRO INSULIN SYRINGE/ - insulin syringe/needle
u-100 1/2 ml 30 x 1/2"...................................................208
GLUCOPRO INSULIN SYRINGE/ - insulin syringe/needle
u-100 1/2 ml 30 x 5/16".................................................208
GLUCOPRO INSULIN SYRINGE/ - insulin syringe/needle
u-100 1/2 ml 31 x 5/16".................................................208
GLUCOPRO INSULIN SYRINGE/ - insulin syringe/needle
u-100 1 ml 30 x 1/2"......................................................208
GLUCOPRO INSULIN SYRINGE/ - insulin syringe/needle
u-100 1 ml 30 x 5/16"....................................................208
GLUCOPRO INSULIN SYRINGE/ - insulin syringe/needle
u-100 1 ml 31 x 5/16"....................................................208
GLUCOSE CONTROL NORMAL - blood glucose
calibration - liquid - normal ...........................................208
GLUCOSE CONTROL SOLUTION - blood glucose
calibration - liquid ......................................................... 208
GLUCOSOURCE LANCET DEVICE - lancet devices
....................................................................................... 208
GLUCOSOURCE LANCETS - lancets ........................... 208
GLUCOTROL - glipizide tab 10 mg.................................. 29
GLUCOTROL - glipizide tab 5 mg.................................... 29
GLUCOTROL XL - glipizide tab sr 24hr 10 mg................. 29
GLUCOTROL XL - glipizide tab sr 24hr 2.5 mg................ 29
GLUCOTROL XL - glipizide tab sr 24hr 5 mg................... 29
GLUCOVANCE - glyburide-metformin tab 1.25-250
mg.................................................................................... 29
GLUCOVANCE - glyburide-metformin tab 2.5-500 mg..... 29
GLUCOVANCE - glyburide-metformin tab 5-500 mg........ 29
GLUMETZA - metformin hcl tab sr 24hr modified release
1000 mg...........................................................................30
GLUMETZA - metformin hcl tab sr 24hr modified release
500 mg.............................................................................29
GLUTARALDEHYDE - glutaral soln 25%........................183
GLYBURIDE - glyburide tab 1.25 mg............................... 30
GLYBURIDE - glyburide tab 2.5 mg................................. 30
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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GLYBURIDE - glyburide tab 5 mg.................................... 30
glyburide-metformin tab 1.25-250 mg
(Glucovance).................................................................. 30
glyburide-metformin tab 2.5-500 mg (Glucovance)...... 30
glyburide-metformin tab 5-500 mg (Glucovance)......... 30
glyburide micronized tab 1.5 mg (Glynase).................. 30
glyburide micronized tab 3 mg (Glynase)..................... 30
glyburide micronized tab 6 mg (Glynase)..................... 30
glyburide tab 1.25 mg..................................................... 30
glyburide tab 2.5 mg....................................................... 30
glyburide tab 5 mg..........................................................30
GLYCATE - glycopyrrolate tab 1.5 mg..............................76
glycine irrigation soln 1.5%............................................85
glycopyrrolate inj 0.2 mg/ml (Robinul).......................... 76
glycopyrrolate inj 0.4 mg/2ml (0.2 mg/ml)
(Robinul)......................................................................... 76
glycopyrrolate inj 1 mg/5ml (0.2 mg/ml) (Robinul)....... 76
glycopyrrolate inj 4 mg/20ml (0.2 mg/ml) (Robinul)..... 76
glycopyrrolate tab 1 mg (Robinul).................................76
glycopyrrolate tab 2 mg (Robinul forte)........................76
GLYNASE - glyburide micronized tab 1.5 mg................... 30
GLYNASE - glyburide micronized tab 3 mg...................... 30
GLYNASE - glyburide micronized tab 6 mg...................... 30
GLYSET - miglitol tab 100 mg.......................................... 30
GLYSET - miglitol tab 25 mg............................................ 30
GLYSET - miglitol tab 50 mg............................................ 30
GMATE BLOOD GLUCOSE TEST - glucose blood test
strip................................................................................ 186
GMATE CONTROL SOLUTION LE - blood glucose
calibration - liquid ......................................................... 208
GMATE LANCETS 30G - lancets .................................. 208
GMATE LANCING DEVICE - lancet devices ................. 208
GMATE SMART STARTER KIT - blood glucose
monitoring kit w/ device ................................................208
GNP CLICKFINE PEN NEEDLE - insulin pen needle 31 g
x 8 mm (1/3" or 5/16")...................................................208
GNP CLICKFINE UNIVERSAL P - insulin pen needle 31 g
x 6 mm (1/4").................................................................208
GNP CLICKFINE UNIVERSAL P - insulin pen needle 31 g
x 8 mm (1/3" or 5/16")...................................................208
GNP INSULIN SYRINGE/0.3ML - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................208
GNP INSULIN SYRINGE/0.3ML - insulin syringe/needle
u-100 0.3 ml 30 x 5/16".................................................208
GNP INSULIN SYRINGE/0.3ML - insulin syringe/needle
u-100 0.3 ml 31 x 5/16".................................................208
GNP INSULIN SYRINGE/0.5ML - insulin syringe/needle
u-100 1/2 ml 28 x 1/2"...................................................208
GNP INSULIN SYRINGE/0.5ML - insulin syringe/needle
u-100 1/2 ml 29 x 1/2"...................................................208
GNP INSULIN SYRINGE/0.5ML - insulin syringe/needle
u-100 1/2 ml 30 x 5/16".................................................208
GNP INSULIN SYRINGE/0.5ML - insulin syringe/needle
u-100 1/2 ml 31 x 5/16".................................................208
GNP INSULIN SYRINGE/1ML/2 - insulin syringe/needle
u-100 1 ml 28 x 1/2"......................................................209
290
GNP INSULIN SYRINGE/1ML/2 - insulin syringe/needle
u-100 1 ml 29 x 1/2"......................................................209
GNP INSULIN SYRINGE/1ML/3 - insulin syringe/needle
u-100 1 ml 30 x 5/16"....................................................209
GNP INSULIN SYRINGE/1ML/3 - insulin syringe/needle
u-100 1 ml 31 x 5/16"....................................................209
GNP LANCETS 21G - lancets ....................................... 209
GNP LANCETS - lancets ...............................................209
GNP LANCETS MICRO THIN 33 - lancets ....................209
GNP LANCETS SUPER THIN 30 - lancets ................... 209
GNP LANCETS THIN 26G - lancets ..............................209
GNP LANCETS THIN - lancets ..................................... 209
GNP MICRO THIN LANCETS 33 - lancets ....................209
GNP SUPER THIN LANCETS/30 - lancets ................... 209
GNP ULTRA COMFORT INSULIN - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................209
GNP ULTRA COMFORT INSULIN - insulin syringe/needle
u-100 0.3 ml 30 x 5/16".................................................209
GNP ULTRA COMFORT INSULIN - insulin syringe/needle
u-100 0.3 ml 31 x 5/16".................................................209
GNP ULTRA COMFORT INSULIN - insulin syringe/needle
u-100 1/2 ml 28 x 1/2"...................................................209
GNP ULTRA COMFORT INSULIN - insulin syringe/needle
u-100 1/2 ml 29 x 1/2"...................................................209
GNP ULTRA COMFORT INSULIN - insulin syringe/needle
u-100 1/2 ml 30 x 5/16".................................................209
GNP ULTRA COMFORT INSULIN - insulin syringe/needle
u-100 1/2 ml 31 x 5/16".................................................209
GNP ULTRA COMFORT INSULIN - insulin syringe/needle
u-100 1 ml 28 x 1/2"......................................................209
GNP ULTRA COMFORT INSULIN - insulin syringe/needle
u-100 1 ml 29 x 1/2"......................................................209
GNP ULTRA COMFORT INSULIN - insulin syringe/needle
u-100 1 ml 30 x 5/16"....................................................209
GNP ULTRA COMFORT INSULIN - insulin syringe/needle
u-100 1 ml 31 x 5/16"....................................................209
GNP VITAMIN D-400 - calcium carbonate-cholecalciferol
tab 90 mg-400 unit........................................................ 146
GOLYTELY - peg 3350-kcl-na bicarb-nacl-na sulfate for
soln 236 gm.....................................................................74
GOLYTELY - peg 3350-kcl-na bicarb-nacl-na sulfate
packet 227.1 gm..............................................................74
GONAL-F - follitropin alfa for inj 1050 unit........................ 38
GONAL-F - follitropin alfa for inj 450 unit.......................... 38
GONAL-F RFF - follitropin alfa for inj 75 unit.................... 38
GONAL-F RFF PEN - follitropin alfa inj 300 unit/0.5ml......38
GONAL-F RFF PEN - follitropin alfa inj 450
unit/0.75ml....................................................................... 38
GONAL-F RFF PEN - follitropin alfa inj 900 unit/1.5ml......38
GONAL-F RFF REDIJECT - follitropin alfa inj 300
unit/0.5ml......................................................................... 38
GONAL-F RFF REDIJECT - follitropin alfa inj 450
unit/0.75ml....................................................................... 38
GONAL-F RFF REDIJECT - follitropin alfa inj 900
unit/1.5ml......................................................................... 38
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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GORDOFILM - salicylic & lactic acids soln
16.7-16.7%.....................................................................172
GORDONS UREA - urea ointment 40%......................... 172
GRALISE - gabapentin (phn) tab 300 mg....................... 104
GRALISE - gabapentin (phn) tab 600 mg....................... 104
GRALISE STARTER - gabapentin (phn) tab starter pack
300 mg (9) & 600 mg (69)............................................ 104
granisetron hcl tab 1 mg................................................ 79
GRANISOL - granisetron hcl oral soln 2 mg/10ml (base
equivalent)....................................................................... 79
GRASTEK - timothy grass pollen allergen ext tab sl 2800
bau................................................................................... 15
GRIFULVIN V - griseofulvin microsize tab 500 mg............. 8
griseofulvin microsize susp 125 mg/5ml........................ 8
griseofulvin microsize tab 500 mg (Grifulvin v)............. 8
griseofulvin ultramicrosize tab 125 mg (Gris-peg)......... 8
griseofulvin ultramicrosize tab 250 mg (Gris-peg)......... 8
GRIS-PEG - griseofulvin ultramicrosize tab 125 mg........... 8
GRIS-PEG - griseofulvin ultramicrosize tab 250 mg........... 8
guaifenesin-codeine liquid 200-8 mg/5ml..................... 66
guaifenesin-codeine liquid 225-7.5 mg/5ml.................. 66
guaifenesin-codeine soln 100-10 mg/5ml......................66
guaifenesin-codeine soln 100-6.3 mg/5ml.....................66
guanfacine hcl tab 1 mg (Tenex)................................... 52
guanfacine hcl tab 2 mg (Tenex)................................... 52
guanfacine hcl tab sr 24hr 1 mg (base equiv)
(Intuniv).........................................................................101
guanfacine hcl tab sr 24hr 2 mg (base equiv)
(Intuniv).........................................................................101
guanfacine hcl tab sr 24hr 3 mg (base equiv)
(Intuniv).........................................................................101
guanfacine hcl tab sr 24hr 4 mg (base equiv)
(Intuniv).........................................................................101
GUANIDINE HCL - guanidine hcl tab 125 mg.................133
GYNAZOLE-1 - butoconazole nitrate (one dose) vaginal
cream 2%........................................................................ 84
H
H&H THINLET LANCETS 26G - lancets.........................209
H&H THINLET SUPER THIN LA - lancets......................209
HAEMOLANCE - lancets ............................................... 210
HAEMOLANCE LOW FLOW LANCE - lancets .............. 210
HAEMOLANCE PLUS HIGH FLOW - lancets ................210
HAEMOLANCE PLUS - lancets .....................................210
HAEMOLANCE PLUS LOW FLOW - lancets .................210
HAEMOLANCE PLUS MAX FLOW - lancets ................. 210
HAEMOLANCE PLUS PEDIATRIC - lancets ................. 210
HALCION - triazolam tab 0.25 mg.................................... 98
HALFLYTELY BOWEL PREP/FLA - bisacodyl tab & peg
3350-kcl-sod bicarb-nacl for soln kit................................74
halobetasol propionate cream 0.05% (Ultravate)........172
halobetasol propionate oint 0.05% (Ultravate)........... 172
halobetasol prop oint 0.05% & ammonium lactate lot
12% kit.......................................................................... 172
HALOG - halcinonide cream 0.1%.................................. 172
HALOG - halcinonide oint 0.1%...................................... 172
HALONATE - halobetasol prop oint 0.05% & ammonium
lactate foam 12% kit......................................................172
haloperidol lactate oral conc 2 mg/ml...........................95
haloperidol tab 0.5 mg....................................................95
haloperidol tab 10 mg.....................................................95
haloperidol tab 1 mg.......................................................95
haloperidol tab 20 mg.....................................................95
haloperidol tab 2 mg.......................................................95
haloperidol tab 5 mg.......................................................95
HALOTIN - haloprogin cream 1%................................... 172
HARVONI - ledipasvir-sofosbuvir tab 90-400 mg................ 9
hc-pramoxine emol cream 2.5-1% & pramoxine wipe
1% kit (Analpram e).....................................................164
HEALTH CARE LANCING DEVIC - lancet devices ....... 210
HEALTHWISE LANCETS 30G - lancets ........................210
HEALTHWISE LANCING PEN - lancet devices .............210
HEALTHWISE MINI PEN NEEDL - insulin pen needle 31
g x 6 mm (1/4")............................................................. 210
HEALTHWISE PEN NEEDLES 29 - insulin pen needle 29
g x 12 mm (1/2")........................................................... 210
HEALTHWISE SHORT PEN NEED - insulin pen needle
31 g x 8 mm (1/3" or 5/16")...........................................210
HEALTHWISE UNIFINE PENTIP - insulin pen needle 32 g
x 4 mm (5/32")...............................................................210
HEALTHY ACCENTS AUTOLET I - lancet devices ....... 210
HEALTHY ACCENTS UNIFINE P - insulin pen needle 29
g x 12 mm (1/2")........................................................... 210
HEALTHY ACCENTS UNIFINE P - insulin pen needle 31
g x 5 mm (3/16")........................................................... 210
HEALTHY ACCENTS UNIFINE P - insulin pen needle 31
g x 6 mm (1/4")............................................................. 210
HEALTHY ACCENTS UNIFINE P - insulin pen needle 31
g x 8 mm (1/3" or 5/16")................................................210
HEALTHY ACCENTS UNIFINE P - insulin pen needle 32
g x 4 mm (5/32")........................................................... 210
HEALTHY ACCENTS UNILET LA - lancets ...................210
H-E-B INCONTROL ADVANCED - lancet devices .........209
H-E-B INCONTROL LANCETS S - lancets ....................209
H-E-B INCONTROL LANCETS U - lancets ................... 209
H-E-B IN CONTROL PEN NEED - insulin pen needle 31 g
x 5 mm (3/16")...............................................................209
H-E-B IN CONTROL PEN NEED - insulin pen needle 31 g
x 6 mm (1/4").................................................................209
H-E-B IN CONTROL PEN NEED - insulin pen needle 31 g
x 8 mm (1/3" or 5/16")...................................................209
H-E-B IN CONTROL PEN NEED - insulin pen needle 32 g
x 4 mm (5/32")...............................................................209
H-E-B INCONTROL PEN NEEDL - insulin pen needle 29
g x 12 mm (1/2")........................................................... 210
HECTOROL - doxercalciferol cap 0.5 mcg....................... 38
HECTOROL - doxercalciferol cap 1 mcg.......................... 38
HECTOROL - doxercalciferol cap 2.5 mcg....................... 38
HELIDAC - metronidaz tab-tetracyc cap-bis subsal chew
tab therapy pack..............................................................76
HEMANGEOL - propranolol hcl oral soln 4.28 mg/ml....... 42
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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2015
HEMATOGEN FA - fe fumarate-vit c-vit b12-fa cap
200-250-0.01-1 mg........................................................ 152
HEMATRON-AF - iron-docusate-b12-folic acid-c-e-cubiotin tab 150-1 mg ...................................................... 152
HEMENATAL OB + DHA - prenat-fe poly cmplx-fe heme
poly-fa tab & omega 3 cap pck..................................... 137
HEMENATAL OB - prenat vit-fe poly cmplx-fe heme polyfa tab 28-6-1 mg .......................................................... 137
HEMETAB - polysacch fe cmplx-fe heme poly-fa-b12 tab
22-6-1-0.025 mg............................................................ 152
HEMOCYTE-F - iron combination elixir ......................... 152
HEMOCYTE PLUS - ferrous fumarate-fa-b complex-c-znmg-mn-cu cap 106-1 mg .............................................. 152
HEPSERA - adefovir dipivoxil tab 10 mg............................ 9
HETLIOZ - tasimelteon capsule 20 mg............................. 98
HEXALEN - altretamine cap 50 mg.................................. 16
HIPREX - methenamine hippurate tab 1 gm.....................82
HM LANCETS MICRO THIN 33G - lancets ................... 210
HM LANCETS ULTRA THIN 30G - lancets ................... 210
homatropine hbr ophth soln 5% (Isopto
homatropine)................................................................ 158
HORIZANT - gabapentin enacarbil tab cr 300 mg...........104
HORIZANT - gabapentin enacarbil tab cr 600 mg...........104
HUMALOG - insulin lispro (human) inj 100 unit/ml............32
HUMALOG - insulin lispro (human) soln cartridge 100 unit/
ml..................................................................................... 32
HUMALOG KWIKPEN - insulin lispro (human) soln peninjector 100 unit/ml.......................................................... 32
HUMALOG MIX 50/50 - insulin lispro prot & lispro (human)
inj 100 unit/ml (50-50)..................................................... 33
HUMALOG MIX 50/50 KWIKPEN - insulin lispro prot &
lispro sus pen-inj 100 unit/ml (50-50).............................. 33
HUMALOG MIX 75/25 - insulin lispro prot & lispro (human)
inj 100 unit/ml (75-25)..................................................... 33
HUMALOG MIX 75/25 KWIKPEN - insulin lispro prot &
lispro sus pen-inj 100 unit/ml (75-25).............................. 33
HUMAPEN LUXURA HD - injection device for insulin.....210
HUMATROPE COMBO PACK - somatropin for inj 5
mg.................................................................................... 38
HUMATROPE - somatropin for inj 12 mg (36 unit)........... 38
HUMATROPE - somatropin for inj 24 mg......................... 38
HUMATROPE - somatropin for inj 5 mg........................... 38
HUMATROPE - somatropin for inj 6 mg (18 unit)............. 38
HUMIRA - adalimumab inj kit 20 mg/0.4ml..................... 118
HUMIRA - adalimumab inj kit 40 mg/0.8ml (50 mg/
ml).................................................................................. 119
HUMIRA - adalimumab prefilled syringe kit 10
mg/0.2ml........................................................................ 118
HUMIRA PEDIATRIC CROHNS D - adalimumab inj kit 40
mg/0.8ml (50 mg/ml)..................................................... 119
HUMIRA PEN - adalimumab inj kit 40 mg/0.8ml (50 mg/
ml).................................................................................. 119
HUMIRA PEN-CROHNS DISEASE - adalimumab inj kit 40
mg/0.8ml (50 mg/ml)..................................................... 119
HUMIRA PEN-PSORIASIS STAR - adalimumab inj kit 40
mg/0.8ml (50 mg/ml)..................................................... 119
292
HUMULIN 70/30 - insulin isophane & regular (human) inj
100 unit/ml (70-30).......................................................... 33
HUMULIN 70/30 KWIKPEN - insulin isophane & regular
susp pen-inj 100 unit/ml (70-30)......................................33
HUMULIN 70/30 PEN - insulin isophane & regular susp
pen-inj 100 unit/ml (70-30).............................................. 33
HUMULIN N - insulin isophane (human) inj 100 unit/
ml..................................................................................... 33
HUMULIN N KWIKPEN - insulin isophane (human) susp
pen-injector 100 unit/ml................................................... 33
HUMULIN N U-100 PEN - insulin isophane (human) susp
pen-injector 100 unit/ml................................................... 33
HUMULIN R - insulin regular (human) inj 100 unit/ml....... 32
HUMULIN R U-500 (CONCENTR - insulin regular (human)
inj 500 unit/ml.................................................................. 32
hyaluronate sodium (emollient) gel 0.2% (Hylira).......173
HYCAMTIN - topotecan hcl cap 0.25 mg (base equiv)......16
HYCAMTIN - topotecan hcl cap 1 mg (base equiv)...........16
HYCET - hydrocodone-acetaminophen soln 7.5-325
mg/15ml......................................................................... 110
hydralazine hcl tab 100 mg............................................ 52
hydralazine hcl tab 10 mg.............................................. 52
hydralazine hcl tab 25 mg.............................................. 52
hydralazine hcl tab 50 mg.............................................. 52
HYDREA - hydroxyurea cap 500 mg................................ 16
HYDRO 35 - urea in lactic acid vehicle foam 35%.......... 173
HYDRO 40 FOAM - urea foam 40%............................... 173
hydrochlorothiazide cap 12.5 mg (Microzide)...............58
hydrochlorothiazide tab 12.5 mg................................... 58
hydrochlorothiazide tab 25 mg...................................... 58
hydrochlorothiazide tab 50 mg...................................... 58
HYDROCODONE/ACETAMINOPHEN - hydrocodoneacetaminophen soln 10-325 mg/15ml........................... 111
HYDROCODONE/ACETAMINOPHEN - hydrocodoneacetaminophen tab 7.5-500 mg.....................................111
HYDROCODONE/ACETAMINOPHEN - hydrocodoneacetaminophen tab 7.5-650 mg.....................................111
HYDROCODONE/ACETAMINOPHEN - hydrocodoneacetaminophen tab 7.5-750 mg.....................................111
hydrocodone-acetaminophen cap 5-500 mg.............. 110
hydrocodone-acetaminophen soln 10-325
mg/15ml........................................................................ 110
hydrocodone-acetaminophen soln 7.5-325 mg/15ml
(Hycet)...........................................................................110
hydrocodone-acetaminophen soln 7.5-500
mg/15ml........................................................................ 110
hydrocodone-acetaminophen tab 10-300 mg
(Xodol)...........................................................................110
hydrocodone-acetaminophen tab 10-325 mg
(Norco).......................................................................... 110
hydrocodone-acetaminophen tab 10-500 mg............. 110
hydrocodone-acetaminophen tab 10-650 mg............. 111
hydrocodone-acetaminophen tab 10-660 mg............. 111
hydrocodone-acetaminophen tab 10-750 mg............. 111
hydrocodone-acetaminophen tab 2.5-325 mg............ 111
hydrocodone-acetaminophen tab 2.5-500 mg............ 111
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
2015
hydrocodone-acetaminophen tab 5-300 mg
(Xodol)...........................................................................111
hydrocodone-acetaminophen tab 5-325 mg
(Norco).......................................................................... 111
hydrocodone-acetaminophen tab 5-500 mg............... 111
hydrocodone-acetaminophen tab 7.5-300 mg
(Xodol)...........................................................................111
hydrocodone-acetaminophen tab 7.5-325 mg
(Norco).......................................................................... 111
hydrocodone-acetaminophen tab 7.5-500 mg............ 111
hydrocodone-acetaminophen tab 7.5-650 mg............ 111
hydrocodone-acetaminophen tab 7.5-750 mg............ 111
HYDROCODONE BITARTRATE/AC - hydrocodoneacetaminophen tab 10-750 mg......................................110
HYDROCODONE BITARTRATE/AC - hydrocodoneacetaminophen tab 2.5-325 mg.....................................110
hydrocodone-ibuprofen tab 10-200 mg (Ibudone)......111
hydrocodone-ibuprofen tab 2.5-200 mg
(Reprexain)................................................................... 111
hydrocodone-ibuprofen tab 5-200 mg
(Reprexain)................................................................... 111
hydrocodone-ibuprofen tab 7.5-200 mg
(Vicoprofen)..................................................................111
hydrocodone w/ homatropine syrup 5-1.5 mg/5ml.......66
hydrocodone w/ homatropine tab 5-1.5 mg.................. 66
hydrocod polst-chlorphen polst cr susp 10-8 mg/5ml
(Tussionex pennkineti)..................................................66
hydrocortisone acetate-aloe vera gel 2% (Nuzon)......173
hydrocortisone acetate suppos 25 mg (Anusolhc)..................................................................................164
hydrocortisone acetate suppos 30 mg
(Proctocort).................................................................. 164
hydrocortisone acetate w/ pramoxine rectal cream
1-1% (Analpram-hc)..................................................... 164
hydrocortisone acetate w/ pramoxine rectal cream
2.5-1% (Analpram-hc).................................................. 164
hydrocortisone butyrate cream 0.1% (Locoid)........... 173
hydrocortisone butyrate hydrophilic lipo base cream
0.1% (Locoid lipocream)............................................. 173
hydrocortisone butyrate oint 0.1% (Locoid)............... 173
hydrocortisone butyrate soln 0.1% (Locoid).............. 173
hydrocortisone cream 1%............................................ 173
hydrocortisone cream 2.5%......................................... 173
hydrocortisone enema 100 mg/60ml (Cortenema)..... 165
hydrocortisone lotion 2.5%.......................................... 173
hydrocortisone lotion 2% (Ala scalp).......................... 173
hydrocortisone oint 1%................................................ 173
hydrocortisone oint 2.5%............................................. 173
hydrocortisone rectal cream 1% (Proctocort)............ 165
hydrocortisone rectal cream 2.5% (Anusol-hc).......... 165
hydrocortisone tab 10 mg (Cortef)................................ 20
hydrocortisone tab 20 mg (Cortef)................................ 20
hydrocortisone tab 5 mg (Cortef).................................. 20
hydrocortisone valerate cream 0.2%...........................173
hydrocortisone valerate oint 0.2% (Westcort)............ 173
hydrocortisone w/ acetic acid otic soln 1-2% (Vosol
hc)..................................................................................162
HYDROMORPHONE HCL ER - hydromorphone hcl tab er
24hr deter 32 mg...........................................................111
HYDROMORPHONE HCL - hydromorphone hcl suppos 3
mg.................................................................................. 111
hydromorphone hcl liqd 1 mg/ml (Dilaudid)............... 111
hydromorphone hcl tab 2 mg (Dilaudid)..................... 111
hydromorphone hcl tab 4 mg (Dilaudid)..................... 111
hydromorphone hcl tab 8 mg (Dilaudid)..................... 111
hydromorphone hcl tab er 24hr deter 12 mg
(Exalgo).........................................................................111
hydromorphone hcl tab er 24hr deter 16 mg
(Exalgo).........................................................................111
hydromorphone hcl tab er 24hr deter 8 mg
(Exalgo).........................................................................111
HYDROXOCOBALAMIN - hydroxocobalamin inj 1000
mcg/ml........................................................................... 152
hydroxychloroquine sulfate tab 200 mg
(Plaquenil).......................................................................13
hydroxyurea cap 500 mg (Hydrea)................................ 16
HYDROXYZINE HCL - hydroxyzine hcl im soln 25 mg/
ml..................................................................................... 87
hydroxyzine hcl syrup 10 mg/5ml..................................87
hydroxyzine hcl tab 10 mg.............................................87
hydroxyzine hcl tab 25 mg.............................................87
hydroxyzine hcl tab 50 mg............................................. 87
hydroxyzine pamoate cap 25 mg (Vistaril)....................87
hydroxyzine pamoate cap 50 mg (Vistaril)....................87
HYDROXYZINE PAMOATE - hydroxyzine pamoate cap
100 mg.............................................................................87
HYLASE WOUND - hyaluronate sodium gel ..................173
HYLIRA - hyaluronate sodium (emollient) gel 0.2%........ 173
HYLIRA - hyaluronate sodium (emollient) lotion 0.1%.....173
hyoscyamine sulfate elixir 0.125 mg/5ml...................... 76
hyoscyamine sulfate soln 0.125 mg/ml......................... 76
hyoscyamine sulfate tab 0.125 mg (Levsin)................. 76
hyoscyamine sulfate tab disp 0.125 mg (Anaspaz)...... 76
hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl)..........76
hyoscyamine sulfate tab sr 12hr 0.375 mg (Levbid).....76
HYPERSAL - sodium chloride soln nebu 3.5%................. 66
HYPERSAL - sodium chloride soln nebu 7%.................... 66
HYPER-SAL - sodium chloride soln nebu 7%...................66
HYPERTENEVIDE-12.5 - carvedilol tab 12.5 mg & dietary
management cap pack.................................................... 43
HYPERTENIPINE-2.5 - amlodipine tab 2.5 mg & dietary
management cap pack.................................................... 46
HYPERTENSOLOL - metoprolol tab 50 mg & dietary
management cap pack.................................................... 52
HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter
100 mg...........................................................................112
HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter
120 mg...........................................................................112
HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter
20 mg.............................................................................111
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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2015
HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter
30 mg.............................................................................111
HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter
40 mg.............................................................................111
HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter
60 mg.............................................................................111
HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter
80 mg.............................................................................111
HY-VEE LANCETS - lancets ......................................... 210
HY-VEE THIN LANCETS - lancets ................................ 210
HYZAAR - losartan potassium & hydrochlorothiazide tab
100-12.5 mg.................................................................... 52
HYZAAR - losartan potassium & hydrochlorothiazide tab
100-25 mg....................................................................... 52
HYZAAR - losartan potassium & hydrochlorothiazide tab
50-12.5 mg...................................................................... 52
I
ibandronate sodium tab 150 mg (base equivalent)
(Boniva)...........................................................................38
IBG STAR BLOOD GLUCOSE MO - blood glucose
monitoring kit w/ device ................................................210
IBUDONE - hydrocodone-ibuprofen tab 10-200 mg........ 112
IBUPROFEN COMFORT PAC - ibuprofen tab 800 mg &
liniment topical gel kit.................................................... 119
ibuprofen susp 100 mg/5ml..........................................119
ibuprofen tab 400 mg....................................................119
ibuprofen tab 600 mg....................................................119
ibuprofen tab 800 mg....................................................119
IC 400 - ibuprofen tab 400 mg & caffeine-vitamins cap
kit................................................................................... 119
IC 800 - ibuprofen tab 800 mg & caffeine-vitamins cap
kit................................................................................... 119
ICAR - carbonyl iron chew tab 15 mg (elemental
iron)................................................................................152
ICAR-C PLUS - iron-vit c-vit b12-folic acid tab
100-250-0.025-1 mg...................................................... 152
ICAR PEDIATRIC - carbonyl iron susp 15 mg/1.25ml
(elemental iron)..............................................................152
ICLUSIG - ponatinib hcl tab 15 mg (base equiv)...............16
ICLUSIG - ponatinib hcl tab 45 mg (base equiv)...............16
ILEVRO - nepafenac ophth susp 0.3%........................... 158
IMBRUVICA - ibrutinib cap 140 mg.................................. 16
IMDUR - isosorbide mononitrate tab sr 24hr 120 mg........ 41
IMDUR - isosorbide mononitrate tab sr 24hr 30 mg.......... 41
IMDUR - isosorbide mononitrate tab sr 24hr 60 mg.......... 41
imipramine hcl tab 10 mg (Tofranil).............................. 90
imipramine hcl tab 25 mg (Tofranil).............................. 90
imipramine hcl tab 50 mg (Tofranil).............................. 90
imipramine pamoate cap 100 mg (Tofranil-pm)............90
imipramine pamoate cap 125 mg (Tofranil-pm)............90
imipramine pamoate cap 150 mg (Tofranil-pm)............90
imipramine pamoate cap 75 mg (Tofranil-pm)..............90
imiquimod cream 5% (Aldara)......................................173
IMITREX STATDOSE REFILL - sumatriptan succinate
solution cartridge 4 mg/0.5ml........................................ 122
294
IMITREX STATDOSE REFILL - sumatriptan succinate
solution cartridge 6 mg/0.5ml........................................ 122
IMITREX STATDOSE SYSTEM - sumatriptan succinate
solution auto-injector 4 mg/0.5ml...................................122
IMITREX STATDOSE SYSTEM - sumatriptan succinate
solution auto-injector 6 mg/0.5ml...................................122
IMITREX - sumatriptan nasal spray 20 mg/act................122
IMITREX - sumatriptan nasal spray 5 mg/act..................122
IMITREX - sumatriptan succinate inj 6 mg/0.5ml............ 122
IMITREX - sumatriptan succinate tab 100 mg.................122
IMITREX - sumatriptan succinate tab 25 mg...................122
IMITREX - sumatriptan succinate tab 50 mg...................122
IMPLANON - etonogestrel subdermal implant 68 mg....... 25
IMURAN - azathioprine tab 50 mg.................................. 242
INATAL ADVANCE - prenatal vit w/ dss-iron carbonyl-fa
tab 90-1 mg ..................................................................137
INATAL GT - prenatal vit w/ dss-iron carbonyl-fa tab 90-1
mg .................................................................................137
INATAL ULTRA - prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg ........................................................................ 137
INCIVEK - telaprevir tab 375 mg........................................ 9
INCRELEX - mecasermin inj 40 mg/4ml (10 mg/ml)......... 38
indapamide tab 1.25 mg................................................. 58
indapamide tab 2.5 mg................................................... 58
INDERAL LA - propranolol hcl cap sr 24hr 120 mg...........43
INDERAL LA - propranolol hcl cap sr 24hr 160 mg...........43
INDERAL LA - propranolol hcl cap sr 24hr 60 mg.............43
INDERAL LA - propranolol hcl cap sr 24hr 80 mg.............43
INDERAL XL - propranolol hcl sustained-release beads
cap sr 24hr 120 mg.........................................................43
INDERAL XL - propranolol hcl sustained-release beads
cap sr 24hr 80 mg...........................................................43
INDOCIN - indomethacin suppos 50 mg.........................119
INDOCIN - indomethacin susp 25 mg/5ml...................... 119
indomethacin cap 25 mg.............................................. 119
indomethacin cap 50 mg.............................................. 119
indomethacin cap cr 75 mg..........................................119
INFANATE BALANCE - prenatal w/o a w/fe cbn-dss-fadha cap 29-1-265 mg ...................................................137
INFANATE PLUS - prenat w/o a w/fe fum-fe cbn-dss-fadha cap 27-1-260 mg ...................................................137
INFANRIX - diph, acellular pert & tet tox inj 25 lf-58
mcg-10 lf/0.5ml................................................................ 15
INFERGEN - interferon alfacon-1 inj 15 mcg/0.5ml.............9
INFERGEN - interferon alfacon-1 inj 9 mcg/0.3ml.............. 9
INFINITY BLOOD GLUCOSE MO - blood glucose
monitoring kit w/ device ................................................210
INFINITY BLOOD GLUCOSE TE - glucose blood test
strip................................................................................ 186
INFINITY CONTROL SOLUTION - blood glucose
calibration - liquid - high ...............................................210
INFINITY CONTROL SOLUTION - blood glucose
calibration - liquid - low ................................................ 210
INFINITY CONTROL SOLUTION - blood glucose
calibration - liquid - normal ...........................................210
INLYTA - axitinib tab 1 mg................................................16
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
2015
INLYTA - axitinib tab 5 mg................................................16
INNOPRAN XL - propranolol hcl sustained-release beads
cap sr 24hr 120 mg.........................................................43
INNOPRAN XL - propranolol hcl sustained-release beads
cap sr 24hr 80 mg...........................................................43
INOVA 4/1 ACNE CONTROL TH - benzoyl perox pad 4%
& salicylic ac pad 1% & vit e 5% kit.............................. 173
INOVA 8/2 ACNE CONTROL TH - benzoyl perox pad 8%
& salicylic ac pad 2% & vit e 5% kit.............................. 173
INOVA - benzoyl peroxide pad 4% & vitamin e topical 5%
kit................................................................................... 173
INOVA - benzoyl peroxide pad 8% & vitamin e topical 5%
kit................................................................................... 173
INSPIREASE DRUG DELIVERY - spacer/aerosol-holding
chambers - device ........................................................210
INSPRA - eplerenone tab 25 mg...................................... 52
INSPRA - eplerenone tab 50 mg...................................... 53
INSULIN SYRINGE/0.3ML/29G - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................211
INSULIN SYRINGE/0.3ML/29G - insulin syringe/needle
u-100 0.3 ml 29 x 1"......................................................211
INSULIN SYRINGE/0.3ML/30G - insulin syringe/needle
u-100 0.3 ml 30 x 5/16".................................................211
INSULIN SYRINGE/0.3ML/31G - insulin syringe/needle
u-100 0.3 ml 31 x 5/16".................................................211
INSULIN SYRINGE/0.5ML/27G - insulin syringe/needle
u-100 1/2 ml 27 x 1/2"...................................................211
INSULIN SYRINGE/0.5ML/28G - insulin syringe/needle
u-100 1/2 ml 28 x 1/2"...................................................211
INSULIN SYRINGE/0.5ML/29G - insulin syringe/needle
u-100 1/2 ml 29 x 1/2"...................................................211
INSULIN SYRINGE/0.5ML/30G - insulin syringe/needle
u-100 1/2 ml 30 x 1/2"...................................................211
INSULIN SYRINGE/0.5ML/30G - insulin syringe/needle
u-100 1/2 ml 30 x 5/16".................................................211
INSULIN SYRINGE/0.5ML/31G - insulin syringe/needle
u-100 1/2 ml 31 x 5/16".................................................211
INSULIN SYRINGE/1ML/28G X - insulin syringe/needle
u-100 1 ml 28 x 1/2"......................................................211
INSULIN SYRINGE/1ML/29G X - insulin syringe/needle
u-100 1 ml 29 x 1/2"......................................................211
INSULIN SYRINGE/1ML/30G X - insulin syringe/needle
u-100 1 ml 30 x 5/16"....................................................211
INSULIN SYRINGE/1ML/31G X - insulin syringe/needle
u-100 1 ml 31 x 5/16"....................................................211
INSULIN SYRINGE/U-100/0.3 - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................210
INSULIN SYRINGE/U-100/0.5 - insulin syringe/needle
u-100 1/2 ml 28 x 1/2"...................................................211
INSULIN SYRINGE/U-100/0.5 - insulin syringe/needle
u-100 1/2 ml 29 x 1/2"...................................................211
INSULIN SYRINGE/U-100/1ML - insulin syringe/needle
u-100 1 ml 28 x 1/2"......................................................211
INSULIN SYRINGE/U-100/1ML - insulin syringe/needle
u-100 1 ml 29 x 1/2"......................................................211
INSULIN SYRINGE/U-100/1ML - insulin syringe/needle
u-100 1 ml 30 x 5/16"....................................................211
INSULIN SYRINGE/U-100/1ML - insulin syringe/needle
u-100 1 ml 31 x 5/16"....................................................211
INSUPEN 33GX4MM - insulin pen needle 33 g x 4 mm
(5/32")............................................................................ 211
INSUPEN PEN NEEDLES 32G X - insulin pen needle 32
g x 4 mm (5/32")........................................................... 211
INSUPEN SENSITIVE 32GX6MM - insulin pen needle 32
g x 6 mm (1/4")............................................................. 211
INSUPEN SENSITIVE 32GX8MM - insulin pen needle 32
g x 8 mm....................................................................... 211
INSUPEN ULTRAFIN 29GX12MM - insulin pen needle 29
g x 12 mm (1/2")........................................................... 211
INSUPEN ULTRAFIN 30GX8MM - insulin pen needle 30 g
x 8 mm (1/3" or 5/16")...................................................211
INSUPEN ULTRAFIN 31GX6MM - insulin pen needle 31 g
x 6 mm (1/4").................................................................211
INSUPEN ULTRAFIN 31GX8MM - insulin pen needle 31 g
x 8 mm (1/3" or 5/16")...................................................211
INTEGRA F - fe fum-fe poly-fa-c-b3 cap
62.5-62.5-1-40-3mg(125 mg fe) ................................... 152
INTEGRA PLUS - fe fum-iron polysacch complex-fa-b
complex-c-biotin cap .................................................... 152
INTELENCE - etravirine tab 100 mg...................................9
INTELENCE - etravirine tab 200 mg...................................9
INTELENCE - etravirine tab 25 mg.....................................9
INTERMEZZO - zolpidem tartrate sl tab 1.75 mg............. 98
INTERMEZZO - zolpidem tartrate sl tab 3.5 mg............... 98
INTROL - glycerin soln 75%............................................. 58
INTRON A - interferon alfa-2b for inj 10000000 unit......... 16
INTRON A - interferon alfa-2b for inj 18000000 unit......... 16
INTRON A - interferon alfa-2b for inj 50000000 unit......... 16
INTRON-A - interferon alfa-2b inj 10000000 unit/ml..........16
INTRON-A - interferon alfa-2b inj 6000000 unit/ml............16
INTRON-A W/DILUENT - interferon alfa-2b for inj
10000000 unit..................................................................16
INTRON-A W/DILUENT - interferon alfa-2b for inj
18000000 unit.................................................................. 16
INTRON-A W/DILUENT - interferon alfa-2b for inj
50000000 unit..................................................................16
INTUNIV - guanfacine hcl tab sr 24hr 1 mg (base
equiv)............................................................................. 101
INTUNIV - guanfacine hcl tab sr 24hr 2 mg (base
equiv)............................................................................. 101
INTUNIV - guanfacine hcl tab sr 24hr 3 mg (base
equiv)............................................................................. 101
INTUNIV - guanfacine hcl tab sr 24hr 4 mg (base
equiv)............................................................................. 101
INVEGA - paliperidone tab sr 24hr 1.5 mg....................... 95
INVEGA - paliperidone tab sr 24hr 3 mg.......................... 95
INVEGA - paliperidone tab sr 24hr 6 mg.......................... 95
INVEGA - paliperidone tab sr 24hr 9 mg.......................... 95
INVIRASE - saquinavir mesylate cap 200 mg.....................9
INVIRASE - saquinavir mesylate tab 500 mg..................... 9
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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INVOKAMET - canagliflozin-metformin hcl tab 150-1000
mg.................................................................................... 30
INVOKAMET - canagliflozin-metformin hcl tab 150-500
mg.................................................................................... 30
INVOKAMET - canagliflozin-metformin hcl tab 50-1000
mg.................................................................................... 30
INVOKAMET - canagliflozin-metformin hcl tab 50-500
mg.................................................................................... 30
INVOKANA - canagliflozin tab 100 mg............................. 30
INVOKANA - canagliflozin tab 300 mg............................. 30
IODINE STRONG - iodine solution strong 5%
(lugol's)...........................................................................146
IODINE TINCTURE - iodine tincture .............................. 183
iodoquinol-hc cream 1%...............................................173
IOPIDINE - apraclonidine hcl ophth soln 0.5% (base
equivalent)..................................................................... 158
IOPIDINE - apraclonidine hcl ophth soln 1% (base
equivalent)..................................................................... 158
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml...... 72
ipratropium bromide inhal soln 0.02%.......................... 72
ipratropium bromide nasal soln 0.03% (21 mcg/spray)
(Atrovent)........................................................................64
ipratropium bromide nasal soln 0.06% (42 mcg/spray)
(Atrovent)........................................................................64
irbesartan-hydrochlorothiazide tab 150-12.5 mg
(Avalide)..........................................................................53
irbesartan-hydrochlorothiazide tab 300-12.5 mg
(Avalide)..........................................................................53
irbesartan tab 150 mg (Avapro)..................................... 53
irbesartan tab 300 mg (Avapro)..................................... 53
irbesartan tab 75 mg (Avapro)....................................... 53
IRON ASP GLY/ POLYSACCH C - fe asp gly-fe
polysacch-succ ac-c-threon ac-b12-fa cap ................... 152
IRON CHEWS PEDIATRIC - carbonyl iron chew tab 15
mg (elemental iron)....................................................... 152
iron combination cap ...................................................150
iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1
mg (Hematron-af).........................................................150
iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg
(Corvite 150)................................................................. 153
IRON - iron combination tab .......................................... 152
iron polysacch complex-vit b12-fa cap 150-0.025-1
mg..................................................................................152
iron-vit c-vit b12-folic acid tab 100-250-0.025-1 mg
(Icar-c plus).................................................................. 153
IROSPAN 24/6 - fe asp gly-fe polys-succ acd-b cmplx-cca-fa tab ther pk ...........................................................153
IS 24/6 - fe asp gly-fe polys-succ acd-b cmplx-c-ca-fa tab
ther pk .......................................................................... 153
ISENTRESS - raltegravir potassium chew tab 100 mg
(base equiv).......................................................................9
ISENTRESS - raltegravir potassium chew tab 25 mg (base
equiv)................................................................................. 9
ISENTRESS - raltegravir potassium packet for susp 100
mg (base equiv)...............................................................10
296
ISENTRESS - raltegravir potassium tab 400 mg (base
equiv)................................................................................. 9
ISOMETHEPTENE/CAFFEINE/AC - acetaminophenisometheptene-caffeine tab 500-130-20 mg.................. 122
isoniazid & rifampin cap 150-300 mg.............................. 7
ISONIAZID - isoniazid syrup 50 mg/5ml............................. 7
isoniazid tab 100 mg.........................................................7
isoniazid tab 300 mg.........................................................7
ISOPTIN SR - verapamil hcl tab cr 120 mg...................... 46
ISOPTIN SR - verapamil hcl tab cr 180 mg...................... 46
ISOPTIN SR - verapamil hcl tab cr 240 mg...................... 46
ISOPTO ATROPINE - atropine sulfate ophth soln
1%..................................................................................158
ISOPTO CARBACHOL - carbachol ophth soln 1.5%...... 158
ISOPTO CARBACHOL - carbachol ophth soln 3%......... 158
ISOPTO CARPINE - pilocarpine hcl ophth soln 1%........ 158
ISOPTO CARPINE - pilocarpine hcl ophth soln 2%........ 158
ISOPTO CARPINE - pilocarpine hcl ophth soln 4%........ 158
ISOPTO HOMATROPINE - homatropine hbr ophth soln
2%..................................................................................158
ISOPTO HOMATROPINE - homatropine hbr ophth soln
5%..................................................................................158
ISOPTO HYOSCINE - scopolamine hbr ophth soln
0.25%.............................................................................158
ISORDIL TITRADOSE - isosorbide dinitrate tab 40
mg.................................................................................... 41
ISORDIL TITRADOSE - isosorbide dinitrate tab 5 mg...... 41
ISOSORBIDE DINITRATE - isosorbide dinitrate sl tab 2.5
mg.................................................................................... 41
ISOSORBIDE DINITRATE - isosorbide dinitrate tab 30
mg.................................................................................... 41
isosorbide dinitrate tab 10 mg.......................................41
isosorbide dinitrate tab 20 mg.......................................41
isosorbide dinitrate tab 30 mg.......................................41
isosorbide dinitrate tab 5 mg (Isordil titradose)........... 41
isosorbide dinitrate tab cr 40 mg.................................. 41
isosorbide mononitrate tab 10 mg................................ 41
isosorbide mononitrate tab 20 mg................................ 41
isosorbide mononitrate tab sr 24hr 120 mg (Imdur).....41
isosorbide mononitrate tab sr 24hr 30 mg (Imdur).......41
isosorbide mononitrate tab sr 24hr 60 mg (Imdur).......41
isotretinoin cap 10 mg..................................................173
isotretinoin cap 20 mg..................................................173
isotretinoin cap 40 mg..................................................173
ISOXSUPRINE HCL - isoxsuprine hcl tab 20 mg..............63
isoxsuprine hcl tab 10 mg..............................................63
ISRADIPINE - isradipine cap 2.5 mg................................ 46
ISRADIPINE - isradipine cap 5 mg................................... 46
ISTALOL - timolol maleate ophth soln 0.5% (oncedaily).............................................................................. 158
itraconazole cap 100 mg (Sporanox)...............................8
ivermectin tab 3 mg (Stromectol).................................. 13
J
JAKAFI - ruxolitinib phosphate tab 10 mg (base
equivalent)....................................................................... 17
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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JAKAFI - ruxolitinib phosphate tab 15 mg (base
equivalent)....................................................................... 17
JAKAFI - ruxolitinib phosphate tab 20 mg (base
equivalent)....................................................................... 17
JAKAFI - ruxolitinib phosphate tab 25 mg (base
equivalent)....................................................................... 17
JAKAFI - ruxolitinib phosphate tab 5 mg (base
equivalent)....................................................................... 16
JALYN - dutasteride-tamsulosin hcl cap 0.5-0.4 mg......... 85
JANUMET - sitagliptin-metformin hcl tab 50-1000 mg.......30
JANUMET - sitagliptin-metformin hcl tab 50-500 mg........ 30
JANUMET XR - sitagliptin-metformin hcl tab sr 24hr
100-1000 mg................................................................... 30
JANUMET XR - sitagliptin-metformin hcl tab sr 24hr
50-1000 mg..................................................................... 30
JANUMET XR - sitagliptin-metformin hcl tab sr 24hr
50-500 mg....................................................................... 30
JANUVIA - sitagliptin phosphate tab 100 mg (base
equiv)............................................................................... 30
JANUVIA - sitagliptin phosphate tab 25 mg (base
equiv)............................................................................... 30
JANUVIA - sitagliptin phosphate tab 50 mg (base
equiv)............................................................................... 30
JARDIANCE - empagliflozin tab 10 mg.............................30
JARDIANCE - empagliflozin tab 25 mg.............................30
J-COF DHC - pseudoephed-bromphen-dihydrocodeine
liqd 15-3-7.5 mg/5ml........................................................66
JENTADUETO - linagliptin-metformin hcl tab 2.5-1000
mg.................................................................................... 30
JENTADUETO - linagliptin-metformin hcl tab 2.5-500
mg.................................................................................... 30
JENTADUETO - linagliptin-metformin hcl tab 2.5-850
mg.................................................................................... 30
JINTELI - norethindrone acetate-ethinyl estradiol tab 1
mg-5 mcg.........................................................................24
J-MAX DHC - dihydrocodeine-guaifenesin liquid 7.5-100
mg/5ml............................................................................. 66
JUBLIA - efinaconazole soln 10%...................................173
JUVISYNC - sitagliptin-simvastatin tab 100-10 mg........... 30
JUVISYNC - sitagliptin-simvastatin tab 100-20 mg........... 31
JUVISYNC - sitagliptin-simvastatin tab 100-40 mg........... 31
JUVISYNC - sitagliptin-simvastatin tab 50-10 mg............. 30
JUVISYNC - sitagliptin-simvastatin tab 50-20 mg............. 30
JUVISYNC - sitagliptin-simvastatin tab 50-40 mg............. 30
JUXTAPID - lomitapide mesylate cap 10 mg (base
equiv)............................................................................... 60
JUXTAPID - lomitapide mesylate cap 20 mg (base
equiv)............................................................................... 60
JUXTAPID - lomitapide mesylate cap 5 mg (base
equiv)............................................................................... 60
K
K.B.G.L. IN TERODERM CREA - ketoprofen-baclofengabapent-lido crm 15-4-10-2% (cmp kit) ...................... 173
KADIAN - morphine sulfate cap sr 24hr 100 mg............. 112
KADIAN - morphine sulfate cap sr 24hr 10 mg............... 112
KADIAN - morphine sulfate cap sr 24hr 130 mg............. 112
KADIAN - morphine sulfate cap sr 24hr 150 mg............. 112
KADIAN - morphine sulfate cap sr 24hr 200 mg............. 112
KADIAN - morphine sulfate cap sr 24hr 20 mg............... 112
KADIAN - morphine sulfate cap sr 24hr 30 mg............... 112
KADIAN - morphine sulfate cap sr 24hr 40 mg............... 112
KADIAN - morphine sulfate cap sr 24hr 50 mg............... 112
KADIAN - morphine sulfate cap sr 24hr 60 mg............... 112
KADIAN - morphine sulfate cap sr 24hr 70 mg............... 112
KADIAN - morphine sulfate cap sr 24hr 80 mg............... 112
KALETRA - lopinavir-ritonavir soln 400-100 mg/5ml (80-20
mg/ml).............................................................................. 10
KALETRA - lopinavir-ritonavir tab 100-25 mg................... 10
KALETRA - lopinavir-ritonavir tab 200-50 mg................... 10
KALYDECO - ivacaftor tab 150 mg...................................74
KANAMYCIN SULFATE - kanamycin sulfate inj 333 mg/
ml....................................................................................... 7
KAPVAY - clonidine hcl tab sr 12hr 0.1 mg.................... 101
KAPVAY DOSE PACK - clonidine hcl tab sr 12hr therapy
pack 0.1 & 0.2 mg.........................................................101
KARBINAL ER - carbinoxamine maleate er susp 4
mg/5ml............................................................................. 64
KAYEXALATE - sodium polystyrene sulfonate powder
....................................................................................... 242
KAZANO - alogliptin-metformin hcl tab 12.5-1000 mg.......31
KAZANO - alogliptin-metformin hcl tab 12.5-500 mg........ 31
KEFLEX - cephalexin cap 250 mg......................................2
KEFLEX - cephalexin cap 500 mg......................................2
KEFLEX - cephalexin cap 750 mg......................................2
KENALOG - triamcinolone acetonide aerosol soln..........173
KEPPRA - levetiracetam oral soln 100 mg/ml.................125
KEPPRA - levetiracetam tab 1000 mg............................ 125
KEPPRA - levetiracetam tab 250 mg..............................125
KEPPRA - levetiracetam tab 500 mg.............................. 125
KEPPRA - levetiracetam tab 750 mg..............................125
KEPPRA XR - levetiracetam tab sr 24hr 500 mg............ 125
KEPPRA XR - levetiracetam tab sr 24hr 750 mg............ 125
KERAFOAM 42 - urea foam 42%................................... 173
KERAFOAM - urea foam 30%........................................ 173
KERALAC - urea cream 47%..........................................173
KERALYT - salicylic acid gel 6%.................................... 173
KERALYT SCALP - salicylic acid shampoo 6% & salicylic
acid gel 6% kit...............................................................173
KERLONE - betaxolol hcl tab 10 mg................................ 43
KERLONE - betaxolol hcl tab 20 mg................................ 43
KERYDIN - tavaborole soln 5%...................................... 173
KETEK - telithromycin tab 300 mg....................................14
KETEK - telithromycin tab 400 mg....................................14
ketoconazole cream 2%................................................173
ketoconazole foam 2% (Extina)................................... 173
ketoconazole shampoo 2% (Nizoral)........................... 173
ketoconazole tab 200 mg................................................. 8
KETODAN KIT - ketoconazole foam 2% & cleanser
kit................................................................................... 173
ketoprofen cap 50 mg...................................................119
ketoprofen cap 75 mg...................................................119
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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2015
KETOPROFEN ER - ketoprofen cap sr 24hr 200 mg......119
KETOROLAC 2% GEL - ketorolac tromethamine gel 2%
(cmpd kit) (base equiv)..................................................173
ketorolac tromethamine ophth soln 0.4% (Acular
ls)...................................................................................158
ketorolac tromethamine ophth soln 0.5% (Acular).....158
ketorolac tromethamine tab 10 mg..............................119
ketotifen fumarate ophth soln 0.025% (base
equiv)............................................................................ 158
KHEDEZLA - desvenlafaxine tab sr 24hr 100 mg............. 90
KHEDEZLA - desvenlafaxine tab sr 24hr 50 mg............... 90
KINERET - anakinra subcutaneous soln prefilled syringe
100 mg/0.67ml............................................................... 119
KINNEY LANCETS - lancets ......................................... 211
KINNEY THIN LANCETS - lancets ................................ 211
KINRAY INSULIN SYRINGE/0. - insulin syringe/needle
u-100 1/2 ml 29 x 1/2"...................................................212
KINRAY INSULIN SYRINGE PR - insulin syringe/needle
u-100 0.3 ml 31 x 5/16".................................................212
KINRAY INSULIN SYRINGE PR - insulin syringe/needle
u-100 1/2 ml 31 x 5/16".................................................212
KINRAY INSULIN SYRINGE PR - insulin syringe/needle
u-100 1 ml 31 x 5/16"....................................................212
KINRIX - diph-tetanus tox ad-acell pert & polio virus, ipv
vac inj.............................................................................. 15
KLARON - sulfacetamide sodium lotion 10% (acne)....... 173
KLONOPIN - clonazepam tab 0.5 mg............................. 125
KLONOPIN - clonazepam tab 1 mg................................125
KLONOPIN - clonazepam tab 2 mg................................125
KLOR-CON 25 - potassium chloride powder packet 25
meq................................................................................ 147
KLOR-CON M15 - potassium chloride microencapsulated
crys cr tab 15 meq........................................................ 147
KMART VALU PLUS INSULIN S - insulin syringe (disp)
u-100 0.3 ml.................................................................. 212
KMART VALU PLUS INSULIN S - insulin syringe (disp)
u-100 1/2 ml.................................................................. 212
KMART VALU PLUS INSULIN S - insulin syringe (disp)
u-100 1 ml..................................................................... 212
KOMBIGLYZE XR - saxagliptin-metformin hcl tab sr 24hr
2.5-1000 mg.................................................................... 31
KOMBIGLYZE XR - saxagliptin-metformin hcl tab sr 24hr
5-1000 mg....................................................................... 31
KOMBIGLYZE XR - saxagliptin-metformin hcl tab sr 24hr
5-500 mg......................................................................... 31
KORLYM - mifepristone tab 300 mg................................. 31
K-PHOS NEUTRAL - pot phos monobasic w/sod phos di &
monobas tab 155-852-130mg....................................... 147
K-PHOS NO 2 - potassium & sodium acid phosphates tab
305-700 mg..................................................................... 85
K-PHOS - potassium phosphate monobasic tab 500
mg.................................................................................. 146
KRISGEL 100 - krisgel 100 gel.......................................240
KRISTALOSE - lactulose oral crystal packet 10 gm..........74
KRISTALOSE - lactulose oral crystal packet 20 gm..........74
298
KROGER BLOOD GLUCOSE MONI - blood glucose
monitoring kit w/ device ................................................212
KROGER BLOOD GLUCOSE TEST - glucose blood test
strip................................................................................ 186
KROGER INSULIN SYRINGE/0. - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................212
KROGER INSULIN SYRINGE/0. - insulin syringe/needle
u-100 0.3 ml 30 x 5/16".................................................212
KROGER INSULIN SYRINGE/0. - insulin syringe/needle
u-100 0.3 ml 31 x 5/16".................................................212
KROGER INSULIN SYRINGE/0. - insulin syringe/needle
u-100 1/2 ml 29 x 1/2"...................................................212
KROGER INSULIN SYRINGE/0. - insulin syringe/needle
u-100 1/2 ml 30 x 5/16".................................................212
KROGER INSULIN SYRINGE/0. - insulin syringe/needle
u-100 1/2 ml 31 x 5/16".................................................212
KROGER INSULIN SYRINGE/1M - insulin syringe/needle
u-100 1 ml 29 x 1/2"......................................................212
KROGER INSULIN SYRINGE/1M - insulin syringe/needle
u-100 1 ml 30 x 5/16"....................................................212
KROGER INSULIN SYRINGE/1M - insulin syringe/needle
u-100 1 ml 31 x 5/16"....................................................212
KROGER INSULIN SYRINGE/U- - insulin syringe/needle
u-100 0.3 ml 30 x 1/2"...................................................212
KROGER LANCETS 21G - lancets ............................... 212
KROGER LANCETS - lancets ....................................... 212
KROGER LANCETS MICRO THIN - lancets ................. 212
KROGER LANCETS SUPER THIN - lancets .................212
KROGER LANCETS THIN 26G - lancets ...................... 212
KROGER LANCETS THIN - lancets .............................. 212
KROGER LANCETS ULTRATHIN - lancets .................. 212
KROGER LANCING DEVICE - lancet devices .............. 212
KROGER PEN NEEDLES 29G X - insulin pen needle 29 g
x 12 mm (1/2")...............................................................212
KROGER PEN NEEDLES 31GX1/ - insulin pen needle 31
g x 6 mm (1/4")............................................................. 212
KROGER PEN NEEDLES 31G X - insulin pen needle 31 g
x 8 mm (1/3" or 5/16")...................................................212
KROGER PREMIUM BLOOD GLUC - blood glucose
monitoring kit w/ device ................................................212
KROGER PREMIUM BLOOD GLUC - glucose blood test
strip................................................................................ 186
KROGER TEST STRIPS - glucose blood test strip.........186
K-TAB - potassium chloride tab cr 10 meq..................... 147
K-TAB - potassium chloride tab cr 20 meq (1500 mg).....147
KUVAN - sapropterin dihydrochloride powder packet 100
mg.................................................................................... 38
KUVAN - sapropterin dihydrochloride soluble tab 100
mg.................................................................................... 38
KYNAMRO - mipomersen sodium soln prefilled syringe
200 mg/ml........................................................................60
L
labetalol hcl tab 100 mg (Trandate)...............................43
labetalol hcl tab 200 mg (Trandate)...............................43
labetalol hcl tab 300 mg (Trandate)...............................43
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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LAC-HYDRIN - lactic acid (ammonium lactate) cream
12%................................................................................173
LAC-HYDRIN - lactic acid (ammonium lactate) lotion
12%................................................................................173
lactated ringer's for irrigation...................................... 242
lactic acid (ammonium lactate) cream 12% (Lachydrin)...........................................................................174
lactic acid (ammonium lactate) lotion 10%................. 174
lactic acid (ammonium lactate) lotion 12% (Lachydrin)...........................................................................174
lactic acid w/ vitamin e cream 10%-3500
unit/30gm...................................................................... 174
LACTOCAL-F - prenatal vit w/ fe fumarate-fa tab 65-1 mg
....................................................................................... 137
lactulose (encephalopathy) solution 10 gm/15ml.........81
lactulose solution 10 gm/15ml....................................... 74
LADY LITE LANCETS - lancets .....................................212
LAMICTAL CHEWABLE DISPERS - lamotrigine tab
chewable dispersible 25 mg.......................................... 126
LAMICTAL CHEWABLE DISPERS - lamotrigine tab
chewable dispersible 5 mg............................................ 125
LAMICTAL - lamotrigine tab 100 mg...............................125
LAMICTAL - lamotrigine tab 150 mg...............................125
LAMICTAL - lamotrigine tab 200 mg...............................125
LAMICTAL - lamotrigine tab 25 mg.................................125
LAMICTAL - lamotrigine tab chewable dispersible 2
mg.................................................................................. 125
LAMICTAL ODT - lamotrigine orally disintegrating tab 100
mg.................................................................................. 126
LAMICTAL ODT - lamotrigine orally disintegrating tab 200
mg.................................................................................. 126
LAMICTAL ODT - lamotrigine orally disintegrating tab 25
mg.................................................................................. 126
LAMICTAL ODT - lamotrigine orally disintegrating tab 50
mg.................................................................................. 126
LAMICTAL ODT - lamotrigine tab disp 25 (14) & 50 mg
(14) & 100 mg (7) kit.....................................................126
LAMICTAL ODT - lamotrigine tab disp 25 mg (21) & 50 mg
(7) titration kit.................................................................126
LAMICTAL ODT - lamotrigine tab disp 50 mg (42) & 100
mg (14) titration kit........................................................ 126
LAMICTAL STARTER/NOT TAKI - lamotrigine tab 25 mg
(42) & 100 mg (7) starter kit..........................................126
LAMICTAL STARTER/TAKING C - lamotrigine tab 25 mg
(84) & 100 mg (14) starter kit........................................126
LAMICTAL STARTER/TAKING V - lamotrigine tab 25 mg
(35) starter kit................................................................ 126
LAMICTAL XR - lamotrigine tab sr 24hr 100 mg.............126
LAMICTAL XR - lamotrigine tab sr 24hr 200 mg.............126
LAMICTAL XR - lamotrigine tab sr 24hr 25 (14) & 50 mg
(14) & 100 mg(7) kit...................................................... 126
LAMICTAL XR - lamotrigine tab sr 24hr 250 mg.............126
LAMICTAL XR - lamotrigine tab sr 24hr 25 mg...............126
LAMICTAL XR - lamotrigine tab sr 24hr 25 mg (21) & 50
mg (7) titration kit.......................................................... 126
LAMICTAL XR - lamotrigine tab sr 24hr 300 mg.............126
LAMICTAL XR - lamotrigine tab sr 24hr 50 (14) & 100
mg(14) & 200 mg(7) kit................................................. 126
LAMICTAL XR - lamotrigine tab sr 24hr 50 mg...............126
LAMISIL SPRAY - terbinafine hcl soln 1%......................174
LAMISIL - terbinafine hcl oral granules packet 125 mg....... 8
LAMISIL - terbinafine hcl oral granules packet 187.5
mg...................................................................................... 8
LAMISIL - terbinafine hcl tab 250 mg................................. 8
lamivudine tab 100 mg (Epivir hbv)...............................10
lamivudine tab 150 mg (Epivir)...................................... 10
lamivudine tab 300 mg (Epivir)...................................... 10
lamivudine-zidovudine tab 150-300 mg (Combivir)...... 10
lamotrigine tab 100 mg (Lamictal)............................... 126
lamotrigine tab 150 mg (Lamictal)............................... 126
lamotrigine tab 200 mg (Lamictal)............................... 126
lamotrigine tab 25 mg (Lamictal)................................. 126
lamotrigine tab chewable dispersible 25 mg (Lamictal
chewable di)................................................................. 126
lamotrigine tab chewable dispersible 5 mg (Lamictal
chewable di)................................................................. 126
lamotrigine tab sr 24hr 100 mg (Lamictal xr)..............126
lamotrigine tab sr 24hr 200 mg (Lamictal xr)..............126
lamotrigine tab sr 24hr 250 mg (Lamictal xr)..............126
lamotrigine tab sr 24hr 25 mg (Lamictal xr)................126
lamotrigine tab sr 24hr 300 mg (Lamictal xr)..............126
lamotrigine tab sr 24hr 50 mg (Lamictal xr)................126
LANCET DEVICE ADJUSTABLE - lancet devices .........212
LANCETS 26G TWIST TOP - lancets ........................... 213
LANCETS 28G - lancets ................................................213
LANCETS 30G - lancets ................................................213
LANCETS 30G TWIST TOP - lancets ........................... 213
LANCETS 31G TWIST TOP - lancets ........................... 213
LANCETS - lancets ........................................................213
LANCETS MICRO THIN 33G - lancets ..........................213
LANCETS SAFETY SEAL 21G - lancets ....................... 213
LANCETS SAFETY SEAL 26G - lancets ....................... 213
LANCETS SAFETY SEAL 28G - lancets ....................... 213
LANCETS SAFETY SEAL 30G - lancets ....................... 213
LANCETS SUPER THIN 28G - lancets ......................... 213
LANCETS THIN - lancets .............................................. 213
LANCETS THIN - lancets .............................................. 213
LANCETS TWIST TOP - lancets ................................... 213
LANCETS ULTRA FINE - lancets ..................................213
LANCETS ULTRA THIN 30G - lancets ..........................213
LANCETS ULTRA THIN - lancets ..................................213
LANCING DEVICE ADJUSTABLE - lancet devices ....... 213
LANCING DEVICE - lancet devices ...............................213
lanolin............................................................................. 240
LANOLIN ANHYDROUS - lanolin anhydrous..................240
LANOLIN - lanolin anhydrous oil.....................................240
LANOXIN - digoxin tab 125 mcg (0.125 mg).....................41
LANOXIN - digoxin tab 187.5 mcg (0.1875 mg)................41
LANOXIN - digoxin tab 250 mcg (0.25 mg)...................... 41
LANOXIN - digoxin tab 62.5 mcg (0.0625 mg)..................41
lansoprazole cap delayed release 15 mg
(Prevacid)........................................................................76
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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lansoprazole cap delayed release 30 mg
(Prevacid)........................................................................76
LANTUS - insulin glargine inj 100 unit/ml......................... 33
LANTUS SOLOSTAR - insulin glargine soln pen-injector
100 unit/ml....................................................................... 33
LARTUS - phenyleph-chlorphen w/ dm-gg liquid
5-2-15-150 mg/5ml.......................................................... 66
LASIX - furosemide tab 20 mg..........................................58
LASIX - furosemide tab 40 mg..........................................58
LASIX - furosemide tab 80 mg..........................................58
LASTACAFT - alcaftadine ophth soln 0.25%.................. 158
latanoprost ophth soln 0.005% (Xalatan).................... 158
LATRIX XM - urea in zinc undecylenate-lactic acid vehicle
emulsion 45%................................................................ 174
LATUDA - lurasidone hcl tab 120 mg............................... 95
LATUDA - lurasidone hcl tab 20 mg................................. 95
LATUDA - lurasidone hcl tab 40 mg................................. 95
LATUDA - lurasidone hcl tab 60 mg................................. 95
LATUDA - lurasidone hcl tab 80 mg................................. 95
LAVOCLEN-4 CREAMY WASH - benzoyl peroxide liq
4%..................................................................................174
LAVOCLEN-8 CREAMY WASH - benzoyl peroxide liq
8%..................................................................................174
LAZANDA - fentanyl citrate nasal spray 100 mcg/act (base
equiv)............................................................................. 112
LAZANDA - fentanyl citrate nasal spray 400 mcg/act (base
equiv)............................................................................. 112
LEADER ADVANCED LANCING D - lancet devices ......213
LEADER INSULIN SYRINGE/0. - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................213
LEADER INSULIN SYRINGE/0. - insulin syringe/needle
u-100 0.3 ml 30 x 5/16".................................................213
LEADER INSULIN SYRINGE/0. - insulin syringe/needle
u-100 0.3 ml 31 x 5/16".................................................213
LEADER INSULIN SYRINGE/0. - insulin syringe/needle
u-100 1/2 ml 28 x 1/2"...................................................213
LEADER INSULIN SYRINGE/0. - insulin syringe/needle
u-100 1/2 ml 29 x 1/2"...................................................213
LEADER INSULIN SYRINGE/0. - insulin syringe/needle
u-100 1/2 ml 30 x 5/16".................................................213
LEADER INSULIN SYRINGE/0. - insulin syringe/needle
u-100 1/2 ml 31 x 5/16".................................................213
LEADER INSULIN SYRINGE/1M - insulin syringe/needle
u-100 1 ml 28 x 1/2"......................................................213
LEADER INSULIN SYRINGE/1M - insulin syringe/needle
u-100 1 ml 29 x 1/2"......................................................213
LEADER INSULIN SYRINGE/1M - insulin syringe/needle
u-100 1 ml 30 x 5/16"....................................................213
LEADER INSULIN SYRINGE/1M - insulin syringe/needle
u-100 1 ml 31 x 5/16"....................................................213
LEADER LANCETS COLORED - lancets ...................... 213
LEADER SUPER THIN LANCET - lancets .................... 213
LEADER THIN LANCETS - lancets ............................... 213
LEADER UNIFINE PENTIPS/MI - insulin pen needle 31 g
x 5 mm (3/16")...............................................................213
300
LEADER UNIFINE PENTIPS/NA - insulin pen needle 32 g
x 4 mm (5/32")...............................................................214
LEADER UNIFINE PENTIPS/PL - insulin pen needle 32 g
x 4 mm (5/32")...............................................................214
LEADER UNIFINE PENTIPS PL - insulin pen needle 31 g
x 5 mm (3/16")...............................................................213
LEADER UNIFINE PENTIPS PL - insulin pen needle 31 g
x 8 mm (1/3" or 5/16")...................................................213
LECITHIN ORGANOGEL - premium lecithin organogel
base gel......................................................................... 240
leflunomide tab 10 mg (Arava).....................................119
leflunomide tab 20 mg (Arava).....................................119
LESCOL - fluvastatin sodium cap 20 mg.......................... 60
LESCOL - fluvastatin sodium cap 40 mg.......................... 60
LESCOL XL - fluvastatin sodium tab sr 24 hr 80 mg.........60
LETAIRIS - ambrisentan tab 10 mg.................................. 63
LETAIRIS - ambrisentan tab 5 mg.................................... 63
letrozole tab 2.5 mg (Femara)........................................ 17
LEUCOVORIN CALCIUM - leucovorin calcium tab 10
mg.................................................................................... 17
LEUCOVORIN CALCIUM - leucovorin calcium tab 15
mg.................................................................................... 17
leucovorin calcium tab 25 mg........................................17
leucovorin calcium tab 5 mg..........................................17
LEUKERAN - chlorambucil tab 2 mg................................ 17
LEUKINE - sargramostim inj 500 mcg/ml........................153
LEUKINE - sargramostim lyophilized for inj 250 mcg...... 153
leuprolide acetate inj kit 5 mg/ml.................................. 17
LEVACET - aspirin-apap-salicylamide-caffeine tab
500-250-150-32.5 mg.................................................... 108
levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)
(Xopenex)........................................................................72
levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv)
(Xopenex)........................................................................72
levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv)
(Xopenex)........................................................................72
LEVALBUTEROL - levalbuterol hcl soln nebu conc 1.25
mg/0.5ml (base equiv)..................................................... 72
LEVAQUIN - levofloxacin oral soln 25 mg/ml......................6
LEVAQUIN - levofloxacin tab 250 mg.................................6
LEVAQUIN - levofloxacin tab 500 mg.................................6
LEVAQUIN - levofloxacin tab 750 mg.................................6
LEVATOL - penbutolol sulfate tab 20 mg......................... 43
LEVBID - hyoscyamine sulfate tab sr 12hr 0.375 mg........76
LEVEMIR FLEXPEN - insulin detemir soln pen-injector
100 unit/ml....................................................................... 33
LEVEMIR FLEXTOUCH - insulin detemir soln pen-injector
100 unit/ml....................................................................... 33
LEVEMIR - insulin detemir inj 100 unit/ml.........................33
levetiracetam oral soln 100 mg/ml (Keppra)............... 126
levetiracetam tab 1000 mg (Keppra)............................126
levetiracetam tab 250 mg (Keppra)..............................126
levetiracetam tab 500 mg (Keppra)..............................127
levetiracetam tab 750 mg (Keppra)..............................127
levetiracetam tab sr 24hr 500 mg (Keppra xr)............ 126
levetiracetam tab sr 24hr 750 mg (Keppra xr)............ 126
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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LEVOBUNOLOL HCL - levobunolol hcl ophth soln
0.25%.............................................................................159
levobunolol hcl ophth soln 0.5% (Betagan)................ 159
levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)...... 38
levocarnitine tab 330 mg (Carnitor)...............................38
levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5
mg/ml) (Xyzal)................................................................ 64
levocetirizine dihydrochloride tab 5 mg (Xyzal)........... 64
levofloxacin ophth soln 0.5%.......................................159
levofloxacin oral soln 25 mg/ml (Levaquin)....................6
levofloxacin tab 250 mg (Levaquin)................................ 6
levofloxacin tab 500 mg (Levaquin)................................ 6
levofloxacin tab 750 mg (Levaquin)................................ 6
LEVOMEFOLATE CALCIUM/ACET - l-methylfolate-algaeb12-acetylcyst tab 6-90.314-2-600mg .......................... 149
LEVOMEFOLATE CALCIUM/ALGA - l-methylfolate-algae
cap 15-90.314 mg ........................................................ 149
LEVOMEFOLATE CALCIUM/ALGA - l-methylfolate-algae
cap 7.5-90.314 mg ....................................................... 149
LEVOMEFOLATE CALCIUM/PYRI - l-methylfolate-algaevit b12-b6 cap 3-90.314-2-35 mg ................................. 149
LEVOMEFOLATE DHA - prenat w/fe fum-l methylfolate-fadha cap 27-1.13-0.4 mg ...............................................137
LEVOMEFOLATE PNV - prenatal w/ fe polycmplxmethylfol-fa pak 29-1.4-0.5 mg .................................... 137
levonorgestrel & ethinyl estradiol (91-day) tab
0.15-0.03 mg................................................................... 25
levonorgestrel & ethinyl estradiol tab 0.15 mg-30
mcg..................................................................................25
levonorgestrel & ethinyl estradiol tab 0.1 mg-20
mcg..................................................................................25
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mg-mcg................................ 25
levonorgestrel tab 0.75 mg (Plan b).............................. 25
levonorgestrel tab 1.5 mg (Plan b one-step).................25
levonorg-eth est tab 0.1-0.02mg(84) & eth est tab
0.01mg(7) (Loseasonique)............................................ 25
levonorg-eth est tab 0.15-0.03mg(84) & eth est tab
0.01mg(7) (Seasonique)................................................ 25
LEVORPHANOL TARTRATE - levorphanol tartrate tab 2
mg.................................................................................. 112
levothyroxine sodium tab 100 mcg (Synthroid)........... 34
levothyroxine sodium tab 112 mcg (Synthroid)........... 34
levothyroxine sodium tab 125 mcg (Synthroid)........... 34
levothyroxine sodium tab 137 mcg (Synthroid)........... 34
levothyroxine sodium tab 150 mcg (Synthroid)........... 34
levothyroxine sodium tab 175 mcg (Synthroid)........... 34
levothyroxine sodium tab 200 mcg (Synthroid)........... 34
levothyroxine sodium tab 25 mcg (Synthroid)............. 34
levothyroxine sodium tab 300 mcg (Synthroid)........... 34
levothyroxine sodium tab 50 mcg (Synthroid)............. 34
levothyroxine sodium tab 75 mcg (Synthroid)............. 34
levothyroxine sodium tab 88 mcg (Synthroid)............. 34
LEVSIN/SL - hyoscyamine sulfate tab sl 0.125 mg........... 77
LEVSIN - hyoscyamine sulfate tab 0.125 mg....................77
LEXAPRO - escitalopram oxalate soln 5 mg/5ml (base
equiv)............................................................................... 90
LEXAPRO - escitalopram oxalate tab 10 mg (base
equiv)............................................................................... 90
LEXAPRO - escitalopram oxalate tab 20 mg (base
equiv)............................................................................... 90
LEXAPRO - escitalopram oxalate tab 5 mg (base
equiv)............................................................................... 90
LEXIVA - fosamprenavir calcium susp 50 mg/ml (base
equiv)............................................................................... 10
LEXIVA - fosamprenavir calcium tab 700 mg (base
equiv)............................................................................... 10
LIALDA - mesalamine tab delayed release 1.2 gm........... 81
LIBERTY CONTROL SOLUTION - blood glucose
calibration - liquid - high ...............................................214
LIBERTY CONTROL SOLUTION - blood glucose
calibration - liquid - normal ...........................................214
LIBERTY GLUCOSE CONTROL L - blood glucose
calibration - liquid ......................................................... 214
LIBERTY GLUCOSE CONTROL M - blood glucose
calibration - liquid ......................................................... 214
LIBERTY GLUCOSE CONTROL N - blood glucose
calibration - liquid - normal ...........................................214
LIBERTY MINI LANCING DEVI - lancet devices ............214
LIBERTY NEXT GENERATION B - glucose blood test
strip................................................................................ 186
LIBERTY TEST STRIPS - glucose blood test strip......... 186
LIBRAX - clidinium & chlordiazepoxide cap 2.5-5 mg....... 77
LIDOCAINE/PRILOCAINE - lidocaine-prilocaine kit
2.5-2.5%.........................................................................174
lidocaine hcl cream 3%................................................ 174
lidocaine hcl gel 2%......................................................174
LIDOCAINE HCL-HYDROCORTIS - lidocainehydrocortisone acetate rectal gel 2.8-0.55%................. 165
LIDOCAINE HCL - lidocaine hcl lotion 3%......................174
lidocaine hcl soln 4% (Xylocaine)................................174
lidocaine hcl viscous soln 2%..................................... 162
lidocaine-hydrocortisone acetate rectal cream
3-0.5%............................................................................165
lidocaine-hydrocortisone acetate rectal cream kit
2-2%...............................................................................165
lidocaine-hydrocortisone acetate rectal cream kit
3-0.5%............................................................................165
lidocaine-hydrocortisone acetate rectal cream kit
3-1%...............................................................................165
lidocaine-hydrocortisone acetate rectal gel kit
3-2.5%............................................................................165
lidocaine oint 5%...........................................................174
lidocaine patch 5% (Lidoderm).................................... 174
lidocaine-prilocaine cream 2.5-2.5% (Emla)................174
LIDODERM - lidocaine patch 5%....................................174
LIDODEXTRAPINE - lidocaine-menthol patch 4-1%.......174
LIDOPIN - lidocaine hcl cream 3.25%.............................174
LIDORX - lidocaine hcl gel 3%....................................... 174
LIDOVIR - acyclovir-lidocaine hcl oint 4-4% (compounding
kit) .................................................................................174
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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LIFESCAN UNISTIK 2 DEEP P - lancets ...................... 214
LIFESCAN UNISTIK II LANCE - lancets ........................214
LIMBREL250 - flavocoxid-citrated zinc bisglycinate cap
250-50 mg..................................................................... 149
LIMBREL500 - flavocoxid-citrated zinc bisglycinate cap
500-50 mg..................................................................... 149
LIMBREL - flavocoxid cap 250 mg..................................149
LIMBREL - flavocoxid cap 500 mg..................................149
LINCOCIN - lincomycin hcl inj 300 mg/ml......................... 14
lindane lotion 1%...........................................................174
lindane shampoo 1%.................................................... 174
LINZESS - linaclotide cap 145 mcg.................................. 81
LINZESS - linaclotide cap 290 mcg.................................. 81
liothyronine sodium tab 25 mcg (Cytomel)...................34
liothyronine sodium tab 50 mcg (Cytomel)...................34
liothyronine sodium tab 5 mcg (Cytomel).....................34
LIPITOR - atorvastatin calcium tab 10 mg (base
equivalent)....................................................................... 60
LIPITOR - atorvastatin calcium tab 20 mg (base
equivalent)....................................................................... 60
LIPITOR - atorvastatin calcium tab 40 mg (base
equivalent)....................................................................... 60
LIPITOR - atorvastatin calcium tab 80 mg (base
equivalent)....................................................................... 60
LIPOFEN - fenofibrate cap 150 mg...................................60
LIPOFEN - fenofibrate cap 50 mg.................................... 60
LIPTRUZET - ezetimibe-atorvastatin tab 10-10 mg.......... 60
LIPTRUZET - ezetimibe-atorvastatin tab 10-20 mg.......... 60
LIPTRUZET - ezetimibe-atorvastatin tab 10-40 mg.......... 60
LIPTRUZET - ezetimibe-atorvastatin tab 10-80 mg.......... 60
LIQUICET - hydrocodone-acetaminophen soln 10-500
mg/15ml......................................................................... 112
lisinopril & hydrochlorothiazide tab 10-12.5 mg
(Zestoretic)..................................................................... 53
lisinopril & hydrochlorothiazide tab 20-12.5 mg
(Zestoretic)..................................................................... 53
lisinopril & hydrochlorothiazide tab 20-25 mg
(Zestoretic)..................................................................... 53
lisinopril tab 10 mg (Prinivil)..........................................53
lisinopril tab 2.5 mg (Zestril).......................................... 53
lisinopril tab 20 mg (Prinivil)..........................................53
lisinopril tab 30 mg (Zestril)........................................... 53
lisinopril tab 40 mg (Zestril)........................................... 53
lisinopril tab 5 mg (Prinivil)............................................53
LISTERINE ESSENTIAL CARE - sod monofluorophoseucal-men-methyl sal-thymol paste 0.76% ...................163
LISTERINE ESSENTIAL CARE - sod monofluorophospheucal-men-methyl sal-thymol gel 0.76% .......................163
LISTERINE RESTORING - sodium fluoride rinse 0.0221%
(0.01% f)........................................................................ 163
LISTERINE SMART RINSE ANT - sodium fluoride rinse
0.02%.............................................................................163
LISTERINE SMART RINSE - sodium fluoride rinse
0.0221% (0.01% f).........................................................163
LISTERINE TOOTH DEFENSE - sodium fluoride rinse
0.0221% (0.01% f).........................................................163
302
LISTERINE TOTAL CARE PLUS - sodium fluoride rinse
0.0221% (0.01% f).........................................................163
LISTERINE TOTAL CARE - sodium fluoride rinse
0.0221% (0.01% f).........................................................163
LISTERINE TOTAL CARE ZERO - sodium fluoride rinse
0.02%.............................................................................163
LISTERINE WHITENING/RESTO - sodium fluoride rinse
0.0221% (0.01% f).........................................................163
LITEAIRE - spacer/aerosol-holding chambers - device
....................................................................................... 214
LITETOUCH INSULIN SYRINGE - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................214
LITETOUCH INSULIN SYRINGE - insulin syringe/needle
u-100 0.3 ml 30 x 5/16".................................................214
LITETOUCH INSULIN SYRINGE - insulin syringe/needle
u-100 0.3 ml 31 x 5/16".................................................214
LITETOUCH INSULIN SYRINGE - insulin syringe/needle
u-100 1/2 ml 28 x 1/2"...................................................214
LITETOUCH INSULIN SYRINGE - insulin syringe/needle
u-100 1/2 ml 29 x 1/2"...................................................214
LITETOUCH INSULIN SYRINGE - insulin syringe/needle
u-100 1/2 ml 30 x 5/16".................................................214
LITETOUCH INSULIN SYRINGE - insulin syringe/needle
u-100 1/2 ml 31 x 5/16".................................................214
LITETOUCH INSULIN SYRINGE - insulin syringe/needle
u-100 1 ml 28 x 1/2"......................................................214
LITETOUCH INSULIN SYRINGE - insulin syringe/needle
u-100 1 ml 29 x 1/2"......................................................214
LITETOUCH INSULIN SYRINGE - insulin syringe/needle
u-100 1 ml 30 x 5/16"....................................................214
LITETOUCH INSULIN SYRINGE - insulin syringe/needle
u-100 1 ml 31 x 5/16"....................................................214
LITE TOUCH LANCETS - lancets ................................. 214
LITETOUCH LANCETS MICRO T - lancets ...................214
LITE TOUCH LANCING DEVICE - lancet devices .........214
LITE TOUCH LANCING PEN - lancet devices ...............214
LITE TOUCH PEN NEEDLES/31 - insulin pen needle 31 g
x 5 mm (3/16")...............................................................214
LITETOUCH PEN NEEDLES 29G - insulin pen needle 29
g x 12.7 mm.................................................................. 214
LITETOUCH PEN NEEDLES 31G - insulin pen needle 31
g x 6 mm (1/4")............................................................. 214
LITETOUCH PEN NEEDLES 31G - insulin pen needle 31
g x 8 mm (1/3" or 5/16")................................................214
lithium carbonate cap 150 mg (Lithium carbonate)......95
lithium carbonate cap 300 mg....................................... 95
lithium carbonate cap 600 mg (Lithium carbonate)......95
LITHIUM CARBONATE - lithium carbonate cap 150
mg.................................................................................... 95
LITHIUM CARBONATE - lithium carbonate cap 600
mg.................................................................................... 95
lithium carbonate tab 300 mg........................................ 95
lithium carbonate tab cr 300 mg (Lithobid)...................95
lithium carbonate tab cr 450 mg....................................95
LITHIUM - lithium oral solution 8 meq/5ml........................ 95
LITHOBID - lithium carbonate tab cr 300 mg.................... 95
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
2015
LITHOSTAT - acetohydroxamic acid tab 250 mg..............85
LIVALO - pitavastatin calcium tab 1 mg (base equiv)........60
LIVALO - pitavastatin calcium tab 2 mg (base equiv)........60
LIVALO - pitavastatin calcium tab 4 mg (base equiv)........60
LIVE BETTER ADVANCED LANC - lancet devices ....... 214
LIVE BETTER LANCET SUPER - lancets ..................... 214
LIVE BETTER LANCET ULTRA - lancets ......................215
LIVE BETTER PEN NEEDLES 2 - insulin pen needle 29 g
x 12 mm (1/2")...............................................................215
LIVE BETTER PEN NEEDLES 3 - insulin pen needle 31 g
x 6 mm (1/4").................................................................215
LIVE BETTER PEN NEEDLES 3 - insulin pen needle 31 g
x 8 mm (1/3" or 5/16")...................................................215
L-METHYL-B6-B12 - l-methylfolate w/ vit b6-vit b12 tab
3-35-2 mg ..................................................................... 148
L-METHYLFOLATE CA/ME-CBL/ - l-methylfolatemethylcobalamin-acetylcyst tab 6-2-600 mg ................ 149
L-METHYLFOLATE CA/P-5-P/M - l-methylfolate-algae-vit
b12-b6 cap 3-90.314-2-35 mg ......................................149
L-METHYLFOLATE CA/P-5-P/M - l-methylfolate w/ vit b6vit b12 tab 3-35-2 mg ...................................................149
L-METHYLFOLATE CALCIUM - l-methylfolate tab 15 mg
....................................................................................... 149
L-METHYLFOLATE CALCIUM - l-methylfolate tab 7.5 mg
....................................................................................... 149
L-METHYLFOLATE CA ME-CBL - l-methylfolate-algaeb12-acetylcyst tab 6-90.314-2-600mg .......................... 148
L-METHYLFOLATE FORMULA 15 - l-methylfolate-algae
cap 15-90.314 mg ........................................................ 149
L-METHYLFOLATE FORMULA 7. - l-methylfolate-algae
cap 7.5-90.314 mg ....................................................... 149
L-METHYLFOLATE FORTE - l-methylfolate-algae cap
15-90.314 mg ............................................................... 149
L-METHYLFOLATE FORTE - l-methylfolate-algae cap
7.5-90.314 mg .............................................................. 149
L-METHYLFOLATE - l-methylfolate tab 15 mg .............. 148
L-METHYLFOLATE - l-methylfolate tab 7.5 mg ............. 148
L-METHYLFOLATE PNV DHA - prenat w/fe fum-l
methylfolate-fa-dha cap 27-1.13-0.4 mg .......................137
L-METHYL-MC - l-methylfolate w/ vit b12-vit b6-vit b2 tab
6-1-50-5 mg ..................................................................148
L-METHYL-MC NAC - l-methylfolate-methylcobalaminacetylcyst tab 6-2-600 mg ............................................ 148
LMTHF/PYRIDOXINE HCL/CYAN - l-methylfolate w/ vit
b6-vit b12 tab 1.13-25-2 mg .........................................149
LO/OVRAL-28 - norgestrel & ethinyl estradiol tab 0.3
mg-30 mcg.......................................................................25
LO/OVRAL - norgestrel & ethinyl estradiol tab 0.3 mg-30
mcg.................................................................................. 25
LOCOID - hydrocortisone butyrate cream 0.1%..............174
LOCOID - hydrocortisone butyrate lotion 0.1%............... 174
LOCOID - hydrocortisone butyrate oint 0.1%..................174
LOCOID - hydrocortisone butyrate soln 0.1%................. 174
LOCOID LIPOCREAM - hydrocortisone butyrate
hydrophilic lipo base cream 0.1%..................................174
LODOSYN - carbidopa tab 25 mg.................................. 130
LOESTRIN 1/20-21 - norethindrone ace & ethinyl estradiol
tab 1 mg-20 mcg............................................................. 26
LOESTRIN 1.5/30-21 - norethindrone ace & ethinyl
estradiol tab 1.5 mg-30 mcg............................................26
LOESTRIN 24 FE - norethindrone ace-ethinyl estradiol-fe
tab 1 mg-20 mcg (24)......................................................26
LOESTRIN FE 1/20 - norethindrone ace & ethinyl
estradiol-fe tab 1 mg-20 mcg.......................................... 25
LOESTRIN FE 1.5/30 - norethindrone ace & ethinyl
estradiol-fe tab 1.5 mg-30 mcg....................................... 25
LOFIBRA - fenofibrate micronized cap 134 mg.................61
LOFIBRA - fenofibrate micronized cap 200 mg.................61
LOFIBRA - fenofibrate micronized cap 67 mg...................61
LOFIBRA - fenofibrate tab 160 mg................................... 61
LOFIBRA - fenofibrate tab 54 mg..................................... 60
LO LOESTRIN FE - norethin-eth estradiol-fe tab 1 mg-10
mcg (24)/10 mcg (2)........................................................25
LO MINASTRIN FE - norethin-eth estrad-fe chew/tab 1
mg-10 mcg/10 mcg ther pack..........................................25
LOMOTIL - diphenoxylate w/ atropine tab 2.5-0.025
mg.................................................................................... 74
LOMUSTINE - lomustine cap 100 mg...............................17
LOMUSTINE - lomustine cap 10 mg.................................17
LOMUSTINE - lomustine cap 40 mg.................................17
LONGS INSULIN SYRINGE/0.5 - insulin syringe/needle
u-100 1/2 ml 31 x 5/16".................................................215
LONGS LANCETS STANDARD - lancets ......................215
LONGS LANCETS THIN - lancets .................................215
LONGS LANCETS ULTRA THIN - lancets .................... 215
loperamide hcl cap 2 mg................................................74
loperamide hcl tab 2 mg.................................................75
LOPID - gemfibrozil tab 600 mg....................................... 61
LOPRESSOR HCT - metoprolol & hydrochlorothiazide tab
100-25 mg....................................................................... 53
LOPRESSOR HCT - metoprolol & hydrochlorothiazide tab
50-25 mg......................................................................... 53
LOPRESSOR - metoprolol tartrate tab 100 mg.................43
LOPRESSOR - metoprolol tartrate tab 50 mg...................43
LOPROX - ciclopirox gel 0.77%......................................174
LOPROX SHAMPOO - ciclopirox shampoo 1%.............. 174
lorazepam conc 2 mg/ml (Lorazepam intensol)............87
LORAZEPAM INTENSOL - lorazepam conc 2 mg/ml....... 87
lorazepam tab 0.5 mg (Ativan)....................................... 87
lorazepam tab 1 mg (Ativan).......................................... 87
lorazepam tab 2 mg (Ativan).......................................... 87
LORCET 10/650 - hydrocodone-acetaminophen tab
10-650 mg..................................................................... 112
LORCET PLUS - hydrocodone-acetaminophen tab
7.5-650 mg.................................................................... 112
LORTAB - hydrocodone-acetaminophen soln 10-300
mg/15ml......................................................................... 112
LORTAB - hydrocodone-acetaminophen soln 7.5-500
mg/15ml......................................................................... 112
LORTAB - hydrocodone-acetaminophen tab 10-500
mg.................................................................................. 112
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LORTAB - hydrocodone-acetaminophen tab 5-500
mg.................................................................................. 112
LORTAB - hydrocodone-acetaminophen tab 7.5-500
mg.................................................................................. 112
LORTUSS EX - pseudoephedrine w/ cod-gg liqd
22.5-10-100 mg/5ml.........................................................67
LORTUSS EX - pseudoephedrine w/ cod-gg liquid
30-10-100 mg/5ml............................................................67
LORZONE - chlorzoxazone tab 375 mg......................... 132
LORZONE - chlorzoxazone tab 750 mg......................... 132
losartan potassium & hydrochlorothiazide tab
100-12.5 mg (Hyzaar).....................................................53
losartan potassium & hydrochlorothiazide tab 100-25
mg (Hyzaar).................................................................... 53
losartan potassium & hydrochlorothiazide tab 50-12.5
mg (Hyzaar).................................................................... 53
losartan potassium tab 100 mg (Cozaar)...................... 53
losartan potassium tab 25 mg (Cozaar)........................ 53
losartan potassium tab 50 mg (Cozaar)........................ 53
LOSEASONIQUE - levonorg-eth est tab 0.1-0.02mg(84) &
eth est tab 0.01mg(7)...................................................... 26
LOTEMAX - loteprednol etabonate ophth gel 0.5%........ 159
LOTEMAX - loteprednol etabonate ophth oint 0.5%....... 159
LOTEMAX - loteprednol etabonate ophth susp 0.5%......159
LOTENSIN - benazepril hcl tab 10 mg..............................53
LOTENSIN - benazepril hcl tab 20 mg..............................53
LOTENSIN - benazepril hcl tab 40 mg..............................53
LOTENSIN HCT - benazepril & hydrochlorothiazide tab
10-12.5 mg...................................................................... 53
LOTENSIN HCT - benazepril & hydrochlorothiazide tab
20-12.5 mg...................................................................... 53
LOTENSIN HCT - benazepril & hydrochlorothiazide tab
20-25 mg......................................................................... 53
LOTREL - amlodipine besylate-benazepril hcl cap 10-20
mg.................................................................................... 53
LOTREL - amlodipine besylate-benazepril hcl cap 10-40
mg.................................................................................... 53
LOTREL - amlodipine besylate-benazepril hcl cap 2.5-10
mg.................................................................................... 53
LOTREL - amlodipine besylate-benazepril hcl cap 5-10
mg.................................................................................... 53
LOTREL - amlodipine besylate-benazepril hcl cap 5-20
mg.................................................................................... 53
LOTREL - amlodipine besylate-benazepril hcl cap 5-40
mg.................................................................................... 53
LOTRISONE - clotrimazole w/ betamethasone cream
1-0.05%..........................................................................174
LOTRONEX - alosetron hcl tab 0.5 mg (base equiv)........ 81
LOTRONEX - alosetron hcl tab 1 mg (base equiv)........... 81
lovastatin tab 10 mg....................................................... 61
lovastatin tab 20 mg (Mevacor)..................................... 61
lovastatin tab 40 mg (Mevacor)..................................... 61
LOVAZA - omega-3-acid ethyl esters cap 1 gm................61
LOVENOX - enoxaparin sodium inj 100 mg/ml............... 155
LOVENOX - enoxaparin sodium inj 120 mg/0.8ml.......... 155
LOVENOX - enoxaparin sodium inj 150 mg/ml............... 155
304
LOVENOX - enoxaparin sodium inj 300 mg/3ml............. 155
LOVENOX - enoxaparin sodium inj 30 mg/0.3ml............ 155
LOVENOX - enoxaparin sodium inj 40 mg/0.4ml............ 155
LOVENOX - enoxaparin sodium inj 60 mg/0.6ml............ 155
LOVENOX - enoxaparin sodium inj 80 mg/0.8ml............ 155
loxapine succinate cap 10 mg....................................... 95
loxapine succinate cap 25 mg....................................... 95
loxapine succinate cap 50 mg....................................... 95
loxapine succinate cap 5 mg......................................... 95
LOXITANE - loxapine succinate cap 10 mg......................95
LOXITANE - loxapine succinate cap 25 mg......................95
LOXITANE - loxapine succinate cap 50 mg......................95
LOXITANE - loxapine succinate cap 5 mg........................95
LOZI-FLUR - sodium fluoride lozenge 1 mg f (from 2.2 mg
naf).................................................................................147
LUFYLLIN - dyphylline tab 200 mg................................... 72
LUFYLLIN - dyphylline tab 400 mg................................... 72
LUGOLS STRONG IODINE - iodine solution .................183
LUMIGAN - bimatoprost ophth soln 0.01%..................... 159
LUMIGAN - bimatoprost ophth soln 0.03%..................... 159
LUNESTA - eszopiclone tab 1 mg.................................... 98
LUNESTA - eszopiclone tab 2 mg.................................... 98
LUNESTA - eszopiclone tab 3 mg.................................... 98
LUPANETA PACK - leuprolide (1 mon) inj 3.75 mg &
norethindrone tab 5 mg kit.............................................. 38
LUPANETA PACK - leuprolide (3 mon) inj 11.25 mg &
norethindrone tab 5 mg kit.............................................. 38
LUPRON DEPOT - leuprolide acetate (3 month) for inj kit
11.25 mg..........................................................................17
LUPRON DEPOT - leuprolide acetate (3 month) for inj kit
22.5 mg............................................................................17
LUPRON DEPOT - leuprolide acetate (4 month) for inj kit
30 mg...............................................................................17
LUPRON DEPOT - leuprolide acetate (6 month) for inj kit
45 mg...............................................................................17
LUPRON DEPOT - leuprolide acetate for inj kit 3.75
mg.................................................................................... 17
LUPRON DEPOT - leuprolide acetate for inj kit 7.5
mg.................................................................................... 17
LUPRON DEPOT-PED - leuprolide acetate (3 month) for
inj pediatric kit 11.25 mg................................................. 38
LUPRON DEPOT-PED - leuprolide acetate (3 month) for
inj pediatric kit 30 mg...................................................... 39
LUPRON DEPOT-PED - leuprolide acetate for inj pediatric
kit 11.25 mg.....................................................................38
LUPRON DEPOT-PED - leuprolide acetate for inj pediatric
kit 15 mg..........................................................................38
LUPRON DEPOT-PED - leuprolide acetate for inj pediatric
kit 7.5 mg.........................................................................38
LURIDE - sodium fluoride chew tab 0.25 mg f (from 0.55
mg naf).......................................................................... 147
LURIDE - sodium fluoride chew tab 0.5 mg f (from 1.1 mg
naf).................................................................................147
LURIDE - sodium fluoride chew tab 1 mg f (from 2.2 mg
naf).................................................................................147
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LURIDE - sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml
naf).................................................................................147
LUVERIS - lutropin alfa for subcutaneous inj 75 unit........ 39
LUVOX CR - fluvoxamine maleate cap sr 24hr 100
mg.................................................................................... 90
LUVOX CR - fluvoxamine maleate cap sr 24hr 150
mg.................................................................................... 90
LUXIQ - betamethasone valerate aerosol foam
0.12%.............................................................................174
LUZU - luliconazole cream 1%....................................... 174
LYCELLE - nit remover - gel ..........................................174
LYRICA - pregabalin cap 100 mg................................... 127
LYRICA - pregabalin cap 150 mg................................... 127
LYRICA - pregabalin cap 200 mg................................... 127
LYRICA - pregabalin cap 225 mg................................... 127
LYRICA - pregabalin cap 25 mg..................................... 127
LYRICA - pregabalin cap 300 mg................................... 127
LYRICA - pregabalin cap 50 mg..................................... 127
LYRICA - pregabalin cap 75 mg..................................... 127
LYRICA - pregabalin soln 20 mg/ml................................127
LYSODREN - mitotane tab 500 mg.................................. 17
LYSTEDA - tranexamic acid tab 650 mg........................ 155
LYTENSOPRIL-90 KIT - lisinopril tab 20 mg & dietary
management cap pack.................................................... 53
LYTENSOPRIL-90 - lisinopril tab 20 mg & dietary
management cap pack.................................................... 53
LYTENSOPRIL KIT - lisinopril tab 20 mg & dietary
management cap pack.................................................... 53
M
MACNATAL CN DHA - prenatal w/o a w/fe cbn-dss-fa-dha
cap 28-1-250 mg .......................................................... 137
MACROBID - nitrofurantoin monohydrate macrocrystalline
cap 100 mg..................................................................... 82
MACRODANTIN - nitrofurantoin macrocrystalline cap 100
mg.................................................................................... 82
MACRODANTIN - nitrofurantoin macrocrystalline cap 25
mg.................................................................................... 82
MACRODANTIN - nitrofurantoin macrocrystalline cap 50
mg.................................................................................... 82
mafenide acetate packet for topical soln 5% (50 gm)
(Sulfamylon)................................................................. 174
MAGELLAN INSULIN SAFETY S - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................215
MAGELLAN INSULIN SAFETY S - insulin syringe/needle
u-100 0.3 ml 30 x 5/16".................................................215
MAGELLAN INSULIN SAFETY S - insulin syringe/needle
u-100 1/2 ml 29 x 1/2"...................................................215
MAGELLAN INSULIN SAFETY S - insulin syringe/needle
u-100 1/2 ml 30 x 5/16".................................................215
MAGELLAN INSULIN SAFETY S - insulin syringe/needle
u-100 1 ml 29 x 1/2"......................................................215
MAGELLAN INSULIN SAFETY S - insulin syringe/needle
u-100 1 ml 30 x 5/16"....................................................215
MAGNACET - oxycodone w/ acetaminophen tab 10-400
mg.................................................................................. 112
MAGNACET - oxycodone w/ acetaminophen tab 5-400
mg.................................................................................. 112
MAGNACET - oxycodone w/ acetaminophen tab 7.5-400
mg.................................................................................. 112
MAGNEBIND 400 - magnesium-calcium-folic acid tab
400-200-1 mg................................................................ 147
MAJOR COMFORT LANCETS - lancets ....................... 215
MALARONE - atovaquone-proguanil hcl tab 250-100
mg.................................................................................... 13
MALARONE - atovaquone-proguanil hcl tab 62.5-25
mg.................................................................................... 13
malathion lotion 0.5% (Ovide)......................................174
MAPROTILINE HCL - maprotiline hcl tab 25 mg.............. 90
MAPROTILINE HCL - maprotiline hcl tab 50 mg.............. 91
MAPROTILINE HCL - maprotiline hcl tab 75 mg.............. 91
MAR-COF BP - pseudoephedrine-bromphen-codeine liqd
30-2-7.5 mg/5ml.............................................................. 67
MAR-COF CG EXPECTORANT - guaifenesin-codeine
liquid 225-7.5 mg/5ml...................................................... 67
MARINOL - dronabinol cap 10 mg....................................79
MARINOL - dronabinol cap 2.5 mg...................................79
MARINOL - dronabinol cap 5 mg......................................79
MARNATAL-F - prenatal w/o vit a w/ fe polysac cmplx-fa
cap 60-1 mg ................................................................. 137
MARPLAN - isocarboxazid tab 10 mg.............................. 91
MATULANE - procarbazine hcl cap 50 mg....................... 17
MAVIK - trandolapril tab 1 mg.......................................... 53
MAVIK - trandolapril tab 2 mg.......................................... 53
MAVIK - trandolapril tab 4 mg.......................................... 53
MAXAIR AUTOHALER - pirbuterol acetate breath
activated inhal aerosol 200mcg/inh................................. 72
MAXALT-MLT - rizatriptan benzoate orally disintegrating
tab 10 mg...................................................................... 122
MAXALT-MLT - rizatriptan benzoate orally disintegrating
tab 5 mg........................................................................ 122
MAXALT - rizatriptan benzoate tab 10 mg...................... 122
MAXALT - rizatriptan benzoate tab 5 mg........................ 122
MAXARON FORTE - fe gly-fe fum-vit c-vit b12methylfolate tab ............................................................ 153
MAXFE - iron-fa-vit b12-biotin-vit c-docusate-mg-zn tab
160-1 mg ...................................................................... 153
MAXI-COMFORT INSULIN SYRI - insulin syringe/needle
u-100 1/2 ml 28 x 1/2"...................................................215
MAXI-COMFORT INSULIN SYRI - insulin syringe/needle
u-100 1 ml 28 x 1/2"......................................................215
MAXIDEX - dexamethasone ophth susp 0.1%................159
MAXIDONE - hydrocodone-acetaminophen tab 10-750
mg.................................................................................. 112
MAXIFED CD - pseudoephedrine w/ cod-gg tab 60-10-400
mg.................................................................................... 67
MAXIFED CDX - pseudoephedrine w/ cod-gg tab
60-20-400 mg.................................................................. 67
MAXIFED-G CD - pseudoephedrine w/ cod-gg tab
40-10-400 mg.................................................................. 67
MAXIFED-G CDX - pseudoephedrine w/ cod-gg tab
40-20-400 mg.................................................................. 67
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MAXIFED-G - pseudoephedrine-guaifenesin tab 40-400
mg.................................................................................... 67
MAXIFLU CD - pseudoephed-codeine-guaifenesin-apap
tab 40-10-400-500 mg..................................................... 67
MAXIFLU CDX - pseudoephed-codeine-guaifenesin-apap
tab 60-20-400-500 mg.....................................................67
MAXIMA BLOOD GLUCOSE MONI - blood glucose
monitoring kit w/ device ................................................215
MAXIMA BLOOD GLUCOSE TEST - glucose blood test
strip................................................................................ 186
MAXIMA CONTROL SOLUTION/N - blood glucose
calibration - liquid - normal ...........................................215
MAXIMA CONTROL SOLUTION - blood glucose
calibration - liquid ......................................................... 215
MAXIMA METER KIT - blood glucose monitoring kit w/
device ........................................................................... 215
MAXIMA STARTER KIT - blood glucose monitoring kit w/
device ........................................................................... 215
MAXINATE - prenatal vit w/ fe gluc-fe fum-fa tab 20-0.8
mg .................................................................................137
MAXIPHEN CD - phenylephrine w/ codeine-gg tab
10-10-400 mg.................................................................. 67
MAXIPHEN CDX - phenylephrine w/ codeine-gg tab
10-20-400 mg.................................................................. 67
MAXITROL - neomycin-polymyxin-dexamethasone ophth
oint 0.1%........................................................................159
MAXITROL - neomycin-polymyxin-dexamethasone ophth
susp 0.1%......................................................................159
MAXZIDE-25 - triamterene & hydrochlorothiazide tab
37.5-25 mg...................................................................... 58
MAXZIDE - triamterene & hydrochlorothiazide tab 75-50
mg.................................................................................... 58
M-CLEAR - guaifenesin-codeine cap 200-9 mg................ 67
meclizine hcl tab 12.5 mg...............................................79
meclizine hcl tab 25 mg..................................................79
meclizine hcl tab 32 mg..................................................79
MECLOFENAMATE SODIUM - meclofenamate sodium
cap 100 mg................................................................... 119
MECLOFENAMATE SODIUM - meclofenamate sodium
cap 50 mg..................................................................... 119
MEDICHOICE PRE-SET SAFETY - lancets .................. 215
MEDICHOICE SAFETY LANCET - lancets ....................215
MEDICINE SHOPPE LANCETS - lancets ......................215
MEDICINE SHOPPE LANCETS T - lancets .................. 215
MEDICINE SHOPPE PEN NEEDL - insulin pen needle 29
g x 12 mm (1/2")........................................................... 215
MEDICINE SHOPPE PEN NEEDL - insulin pen needle 31
g x 6 mm (1/4")............................................................. 215
MEDICINE SHOPPE PEN NEEDL - insulin pen needle 31
g x 8 mm (1/3" or 5/16")................................................215
MEDIC INSULIN SYRINGE/0.3 - insulin syringe/needle
u-100 0.3 ml 30 x 5/16".................................................215
MEDIC INSULIN SYRINGE/0.5 - insulin syringe/needle
u-100 1/2 ml 30 x 5/16".................................................215
MEDI-DERM/L-RX - lidocaine-capsaicin-menthol-methyl
sal cream 2-0.035-5-20%.............................................. 174
306
MEDI-DERM-RX - capsaicin-menthol-methyl salicylate
cream 0.035-5-20%....................................................... 174
MEDI-LANCE LANCETS - lancets .................................215
MEDI-PATCH RX - lidocaine-capsaicin-menthol-methyl sal
patch 0.5-0.035-5-20%.................................................. 174
MEDISENSE GLUCOSE KETONE - blood glucose
calibration - liquid ......................................................... 215
MEDISENSE HIGH/LOW CONTRO - blood glucose
calibration - liquid ......................................................... 216
MEDISENSE HIGH/MID/LOW CO - blood glucose
calibration - liquid ......................................................... 216
MEDISENSE MID CONTROL SOL - blood glucose
calibration - liquid ......................................................... 216
MEDISENSE THIN LANCETS - lancets ........................ 216
MEDLANCE/EXTRA - lancets ........................................216
MEDLANCE/LITE - lancets ............................................ 216
MEDLANCE/UNIVERSAL - lancets ............................... 216
MEDLANCE PLUS/LITE 25G - lancets ..........................216
MEDLANCE PLUS EXTRA LANCE - lancets ................ 216
MEDLANCE PLUS LANCETS - lancets .........................216
MEDLANCE PLUS LANCETS LIT - lancets ...................216
MEDLANCE PLUS LITE LANCET - lancets ...................216
MEDLANCE PLUS SPECIAL LAN - lancets .................. 216
MEDLANCE PLUS SUPERLITE 3 - lancets .................. 216
MEDLANCE PLUS UNIVERSAL L - lancets .................. 216
MEDROL DOSEPAK - methylprednisolone tab 4 mg dose
pack................................................................................. 20
MEDROL - methylprednisolone tab 16 mg....................... 20
MEDROL - methylprednisolone tab 2 mg......................... 20
MEDROL - methylprednisolone tab 32 mg....................... 20
MEDROL - methylprednisolone tab 4 mg......................... 20
MEDROL - methylprednisolone tab 8 mg......................... 20
MEDROX-RX - capsaicin-menthol-methyl salicylate oint
0.05-7-20%.................................................................... 174
medroxyprogesterone acetate im susp 150 mg/ml
(Depo-provera contrac)................................................. 26
medroxyprogesterone acetate tab 10 mg (Provera).....27
medroxyprogesterone acetate tab 2.5 mg
(Provera)......................................................................... 27
medroxyprogesterone acetate tab 5 mg (Provera).......27
mefenamic acid cap 250 mg (Ponstel)........................ 119
mefloquine hcl tab 250 mg.............................................13
MEGACE ES - megestrol acetate susp 625 mg/5ml......... 28
MEGACE ORAL - megestrol acetate susp 40 mg/ml........ 17
megestrol acetate susp 40 mg/ml (Megace oral)..........17
megestrol acetate tab 20 mg..........................................17
megestrol acetate tab 40 mg..........................................17
MEIJER BLOOD GLUCOSE MONI - blood glucose
monitoring kit w/ device ................................................216
MEIJER BLOOD GLUCOSE TEST - glucose blood test
strip................................................................................ 186
MEIJER COLOR LANCETS UNIV - lancets ...................216
MEIJER LANCETS - lancets ..........................................216
MEIJER LANCETS THIN - lancets ................................ 216
MEIJER LANCETS UNIVERSAL - lancets .....................216
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide January 2015
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MEIJER PEN NEEDLES 29G X - insulin pen needle 29 g
x 12 mm (1/2")...............................................................216
MEIJER PEN NEEDLES 31G X - insulin pen needle 31 g
x 6 mm (1/4").................................................................216
MEIJER PEN NEEDLES 31G X - insulin pen needle 31 g
x 8 mm (1/3" or 5/16")...................................................216
MEIJER PREMIUM BLOOD GLUC - blood glucose
monitoring kit w/ device ................................................216
MEIJER PREMIUM BLOOD GLUC - glucose blood test
strip................................................................................ 186
MEIJER SUPER THIN LANCETS - lancets ................... 216
MEIJER TRUE2GO BLOOD GLUC - blood glucose
monitoring kit w/ device ................................................216
MEIJER TRUERESULT BLOOD G - blood glucose
monitoring kit w/ device ................................................216
MEIJER TRUETEST BLOOD GLU - glucose blood test
strip................................................................................ 187
MEIJER TRUETRACK BLOOD GL - blood glucose
monitoring kit w/ device ................................................216
MEIJER TRUETRACK BLOOD GL - glucose blood test
strip................................................................................ 187
MEKINIST - trametinib dimethyl sulfoxide tab 0.5 mg
(base equivalent)............................................................. 17
MEKINIST - trametinib dimethyl sulfoxide tab 2 mg (base
equivalent)....................................................................... 17
MELOXICAM COMFORT PAC - meloxicam tab 15 mg &
liniment topical gel kit.................................................... 119
MELOXICAM - meloxicam susp 7.5 mg/5ml................... 119
meloxicam tab 15 mg (Mobic)......................................119
meloxicam tab 7.5 mg (Mobic).....................................119
M-END MAX D - pseudoephedrine-dexbromphen-codeine
liqd 20-0.667-6 mg/5ml....................................................67
M-END PE - phenylephrine-bromphen w/ codeine liqd
3.33-1.33-6.33 mg/5ml.....................................................67
MENEST - esterified estrogens tab 0.3 mg.......................24
MENEST - esterified estrogens tab 0.625 mg...................24
MENEST - esterified estrogens tab 1.25 mg.....................24
MENEST - esterified estrogens tab 2.5 mg.......................24
MENOPUR - menotropins for subcutaneous inj 75
unit................................................................................... 39
MENOSTAR - estradiol td patch weekly 14 mcg/24hr.......24
MENTAX - butenafine hcl cream 1%.............................. 174
MEPERIDINE HCL/PROMETHAZI - meperidine w/
promethazine cap 50-25 mg..........................................112
MEPERIDINE HCL - meperidine hcl oral soln 50
mg/5ml........................................................................... 112
meperidine hcl tab 100 mg (Demerol)......................... 112
meperidine hcl tab 50 mg (Demerol)........................... 112
MEPHYTON - phytonadione tab 5 mg............................ 134
meprobamate tab 200 mg...............................................87
meprobamate tab 4