Drug Formulary - Blue Cross Blue Shield of Nebraska
January 2015 Blue Cross and Blue Shield of Nebraska Preferred Drug List Click to search for a drug name in this document Contents Key Drug Formulary .............................................................. I caps .................................................................... capsules At your health care professional’s office ...................... I chew tabs.............................................. chewable tablets At the pharmacy ........................................................... I conc............................................................... concentrate Specialty drugs ............................................................. I crm ......................................................................... cream For more information .................................................... I inhal................................................................... inhalation How to use this list ...................................................... II inj ....................................................................... injectable Therapeutic Class Drug List ........................................ 1 IR ........................................................ immediate-release Anti-Infective Agents ................................................... 1 liq .............................................................................. liquid Immunizing Agents ...................................................... 3 lotn ........................................................................... lotion Cancer Drugs .............................................................. 3 NF ............................................................... non-formulary Hormones, Diabetes and Related Drugs .................... 4 oint ..................................................................... ointment Heart and Circulatory Drugs ........................................ 6 ODT ........................................... orally disintegrating tabs Respiratory Agents ...................................................... 7 OSM ......................................................... osmotic-release Gastrointestinal Agents ............................................... 8 SL ..................................................................... sublingual Genitourinary Agents................................................... 9 soln ....................................................................... solution Central Nervous System Drugs ................................... 9 supp ............................................................ suppositories Pain Relief Drugs ...................................................... 11 susp................................................................ suspension Neuromuscular Drugs ............................................... 12 tabs.........................................................................tablets Supplements ............................................................. 13 Topical Drugs ............................................................ 13 Miscellaneous Products ............................................ 15 Index ............................................................................ 17 To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click on Search. Blue Cross and Blue Shield of Nebraska is an independent licensee of the Blue Cross and Blue Shield ® ® Association. BLUE CROSS , BLUE SHIELD , and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Prime Therapeutics LLC is an independent company providing pharmacy benefit management services. 2296 NE © Prime Therapeutics LLC 01/15 Drug formulary This Patient Medication List, also called a formulary, is a list of medications included in most prescription drug benefits. Coverage of formulary and non-formulary (NF) drugs is subject to your prescription benefit plan design. A Pharmacy and Therapeutics Committee reviewed and approved this medication list. All medications on the list were selected after consideration of safety, effectiveness, uniqueness and cost. The Committee includes practicing physicians and pharmacists dedicated to providing patients with high-quality, cost-effective drug therapy. The Committee meets periodically to consider updates to the formulary. Medications listed in this booklet are formulary drugs. Drugs not listed are NF. At your health care professional’s office: Show this booklet to your health care professional each time a prescription is written Ask your health care professional if there are appropriate generic drugs to treat your condition At the pharmacy: Bring this booklet to the pharmacy each time you have a prescription filled Ask the pharmacist to fill your prescriptions with generic drugs, when appropriate Generic drugs are as safe and effective as their brand counterparts, and generally have a lower copay or co-insurance than brand drugs. To encourage the use of generic drugs, brand formulary drugs usually move to non-formulary (NF) status after a generic version becomes available. Formulary drugs are subject to annual review. Drug additions/removals may occur quarterly. However, the formulary may be updated at any time without notice. Specialty drugs Some Blue Cross and Blue Shield of Nebraska groups offer specific benefits for specialty drug products. Please refer to your Certificate of Coverage and/or Schedule of Benefits to determine the specific quantities allowed under your group’s benefit. Specialty products are typically injectable drugs that can be self administered by a patient or family member and are used to treat serious or chronic medical conditions such as multiple sclerosis, hemophilia, hepatitis and rheumatoid arthritis. For more information To access a searchable version of the Blue Cross and Blue Shield of Nebraska Drug formulary, visit our website at www.nebraskablue.com. If you have questions about your prescription benefit or how to use this booklet, please call the number on the back of your member ID card. I Blue Cross and Blue Shield of Nebraska Drug Formulary, January 2015 How to use this list This list is organized into broad therapeutic categories. For example, Anti-infective Drugs is a broad category. Within most categories, drugs are sub-grouped based upon drug class, for example under Anti-infective Drugs you will find Penicillins. All drugs listed, whether generic or brand, are formulary drugs. The first column of the chart lists the drug name. Generic drugs are shown in lower-case boldface type. Example: amoxicillin caps, susp, tabs Formulary brand drugs are listed in all CAPITAL letters. Example: AUGMENTIN susp, 125 mg/5 mL The following examples are given to assist you and your doctor in reading listings that include specific strengths and dosage forms. These examples can be applied to other drugs on the formulary. Any exceptions are noted and some listings contain additional information about specific products or dosage forms. Extended-release and delayed-release products require their own entry. Example: amoxicillin/potassium clavulanate ext-release The long-acting product amoxicillin/potassium clavulanate ext-release is on the formulary, but requires a separate entry from the non ext-release product amoxicillin/potassium clavulanate. Some products may show a strength, if so only that strength indicated is on the formulary. Example: AUGMENTIN susp, 125 mg/5 mL The second column indicates if the drug is a specialty drug. Note: Additional information about specialty drugs can be found in this document under the header for Specialty Drugs. The remaining columns indicate the Utilization Management (UM) program(s) that apply to the prescription drug (e.g., Maximum Monthly Quantity). If an indicator is present in the column(s), then the UM program noted is possibly applied to your benefit. Some plans may have UM on additional medications beyond those noted in this document. is possibly applied to your benefit. Some plans may have UM on additional medications beyond those noted in this document. Blue Cross and Blue Shield of Nebraska Drug Formulary, January 2015 II ANTI-INFECTIVE DRUGS doxycycline hyclate PENICILLINS doxycycline monohydrate amoxicillin caps, susp, tabs minocycline AMOXICILLIN chew tabs TETRACYCLINE amoxicillin/potassium clavulanate FLUOROQUINOLONES amoxicillin/potassium clavulanate extrelease ciprofloxacin IR, susp ampicillin caps levofloxacin ampicillin susp ofloxacin AUGMENTIN susp, 125 mg/5 mL AMINOGLYCOSIDES dicloxacillin neomycin sulfate penicillin v potassium paromomycin CEPHALOSPORINS tobramycin inhal soln cefaclor caps TUBERCULOSIS cefadroxil ethambutol cefdinir ISONIAZID syrup cefpodoxime isoniazid tabs cefprozil PRIFTIN ceftriaxone pyrazinamide cefuroxime rifabutin cephalexin, NF = tabs rifampin SUPRAX FUNGAL INFECTIONS MACROLIDES fluconazole AZITHROMYCIN packets flucytosine azithromycin susp, tabs griseofulvin microsize clarithromycin itraconazole clarithromycin ext-release LAMISIL granules E.E.S. 400 NOXAFIL ERY-TAB nystatin oral ERYTHROCIN STEARATE SPORANOX soln erythromycin base terbinafine erythromycin delayed-release caps voriconazole erythromycin ethylsuccinate VIRAL INFECTIONS TETRACYCLINES Cytomegalovirus demeclocycline VALCYTE Maximum Monthly Quantity Drug Name Specialty Maximum Monthly Quantity Drug Name Specialty 2015 ciprofloxacin ext-release Blue Cross and Blue Shield of Nebraska Drug Formulary, January 2015 • 1 valganciclovir tab, 450 mg nevirapine ext-release Hepatitis NORVIR adefovir PREZISTA entecavir RESCRIPTOR EPIVIR HBV oral soln REYATAZ lamivudine SELZENTRY OLYSIO PEGASYS ribavirin SOVALDI • • • • stavudine STRIBILD SUSTIVA TIVICAY Herpes TRIUMEQ acyclovir TRUVADA famciclovir TYBOST valacyclovir VIDEX HIV/AIDS VIRACEPT abacavir VIRAMUNE susp abacavir/lamivudine/zidovudine VIRAMUNE XR tabs, 100 mg APTIVUS VIREAD ATRIPLA ZIAGEN soln COMPLERA zidovudine CRIXIVAN Influenza didanosine delayed-release TAMIFLU EDURANT MALARIA EMTRIVA atovaquone/proguanil EPIVIR oral soln chloroquine phosphate EPZICOM COARTEM FUZEON • DARAPRIM INTELENCE hydroxychloroquine INVIRASE mefloquine ISENTRESS PRIMAQUINE KALETRA WORM INFECTIONS lamivudine ALBENZA lamivudine/zidovudine BILTRICIDE LEXIVA ivermectin nevirapine IR STROMECTOL 2 Maximum Monthly Quantity Drug Name Specialty Maximum Monthly Quantity Drug Name Specialty 2015 Blue Cross and Blue Shield of Nebraska Drug Formulary, January 2015 OTHER ANTI-INFECTIVES flutamide clindamycin GILOTRIF dapsone GLEEVEC erythromycin/sulfisoxazole HEXALEN metronidazole HYCAMTIN caps NEBUPENT hydroxyurea SIVEXTRO ICLUSIG sulfamethoxazole/trimethoprim IMBRUVICA trimethoprim INLYTA vancomycin JAKAFI XIFAXAN 550 mg KEYTRUDA ZYVOX letrozole IMMUNIZING AGENTS leucovorin calcium BCG VACCINE LEUKERAN SYNAGIS • CANCER DRUGS The list of drugs shown below includes selected oral and injectable cancer drugs on the formulary. A complete listing of generic and brand cancer drugs are listed in the alphabetical index. AFINITOR AFINITOR DISPERZ • • LYSODREN MATULANE mercaptopurine MESNEX tabs MYLERAN bicalutamide NEXAVAR CAPRELSA COMETRIQ CYCLOPHOSPHAMIDE ERIVEDGE POMALYST SOLTAMOX SUTENT etoposide caps SYLATRON exemestane TABLOID FARESTON TAFINLAR FIRMAGON • • PURIXAN STIVARGA • • NILANDRON SPRYCEL EMCYT • • MEKINIST anastrozole capecitabine • • • • megestrol methotrexate • • • • • • • • LOMUSTINE ALKERAN tabs BOSULIF Maximum Monthly Quantity Drug Name Specialty Maximum Monthly Quantity Drug Name Specialty 2015 • • • • tamoxifen Blue Cross and Blue Shield of Nebraska Drug Formulary, January 2015 3 TARCEVA TARGRETIN caps TASIGNA temozolomide tretinoin caps TYKERB VOTRIENT XALKORI XTANDI ZELBORAF ZOLINZA • • • • • • • • • • • ZYDELIG ZYKADIA ZYTIGA testosterone enanthate ESTROGENS CLIMARA PRO DIVIGEL estradiol estradiol/norethindrone acetate estropipate FEMHRT LOW DOSE PREMARIN tabs PREMPHASE PREMPRO VIVELLE-DOT • • PROGESTINS medroxyprogesterone acetate HORMONES, DIABETES AND RELATED DRUGS norethindrone acetate CORTICOSTEROIDS progesterone micronized budesonide ext-release BIRTH CONTROL cortisone dexamethasone desogestrel/ethinyl estradiol, biphasic – Azurette, Kariva, Pimtrea, Viorele DEXAMETHASONE INTENSOL ELLA fludrocortisone levonorgestrel – Next Choice hydrocortisone MILLIPRED tabs levonorgestrel/ethinyl estradiol, 0.1 mg/20 mcg – Aubra, Aviane, Falmina, Lessina, Lutera, Orsythia, Sronyx prednisolone norelgestromin/ethinyl estradiol – Xulane prednisolone sodium phosphate, NF = 25 mg/5 mL norethindrone – Camila, Errin, Heather, Jencycla, Jolivette, Lyza, Nora-Be prednisone norethindrone/ethinyl estradiol, 1 mg/35 mcg – Alyacen, Cyclafem, Dasetta, Necon, Nortrel, Pirmella methylprednisolone PREDNISONE soln, 5 mg/5 mL; tabs, 50 mg MALE HORMONES ANDROGEL norgestimate/ethinyl estradiol, triphasic – Trinessa, Tri-Estaryll, Tri-Linyah, TriPrevifem, Tri-Sprintec ANDROXY INFERTILITY danazol CETROTIDE testosterone cypionate chorionic gonadotropin ANDRODERM 4 Maximum Monthly Quantity Drug Name Specialty Maximum Monthly Quantity Drug Name Specialty 2015 • • Blue Cross and Blue Shield of Nebraska Drug Formulary, January 2015 clomiphene GONAL-F REPRONEX Maximum Monthly Quantity Drug Name Specialty Maximum Monthly Quantity Drug Name Specialty 2015 RELION R • • Intermediate-Acting Insulins NOVOLIN N DIABETES NOVOLIN 70/30 acarbose NOVOLOG MIX 70/30 BYDUREON Basal Insulins BYETTA LANTUS glimepiride LEVEMIR glipizide THYROID REGULATION glipizide ext-release levothyroxine glipizide/metformin liothyronine GLUCAGON EMERGENCY KIT methimazole glyburide propylthiouracil glyburide micronized GROWTH HORMONE glyburide/metformin INCRELEX INVOKAMET OMNITROPE INVOKANA OTHER HORMONES AND RELATED DRUGS JANUMET alendronate JANUMET XR cabergoline JANUVIA calcitonin-salmon KOMBIGLYZE XR calcitriol metformin desmopressin metformin ext-release etidronate metformin ext-release OSM FABRAZYME nateglinide ibandronate ONGLYZA levocarnitine pioglitazone methylergonovine pioglitazone/metformin octreotide repaglinide ORFADIN VICTOZA paricalcitol DIABETES - INSULINS PROLIA Rapid-Acting Insulins raloxifene NOVOLOG risedronate Short-Acting Insulins SANDOSTATIN LAR DEPOT NOVOLIN R SENSIPAR Blue Cross and Blue Shield of Nebraska Drug Formulary, January 2015 • • • • • • 5 HEART AND CIRCULATORY DRUGS bisoprolol ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS AND COMBINATIONS bisoprolol/hydrochlorothiazide benazepril DUTOPROL benazepril/hydrochlorothiazide labetalol captopril metoprolol succinate ext-release captopril/hydrochlorothiazide 25-15 mg, 50-15 mg metoprolol tartrate carvedilol nadolol enalapril pindolol enalapril/hydrochlorothiazide PROPRANOLOL soln fosinopril propranolol tabs fosinopril/hydrochlorothiazide propranolol ext-release lisinopril propranolol/hydrochlorothiazide lisinopril/hydrochlorothiazide timolol moexipril moexipril/hydrochlorothiazide CALCIUM CHANNEL BLOCKERS AND COMBINATIONS perindopril amlodipine quinapril amlodipine/benazepril quinapril/hydrochlorothiazide amlodipine/valsartan ramipril diltiazem trandolapril diltiazem ext-release ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS) AND COMBINATIONS felodipine ext-release BENICAR BENICAR HCT EXFORGE HCT irbesartan irbesartan/hydrochlorothiazide losartan losartan/hydrochlorothiazide valsartan valsartan/hydrochlorothiazide BETA BLOCKERS AND COMBINATIONS acebutolol atenolol atenolol/chlorthalidone 6 Maximum Monthly Quantity Drug Name Specialty Maximum Monthly Quantity Drug Name Specialty 2015 nifedipine ext-release verapamil verapamil ext-release CHEST PAIN (ANGINA) isosorbide dinitrate isosorbide mononitrate isosorbide mononitrate ext-release NITRO-BID nitroglycerin NITROSTAT CHOLESTEROL LOWERING atorvastatin cholestyramine Blue Cross and Blue Shield of Nebraska Drug Formulary, January 2015 colestipol propafenone CRESTOR propafenone ext-release fenofibrate quinidine gluconate ext-release fenofibrate micronized quinidine sulfate fenofibric acid delayed-release QUINIDINE SULFATE ext-release gemfibrozil sotalol lovastatin sotalol AF niacin ext-release OTHER HEART RELATED DRUGS pravastatin ADCIRCA simvastatin amlodipine/atorvastatin WELCHOL clonidine tabs FLUID RETENTION clonidine transdermal patches acetazolamide DIBENZYLINE acetazolamide ext-release digoxin amiloride doxazosin amiloride/hydrochlorothiazide eplerenone bumetanide guanfacine chlorothiazide hydralazine chlorthalidone LETAIRIS furosemide methyldopa hydrochlorothiazide caps, tabs midodrine indapamide minoxidil methazolamide OPSUMIT metolazone prazosin spironolactone sildenafil 20 mg spironolactone/hydrochlorothiazide terazosin torsemide TRACLEER triamterene/hydrochlorothiazide, NF = 50-25 mg ERECTILE DYSFUNCTION HEART RHYTHM BEE STING KITS amiodarone EPIPEN disopyramide EPIPEN-JR flecainide RESPIRATORY AGENTS mexiletine ANTIHISTAMINES MULTAQ cetirizine syrup Maximum Monthly Quantity Drug Name Specialty Maximum Monthly Quantity Drug Name Specialty 2015 • • • • • CIALIS Blue Cross and Blue Shield of Nebraska Drug Formulary, January 2015 7 cyproheptadine QVAR promethazine SEREVENT DISKUS NASAL PRODUCTS SPIRIVA HANDIHALER ASTEPRO SPIRIVA RESPIMAT azelastine SYMBICORT BACTROBAN NASAL terbutaline flunisolide 25 mcg/spray theophylline ext-release fluticasone propionate VENTOLIN HFA ipratropium zafirlukast NASONEX OTHER RESPIRATORY DRUGS triamcinolone CINRYZE COUGH/COLD/ALLERGY FIRAZYR acetylcysteine KALYDECO SSKI PULMOZYME ASTHMA/COPD GASTROINTESTINAL DRUGS ADVAIR DISKUS LAXATIVES ADVAIR HFA lactulose albuterol inhal soln, syrup, tabs PEG – electrolytes for soln ANORO ELLIPTA ANTIDIARRHEALS ASMANEX loperamide ATROVENT HFA ULCER/GERD BREO ELLIPTA CARAFATE susp budesonide inhal soln cimetidine COMBIVENT RESPIMAT dicyclomine cromolyn sodium famotidine DULERA glycopyrrolate FLOVENT DISKUS hyoscyamine FLOVENT HFA hyoscyamine ext-release FORADIL AEROLIZER lansoprazole delayed-release ipratropium methscopolamine ipratropium/albuterol misoprostol levalbuterol inhal soln NEXIUM montelukast omeprazole delayed-release PROAIR HFA pantoprazole delayed-release PULMICORT RESPULES 1 mg/2 mL PROPANTHELINE 8 Maximum Monthly Quantity Drug Name Specialty Maximum Monthly Quantity Drug Name Specialty 2015 • • • • Blue Cross and Blue Shield of Nebraska Drug Formulary, January 2015 ranitidine sucralfate nitrofurantoin monohydrate/ macrocrystalline NAUSEA AND VOMITING URINARY TRACT SPASMS ALOXI oxybutynin EMEND oxybutynin ext-release granisetron tolterodine meclizine tolterodine ext-release ondansetron VESICARE trimethobenzamide VAGINAL PRODUCTS DIGESTIVE ENZYMES CLEOCIN supp CREON clindamycin crm ZENPEP ESTRACE crm OTHER GASTROINTESTINAL DRUGS metronidazole gel ASACOL HD terconazole balsalazide VAGIFEM calcium acetate OTHER GENITOURINARY DRUGS CANASA alfuzosin ext-release CHENODAL • Maximum Monthly Quantity Drug Name Specialty Maximum Monthly Quantity Drug Name Specialty 2015 AVODART DELZICOL CYSTAGON diphenoxylate/atropine CYTRA-3 lactulose finasteride LIALDA K-PHOS NO. 2 LINZESS pot & sod citrates/citric acid soln mesalamine potassium citrate ext-release metoclopramide potassium citrate/citric acid powder PENTASA sodium citrate/citric acid RENVELA tamsulosin sulfasalazine CENTRAL NERVOUS SYSTEM DRUGS sulfasalazine delayed-release ANXIETY ursodiol alprazolam GENITOURINARY DRUGS alprazolam ext-release URINARY TRACT INFECTIONS ALPRAZOLAM INTENSOL MACRODANTIN 25 mg buspirone nitrofurantoin diazepam oral soln, 1 mg/mL nitrofurantoin macrocrystalline diazepam tabs Blue Cross and Blue Shield of Nebraska Drug Formulary, January 2015 9 DIAZEPAM INTENSOL haloperidol tabs hydroxyzine hcl LITHIUM hydroxyzine pamoate lithium carbonate lorazepam lithium carbonate ext-release DEPRESSION loxapine amitriptyline olanzapine bupropion perphenazine bupropion ext-release prochlorperazine citalopram quetiapine clomipramine risperidone desipramine SEROQUEL XR doxepin thiothixene duloxetine delayed-release trifluoperazine escitalopram ziprasidone fluoxetine, NF = 60 mg SLEEP AIDS fluvoxamine estazolam imipramine hcl phenobarbital mirtazapine PHENOBARBITAL 64.8 mg, 97.2 mg nortriptyline temazepam paroxetine hcl zaleplon paroxetine hcl ext-release zolpidem phenelzine zolpidem ext-release sertraline HYPERACTIVITY/NARCOLEPSY tranylcypromine amphetamine/dextroamphetamine trazodone venlafaxine amphetamine/dextroamphetamine extrelease venlafaxine ext-release, NF = 225 mg caffeine citrate PSYCHOTIC AND BIPOLAR DISORDERS dextroamphetamine chlorpromazine dextroamphetamine ext-release clozapine INTUNIV fluphenazine decanoate inj methylphenidate tabs FLUPHENAZINE HCL conc, elixir methylphenidate ext-release, NF = tabs, 10 mg fluphenazine hcl tabs haloperidol decanoate haloperidol lactate oral soln 10 Maximum Monthly Quantity Drug Name Specialty Maximum Monthly Quantity Drug Name Specialty 2015 modafinil VYVANSE Blue Cross and Blue Shield of Nebraska Drug Formulary, January 2015 • • • • • BETASERON COPAXONE PLEGRIDY REBIF TECFIDERA codeine sulfate tabs, 30 mg, 60 mg fentanyl patches hydrocodone/acetaminophen, NF = tabs, 2.5-325 mg hydrocodone/ibuprofen hydromorphone soln, tabs acamprosate delayed-release hydromorphone supp bupropion ext-release – smoking deterrent KADIAN caps, 10 mg, 40 mg, 70 mg, 130 mg, 150 mg, 200 mg CHANTIX methadone conc, soln, tabs disulfiram morphine sulfate conc, soln, supp, tabs donepezil morphine sulfate ext-release galantamine NUCYNTA ER galantamine ext-release oxycodone naltrexone oxycodone/acetaminophen NAMENDA oxycodone/aspirin NAMENDA XR OXYCONTIN NICOTROL INHALER ROXICET soln NICOTROL NS SUBOXONE film NUEDEXTA tramadol ORAP tramadol ext-release rivastigmine tramadol/acetaminophen • • fentanyl lollipops OTHER CENTRAL NERVOUS SYSTEM DRUGS XENAZINE Maximum Monthly Quantity • • • • • MULTIPLE SCLEROSIS Drug Name Specialty Maximum Monthly Quantity Drug Name Specialty 2015 • RHEUMATOID AND OSTEOARTHRITIS PAIN RELIEF DRUGS CELEBREX NON-NARCOTIC DRUGS diclofenac potassium butalbital/acetaminophen diclofenac sodium delayed-release butalbital/acetaminophen/caffeine diclofenac sodium ext-release butalbital/aspirin/caffeine ENBREL salsalate ENBREL SURECLICK NARCOTIC DRUGS etodolac acetaminophen/codeine etodolac ext-release buprenorphine flurbiprofen buprenorphine/naloxone HUMIRA butalbital/aspirin/caffeine/codeine ibuprofen Blue Cross and Blue Shield of Nebraska Drug Formulary, January 2015 • • • • • • 11 divalproex ext-release indomethacin ethosuximide ketoprofen gabapentin leflunomide lamotrigine meloxicam tabs levetiracetam nabumetone oxcarbazepine naproxen phenytoin naproxen delayed-release phenytoin sodium ext-release naproxen sodium primidone oxaprozin SABRIL piroxicam TEGRETOL-XR 100 mg sulindac topiramate MIGRAINE HEADACHES valproic acid acetaminophen/isometheptene/ dichloralphenazone zonisamide MIGRANAL naratriptan rizatriptan sumatriptan auto-injector; cartridge; inj, 6 mg/0.5 mL; tabs SUMATRIPTAN nasal spray GOUT allopurinol probenecid probenecid/colchicine NEUROMUSCULAR DRUGS SEIZURES BANZEL carbamazepine carbamazepine ext-release CELONTIN clonazepam DIASTAT DILANTIN caps; susp, 125 mg/5 mL divalproex delayed-release 12 Maximum Monthly Quantity • Drug Name Specialty ILARIS Maximum Monthly Quantity Drug Name Specialty 2015 • • • • • PARKINSON'S DISEASE amantadine, NF = tabs AZILECT benztropine bromocriptine carbidopa/levodopa carbidopa/levodopa ext-release entacapone pramipexole ropinirole selegiline trihexyphenidyl MUSCLE RELAXANTS baclofen chlorzoxazone cyclobenzaprine dantrolene, NF = 100 mg metaxalone methocarbamol orphenadrine citrate ext-release orphenadrine/aspirin/caffeine Blue Cross and Blue Shield of Nebraska Drug Formulary, January 2015 tizanidine ELOCTATE • OTHER NEUROMUSCULAR DRUGS enoxaparin MESTINON syrup folic acid tabs, 1 mg MESTINON TIMESPAN GRANIX pyridostigmine NEULASTA riluzole NEUMEGA SUPPLEMENTS pentoxifylline ext-release VITAMINS PRADAXA ergocalciferol PROCRIT MEPHYTON SOLIRIS MULTIVITAMINS TRETTEN pediatric multivitamins warfarin pediatric vitamins ADC XARELTO PRENATAL MULTIVITAMINS/FOLIC ACID TOPICAL DRUGS TRI-VIT/FLUORIDE/IRON EYE MINERALS AND ELECTROLYTES Anti-infectives FLUOR-A-DAY bacitracin oint FLURA-DROPS bacitracin/polymyxin B oint K-PHOS CILOXAN oint potassium bicarbonate/chloride effervescent 25 mEq ciprofloxacin soln potassium chloride ext-release gentamicin oint, soln potassium phosphate/sodium phosphates MOXEZA • • • NATACYN neomycin/polymyxin B/bacitracin oint SODIUM FLUORIDE tabs, 0.5 mg neomycin/polymyxin B/gramicidin soln sodium fluoride tabs, 1 mg F (from 2.2 mg NaF) ofloxacin soln polymyxin B/trimethoprim soln BLOOD MODIFYING DRUGS • sulfacetamide sodium soln tobramycin soln anagrelide ARANESP • • erythromycin oint sodium fluoride chew tabs, soln ALPROLIX Maximum Monthly Quantity Specialty Maximum Monthly Quantity Drug Name Drug Name Specialty 2015 • trifluridine soln cilostazol VIGAMOX clopidogrel Steroids and Combination Products cyanocobalamin inj dexamethasone sodium phosphate soln dipyridamole fluorometholone susp Blue Cross and Blue Shield of Nebraska Drug Formulary, January 2015 13 LOTEMAX acetic acid soln neomycin/polymyxin B/bacitracin/ hydrocortisone oint benzocaine/antipyrine soln neomycin/polymyxin B/dexamethasone oint, susp hydrocortisone/acetic acid soln CIPRODEX prednisolone acetate susp neomycin/polymyxin B/hydrocortisone soln, susp prednisolone sodium phosphate soln ofloxacin soln sulfacetamide sodium/prednisolone soln MOUTH AND THROAT (local) tobramycin/dexamethasone susp cevimeline ZYLET chlorhexidine oral rinse Glaucoma clotrimazole troche AZOPT lidocaine viscous brimonidine soln nystatin susp carteolol soln pilocarpine dorzolamide soln sodium fluoride dorzolamide/timolol maleate soln triamcinolone dental paste latanoprost soln ANORECTAL AGENTS levobunolol soln CORTIFOAM LUMIGAN hydrocortisone acetate rectal crm, supp pilocarpine soln hydrocortisone enema SIMBRINZA SKIN CONDITIONS/PRODUCTS timolol maleate soln Acne TRAVATAN Z adapalene gel, crm Other Eye Products clindamycin topical atropine sulfate oint, soln clindamycin/benzoyl peroxide azelastine soln EPIDUO cromolyn sodium soln erythromycin cyclopentolate soln erythromycin/benzoyl peroxide diclofenac soln FINACEA flurbiprofen soln isotretinoin 10 mg, 20 mg, 40 mg homatropine soln metronidazole topical ketorolac soln sulfacetamide sodium lotn PATADAY sulfacetamide sodium/sulfur crm, emul, foam, gel, lotn, susp; wash, 8-4% tropicamide soln EAR 14 Maximum Monthly Quantity Drug Name Specialty Maximum Monthly Quantity Drug Name Specialty 2015 SULFACETAMIDE SODIUM/SULFUR susp, 10-5% Blue Cross and Blue Shield of Nebraska Drug Formulary, January 2015 Maximum Monthly Quantity Drug Name Specialty Maximum Monthly Quantity Drug Name Specialty 2015 TAZORAC calcipotriene tretinoin microsphere CARAC tretinoin, NF = emollient crm diclofenac sodium gel Anti-infectives ELIDEL ciclopirox fluorouracil DENAVIR imiquimod econazole lidocaine/prilocaine crm, kit gentamicin sulfate topical lidocaine, NF = lotn ketoconazole crm; shampoo, 2% lindane mupirocin malathion nystatin topical permethrin silver sulfadiazine PICATO VOLTAREN podofilox Corticosteroids PROTOPIC alclometasone selenium sulfide amcinonide crm ULESFIA betamethasone dipropionate VALCHLOR betamethasone dipropionate, augmented XERAC AC betamethasone valerate ZYCLARA clobetasol desonide MISCELLANEOUS CATEGORIES (includes supplies and devices) desoximetasone crm; gel; oint, 0.25% DIABETIC SUPPLIES diflorasone BLOOD GLUCOSE METER – BAYER BREEZE 2, CONTOUR, CONTOUR LINK, CONTOUR NEXT EZ, CONTOUR NEXT LINK, DIDGET fluocinolone fluocinonide fluticasone propionate halobetasol hydrocortisone topical hydrocortisone valerate mometasone nystatin/triamcinolone triamcinolone Other Skin Products acitretin • BLOOD GLUCOSE METER – ROCHE ACCU-CHEK AVIVA PLUS, COMPACT PLUS, NANO SMARTVIEW CALIBRATION LIQUID – BAYER ASCENSIA, BREEZE 2, CONTOUR, CONTOUR NEXT CALIBRATION LIQUID – ROCHE ACCUCHEK ACTIVE, ACCUTREND, AVIVA, COMFORT CURVE, COMPACT BLUE, COMPACT PLUS, INSTANT, SMARTVIEW aluminum chloride Blue Cross and Blue Shield of Nebraska Drug Formulary, January 2015 15 Maximum Monthly Quantity Drug Name Specialty 2015 INSULIN ADMINISTRATION/INSULIN PUMP SUPPLIES – VARIOUS INSULIN PEN NEEDLES – VARIOUS INSULIN SYRINGES – VARIOUS LANCETS – BAYER, ROCHE, VARIOUS TEST STRIPS – BAYER ASCENSIA AUTODISC, BREEZE 2, CONTOUR, CONTOUR NEXT TEST STRIPS – ROCHE ACCU-CHEK ACTIVE, AVIVA, AVIVA PLUS, COMFORT CURVE, COMPACT, SMARTVIEW; ACCUTREND MEDICAL DEVICES INHALER ASSIST DEVICES – SPACERS MISCELLANEOUS DRUGS azathioprine CELLCEPT susp CHEMET CUPRIMINE cyclosporine cyclosporine modified caps, 25 mg, 100 mg; soln CYCLOSPORINE MODIFIED caps, 50 mg mycophenolate mofetil mycophenolate mofetil oral susp, 200 mg/ mL mycophenolate sodium delayed-release naloxone inj, 0.4 mg/mL RAPAMUNE soln; tabs, 1 mg, 2 mg REVLIMID • sirolimus sodium polystyrene sulfonate tacrolimus THALOMID • ZORTRESS 16 Blue Cross and Blue Shield of Nebraska Drug Formulary, January 2015 2015 INDEX A abacavir.............................................................................. 2 abacavir/lamivudine/zidovudine.......................................2 acamprosate delayed-release........................................ 11 acarbose............................................................................. 5 acebutolol...........................................................................6 acetaminophen/codeine..................................................11 acetaminophen/isometheptene/ dichloralphenazone....................................................... 12 acetazolamide.................................................................... 7 acetazolamide ext-release................................................ 7 acetic acid ear soln.........................................................14 acetylcysteine.................................................................... 8 acitretin.............................................................................15 acyclovir............................................................................. 2 adapalene gel, crm..........................................................14 ADCIRCA.............................................................................7 adefovir...............................................................................2 ADVAIR DISKUS.................................................................8 ADVAIR HFA.......................................................................8 AFINITOR............................................................................ 3 AFINITOR DISPERZ........................................................... 3 ALBENZA............................................................................ 2 albuterol inhal soln, syrup, tabs......................................8 alclometasone..................................................................15 alendronate........................................................................ 5 alfuzosin ext-release......................................................... 9 ALKERAN tabs....................................................................3 allopurinol........................................................................ 12 ALOXI.................................................................................. 9 alprazolam.......................................................................... 9 alprazolam ext-release...................................................... 9 ALPRAZOLAM INTENSOL................................................. 9 ALPROLIX......................................................................... 13 aluminum chloride.......................................................... 15 amantadine, NF = tabs....................................................12 amcinonide crm...............................................................15 amiloride.............................................................................7 amiloride/hydrochlorothiazide......................................... 7 amiodarone........................................................................ 7 amitriptyline..................................................................... 10 amlodipine..........................................................................6 amlodipine/atorvastatin.................................................... 7 amlodipine/benazepril....................................................... 6 amlodipine/valsartan......................................................... 6 amoxicillin/potassium clavulanate.................................. 1 amoxicillin/potassium clavulanate ext-release...............1 amoxicillin caps, susp, tabs............................................ 1 AMOXICILLIN chew tabs.................................................... 1 amphetamine/dextroamphetamine................................ 10 amphetamine/dextroamphetamine ext-release.............10 ampicillin caps...................................................................1 ampicillin susp.................................................................. 1 anagrelide.........................................................................13 anastrozole.........................................................................3 ANDRODERM..................................................................... 4 ANDROGEL.........................................................................4 ANDROXY........................................................................... 4 ANORO ELLIPTA................................................................8 APTIVUS............................................................................. 2 ARANESP..........................................................................13 ASACOL HD........................................................................9 ASMANEX........................................................................... 8 ASTEPRO............................................................................8 atenolol............................................................................... 6 atenolol/chlorthalidone..................................................... 6 atorvastatin........................................................................ 6 atovaquone/proguanil....................................................... 2 ATRIPLA..............................................................................2 atropine sulfate eye oint, soln....................................... 14 ATROVENT HFA.................................................................8 AUGMENTIN susp, 125 mg/5 mL.......................................1 AVODART........................................................................... 9 azathioprine......................................................................16 azelastine eye soln..........................................................14 azelastine nasal................................................................. 8 AZILECT............................................................................ 12 AZITHROMYCIN packets....................................................1 azithromycin susp, tabs................................................... 1 AZOPT...............................................................................14 B bacitracin/polymyxin B eye oint.................................... 13 bacitracin eye oint...........................................................13 baclofen............................................................................ 12 BACTROBAN NASAL......................................................... 8 balsalazide..........................................................................9 BANZEL.............................................................................12 BCG VACCINE....................................................................3 benazepril........................................................................... 6 benazepril/hydrochlorothiazide........................................6 BENICAR.............................................................................6 BENICAR HCT.................................................................... 6 benzocaine/antipyrine ear soln......................................14 benztropine...................................................................... 12 betamethasone dipropionate......................................... 15 betamethasone dipropionate, augmented.................... 15 betamethasone valerate..................................................15 BETASERON.....................................................................11 bicalutamide.......................................................................3 BILTRICIDE......................................................................... 2 bisoprolol........................................................................... 6 bisoprolol/hydrochlorothiazide........................................ 6 BLOOD GLUCOSE METER – BAYER BREEZE 2, CONTOUR, CONTOUR LINK, CONTOUR NEXT EZ, CONTOUR NEXT LINK, DIDGET................................... 15 Blue Cross and Blue Shield of Nebraska Drug Formulary, January 2015 17 2015 BLOOD GLUCOSE METER – ROCHE ACCUCHEK AVIVA PLUS, COMPACT PLUS, NANO SMARTVIEW................................................................... 15 BOSULIF............................................................................. 3 BREO ELLIPTA...................................................................8 brimonidine eye soln...................................................... 14 bromocriptine...................................................................12 budesonide ext-release.....................................................4 budesonide inhal soln...................................................... 8 bumetanide.........................................................................7 buprenorphine................................................................. 11 buprenorphine/naloxone.................................................11 bupropion......................................................................... 10 bupropion ext-release..................................................... 10 bupropion ext-release – smoking deterrent..................11 buspirone........................................................................... 9 butalbital/acetaminophen............................................... 11 butalbital/acetaminophen/caffeine.................................11 butalbital/aspirin/caffeine............................................... 11 butalbital/aspirin/caffeine/codeine.................................11 BYDUREON........................................................................ 5 BYETTA...............................................................................5 C cabergoline.........................................................................5 caffeine citrate................................................................. 10 calcipotriene.....................................................................15 calcitonin-salmon.............................................................. 5 calcitriol.............................................................................. 5 calcium acetate..................................................................9 CALIBRATION LIQUID – BAYER ASCENSIA, BREEZE 2, CONTOUR, CONTOUR NEXT........................................15 CALIBRATION LIQUID – ROCHE ACCU-CHEK ACTIVE, ACCUTREND, AVIVA, COMFORT CURVE, COMPACT BLUE, COMPACT PLUS, INSTANT, SMARTVIEW........ 15 CANASA.............................................................................. 9 capecitabine....................................................................... 3 CAPRELSA..........................................................................3 captopril..............................................................................6 captopril/hydrochlorothiazide 25-15 mg, 50-15 mg........ 6 CARAC.............................................................................. 15 CARAFATE susp.................................................................8 carbamazepine.................................................................12 carbamazepine ext-release.............................................12 carbidopa/levodopa.........................................................12 carbidopa/levodopa ext-release.....................................12 carteolol eye soln............................................................14 carvedilol............................................................................ 6 cefaclor caps..................................................................... 1 cefadroxil............................................................................1 cefdinir................................................................................1 cefpodoxime.......................................................................1 cefprozil.............................................................................. 1 ceftriaxone..........................................................................1 cefuroxime..........................................................................1 CELEBREX........................................................................11 18 CELLCEPT susp............................................................... 16 CELONTIN.........................................................................12 cephalexin, NF = tabs....................................................... 1 cetirizine syrup.................................................................. 7 CETROTIDE........................................................................ 4 cevimeline........................................................................ 14 CHANTIX........................................................................... 11 CHEMET............................................................................16 CHENODAL.........................................................................9 chlorhexidine oral rinse..................................................14 chloroquine phosphate.....................................................2 chlorothiazide.................................................................... 7 chlorpromazine................................................................ 10 chlorthalidone.................................................................... 7 chlorzoxazone..................................................................12 cholestyramine.................................................................. 6 chorionic gonadotropin.................................................... 4 CIALIS................................................................................. 7 ciclopirox..........................................................................15 cilostazol.......................................................................... 13 CILOXAN oint....................................................................13 cimetidine........................................................................... 8 CINRYZE............................................................................. 8 CIPRODEX........................................................................ 14 ciprofloxacin ext-release.................................................. 1 ciprofloxacin eye soln.................................................... 13 ciprofloxacin IR, susp.......................................................1 citalopram.........................................................................10 clarithromycin.................................................................... 1 clarithromycin ext-release................................................ 1 CLEOCIN supp....................................................................9 CLIMARA PRO....................................................................4 clindamycin/benzoyl peroxide....................................... 14 clindamycin oral................................................................ 3 clindamycin topical......................................................... 14 clindamycin vaginal crm.................................................. 9 clobetasol......................................................................... 15 clomiphene.........................................................................5 clomipramine................................................................... 10 clonazepam...................................................................... 12 clonidine tabs.................................................................... 7 clonidine transdermal patches........................................ 7 clopidogrel....................................................................... 13 clotrimazole troche......................................................... 14 clozapine.......................................................................... 10 COARTEM...........................................................................2 codeine sulfatetabs, 30 mg, 60 mg................................11 colestipol............................................................................ 7 COMBIVENT RESPIMAT....................................................8 COMETRIQ......................................................................... 3 COMPLERA.........................................................................2 COPAXONE...................................................................... 11 CORTIFOAM..................................................................... 14 cortisone.............................................................................4 CREON................................................................................9 CRESTOR........................................................................... 7 Blue Cross and Blue Shield of Nebraska Drug Formulary, January 2015 2015 CRIXIVAN............................................................................2 cromolyn sodium eye soln.............................................14 cromolyn sodium inhal soln............................................ 8 CUPRIMINE.......................................................................16 cyanocobalamin inj......................................................... 13 cyclobenzaprine...............................................................12 cyclopentolate eye soln..................................................14 CYCLOPHOSPHAMIDE......................................................3 cyclosporine.....................................................................16 cyclosporine modified caps, 25 mg, 100 mg; soln....... 16 CYCLOSPORINE MODIFIED caps, 50 mg.......................16 cyproheptadine.................................................................. 8 CYSTAGON.........................................................................9 CYTRA-3............................................................................. 9 D danazol............................................................................... 4 dantrolene, NF = 100 mg................................................ 12 dapsone.............................................................................. 3 DARAPRIM..........................................................................2 DELZICOL........................................................................... 9 demeclocycline.................................................................. 1 DENAVIR...........................................................................15 desipramine......................................................................10 desmopressin.................................................................... 5 desogestrel/ethinyl estradiol, biphasic – Azurette, Kariva, Pimtrea, Viorele.................................................. 4 desonide........................................................................... 15 desoximetasone crm; gel; oint, 0.25%.......................... 15 dexamethasone..................................................................4 DEXAMETHASONE INTENSOL......................................... 4 dexamethasone sodium phosphate eye soln............... 13 dextroamphetamine.........................................................10 dextroamphetamine ext-release.....................................10 DIASTAT............................................................................12 DIAZEPAM INTENSOL..................................................... 10 diazepam oral soln, 1 mg/mL...........................................9 diazepam tabs....................................................................9 DIBENZYLINE..................................................................... 7 diclofenac eye soln......................................................... 14 diclofenac potassium......................................................11 diclofenac sodium delayed-release............................... 11 diclofenac sodium ext-release....................................... 11 diclofenac sodium gel.................................................... 15 dicloxacillin........................................................................ 1 dicyclomine........................................................................ 8 didanosine delayed-release..............................................2 diflorasone....................................................................... 15 digoxin................................................................................ 7 DILANTIN caps; susp, 125 mg/5 mL................................ 12 diltiazem............................................................................. 6 diltiazem ext-release......................................................... 6 diphenoxylate/atropine..................................................... 9 dipyridamole.................................................................... 13 disopyramide..................................................................... 7 disulfiram..........................................................................11 divalproex delayed-release.............................................12 divalproex ext-release.....................................................12 DIVIGEL...............................................................................4 donepezil.......................................................................... 11 dorzolamide/timolol maleate eye soln...........................14 dorzolamide eye soln......................................................14 doxazosin........................................................................... 7 doxepin............................................................................. 10 doxycycline hyclate.......................................................... 1 doxycycline monohydrate................................................ 1 DULERA.............................................................................. 8 duloxetine delayed-release.............................................10 DUTOPROL.........................................................................6 E E.E.S. 400........................................................................... 1 econazole......................................................................... 15 EDURANT........................................................................... 2 ELIDEL.............................................................................. 15 ELLA.................................................................................... 4 ELOCTATE........................................................................13 EMCYT................................................................................ 3 EMEND................................................................................9 EMTRIVA.............................................................................2 enalapril.............................................................................. 6 enalapril/hydrochlorothiazide...........................................6 ENBREL............................................................................ 11 ENBREL SURECLICK.......................................................11 enoxaparin........................................................................13 entacapone.......................................................................12 entecavir............................................................................. 2 EPIDUO............................................................................. 14 EPIPEN................................................................................7 EPIPEN-JR.......................................................................... 7 EPIVIR HBV oral soln......................................................... 2 EPIVIR oral soln..................................................................2 eplerenone..........................................................................7 EPZICOM............................................................................ 2 ergocalciferol................................................................... 13 ERIVEDGE.......................................................................... 3 ERY-TAB............................................................................. 1 ERYTHROCIN STEARATE.................................................1 erythromycin/benzoyl peroxide..................................... 14 erythromycin/sulfisoxazole.............................................. 3 erythromycin base............................................................ 1 erythromycin delayed-release caps................................ 1 erythromycin ethylsuccinate............................................1 erythromycin eye oint.....................................................13 erythromycin topical....................................................... 14 escitalopram.....................................................................10 estazolam......................................................................... 10 ESTRACE crm.................................................................... 9 estradiol..............................................................................4 estradiol/norethindrone acetate.......................................4 estropipate......................................................................... 4 ethambutol......................................................................... 1 Blue Cross and Blue Shield of Nebraska Drug Formulary, January 2015 19 2015 ethosuximide....................................................................12 etidronate........................................................................... 5 etodolac............................................................................ 11 etodolac ext-release........................................................ 11 etoposide caps.................................................................. 3 exemestane........................................................................ 3 EXFORGE HCT.................................................................. 6 F FABRAZYME.......................................................................5 famciclovir..........................................................................2 famotidine...........................................................................8 FARESTON......................................................................... 3 felodipine ext-release........................................................6 FEMHRT LOW DOSE.........................................................4 fenofibrate.......................................................................... 7 fenofibrate micronized...................................................... 7 fenofibric acid delayed-release........................................7 fentanyl lollipops.............................................................11 fentanyl patches.............................................................. 11 FINACEA........................................................................... 14 finasteride...........................................................................9 FIRAZYR............................................................................. 8 FIRMAGON......................................................................... 3 flecainide............................................................................ 7 FLOVENT DISKUS............................................................. 8 FLOVENT HFA....................................................................8 fluconazole......................................................................... 1 flucytosine..........................................................................1 fludrocortisone.................................................................. 4 flunisolide 25 mcg/spray.................................................. 8 fluocinolone..................................................................... 15 fluocinonide..................................................................... 15 FLUOR-A-DAY.................................................................. 13 fluorometholone eye susp..............................................13 fluorouracil....................................................................... 15 fluoxetine, NF = 60 mg................................................... 10 fluphenazine decanoate inj............................................ 10 FLUPHENAZINE HCL conc, elixir.....................................10 fluphenazine hcl tabs......................................................10 FLURA-DROPS................................................................. 13 flurbiprofen eye soln.......................................................14 flurbiprofen tabs..............................................................11 flutamide.............................................................................3 fluticasone propionate nasal............................................8 fluticasone propionate topical....................................... 15 fluvoxamine......................................................................10 folic acid tabs, 1 mg....................................................... 13 FORADIL AEROLIZER....................................................... 8 fosinopril............................................................................ 6 fosinopril/hydrochlorothiazide......................................... 6 furosemide......................................................................... 7 FUZEON.............................................................................. 2 G gabapentin........................................................................12 20 galantamine......................................................................11 galantamine ext-release..................................................11 gemfibrozil..........................................................................7 gentamicin eye oint, soln............................................... 13 gentamicin sulfate topical.............................................. 15 GILOTRIF............................................................................ 3 GLEEVEC............................................................................3 glimepiride..........................................................................5 glipizide.............................................................................. 5 glipizide/metformin............................................................5 glipizide ext-release.......................................................... 5 GLUCAGON EMERGENCY KIT......................................... 5 glyburide.............................................................................5 glyburide/metformin.......................................................... 5 glyburide micronized........................................................ 5 glycopyrrolate.................................................................... 8 GONAL-F.............................................................................5 granisetron......................................................................... 9 GRANIX............................................................................. 13 griseofulvin microsize.......................................................1 guanfacine..........................................................................7 H halobetasol.......................................................................15 haloperidol decanoate.................................................... 10 haloperidol lactate oral soln.......................................... 10 haloperidol tabs...............................................................10 HEXALEN............................................................................ 3 homatropine eye soln..................................................... 14 HUMIRA.............................................................................11 HYCAMTIN caps................................................................. 3 hydralazine......................................................................... 7 hydrochlorothiazide caps, tabs....................................... 7 hydrocodone/acetaminophen, NF = tabs, 2.5-325 mg....................................................................................11 hydrocodone/ibuprofen.................................................. 11 hydrocortisone...................................................................4 hydrocortisone/acetic acid ear soln.............................. 14 hydrocortisone acetate rectal crm, supp...................... 14 hydrocortisone enema.................................................... 14 hydrocortisone topical....................................................15 hydrocortisone valerate..................................................15 hydromorphone soln, tabs............................................. 11 hydromorphone supp..................................................... 11 hydroxychloroquine.......................................................... 2 hydroxyurea....................................................................... 3 hydroxyzine hcl............................................................... 10 hydroxyzine pamoate......................................................10 hyoscyamine...................................................................... 8 hyoscyamine ext-release.................................................. 8 I ibandronate........................................................................ 5 ibuprofen.......................................................................... 11 ICLUSIG.............................................................................. 3 ILARIS............................................................................... 12 Blue Cross and Blue Shield of Nebraska Drug Formulary, January 2015 2015 IMBRUVICA.........................................................................3 imipramine hcl................................................................. 10 imiquimod.........................................................................15 INCRELEX...........................................................................5 indapamide.........................................................................7 indomethacin................................................................... 12 INHALER ASSIST DEVICES – SPACERS....................... 16 INLYTA................................................................................ 3 INSULIN ADMINISTRATION/INSULIN PUMP SUPPLIES – VARIOUS..................................................................... 16 INSULIN PEN NEEDLES – VARIOUS..............................16 INSULIN SYRINGES – VARIOUS.................................... 16 INTELENCE.........................................................................2 INTUNIV............................................................................ 10 INVIRASE............................................................................ 2 INVOKAMET........................................................................5 INVOKANA.......................................................................... 5 ipratropium/albuterol.........................................................8 ipratropium inhal soln...................................................... 8 ipratropium nasal soln......................................................8 irbesartan........................................................................... 6 irbesartan/hydrochlorothiazide........................................ 6 ISENTRESS........................................................................ 2 ISONIAZID syrup.................................................................1 isoniazid tabs.....................................................................1 isosorbide dinitrate........................................................... 6 isosorbide mononitrate.....................................................6 isosorbide mononitrate ext-release.................................6 isotretinoin 10 mg, 20 mg, 40 mg.................................. 14 itraconazole........................................................................1 ivermectin...........................................................................2 J JAKAFI.................................................................................3 JANUMET............................................................................5 JANUMET XR..................................................................... 5 JANUVIA..............................................................................5 K KADIAN caps, 10 mg, 40 mg, 70 mg, 130 mg, 150 mg, 200 mg.............................................................................11 KALETRA............................................................................ 2 KALYDECO......................................................................... 8 ketoconazole crm; shampoo, 2%.................................. 15 ketoprofen........................................................................ 12 ketorolac eye soln...........................................................14 KEYTRUDA......................................................................... 3 KOMBIGLYZE XR............................................................... 5 K-PHOS............................................................................. 13 K-PHOS NO. 2....................................................................9 L labetalol.............................................................................. 6 lactulose............................................................................. 8 lactulose............................................................................. 9 LAMISIL granules................................................................1 lamivudine.......................................................................... 2 lamivudine.......................................................................... 2 lamivudine/zidovudine...................................................... 2 lamotrigine....................................................................... 12 LANCETS – BAYER, ROCHE, VARIOUS........................ 16 lansoprazole delayed-release...........................................8 LANTUS...............................................................................5 latanoprost eye soln....................................................... 14 leflunomide.......................................................................12 LETAIRIS.............................................................................7 letrozole.............................................................................. 3 leucovorin calcium............................................................3 LEUKERAN......................................................................... 3 levalbuterol inhal soln...................................................... 8 LEVEMIR............................................................................. 5 levetiracetam....................................................................12 levobunolol eye soln.......................................................14 levocarnitine.......................................................................5 levofloxacin........................................................................ 1 levonorgestrel/ethinyl estradiol, 0.1 mg/20 mcg – Aubra, Aviane, Falmina, Lessina, Lutera, Orsythia, Sronyx...............................................................................4 levonorgestrel – Next Choice...........................................4 levothyroxine..................................................................... 5 LEXIVA................................................................................ 2 LIALDA................................................................................ 9 lidocaine, NF = lotn.........................................................15 lidocaine/prilocaine crm, kit........................................... 15 lidocaine viscous............................................................ 14 lindane.............................................................................. 15 LINZESS..............................................................................9 liothyronine........................................................................ 5 lisinopril..............................................................................6 lisinopril/hydrochlorothiazide.......................................... 6 LITHIUM............................................................................ 10 lithium carbonate............................................................ 10 lithium carbonate ext-release.........................................10 LOMUSTINE........................................................................3 loperamide..........................................................................8 lorazepam......................................................................... 10 losartan...............................................................................6 losartan/hydrochlorothiazide........................................... 6 LOTEMAX..........................................................................14 lovastatin............................................................................ 7 loxapine............................................................................ 10 LUMIGAN.......................................................................... 14 LYSODREN......................................................................... 3 M MACRODANTIN 25 mg...................................................... 9 malathion..........................................................................15 MATULANE......................................................................... 3 meclizine.............................................................................9 medroxyprogesterone acetate......................................... 4 mefloquine..........................................................................2 megestrol............................................................................3 Blue Cross and Blue Shield of Nebraska Drug Formulary, January 2015 21 2015 MEKINIST............................................................................3 meloxicam tabs............................................................... 12 MEPHYTON...................................................................... 13 mercaptopurine..................................................................3 mesalamine........................................................................ 9 MESNEX tabs..................................................................... 3 MESTINON syrup..............................................................13 MESTINON TIMESPAN.................................................... 13 metaxalone....................................................................... 12 metformin........................................................................... 5 metformin ext-release....................................................... 5 metformin ext-release OSM..............................................5 methadone conc, soln, tabs...........................................11 methazolamide...................................................................7 methimazole....................................................................... 5 methocarbamol................................................................ 12 methotrexate...................................................................... 3 methscopolamine.............................................................. 8 methyldopa.........................................................................7 methylergonovine..............................................................5 methylphenidate ext-release, NF = tabs, 10 mg........... 10 methylphenidate tabs......................................................10 methylprednisolone...........................................................4 metoclopramide................................................................. 9 metolazone......................................................................... 7 metoprolol succinate ext-release.................................... 6 metoprolol tartrate............................................................ 6 metronidazole tabs............................................................3 metronidazole topical......................................................14 metronidazole vaginal gel................................................ 9 mexiletine........................................................................... 7 midodrine........................................................................... 7 MIGRANAL........................................................................ 12 MILLIPRED tabs..................................................................4 minocycline........................................................................ 1 minoxidil............................................................................. 7 mirtazapine.......................................................................10 misoprostol........................................................................ 8 modafinil...........................................................................10 moexipril.............................................................................6 moexipril/hydrochlorothiazide......................................... 6 mometasone.....................................................................15 montelukast........................................................................8 morphine sulfate conc, soln, supp, tabs...................... 11 morphine sulfate ext-release..........................................11 MOXEZA............................................................................13 MULTAQ..............................................................................7 mupirocin......................................................................... 15 mycophenolate mofetil................................................... 16 mycophenolate mofetil oral susp, 200 mg/mL..............16 mycophenolate sodium delayed-release...................... 16 MYLERAN........................................................................... 3 N nabumetone..................................................................... 12 nadolol................................................................................ 6 22 naloxone inj, 0.4 mg/mL................................................. 16 naltrexone.........................................................................11 NAMENDA.........................................................................11 NAMENDA XR.................................................................. 11 naproxen...........................................................................12 naproxen delayed-release.............................................. 12 naproxen sodium............................................................ 12 naratriptan........................................................................ 12 NASONEX........................................................................... 8 NATACYN..........................................................................13 nateglinide..........................................................................5 NEBUPENT......................................................................... 3 neomycin/polymyxin B/bacitracin/hydrocortisone eye oint.................................................................................. 14 neomycin/polymyxin B/bacitracin eye oint...................13 neomycin/polymyxin B/dexamethasone eye oint, susp.................................................................................14 neomycin/polymyxin B/gramicidin eye soln.................13 neomycin/polymyxin B/hydrocortisone ear soln, susp.................................................................................14 neomycin sulfate............................................................... 1 NEULASTA........................................................................13 NEUMEGA.........................................................................13 nevirapine ext-release.......................................................2 nevirapine IR......................................................................2 NEXAVAR............................................................................3 NEXIUM...............................................................................8 niacin ext-release.............................................................. 7 NICOTROL INHALER....................................................... 11 NICOTROL NS..................................................................11 nifedipine ext-release........................................................6 NILANDRON........................................................................3 NITRO-BID.......................................................................... 6 nitrofurantoin..................................................................... 9 nitrofurantoin macrocrystalline....................................... 9 nitrofurantoin monohydrate/macrocrystalline................9 nitroglycerin....................................................................... 6 NITROSTAT........................................................................ 6 norelgestromin/ethinyl estradiol – Xulane...................... 4 norethindrone/ethinyl estradiol, 1 mg/35 mcg – Alyacen, Cyclafem, Dasetta, Necon, Nortrel, Pirmella............................................................................. 4 norethindrone acetate.......................................................4 norethindrone – Camila, Errin, Heather, Jencycla, Jolivette, Lyza, Nora-Be.................................................. 4 norgestimate/ethinyl estradiol, triphasic – Trinessa, Tri-Estaryll, Tri-Linyah, Tri-Previfem, Tri-Sprintec........4 nortriptyline......................................................................10 NORVIR...............................................................................2 NOVOLIN 70/30.................................................................. 5 NOVOLIN N.........................................................................5 NOVOLIN R.........................................................................5 NOVOLOG...........................................................................5 NOVOLOG MIX 70/30.........................................................5 NOXAFIL............................................................................. 1 NUCYNTA ER................................................................... 11 Blue Cross and Blue Shield of Nebraska Drug Formulary, January 2015 2015 NUEDEXTA....................................................................... 11 nystatin/triamcinolone.................................................... 15 nystatin oral....................................................................... 1 nystatin susp................................................................... 14 nystatin topical................................................................ 15 O octreotide........................................................................... 5 ofloxacin ear soln............................................................14 ofloxacin eye soln........................................................... 13 ofloxacin tabs.................................................................... 1 olanzapine........................................................................ 10 OLYSIO............................................................................... 2 omeprazole delayed-release.............................................8 OMNITROPE....................................................................... 5 ondansetron....................................................................... 9 ONGLYZA............................................................................5 OPSUMIT............................................................................ 7 ORAP.................................................................................11 ORFADIN.............................................................................5 orphenadrine/aspirin/caffeine........................................ 12 orphenadrine citrate ext-release....................................12 oxaprozin..........................................................................12 oxcarbazepine..................................................................12 oxybutynin..........................................................................9 oxybutynin ext-release......................................................9 oxycodone........................................................................11 oxycodone/acetaminophen............................................ 11 oxycodone/aspirin........................................................... 11 OXYCONTIN..................................................................... 11 P pantoprazole delayed-release.......................................... 8 paricalcitol..........................................................................5 paromomycin..................................................................... 1 paroxetine hcl.................................................................. 10 paroxetine hcl ext-release.............................................. 10 PATADAY.......................................................................... 14 pediatric multivitamins................................................... 13 pediatric vitamins ADC...................................................13 PEGASYS............................................................................2 PEG – electrolytes for soln.............................................. 8 penicillin v potassium.......................................................1 PENTASA............................................................................ 9 pentoxifylline ext-release................................................13 perindopril.......................................................................... 6 permethrin........................................................................ 15 perphenazine....................................................................10 phenelzine........................................................................ 10 phenobarbital................................................................... 10 PHENOBARBITAL 64.8 mg, 97.2 mg............................... 10 phenytoin..........................................................................12 phenytoin sodium ext-release........................................12 PICATO............................................................................. 15 pilocarpine eye soln........................................................14 pilocarpine tabs...............................................................14 pindolol...............................................................................6 pioglitazone........................................................................5 pioglitazone/metformin..................................................... 5 piroxicam..........................................................................12 PLEGRIDY.........................................................................11 podofilox...........................................................................15 polymyxin B/trimethoprim eye soln.............................. 13 POMALYST......................................................................... 3 pot & sod citrates/citric acid soln................................... 9 potassium bicarbonate/chloride effervescent 25 mEq................................................................................. 13 potassium chloride ext-release......................................13 potassium citrate/citric acid powder............................... 9 potassium citrate ext-release...........................................9 potassium phosphate/sodium phosphates.................. 13 PRADAXA..........................................................................13 pramipexole......................................................................12 pravastatin..........................................................................7 prazosin.............................................................................. 7 prednisolone...................................................................... 4 prednisolone acetate eye susp......................................14 prednisolone sodium phosphate, NF = 25 mg/5 mL...... 4 prednisolone sodium phosphate eye soln................... 14 prednisone......................................................................... 4 PREDNISONE soln, 5 mg/5 mL; tabs, 50 mg..................... 4 PREMARIN tabs..................................................................4 PREMPHASE...................................................................... 4 PREMPRO...........................................................................4 PRENATAL MULTIVITAMINS/FOLIC ACID......................13 PREZISTA........................................................................... 2 PRIFTIN...............................................................................1 PRIMAQUINE...................................................................... 2 primidone......................................................................... 12 PROAIR HFA...................................................................... 8 probenecid....................................................................... 12 probenecid/colchicine.....................................................12 prochlorperazine..............................................................10 PROCRIT...........................................................................13 progesterone micronized..................................................4 PROLIA................................................................................5 promethazine..................................................................... 8 propafenone....................................................................... 7 propafenone ext-release................................................... 7 PROPANTHELINE.............................................................. 8 propranolol/hydrochlorothiazide..................................... 6 propranolol ext-release.....................................................6 PROPRANOLOL soln......................................................... 6 propranolol tabs................................................................ 6 propylthiouracil..................................................................5 PROTOPIC........................................................................ 15 PULMICORT RESPULES 1 mg/2 mL.................................8 PULMOZYME...................................................................... 8 PURIXAN.............................................................................3 pyrazinamide......................................................................1 pyridostigmine................................................................. 13 Blue Cross and Blue Shield of Nebraska Drug Formulary, January 2015 23 2015 Q quetiapine.........................................................................10 quinapril..............................................................................6 quinapril/hydrochlorothiazide.......................................... 6 quinidine gluconate ext-release.......................................7 quinidine sulfate................................................................7 QUINIDINE SULFATE ext-release......................................7 QVAR...................................................................................8 R raloxifene............................................................................5 ramipril................................................................................6 ranitidine.............................................................................9 RAPAMUNE soln; tabs, 1 mg, 2 mg................................. 16 REBIF................................................................................ 11 RELION R........................................................................... 5 RENVELA............................................................................ 9 repaglinide..........................................................................5 REPRONEX.........................................................................5 RESCRIPTOR..................................................................... 2 REVLIMID..........................................................................16 REYATAZ............................................................................ 2 ribavirin...............................................................................2 rifabutin.............................................................................. 1 rifampin...............................................................................1 riluzole.............................................................................. 13 risedronate......................................................................... 5 risperidone....................................................................... 10 rivastigmine......................................................................11 rizatriptan......................................................................... 12 ropinirole.......................................................................... 12 ROXICET soln...................................................................11 S SABRIL.............................................................................. 12 salsalate............................................................................11 SANDOSTATIN LAR DEPOT............................................. 5 selegiline.......................................................................... 12 selenium sulfide.............................................................. 15 SELZENTRY........................................................................2 SENSIPAR...........................................................................5 SEREVENT DISKUS...........................................................8 SEROQUEL XR................................................................ 10 sertraline...........................................................................10 sildenafil 20 mg................................................................. 7 silver sulfadiazine........................................................... 15 SIMBRINZA....................................................................... 14 simvastatin......................................................................... 7 sirolimus...........................................................................16 SIVEXTRO...........................................................................3 sodium citrate/citric acid..................................................9 sodium fluoride............................................................... 14 sodium fluoride chew tabs, soln................................... 13 SODIUM FLUORIDE tabs, 0.5 mg....................................13 sodium fluoride tabs, 1 mg F (from 2.2 mg NaF).......... 13 24 sodium polystyrene sulfonate....................................... 16 SOLIRIS.............................................................................13 SOLTAMOX.........................................................................3 sotalol................................................................................. 7 sotalol AF........................................................................... 7 SOVALDI............................................................................. 2 SPIRIVA HANDIHALER...................................................... 8 SPIRIVA RESPIMAT........................................................... 8 spironolactone................................................................... 7 spironolactone/hydrochlorothiazide................................7 SPORANOX soln................................................................ 1 SPRYCEL............................................................................ 3 SSKI.....................................................................................8 stavudine............................................................................ 2 STIVARGA...........................................................................3 STRIBILD.............................................................................2 STROMECTOL....................................................................2 SUBOXONE film............................................................... 11 sucralfate............................................................................9 sulfacetamide sodium/prednisolone eye soln..............14 sulfacetamide sodium/sulfur, crm, emul, foam, gel, lotn, susp; wash, 8-4%..................................................14 SULFACETAMIDE SODIUM/SULFUR susp, 10-5%.........14 sulfacetamide sodium eye soln..................................... 13 sulfacetamide sodium lotn............................................. 14 sulfamethoxazole/trimethoprim....................................... 3 sulfasalazine...................................................................... 9 sulfasalazine delayed-release.......................................... 9 sulindac............................................................................ 12 sumatriptan auto-injector; cartridge; inj, 6 mg/0.5 mL; tabs..................................................................................12 SUMATRIPTAN nasal spray............................................. 12 SUPRAX.............................................................................. 1 SUSTIVA............................................................................. 2 SUTENT.............................................................................. 3 SYLATRON......................................................................... 3 SYMBICORT....................................................................... 8 SYNAGIS.............................................................................3 T TABLOID............................................................................. 3 tacrolimus.........................................................................16 TAFINLAR........................................................................... 3 TAMIFLU............................................................................. 2 tamoxifen............................................................................3 tamsulosin..........................................................................9 TARCEVA............................................................................4 TARGRETIN caps............................................................... 4 TASIGNA............................................................................. 4 TAZORAC..........................................................................15 TECFIDERA...................................................................... 11 TEGRETOL-XR 100 mg....................................................12 temazepam....................................................................... 10 temozolomide.....................................................................4 terazosin............................................................................. 7 terbinafine.......................................................................... 1 Blue Cross and Blue Shield of Nebraska Drug Formulary, January 2015 2015 terbutaline.......................................................................... 8 terconazole.........................................................................9 testosterone cypionate..................................................... 4 testosterone enanthate..................................................... 4 TEST STRIPS – BAYER ASCENSIA AUTODISC, BREEZE 2, CONTOUR, CONTOUR NEXT.................... 16 TEST STRIPS – ROCHE ACCU-CHEK ACTIVE, AVIVA, AVIVA PLUS, COMFORT CURVE, COMPACT, SMARTVIEW; ACCUTREND.......................................... 16 TETRACYCLINE................................................................. 1 THALOMID........................................................................ 16 theophylline ext-release....................................................8 thiothixene........................................................................10 timolol maleate eye soln................................................ 14 timolol tabs........................................................................ 6 TIVICAY...............................................................................2 tizanidine.......................................................................... 13 tobramycin/dexamethasone eye susp...........................14 tobramycin eye soln....................................................... 13 tobramycin inhal soln....................................................... 1 tolterodine.......................................................................... 9 tolterodine ext-release...................................................... 9 topiramate........................................................................ 12 torsemide............................................................................7 TRACLEER..........................................................................7 tramadol............................................................................11 tramadol/acetaminophen................................................ 11 tramadol ext-release....................................................... 11 trandolapril......................................................................... 6 tranylcypromine...............................................................10 TRAVATAN Z.................................................................... 14 trazodone..........................................................................10 tretinoin, NF = emollient crm......................................... 15 tretinoin caps.....................................................................4 tretinoin microsphere......................................................15 TRETTEN.......................................................................... 13 triamcinolone..................................................................... 8 triamcinolone dental paste.............................................14 triamcinolone topical...................................................... 15 triamterene/hydrochlorothiazide, NF = 50-25 mg........... 7 trifluoperazine.................................................................. 10 trifluridine eye soln......................................................... 13 trihexyphenidyl................................................................ 12 trimethobenzamide............................................................9 trimethoprim.......................................................................3 TRIUMEQ............................................................................ 2 TRI-VIT/FLUORIDE/IRON................................................. 13 tropicamide eye soln...................................................... 14 TRUVADA............................................................................2 TYBOST.............................................................................. 2 TYKERB.............................................................................. 4 U ULESFIA............................................................................15 ursodiol...............................................................................9 V VAGIFEM.............................................................................9 valacyclovir........................................................................ 2 VALCHLOR....................................................................... 15 VALCYTE............................................................................ 1 valganciclovir tab, 450 mg............................................... 2 valproic acid.................................................................... 12 valsartan............................................................................. 6 valsartan/hydrochlorothiazide..........................................6 vancomycin........................................................................ 3 venlafaxine....................................................................... 10 venlafaxine ext-release, NF = 225 mg........................... 10 VENTOLIN HFA.................................................................. 8 verapamil............................................................................ 6 verapamil ext-release........................................................ 6 VESICARE...........................................................................9 VICTOZA............................................................................. 5 VIDEX.................................................................................. 2 VIGAMOX.......................................................................... 13 VIRACEPT...........................................................................2 VIRAMUNE susp.................................................................2 VIRAMUNE XR tabs, 100 mg............................................. 2 VIREAD............................................................................... 2 VIVELLE-DOT..................................................................... 4 VOLTAREN GEL...............................................................15 voriconazole.......................................................................1 VOTRIENT...........................................................................4 VYVANSE..........................................................................10 W warfarin.............................................................................13 WELCHOL........................................................................... 7 X XALKORI............................................................................. 4 XARELTO.......................................................................... 13 XENAZINE.........................................................................11 XERAC AC........................................................................ 15 XIFAXAN 550 mg................................................................3 XTANDI................................................................................4 Y Z zafirlukast........................................................................... 8 zaleplon............................................................................ 10 ZELBORAF..........................................................................4 ZENPEP.............................................................................. 9 ZIAGEN soln....................................................................... 2 zidovudine.......................................................................... 2 ziprasidone.......................................................................10 ZOLINZA..............................................................................4 zolpidem........................................................................... 10 zolpidem ext-release....................................................... 10 zonisamide....................................................................... 12 ZORTRESS....................................................................... 16 Blue Cross and Blue Shield of Nebraska Drug Formulary, January 2015 25 2015 ZYCLARA.......................................................................... 15 ZYDELIG............................................................................. 4 ZYKADIA............................................................................. 4 ZYLET................................................................................14 ZYTIGA................................................................................4 ZYVOX.................................................................................3 26 Blue Cross and Blue Shield of Nebraska Drug Formulary, January 2015
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