Drug List - PrimeHelps.com
< January 2015 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products Contents Therapeutic Class Drug List Introduction .................................................................... I Anti-Infective Agents ....................................................... 1 Biologicals ..................................................................... 13 How Formulary Drugs Are Selected for BlueCare Products ....................................................... I Antineoplastic Agents ................................................... 18 Tiers ................................................................................. I Endocrine and Metabolic Drugs ................................... 22 Affordable Care Act ......................................................... I Cardiovascular Agents .................................................. 43 Specialty Products .......................................................... II Respiratory Agents ....................................................... 63 Step Therapy .................................................................. II Gastrointestinal Agents ................................................. 70 Prior Authorization .......................................................... II Genitourinary Agents .................................................... 77 Quantity Limits ................................................................ II Central Nervous System Drugs .................................... 81 Excluded Drugs .............................................................. II Analgesics and Anesthetics ........................................ 100 Key ................................................................................. III Neuromuscular Drugs ................................................. 119 Nutritional Products .................................................... 128 Hematological Agents ................................................. 134 Topical Products ......................................................... 141 Miscellaneous Products .............................................. 166 Index........................................................................... 173 The Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products is regularly updated. Please visit www.bcbsks.com or Prime Therapeutics website at www.MyPrime.com for the most up-to-date information. To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click on Search. Blue Cross and Blue Shield of Kansas and BlueCross BlueShield Kansas Solutions are independent licensees 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 Specialty Pharmacy LLC, owner of PrimeMail®, provides pharmacy benefits and is not affiliated with Blue Cross and Blue Shield of Kansas or BlueCross BlueShield Kansas Solutions. 5-103-D KS IVL © Prime Therapeutics LLC 01/15 Introduction The attached Formulary for BlueCare Products shows covered drugs for a broad range of diseases. Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand drug in (parentheses). Some generic products have no reference brand. Brand prescription drugs are shown in capital letters followed by the generic name. The Formulary for BlueCare Products is organized into broad categories (e.g. Anti-Infective Agents). Within most categories, drugs are sub-grouped by drug class (e.g. Penicillins) or by use for a specific medical condition (e.g. Diabetes). Members are encouraged to show this list to their physicians and pharmacists. Physicians are encouraged to prescribe drugs on this list, when right for the member. However, decisions regarding therapy and treatment are always between members and their physician. The current version of the Formulary for BlueCare Products is available at the BCBSKS website at www.bcbsks.com or by calling BCBSKS customer service at 1.800.432.3990. Online pharmacy tools are available through the Prime Therapeutics website at www.MyPrime.com. You can find drug cost estimates or check if a particular drug is on the Formulary for BlueCare Products.. How Formulary Drugs Are Selected for BlueCare Products Drugs on this list are selected based on the recommendations of a committee made up of physicians and pharmacists from throughout the country. Both drugs that are newly approved by the U.S. Food and Drug Administration (FDA) as well as those that have been on the market for some time are considered. Drugs are selected based on safety, efficacy, cost and how they compare to other drugs currently on the list. Tiers This prescription benefit is multi-tiered, placing prescription drugs into one of five copay/coinsurance levels: • Generic Drugs (Tier 1) • Preferred Brand Drugs (Tier 2) • Non-Preferred Brand Drugs (Tier 3) • Preferred Specialty Drugs (Tier 4) • Non-Preferred Specialty Drugs (Tier 5) • Drugs Subject to Medical Benefit (M) Affordable Care Act Please note, some drugs may have limited or $0 cost-sharing under the Affordable Care Act; examples of categories of drugs that may be subject to limited or $0 cost share include aspirin, fluoride supplements, folic acid supplements, iron supplements, tobacco cessation, vitamin D supplements, breast cancer prevention, and some contraceptive drugs and devices. If you do not find the drug you are searching for, contact BCBSKS to find out if the drug is available over the counter or is covered under your medical benefit. I Blue Cross and Blue Shield of Kansas Formulary for BlueCareSM Products January 2015 Specialty Products Specialty drugs are used in the treatment of medical conditions such as hepatitis, multiple sclerosis and rheumatoid arthritis. Specialty drugs may be oral or injectable medications that can either be self-administered or administered by a health care professional. Your prescription drug benefit may require you to use Prime Specialty Pharmacy to be eligible for in-network benefits. If you have questions about your specialty pharmacy benefit, please call the phone number on the back of your ID card. Oral oncology drugs subject to the medical benefit are listed as drug tier M. Step Therapy Your benefit plan may include a step therapy program. This means you may need to try another proven, cost-effective medication before coverage may be available for the drug included in the program. Many brand drugs have less-expensive generic or brand alternatives that might be an option for you. If a step therapy is required for a medication listed in this document, it will be noted next to the medication with a dot under the step therapy column. Prior Authorization Your benefit plan may require prior authorization for certain drugs that are high-cost or have the potential for misuse. This means that your doctor will need to submit a prior authorization request for coverage of these medications, and the request will need to be approved, before the medication will be covered under your plan. If a prior authorization is required for a medication listed in this document, it will be noted next to the medication with a dot under the prior authorization column. Quantity Limits Drug quantity limits help encourage medication use as intended by the FDA. Quantity limits are placed on medications in certain drug categories. For the medications listed in this document, if a quantity limit applies, it will be noted next to the medication with a dot under the quantity limits column. A list of medications subject to quantity limits may be found at Quantity Limit List. Limits may include: quantity of covered medication per prescription and/or quantity of covered medication in a given time period. If your doctor prescribes a greater quantity of medication than what the quantity limit allows, you can still get the medication. However, you will be responsible for the full cost of the prescription beyond what your coverage allows. There may also be limits for members within a certain age range, and coverage only for members of a specific gender. Excluded Drugs A list of drugs excluded from coverage may be found at Excluded Drugs. Drugs excluded from coverage will be allowed if certain exception criteria are met. The criteria may be found at Exception Criteria. Blue Cross and Blue Shield of Kansas Formulary for BlueCareSM Products January 2015 II Medical Drugs Some drugs are covered under your medical benefit. A list of drugs that may be covered under your medical benefit may be found at Medical Drug List. Key cap ...................................................................... capsules odt ............................................. orally disintegrating tabs chew .................................................................. chewable oint ..................................................................... ointment conc ............................................................. concentrate ophth ............................................................... ophthalmic cr ..........................................................controlled-release osm.......................................................... osmotic-release dr ............................................................. delayed-release powd..................................................................... powder ec ................................................................ enteric coated sa ............................................................ sustained-action effe................................................................. effervescent sl ...................................................................... sublingual equiv ................................................................ equivalent soln....................................................................... solution er .......................................................... extended-release sr .......................................................... sustained-release inhal................................................................... inhalation suppos ........................................................ suppositories inj ......................................................................... injection susp................................................................ suspension liq .............................................................................. liquid tab........................................................................... tablets lotn ........................................................................... lotion td ................................................................... transdermal nebu ................................................................... nebulizer III Blue Cross and Blue Shield of Kansas Formulary for BlueCareSM Products January 2015 ANTI-INFECTIVE AGENTS PENICILLINS AMOXICILLIN ER - amoxicillin (trihydrate) tab sr 24hr 775 mg 3 AMOXICILLIN - amoxicillin (trihydrate) chew tab 125 mg 2 AMPICILLIN - ampicillin for susp 125 mg/5ml 2 AMOXICILLIN - amoxicillin (trihydrate) chew tab 250 mg 2 AMPICILLIN - ampicillin for susp 250 mg/5ml 2 amoxicillin (trihydrate) cap 250 mg 1 ampicillin cap 250 mg 1 amoxicillin (trihydrate) cap 500 mg 1 ampicillin cap 500 mg 1 amoxicillin (trihydrate) for susp 125 mg/5ml 1 AUGMENTIN - amoxicillin & k clavulanate tab 500-125 mg 3 amoxicillin (trihydrate) for susp 200 mg/5ml 1 AUGMENTIN - amoxicillin & k clavulanate tab 875-125 mg 3 amoxicillin (trihydrate) for susp 250 mg/5ml 1 2 amoxicillin (trihydrate) for susp 400 mg/5ml 1 AUGMENTIN - amoxicillin & k clavulanate for susp 125-31.25 mg/5ml 3 amoxicillin (trihydrate) tab 500 mg 1 AUGMENTIN - amoxicillin & k clavulanate for susp 250-62.5 mg/5ml 1 AUGMENTIN ES-600 - amoxicillin & k clavulanate for susp 600-42.9 mg/5ml 3 amoxicillin (trihydrate) tab 875 mg amoxicillin & k clavulanate chew tab 200-28.5 mg 1 AUGMENTIN XR - amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg 3 amoxicillin & k clavulanate chew tab 400-57 mg 1 BICILLIN C-R - penicillin g benzathine & procaine inj susp 1200000 unit/2ml 3 amoxicillin & k clavulanate for susp 200-28.5 mg/5ml 1 BICILLIN C-R - penicillin g benzathine & procaine inj 900000-300000 unt/2ml 3 amoxicillin & k clavulanate for susp 250-62.5 mg/5ml (Augmentin) 1 BICILLIN L-A - penicillin g benzathine intramuscular susp 600000 unit/ml 3 amoxicillin & k clavulanate for susp 400-57 mg/5ml 1 BICILLIN L-A - penicillin g benzathine intramuscular susp 1200000 unit/2ml 3 BICILLIN L-A - penicillin g benzathine intramuscular susp 2400000 unit/4ml 3 dicloxacillin sodium cap 250 mg 1 dicloxacillin sodium cap 500 mg 1 MOXATAG - amoxicillin (trihydrate) tab sr 24hr 775 mg 3 nafcillin sodium for inj 1 gm 1 nafcillin sodium for inj 10 gm 1 nafcillin sodium for inj 2 gm 1 oxacillin sodium for inj 1 gm 1 1 amoxicillin & k clavulanate for susp 600-42.9 mg/5ml (Augmentin es-600) 1 amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg (Augmentin xr) 1 amoxicillin & k clavulanate tab 250-125 mg 1 amoxicillin & k clavulanate tab 500-125 mg (Augmentin) 1 amoxicillin & k clavulanate tab 875-125 mg (Augmentin) SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 1 1 oxacillin sodium for inj 2 gm 1 3 penicillin g potassium for inj 20000000 unit (Pfizerpen-g) 1 CEFAZOLIN SODIUM - cefazolin sodium (bulk) for inj 100 gm 3 penicillin g potassium for inj 5000000 unit (Pfizerpen-g) 1 CEFAZOLIN SODIUM - cefazolin sodium (bulk) for inj 300 gm cefazolin sodium for inj 1 gm 1 PENICILLIN G PROCAINE - penicillin g procaine intramuscular susp 600000 unit/ml 3 cefazolin sodium for inj 10 gm 1 cefazolin sodium for inj 20 gm 1 3 cefazolin sodium for inj 500 mg 1 PENICILLIN G SODIUM - penicillin g sodium for inj 5000000 unit cefdinir cap 300 mg 1 penicillin v potassium for soln 125 mg/5ml 1 cefdinir for susp 125 mg/5ml 1 cefdinir for susp 250 mg/5ml 1 penicillin v potassium for soln 250 mg/5ml 1 CEFDITOREN PIVOXIL - cefditoren pivoxil tab 200 mg (base equivalent) 3 penicillin v potassium tab 250 mg 1 3 penicillin v potassium tab 500 mg 1 CEFDITOREN PIVOXIL - cefditoren pivoxil tab 400 mg (base equivalent) PFIZERPEN-G - penicillin g potassium for inj 5000000 unit 3 cefepime hcl for inj 1 gm (Maxipime) 1 cefepime hcl for inj 2 gm (Maxipime) 1 PFIZERPEN-G - penicillin g potassium for inj 20000000 unit 3 cefotaxime sodium for inj 1 gm (Claforan) 1 cefotaxime sodium for inj 10 gm (Claforan) 1 cefotaxime sodium for inj 2 gm (Claforan) 1 cefotaxime sodium for inj 500 mg (Claforan) 1 CEFOTETAN - cefotetan disodium for inj 1 gm 3 CEFOTETAN - cefotetan disodium for inj 2 gm 3 CEFOTETAN - cefotetan disodium for inj 10 gm 3 cefoxitin sodium for inj 10 gm 1 CEPHALOSPORINS CEDAX - ceftibuten cap 400 mg 3 CEDAX - ceftibuten for susp 90 mg/5ml 3 CEDAX - ceftibuten for susp 180 mg/5ml 3 CEFACLOR - cefaclor for susp 125 mg/5ml 3 CEFACLOR - cefaclor for susp 250 mg/5ml 3 CEFACLOR - cefaclor for susp 375 mg/5ml 3 cefaclor cap 250 mg 1 cefaclor cap 500 mg 1 3 cefpodoxime proxetil for susp 100 mg/5ml 1 CEFACLOR ER - cefaclor monohydrate tab sr 12hr 500 mg 1 cefpodoxime proxetil for susp 50 mg/5ml 1 cefadroxil cap 500 mg cefadroxil for susp 250 mg/5ml 1 cefpodoxime proxetil tab 100 mg 1 cefadroxil for susp 500 mg/5ml 1 2 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits cefadroxil tab 1 gm Step Therapy 1 Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy oxacillin sodium for inj 10 gm Prior Authorization Drug Name Drug Tier 2015 1 cefprozil for susp 125 mg/5ml 1 cephalexin for susp 125 mg/5ml 1 cefprozil for susp 250 mg/5ml 1 cephalexin for susp 250 mg/5ml 1 cefprozil tab 250 mg 1 3 cefprozil tab 500 mg 1 CLAFORAN - cefotaxime sodium for inj 500 mg CEFTIBUTEN - ceftibuten cap 400 mg 3 3 CEFTIBUTEN - ceftibuten for susp 180 mg/5ml 3 CLAFORAN - cefotaxime sodium for inj 1 gm 3 CEFTIN - cefuroxime axetil tab 250 mg 3 CLAFORAN - cefotaxime sodium for inj 2 gm 3 CLAFORAN - cefotaxime sodium for inj 10 gm 3 CEFTIN - cefuroxime axetil tab 500 mg CEFTIN - cefuroxime axetil for susp 125 mg/5ml 3 KEFLEX - cephalexin cap 250 mg 3 3 KEFLEX - cephalexin cap 500 mg 3 CEFTIN - cefuroxime axetil for susp 250 mg/5ml KEFLEX - cephalexin cap 750 mg 3 ceftriaxone sodium for inj 1 gm (Rocephin) 1 MAXIPIME - cefepime hcl for inj 1 gm 3 MAXIPIME - cefepime hcl for inj 2 gm 3 ceftriaxone sodium for inj 2 gm 1 3 ceftriaxone sodium for inj 250 mg 1 ROCEPHIN - ceftriaxone sodium for inj 500 mg ceftriaxone sodium for inj 500 mg (Rocephin) 1 ROCEPHIN - ceftriaxone sodium for inj 1 gm 3 cefuroxime axetil for susp 125 mg/5ml (Ceftin) 1 SPECTRACEF - cefditoren pivoxil tab 200 mg (base equivalent) 3 cefuroxime axetil tab 250 mg (Ceftin) 1 3 cefuroxime axetil tab 500 mg (Ceftin) 1 SPECTRACEF - cefditoren pivoxil tab 400 mg (base equivalent) 3 SUPRAX - cefixime cap 400 mg 2 CEFUROXIME SODIUM - cefuroxime sodium (bulk) for inj 75 gm SUPRAX - cefixime tab 400 mg 2 CEFUROXIME SODIUM - cefuroxime sodium (bulk) for inj 225 gm 3 SUPRAX - cefixime chew tab 100 mg 2 SUPRAX - cefixime chew tab 200 mg 2 cefuroxime sodium for inj 1.5 gm (Zinacef) 1 SUPRAX - cefixime for susp 100 mg/5ml 2 cefuroxime sodium for inj 7.5 gm (Zinacef) 1 SUPRAX - cefixime for susp 200 mg/5ml 2 cefuroxime sodium for inj 750 mg (Zinacef) 1 SUPRAX - cefixime for susp 500 mg/5ml 2 CEPHALEXIN - cephalexin tab 250 mg 3 3 CEPHALEXIN - cephalexin tab 500 mg 3 ZINACEF - cefuroxime sodium for inj 750 mg cephalexin cap 250 mg (Keflex) 1 cephalexin cap 500 mg (Keflex) 1 Quantity Limits cephalexin cap 750 mg (Keflex) Step Therapy 1 Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy cefpodoxime proxetil tab 200 mg Prior Authorization Drug Name Drug Tier 2015 ZINACEF - cefuroxime sodium for inj 1.5 3 gm SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 3 ZINACEF - cefuroxime sodium for inj 7.5 3 gm ERYPED 200 - erythromycin ethylsuccinate for susp 200 mg/5ml 3 MACROLIDES 3 AZITHROMYCIN - azithromycin powd pack for susp 1 gm 2 ERYPED 400 - erythromycin ethylsuccinate for susp 400 mg/5ml 2 azithromycin for susp 100 mg/5ml (Zithromax) 1 ERYTHROCIN STEARATE erythromycin stearate tab 250 mg 2 azithromycin for susp 200 mg/5ml (Zithromax) 1 ERYTHROMYCIN BASE - erythromycin tab 250 mg 2 azithromycin tab 250 mg (Zithromax) 1 ERYTHROMYCIN BASE - erythromycin tab 500 mg azithromycin tab 500 mg (Zithromax) 1 2 azithromycin tab 600 mg (Zithromax) 1 ERYTHROMYCIN ETHYLSUCCINA erythromycin ethylsuccinate tab 400 mg BIAXIN - clarithromycin tab 250 mg 3 BIAXIN - clarithromycin tab 500 mg erythromycin w/ delayed release particles cap 250 mg 1 3 BIAXIN - clarithromycin for susp 250 mg/5ml 3 PCE - erythromycin w/ enteric coated particles tab 333 mg 3 BIAXIN XL - clarithromycin tab sr 24hr 500 mg 3 PCE - erythromycin w/ enteric coated particles tab 500 mg 3 BIAXIN XL PAC - clarithromycin tab sr 24hr 500 mg 3 ZITHROMAX - azithromycin tab 250 mg 3 ZITHROMAX - azithromycin tab 500 mg 3 clarithromycin for susp 125 mg/5ml 1 ZITHROMAX - azithromycin tab 600 mg 3 clarithromycin for susp 250 mg/5ml (Biaxin) 1 ZITHROMAX - azithromycin for susp 100 mg/5ml 3 clarithromycin tab sr 24hr 500 mg (Biaxin xl pac) 1 ZITHROMAX - azithromycin for susp 200 mg/5ml 3 clarithromycin tab 250 mg (Biaxin) 1 clarithromycin tab 500 mg (Biaxin) ZITHROMAX - azithromycin powd pack for susp 1 gm 3 1 DIFICID - fidaxomicin tab 200 mg 3 3 E.E.S. GRANULES - erythromycin ethylsuccinate for susp 200 mg/5ml 3 ZITHROMAX TRI-PAK - azithromycin tab 500 mg 3 E.E.S. 400 - erythromycin ethylsuccinate tab 400 mg 2 ZITHROMAX Z-PAK - azithromycin tab 250 mg 3 ERY-TAB - erythromycin tab delayed release 250 mg 2 ZMAX - azithromycin extended release for oral susp 2 gm ERY-TAB - erythromycin tab delayed release 333 mg 2 ERY-TAB - erythromycin tab delayed release 500 mg 2 4 TETRACYCLINES demeclocycline hcl tab 150 mg 1 demeclocycline hcl tab 300 mg 1 doxycycline hyclate cap 100 mg (Vibramycin) 1 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 3 1 AVELOX ABC PACK - moxifloxacin hcl tab 400 mg (base equiv) 3 doxycycline hyclate tab 100 mg 1 CIPRO - ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) doxycycline hyclate tab 20 mg 1 3 doxycycline monohydrate cap 100 mg (Monodox) 1 CIPRO - ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) 3 doxycycline monohydrate cap 150 mg (Adoxa) 1 CIPRO - ciprofloxacin hcl tab 250 mg (base equiv) 3 doxycycline monohydrate cap 50 mg 1 CIPRO - ciprofloxacin hcl tab 500 mg (base equiv) 1 CIPRO XR - ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq) 3 doxycycline monohydrate cap 75 mg (Monodox) 1 CIPRO XR - ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq) 3 doxycycline monohydrate tab 100 mg (Adoxa pak 1/100) 1 ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) (Cipro) 1 doxycycline monohydrate tab 150 mg (Adoxa pak 1/150) doxycycline monohydrate tab 50 mg (Adoxa) 1 1 doxycycline monohydrate tab 75 mg (Adoxa) 1 ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) (Cipro) ciprofloxacin hcl tab 100 mg (base equiv) 1 ciprofloxacin hcl tab 250 mg (base equiv) (Cipro) 1 ciprofloxacin hcl tab 500 mg (base equiv) (Cipro) 1 ciprofloxacin hcl tab 750 mg (base equiv) 1 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq) (Cipro xr) 1 1 minocycline hcl cap 100 mg (Minocin) 1 minocycline hcl cap 50 mg (Minocin) 1 minocycline hcl cap 75 mg (Minocin) 1 minocycline hcl tab sr 24hr 135 mg 1 minocycline hcl tab sr 24hr 45 mg 1 minocycline hcl tab sr 24hr 90 mg 1 minocycline hcl tab 100 mg 1 minocycline hcl tab 50 mg 1 minocycline hcl tab 75 mg 1 TETRACYCLINE HCL - tetracycline hcl cap 250 mg 2 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq) (Cipro xr) 3 TETRACYCLINE HCL - tetracycline hcl cap 500 mg 2 FACTIVE - gemifloxacin mesylate tab 320 mg (base equiv) LEVAQUIN - levofloxacin tab 250 mg 3 VIBRAMYCIN - doxycycline calcium syrup 50 mg/5ml 3 LEVAQUIN - levofloxacin tab 500 mg 3 LEVAQUIN - levofloxacin tab 750 mg 3 LEVAQUIN - levofloxacin oral soln 25 mg/ml 3 FLUOROQUINOLONES AVELOX - moxifloxacin hcl tab 400 mg (base equiv) 3 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier doxycycline hyclate tab delayed release 150 mg (Doryx) Quantity Limits 1 Step Therapy doxycycline hyclate cap 50 mg Prior Authorization Drug Name Drug Tier 2015 5 levofloxacin oral soln 25 mg/ml (Levaquin) 1 tobramycin sulfate inj 2 gm/50ml (40 mg/ml) 1 levofloxacin tab 250 mg (Levaquin) 1 1 levofloxacin tab 500 mg (Levaquin) 1 tobramycin sulfate inj 80 mg/2ml (40 mg/ml) levofloxacin tab 750 mg (Levaquin) 1 SULFONAMIDES moxifloxacin hcl tab 400 mg (base equiv) (Avelox) 1 SULFADIAZINE - sulfadiazine tab 500 mg NOROXIN - norfloxacin tab 400 mg 3 ANTIMYCOBACTERIAL AGENTS OFLOXACIN - ofloxacin tab 400 mg 3 3 ofloxacin tab 200 mg 1 CAPASTAT SULFATE - capreomycin sulfate for inj 1 gm 1 CYCLOSERINE - cycloserine cap 250 mg 3 ofloxacin tab 300 mg ofloxacin tab 400 mg 1 ethambutol hcl tab 100 mg (Myambutol) 1 AMINOGLYCOSIDES 3 amikacin sulfate inj 1 gm/4ml (250 mg/ml) 1 ethambutol hcl tab 400 mg (Myambutol) 1 amikacin sulfate inj 500 mg/2ml (250 mg/ml) 1 ISONIAZID - isoniazid syrup 50 mg/5ml 2 ISONIAZID - isoniazid inj 100 mg/ml 3 BETHKIS - tobramycin nebu soln 300 mg/4ml 5 isoniazid & rifampin cap 150-300 mg 1 1 isoniazid tab 100 mg 1 gentamicin sulfate inj 10 mg/ml 1 isoniazid tab 300 mg 1 gentamicin sulfate inj 40 mg/ml 3 MYAMBUTOL - ethambutol hcl tab 100 mg 3 KANAMYCIN SULFATE - kanamycin sulfate inj 333 mg/ml 1 MYAMBUTOL - ethambutol hcl tab 400 mg 3 neomycin sulfate tab 500 mg paromomycin sulfate cap 250 mg 1 MYCOBUTIN - rifabutin cap 150 mg 3 STREPTOMYCIN SULFATE streptomycin sulfate for inj 1 gm 3 PASER - aminosalicylic acid cr granules packet 4 gm 3 TOBI - tobramycin nebu soln 300 mg/5ml 5 PRIFTIN - rifapentine tab 150 mg 2 5 pyrazinamide tab 500 mg 1 TOBI PODHALER - tobramycin inhal cap 28 mg rifabutin cap 150 mg (Mycobutin) 1 tobramycin nebu soln 300 mg/5ml (Tobi) 4 RIFADIN - rifampin cap 150 mg 3 RIFADIN - rifampin cap 300 mg 3 tobramycin sulfate for inj 1.2 gm 1 3 tobramycin sulfate inj 1.2 gm/30ml (40 mg/ml) 1 RIFAMATE - isoniazid & rifampin cap 150-300 mg rifampin cap 150 mg (Rifadin) 1 tobramycin sulfate inj 10 mg/ml 1 rifampin cap 300 mg (Rifadin) 1 6 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 RIFATER - isoniazid-rifampin w/ pyrazinamide tab 50-120-300 mg 3 griseofulvin microsize susp 125 mg/5ml 1 SEROMYCIN - cycloserine cap 250 mg 3 1 SIRTURO - bedaquiline fumarate tab 100 mg (base equiv) 3 griseofulvin microsize tab 500 mg (Grifulvin v) 1 TRECATOR - ethionamide tab 250 mg 3 griseofulvin ultramicrosize tab 125 mg (Gris-peg) griseofulvin ultramicrosize tab 250 mg (Gris-peg) 1 itraconazole cap 100 mg (Sporanox) 1 ketoconazole tab 200 mg 1 ANTIFUNGALS nystatin oral powder 1 AMPHOTERICIN B - amphotericin b for inj 50 mg 3 ANCOBON - flucytosine cap 250 mg 3 LAMISIL - terbinafine hcl tab 250 mg 3 ANCOBON - flucytosine cap 500 mg 3 2 BIO-STATIN - nystatin cap 500000 unit 3 LAMISIL - terbinafine hcl oral granules packet 125 mg LAMISIL - terbinafine hcl oral granules packet 187.5 mg 2 NOXAFIL - posaconazole tab delayed release 100 mg 3 2 BIO-STATIN - nystatin cap 1000000 unit 3 3 DIFLUCAN - fluconazole tab 50 mg DIFLUCAN - fluconazole tab 100 mg 3 DIFLUCAN - fluconazole tab 150 mg 3 DIFLUCAN - fluconazole tab 200 mg 3 NOXAFIL - posaconazole susp 40 mg/ ml DIFLUCAN - fluconazole for susp 10 mg/ml 3 nystatin tab 500000 unit 1 ONMEL - itraconazole tab 200 mg 3 DIFLUCAN - fluconazole for susp 40 mg/ml 3 SPORANOX - itraconazole cap 100 mg 3 2 fluconazole for susp 10 mg/ml (Diflucan) 1 SPORANOX - itraconazole oral soln 10 mg/ml fluconazole for susp 40 mg/ml (Diflucan) SPORANOX PULSEPAK - itraconazole cap 100 mg 3 1 terbinafine hcl tab 250 mg (Lamisil) 1 fluconazole tab 100 mg (Diflucan) 1 fluconazole tab 150 mg (Diflucan) TERBINEX - terbinafine oral tab 250 mg & hydrxyprop chitosan liq 1% kit 3 1 fluconazole tab 200 mg (Diflucan) 1 VFEND - voriconazole tab 50 mg 3 fluconazole tab 50 mg (Diflucan) 1 VFEND - voriconazole tab 200 mg 3 flucytosine cap 250 mg (Ancobon) 1 3 flucytosine cap 500 mg (Ancobon) 1 VFEND - voriconazole for susp 40 mg/ ml GRIFULVIN V - griseofulvin microsize tab 500 mg 3 voriconazole for susp 40 mg/ml (Vfend) 1 GRIS-PEG - griseofulvin ultramicrosize tab 125 mg 3 voriconazole tab 200 mg (Vfend) 1 voriconazole tab 50 mg (Vfend) 1 GRIS-PEG - griseofulvin ultramicrosize tab 250 mg 3 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 ANTIVIRALS SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 7 EMTRIVA - emtricitabine soln 10 mg/ml 2 entecavir tab 0.5 mg (Baraclude) 1 entecavir tab 1 mg (Baraclude) 1 abacavir sulfate-lamivudinezidovudine tab 300-150-300 mg (Trizivir) 1 acyclovir cap 200 mg (Zovirax) 1 EPIVIR - lamivudine tab 150 mg 3 acyclovir susp 200 mg/5ml (Zovirax) 1 EPIVIR - lamivudine tab 300 mg 3 acyclovir tab 400 mg (Zovirax) 1 EPIVIR - lamivudine oral soln 10 mg/ml 2 acyclovir tab 800 mg (Zovirax) 1 EPIVIR HBV - lamivudine tab 100 mg 3 adefovir dipivoxil tab 10 mg (Hepsera) 1 EPIVIR HBV - lamivudine oral soln 5 mg/ml 2 APTIVUS - tipranavir cap 250 mg 2 2 APTIVUS - tipranavir oral soln 100 mg/ ml 2 EPZICOM - abacavir sulfate-lamivudine tab 600-300 mg famciclovir tab 125 mg (Famvir) 1 ATRIPLA - efavirenz-emtricitabinetenofovir df tab 600-200-300 mg 2 famciclovir tab 250 mg (Famvir) 1 famciclovir tab 500 mg (Famvir) 1 BARACLUDE - entecavir tab 0.5 mg 3 FAMVIR - famciclovir tab 125 mg 3 BARACLUDE - entecavir tab 1 mg 3 FAMVIR - famciclovir tab 250 mg 3 BARACLUDE - entecavir oral soln 0.05 mg/ml 2 FAMVIR - famciclovir tab 500 mg 3 COMBIVIR - lamivudine-zidovudine tab 150-300 mg FLUMADINE - rimantadine hydrochloride tab 100 mg 3 3 4 2 FUZEON - enfuvirtide for inj 90 mg COMPLERA - emtricitabine-rilpivirinetenofovir df tab 200-25-300 mg 5 COPEGUS - ribavirin tab 200 mg 5 HARVONI - ledipasvir-sofosbuvir tab 90-400 mg 3 2 HEPSERA - adefovir dipivoxil tab 10 mg CRIXIVAN - indinavir sulfate cap 200 mg INCIVEK - telaprevir tab 375 mg 5 2 INFERGEN - interferon alfacon-1 inj 9 mcg/0.3ml 5 CRIXIVAN - indinavir sulfate cap 400 mg 1 INFERGEN - interferon alfacon-1 inj 15 mcg/0.5ml 5 didanosine delayed release capsule 125 mg (Videx ec) 1 INTELENCE - etravirine tab 25 mg 2 didanosine delayed release capsule 200 mg (Videx ec) INTELENCE - etravirine tab 100 mg 2 didanosine delayed release capsule 250 mg (Videx ec) 1 INTELENCE - etravirine tab 200 mg 2 2 didanosine delayed release capsule 400 mg (Videx ec) 1 INVIRASE - saquinavir mesylate cap 200 mg 2 EDURANT - rilpivirine hcl tab 25 mg (base equivalent) 2 INVIRASE - saquinavir mesylate tab 500 mg 8 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare • • Products January 2015 Quantity Limits 2 1 Step Therapy EMTRIVA - emtricitabine caps 200 mg abacavir sulfate tab 300 mg (base equiv) (Ziagen) Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 ISENTRESS - raltegravir potassium chew tab 25 mg (base equiv) 2 • ISENTRESS - raltegravir potassium chew tab 100 mg (base equiv) 2 ISENTRESS - raltegravir potassium packet for susp 100 mg (base equiv) 2 KALETRA - lopinavir-ritonavir tab 100-25 mg 2 KALETRA - lopinavir-ritonavir tab 200-50 mg 2 KALETRA - lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) 2 lamivudine tab 100 mg (Epivir hbv) 1 lamivudine tab 150 mg (Epivir) 1 lamivudine tab 300 mg (Epivir) 1 lamivudine-zidovudine tab 150-300 mg (Combivir) 1 LEXIVA - fosamprenavir calcium tab 700 mg (base equiv) 2 LEXIVA - fosamprenavir calcium susp 50 mg/ml (base equiv) 2 MODERIBA - ribavirin tab 200 mg & ribavirin tab 400 mg dose pack 5 MODERIBA - ribavirin tab 400 mg & ribavirin tab 600 mg dose pack 5 MODERIBA 1200 DOSE PACK ribavirin tab 600 mg 5 MODERIBA 800 DOSE PACK - ribavirin tab 400 mg 5 NEVIRAPINE - nevirapine susp 50 mg/5ml 3 nevirapine tab sr 24hr 400 mg (Viramune xr) 1 nevirapine tab 200 mg (Viramune) 1 NORVIR - ritonavir cap 100 mg 2 NORVIR - ritonavir tab 100 mg 2 NORVIR - ritonavir oral soln 80 mg/ml 2 PEG-INTRON - peginterferon alfa-2b for 5 inj kit 50 mcg/0.5ml PEG-INTRON - peginterferon alfa-2b for 5 inj kit 80 mcg/0.5ml PEG-INTRON - peginterferon alfa-2b for 5 inj kit 120 mcg/0.5ml PEG-INTRON - peginterferon alfa-2b for 5 inj kit 150 mcg/0.5ml PEG-INTRON REDIPEN - peginterferon 5 alfa-2b for inj kit 50 mcg/0.5ml PEG-INTRON REDIPEN - peginterferon 5 alfa-2b for inj kit 80 mcg/0.5ml PEG-INTRON REDIPEN - peginterferon 5 alfa-2b for inj kit 120 mcg/0.5ml PEG-INTRON REDIPEN - peginterferon 5 alfa-2b for inj kit 150 mcg/0.5ml 5 PEG-INTRON REDIPEN PAK 4 peginterferon alfa-2b for inj kit 50 mcg/0.5ml 5 PEG-INTRON REDIPEN PAK 4 peginterferon alfa-2b for inj kit 80 mcg/0.5ml 5 PEG-INTRON REDIPEN PAK 4 peginterferon alfa-2b for inj kit 120 mcg/0.5ml 5 PEG-INTRON REDIPEN PAK 4 peginterferon alfa-2b for inj kit 150 mcg/0.5ml 4 PEGASYS - peginterferon alfa-2a inj 180 mcg/ml 4 PEGASYS - peginterferon alfa-2a inj 180 mcg/0.5ml PEGASYS - peginterferon alfa-2a inj kit 4 180 mcg/0.5ml 4 PEGASYS PROCLICK - peginterferon alfa-2a inj 135 mcg/0.5ml 4 PEGASYS PROCLICK - peginterferon alfa-2a inj 180 mcg/0.5ml SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Prior Authorization • Drug Name Step Therapy Drug Tier 4 Quantity Limits OLYSIO - simeprevir sodium cap 150 mg (base equivalent) Step Therapy 2 Drug Tier ISENTRESS - raltegravir potassium tab 400 mg (base equiv) Drug Name Prior Authorization 2015 • • • • • • • • • • • • • • • • 9 PEGINTRON - peginterferon alfa-2b for inj kit 80 mcg/0.5ml • RIBASPHERE RIBAPAK - ribavirin tab 400 mg 5 5 PEGINTRON - peginterferon alfa-2b for inj kit 120 mcg/0.5ml • RIBASPHERE RIBAPAK - ribavirin tab 600 mg 5 5 5 • RIBASPHERE RIBAPAK - ribavirin tab 200 mg & ribavirin tab 400 mg dose pack 5 PEGINTRON - peginterferon alfa-2b for inj kit 150 mcg/0.5ml RIBASPHERE RIBAPAK - ribavirin tab 400 mg & ribavirin tab 600 mg dose pack 5 RIBATAB - ribavirin tab 400 mg 5 RIBATAB - ribavirin tab 600 mg 5 RIBATAB - ribavirin tab 400 mg & ribavirin tab 600 mg dose pack 5 ribavirin cap 200 mg (Rebetol) 4 ribavirin tab 200 mg (Copegus) 4 rimantadine hydrochloride tab 100 mg (Flumadine) 1 RIMANTALIST - rimantadine tab 100 mg & dietary management cap pack 3 SELZENTRY - maraviroc tab 150 mg 2 SELZENTRY - maraviroc tab 300 mg 2 SITAVIG - acyclovir buccal tab 50 mg 3 SOVALDI - sofosbuvir tab 400 mg 4 stavudine cap 15 mg (Zerit) 1 stavudine cap 20 mg (Zerit) 1 stavudine cap 30 mg (Zerit) 1 stavudine cap 40 mg (Zerit) 1 stavudine for oral soln 1 mg/ml (Zerit) 1 STRIBILD - elvitegrav-cobicisemtricitab-tenofov tab 150-150-200-300 mg 2 SUSTIVA - efavirenz cap 50 mg 2 SUSTIVA - efavirenz cap 200 mg 2 SUSTIVA - efavirenz tab 600 mg 2 PREZISTA - darunavir ethanolate tab 75 2 mg (base equiv) 2 PREZISTA - darunavir ethanolate tab 150 mg (base equiv) 2 PREZISTA - darunavir ethanolate tab 400 mg (base equiv) 2 PREZISTA - darunavir ethanolate tab 600 mg (base equiv) 2 PREZISTA - darunavir ethanolate tab 800 mg (base equiv) 2 PREZISTA - darunavir ethanolate susp 100 mg/ml (base equiv) 5 REBETOL - ribavirin cap 200 mg REBETOL - ribavirin soln 40 mg/ml 5 RELENZA DISKHALER - zanamivir aero powder breath activated 5 mg/ blister 3 RESCRIPTOR - delavirdine mesylate tab 100 mg 2 RESCRIPTOR - delavirdine mesylate tab 200 mg 2 RETROVIR - zidovudine cap 100 mg 3 RETROVIR - zidovudine syrup 10 mg/ml 3 2 REYATAZ - atazanavir sulfate cap 100 mg (base equiv) 2 REYATAZ - atazanavir sulfate cap 150 mg (base equiv) 2 REYATAZ - atazanavir sulfate cap 200 mg (base equiv) 2 REYATAZ - atazanavir sulfate cap 300 mg (base equiv) 5 RIBASPHERE - ribavirin tab 400 mg 10 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare • Products January 2015 Quantity Limits 5 Step Therapy RIBASPHERE - ribavirin tab 600 mg Prior Authorization • Drug Name Drug Tier 5 Quantity Limits Prior Authorization PEGINTRON - peginterferon alfa-2b for inj kit 50 mcg/0.5ml Drug Name Step Therapy Drug Tier 2015 TAMIFLU - oseltamivir phosphate cap 30 mg (base equiv) 2 VIRACEPT - nelfinavir mesylate tab 625 mg 2 TAMIFLU - oseltamivir phosphate cap 45 mg (base equiv) 2 VIRAMUNE - nevirapine tab 200 mg 3 TAMIFLU - oseltamivir phosphate cap 75 mg (base equiv) VIRAMUNE - nevirapine susp 50 mg/5ml 2 2 2 VIRAMUNE XR - nevirapine tab sr 24hr 100 mg 2 TAMIFLU - oseltamivir phosphate for susp 6 mg/ml (base equiv) 2 VIRAMUNE XR - nevirapine tab sr 24hr 400 mg 3 TIVICAY - dolutegravir sodium tab 50 mg (base equiv) VIRAZOLE - ribavirin for inhal soln 6 gm 3 TRIUMEQ - abacavir-dolutegravirlamivudine tab 600-50-300 mg 2 VIREAD - tenofovir disoproxil fumarate tab 150 mg 2 TRIZIVIR - abacavir sulfate-lamivudinezidovudine tab 300-150-300 mg 3 VIREAD - tenofovir disoproxil fumarate tab 200 mg 2 TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab 200-300 mg 2 VIREAD - tenofovir disoproxil fumarate tab 250 mg 2 TYBOST - cobicistat tab 150 mg 2 3 VIREAD - tenofovir disoproxil fumarate tab 300 mg 2 TYZEKA - telbivudine tab 600 mg valacyclovir hcl tab 1 gm (Valtrex) 1 2 valacyclovir hcl tab 500 mg (Valtrex) 1 VIREAD - tenofovir disoproxil fumarate oral powder 40 mg/gm VALCYTE - valganciclovir hcl tab 450 mg 2 ZERIT - stavudine cap 15 mg 3 ZERIT - stavudine cap 20 mg 3 ZERIT - stavudine cap 30 mg 3 ZERIT - stavudine cap 40 mg 3 ZERIT - stavudine for oral soln 1 mg/ml 3 ZIAGEN - abacavir sulfate tab 300 mg (base equiv) 3 2 VALCYTE - valganciclovir hcl for soln 50 2 mg/ml (base equiv) VALTREX - valacyclovir hcl tab 500 mg 3 VALTREX - valacyclovir hcl tab 1 gm 3 VICTRELIS - boceprevir cap 200 mg 5 VIDEX - didanosine for soln 2 gm 2 VIDEX - didanosine for soln 4 gm 2 ZIAGEN - abacavir sulfate soln 20 mg/ ml (base equiv) VIDEX EC - didanosine delayed release capsule 125 mg 3 zidovudine cap 100 mg (Retrovir) 1 zidovudine syrup 10 mg/ml (Retrovir) 1 VIDEX EC - didanosine delayed release capsule 200 mg 3 zidovudine tab 300 mg 1 ZOVIRAX - acyclovir cap 200 mg 3 VIDEX EC - didanosine delayed release capsule 250 mg 3 ZOVIRAX - acyclovir tab 400 mg 3 3 ZOVIRAX - acyclovir tab 800 mg 3 VIDEX EC - didanosine delayed release capsule 400 mg ZOVIRAX - acyclovir susp 200 mg/5ml 3 VIRACEPT - nelfinavir mesylate tab 250 mg 2 • Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 ANTIMALARIALS SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 11 ARALEN - chloroquine phosphate tab 500 mg 3 ALINIA - nitazoxanide for susp 100 mg/5ml 3 atovaquone-proguanil hcl tab 250-100 mg (Malarone) 1 atovaquone susp 750 mg/5ml (Mepron) 1 atovaquone-proguanil hcl tab 62.5-25 mg (Malarone) 1 AZACTAM - aztreonam for inj 1 gm 3 AZACTAM - aztreonam for inj 2 gm 3 chloroquine phosphate tab 250 mg 1 aztreonam for inj 1 gm (Azactam) 1 chloroquine phosphate tab 500 mg (Aralen) 1 aztreonam for inj 2 gm (Azactam) 1 2 BACITRACIN - bacitracin intramuscular for soln 50000 unit 3 COARTEM - artemether-lumefantrine tab 20-120 mg 2 bacitracin intramuscular for soln 50000 unit (Bacitracin) 1 DARAPRIM - pyrimethamine tab 25 mg hydroxychloroquine sulfate tab 200 mg (Plaquenil) 1 BACTRIM - sulfamethoxazoletrimethoprim tab 400-80 mg 3 MALARONE - atovaquone-proguanil hcl tab 62.5-25 mg 3 BACTRIM DS - sulfamethoxazoletrimethoprim tab 800-160 mg 3 MALARONE - atovaquone-proguanil hcl tab 250-100 mg 3 CAYSTON - aztreonam lysine for inhal soln 75 mg (base equivalent) 5 mefloquine hcl tab 250 mg 1 CLEOCIN - clindamycin hcl cap 75 mg 3 PLAQUENIL - hydroxychloroquine sulfate tab 200 mg 3 CLEOCIN - clindamycin hcl cap 150 mg 3 2 CLEOCIN - clindamycin hcl cap 300 mg 3 PRIMAQUINE PHOSPHATE primaquine phosphate tab 26.3 mg 3 QUALAQUIN - quinine sulfate cap 324 mg 3 CLEOCIN PEDIATRIC GRANULE clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) 1 CLEOCIN PHOSPHATE - clindamycin phosphate inj 300 mg/2ml 3 quinine sulfate cap 324 mg (Qualaquin) CLEOCIN PHOSPHATE - clindamycin phosphate inj 600 mg/4ml 3 AMEBICIDES YODOXIN - iodoquinol tab 210 mg 3 YODOXIN - iodoquinol tab 650 mg CLEOCIN PHOSPHATE - clindamycin phosphate inj 900 mg/6ml 3 3 3 ALBENZA - albendazole tab 200 mg 2 CLEOCIN PHOSPHATE - clindamycin phosphate inj 9 gm/60ml BILTRICIDE - praziquantel tab 600 mg 2 clindamycin hcl cap 150 mg (Cleocin) 1 ivermectin tab 3 mg (Stromectol) 1 clindamycin hcl cap 300 mg (Cleocin) 1 STROMECTOL - ivermectin tab 3 mg 2 clindamycin hcl cap 75 mg (Cleocin) 1 clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) (Cleocin pediatric gr) 1 ANTHELMINTICS ANTI-INFECTIVE AGENTS - MISC. ALINIA - nitazoxanide tab 500 mg 12 3 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 clindamycin phosphate inj 300 mg/2ml (Cleocin phosphate) 1 PENTAM 300 - pentamidine isethionate for soln 300 mg 3 clindamycin phosphate inj 600 mg/4ml (Cleocin phosphate) 1 polymyxin b sulfate for inj 500000 unit 1 clindamycin phosphate inj 9 gm/60ml (Cleocin phosphate) 1 clindamycin phosphate inj 900 mg/6ml (Cleocin phosphate) 1 colistimethate sodium for inj 150 mg (Coly-Mycin M) 1 PRIMSOL - trimethoprim hcl oral soln 50 3 mg/5ml (base equiv) 2 SIVEXTRO - tedizolid phosphate tab 200 mg sulfamethoxazole-trimethoprim susp 1 200-40 mg/5ml 1 sulfamethoxazole-trimethoprim tab 400-80 mg (Bactrim) 1 sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrim ds) 3 TINDAMAX - tinidazole tab 250 mg COLY-MYCIN M - colistimethate sodium 3 for inj 150 mg 2 DAPSONE - dapsone tab 25 mg DAPSONE - dapsone tab 100 mg 2 erythromycin-sulfisoxazole for susp 200-600 mg/5ml 1 FIRST-VANCOMYCIN 25 - vancomycin hcl oral soln 25 mg/ml (compound kit) 3 FIRST-VANCOMYCIN 50 - vancomycin hcl oral soln 50 mg/ml (compound kit) 3 FLAGYL - metronidazole cap 375 mg 3 FLAGYL - metronidazole tab 250 mg 3 FLAGYL - metronidazole tab 500 mg 3 FLAGYL ER - metronidazole tab sr 24hr 750 mg TINDAMAX - tinidazole tab 500 mg 3 tinidazole tab 250 mg (Tindamax) 1 tinidazole tab 500 mg (Tindamax) 1 trimethoprim tab 100 mg 1 VANCOCIN HCL - vancomycin hcl cap 125 mg 3 VANCOCIN HCL - vancomycin hcl cap 250 mg 3 3 vancomycin hcl cap 125 mg (Vancocin hcl) 1 INVANZ - ertapenem sodium for inj 1 gm (base equivalent) 3 vancomycin hcl cap 250 mg (Vancocin hcl) 1 KETEK - telithromycin tab 300 mg 3 XIFAXAN - rifaximin tab 200 mg 3 KETEK - telithromycin tab 400 mg 3 XIFAXAN - rifaximin tab 550 mg 2 LINCOCIN - lincomycin hcl inj 300 mg/ ml 3 ZYVOX - linezolid tab 600 mg 2 ZYVOX - linezolid for susp 100 mg/5ml 2 MEPRON - atovaquone susp 750 mg/5ml 3 metronidazole cap 375 mg (Flagyl) 1 metronidazole tab 250 mg (Flagyl) 1 metronidazole tab 500 mg (Flagyl) 1 NEBUPENT - pentamidine isethionate for nebulization soln 300 mg 2 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 BIOLOGICALS SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare ACTHIB - haemophilus b polysaccharide conjugate vaccine for inj 2 AFLURIA PF 2012-2013 - influenza virus vaccine split preservative free inj 2 Products January 2015 13 AFLURIA PF 2013-2014 - influenza virus vaccine split preservative free inj 2 FLUBLOK 2014-2015 - influenza virus vac recombinant hemagglutinin (ha) inj 2 AFLURIA PF 2014-2015 - influenza virus vaccine split preservative free inj 2 FLUCELVAX 2012-2013 - influenza virus vaccine tissue-cultured subunit inj 2 AFLURIA 2012-2013 - influenza virus vaccine split inj 2 2 AFLURIA 2013-2014 - influenza virus vaccine split inj 2 FLUCELVAX 2013-2014 - influenza virus vaccine tissue-cultured subunit inj 2 AFLURIA 2014-2015 - influenza virus vaccine split inj 2 FLUCELVAX 2014-2015 - influenza virus vaccine tissue-cultured subunit inj CERVARIX - human papillomavirus (hpv) bival (type 16, 18) recmb vac inj 2 FLULAVAL QUADRIVALENT 201 - influenza virus vaccine split quadrivalent im inj 2 FLULAVAL QUADRIVALENT 201 - influenza virus vaccine split quadrivalent inj 0.5 ml 2 FLULAVAL 2012-2013 - influenza virus vaccine split inj 2 FLULAVAL 2013-2014 - influenza virus vaccine split inj 2 FLULAVAL 2014-2015 - influenza virus vaccine split inj 2 FLUMIST NASAL VACCINE 201 influenza virus vaccine live intranasal liquid 2 FLUMIST QUADRIVALENT - influenza virus vaccine live quadrivalent intranasal susp 2 FLUVIRIN PF 2012-2013 - influenza virus vaccine types a & b preservative free inj 2 FLUVIRIN PF 2013-2014 - influenza virus vaccine types a & b preservative free inj 2 FLUVIRIN PF 2014-2015 - influenza virus vaccine types a & b preservative free inj 2 FLUVIRIN 2012-2013 - influenza virus vaccine types a & b surface antigen inj 2 COMVAX - haemophilus b polysac conj- 2 hepatitis b (recomb) vac im susp 2 ENGERIX-B - hepatitis b vaccine (recombinant) susp 10 mcg/0.5ml 2 ENGERIX-B - hepatitis b vaccine (recombinant) susp 20 mcg/ml 2 ENGERIX-B - hepatitis b vaccine (recombinant) 10 mcg/0.5ml 2 ENGERIX-B - hepatitis b vaccine (recombinant) 20 mcg/ml 2 FLUARIX QUADRIVALENT 2013 influenza virus vaccine split quadrivalent inj 0.5 ml 2 FLUARIX QUADRIVALENT 2014 influenza virus vaccine split quadrivalent inj 0.5 ml 2 FLUARIX 2012-2013 - influenza virus vaccine split preservative free inj 2 FLUARIX 2013-2014 - influenza virus vaccine split preservative free inj 2 FLUARIX 2014-2015 - influenza virus vaccine split preservative free inj 2 FLUBLOK 2013-2014 - influenza virus vac recombinant hemagglutinin (ha) inj 14 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 FLUVIRIN 2013-2014 - influenza virus vaccine types a & b surface antigen inj 2 FLUZONE QUADRIVALENT 2014 influenza virus vaccine split quadrivalent inj 0.25 ml 2 FLUVIRIN 2014-2015 - influenza virus vaccine types a & b surface antigen inj 2 FLUZONE QUADRIVALENT 2014 influenza virus vaccine split quadrivalent inj 0.5 ml 2 FLUZONE HIGH-DOSE PF 2012 influenza virus vac split high-dose preservative free inj 2 FLUZONE SPLIT 2012-2013 - influenza virus vaccine split inj 2 2 FLUZONE SPLIT 2013-2014 - influenza virus vaccine split inj 2 FLUZONE HIGH-DOSE PF 2013 influenza virus vac split high-dose preservative free inj FLUZONE SPLIT 2014-2015 - influenza virus vaccine split inj 2 FLUZONE HIGH-DOSE PF 2014 influenza virus vac split high-dose preservative free inj 2 GARDASIL - human papillomavirus (hpv) quadrivalent recombinant vac inj 2 FLUZONE INTRADERMAL - influenza virus vaccine split intradermal inj 9 mcg/strain 2 HAVRIX - hepatitis a vaccine inj susp 720 el unit/0.5ml 2 2 HAVRIX - hepatitis a vaccine inj susp 1440 el unit/ml 2 FLUZONE PEDIATRIC PF 2012 influenza virus vaccine split preservative free inj 2 FLUZONE PEDIATRIC PF 2013 influenza virus vaccine split preservative free inj 2 HIBERIX - haemophilus b polysaccharide conjugate vac for inj 10 mcg 2 FLUZONE PF 2012-2013 - influenza virus vaccine split preservative free inj 2 IMOVAX RABIES (H.D.C.V.) - rabies virus vaccine, hdc inj 2 FLUZONE PF 2013-2014 - influenza virus vaccine split preservative free inj 2 INFLUENZA A (H1N1) MONOVA influenza a (h1n1) monovalent vaccine live intranasal liquid IPOL INACTIVATED IPV - poliovirus vaccine, ipv injection 2 FLUZONE PF 2014-2015 - influenza virus vaccine split preservative free inj 2 M-M-R II W/DILUENT 10 DOS measles, mumps & rubella virus vaccines for inj 2 FLUZONE QUADRIVALENT 2013 influenza virus vaccine split quadrivalent inj 0.25 ml 2 MENACTRA - meningococcal (a, c, y, and w-135) conjugate vaccine inj 2 2 FLUZONE QUADRIVALENT 2013 influenza virus vaccine split quadrivalent inj 0.5 ml 2 MENHIBRIX - meningococcal (c & y)haemophilus b tet tox conj vac for inj 2 FLUZONE QUADRIVALENT 2014 influenza virus vaccine split quadrivalent im inj 2 MENOMUNE-A/C/Y/W-135 meningococcal vaccine a, c, y, and w-135 inj MENVEO - meningococcal (a, c, y, and w-135) oligo conj vac for inj 2 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 15 PEDVAX HIB - haemophilus b polysaccharide conj vac im susp 7.5 mcg/0.5 ml 2 PNEUMOVAX 23 - pneumococcal vaccine polyvalent inj 25 mcg/0.5ml 2 PNEUMOVAX 23/1 DOSE pneumococcal vaccine polyvalent inj 25 mcg/0.5ml 2 PNEUMOVAX 23/5 DOSE pneumococcal vaccine polyvalent inj 25 mcg/0.5ml 2 PREVNAR 13 - pneumococcal 13-valent 2 conjugate vaccine inj 2 PROQUAD - measles-mumps-rubellavaricella virus vaccines for inj 2 RABAVERT - rabies vaccine, pcec for inj RECOMBIVAX HB - hepatitis b vaccine 2 (recombinant) susp 5 mcg/0.5ml RECOMBIVAX HB - hepatitis b vaccine 2 (recombinant) susp 10 mcg/ml RECOMBIVAX HB - hepatitis b vaccine 2 (recombinant) susp 40 mcg/ml 2 ROTARIX - rotavirus vaccine, live for oral susp 2 ROTATEQ - rotavirus vaccine, live oral pentavalent soln 2 TWINRIX - hepatitis a (inact)-hep b (recomb) vac inj 720-20 elu-mcg/ml VAQTA - hepatitis a vaccine inj susp 25 2 unit/0.5ml VAQTA - hepatitis a vaccine inj susp 50 2 unit/ml 2 VARIVAX - varicella virus vac live for subcutaneous inj 1350 pfu/0.5ml 2 ZOSTAVAX - zoster vaccine live for inj 19400 unit/0.65ml 2 ADACEL - tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lf-mcg/0.5ml 2 BOOSTRIX - tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lf-lf-mcg/0.5ml 16 DAPTACEL - diph, acellular pert & tet tox inj 15 lf-10 mcg-5 lf/0.5ml 2 DIPHTHERIA/TETANUS TOXOID diphtheria-tetanus tox adsorbed (dt) im inj 25-5 unit/0.5ml 2 INFANRIX - diph, acellular pert & tet tox inj 25 lf-58 mcg-10 lf/0.5ml 2 KINRIX - diph-tetanus tox ad-acell pert & polio virus, ipv vac inj 2 PEDIARIX - diph-tetanus tox-acell perthepatitis b-polio ipv vac inj 2 PENTACEL - diph-ac per-tet tox adpoliov-haemoph b poly vac for im susp 2 TENIVAC - tetanus-diphtheria toxoids (td) inj 5-2 lfu 2 TETANUS TOXOID ADSORBED tetanus toxoid adsorbed inj 5 lf 2 TETANUS/DIPHTHERIA TOXOID tetanus-diphtheria toxoids (td) inj 2-2 lf/0.5ml 2 PASSIVE IMMUNIZING AGENTS ANTIVENIN LATRODECTUS MAC antivenin latrodectus mactans inj kit 3 GAMASTAN S/D - immune globulin (human) inj 3 GAMMAGARD LIQUID - immune globulin (human) iv or subcutaneous soln 1 gm/10ml 3 • GAMMAGARD LIQUID - immune globulin (human) iv or subcutaneous soln 2.5 gm/25ml 3 • GAMMAGARD LIQUID - immune globulin (human) iv or subcutaneous soln 5 gm/50ml 3 • GAMMAGARD LIQUID - immune globulin (human) iv or subcutaneous soln 10 gm/100ml 3 • GAMMAGARD LIQUID - immune globulin (human) iv or subcutaneous soln 20 gm/200ml 3 • SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 3 • GAMMAKED - immune globulin (human) iv or subcutaneous soln 5 gm/50ml 3 • GAMMAKED - immune globulin (human) iv or subcutaneous soln 10 gm/100ml 3 GAMMAKED - immune globulin (human) iv or subcutaneous soln 20 gm/200ml 3 GAMUNEX-C - immune globulin (human) iv or subcutaneous soln 1 gm/10ml 3 GAMUNEX-C - immune globulin (human) iv or subcutaneous soln 2.5 gm/25ml 3 GAMUNEX-C - immune globulin (human) iv or subcutaneous soln 5 gm/50ml 3 • GAMUNEX-C - immune globulin (human) iv or subcutaneous soln 10 gm/100ml 3 • GAMUNEX-C - immune globulin (human) iv or subcutaneous soln 20 gm/200ml 3 • GAMUNEX-C - immune globulin (human) iv or subcutaneous soln 40 gm/400ml 3 • HEPAGAM B - hepatitis b immune globulin (human) inj soln 3 HIZENTRA - immune globulin (human) subcutaneous inj 1 gm/5ml 3 • HIZENTRA - immune globulin (human) subcutaneous inj 2 gm/10ml 3 • 3 • HIZENTRA - immune globulin (human) subcutaneous inj 10 gm/50ml 3 • • HYPERHEP B S/D - hepatitis b immune globulin (human) im inj soln 3 HYPERRAB S/D - rabies immune globulin (human) inj 150 unit/ml 3 HYPERRHO S/D - rho d immune globulin (human) im inj 50 mcg 3 HYPERRHO S/D - rho d immune globulin (human) im inj 300 mcg 3 • HYPERRHO S/D MINI-DOSE - rho d immune globulin (human) im inj 50 mcg 3 • HYPERTET S/D - tetanus immune globulin (human) inj 250 unit/ml 3 • HYQVIA - immun glob inj 2.5 gm/25mlhyaluron inj 200 unt/1.25 ml kit 3 HYQVIA - immun glob inj 5 gm/50mlhyaluron inj 400 unt/2.5 ml kit 3 • HYQVIA - immun glob inj 10 gm/100mlhyaluron inj 800 unt/5 ml kit 3 HYQVIA - immun glob inj 20 gm/200mlhyaluron inj 1600 unt/10 ml kit 3 HYQVIA - immun glob inj 30 gm/300mlhyaluron inj 2400 unt/15 ml kit 3 IMOGAM RABIES-HT - rabies immune globulin (human) inj 150 unit/ml 3 MICRHOGAM ULTRA-FILTERED - rho d immune globulin (human) im inj 50 mcg 3 NABI-HB - hepatitis b immune globulin (human) im inj soln 3 RHOGAM ULTRA-FILTERED PLU - rho d immune globulin (human) im inj 300 mcg 3 RHOPHYLAC - rho d immune globulin (human) inj 1500 unt/2ml (300 mcg/2ml) 3 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits GAMMAKED - immune globulin (human) iv or subcutaneous soln 2.5 gm/25ml HIZENTRA - immune globulin (human) subcutaneous inj 4 gm/20ml Drug Name Step Therapy GAMMAKED - immune globulin (human) iv or subcutaneous soln 1 gm/10ml 3 Prior Authorization • Drug Tier 3 Quantity Limits Prior Authorization GAMMAGARD LIQUID - immune globulin (human) iv or subcutaneous soln 30 gm/300ml Drug Name Step Therapy Drug Tier 2015 17 anastrozole tab 1 mg (Arimidex) M ARIMIDEX - anastrozole tab 1 mg M AROMASIN - exemestane tab 25 mg M azacitidine for inj 100 mg (Vidaza) 1 bicalutamide tab 50 mg (Casodex) M bleomycin sulfate for inj 15 unit 1 bleomycin sulfate for inj 30 unit 1 BOSULIF - bosutinib tab 100 mg M BOSULIF - bosutinib tab 500 mg M CALCIUM FOLINATE - leucovorin calcium inj 100 mg/10ml (10 mg/ml) 2 CALCIUM FOLINATE - leucovorin calcium inj 300 mg/30ml (10 mg/ml) 2 capecitabine tab 150 mg (Xeloda) M • capecitabine tab 500 mg (Xeloda) M CAPRELSA - vandetanib tab 100 mg M • CAPRELSA - vandetanib tab 300 mg M CASODEX - bicalutamide tab 50 mg M CEENU - lomustine cap 10 mg M CEENU - lomustine cap 40 mg M CEENU - lomustine cap 100 mg M BIOLOGICALS MISC ADAGEN - pegademase bovine inj 250 unit/ml 3 GRASTEK - timothy grass pollen allergen ext tab sl 2800 bau 3 ORALAIR - grass mixed pollen ext tab sl 3 300 ir (index of reactivity) 3 RAGWITEK - short ragweed pollen allergen extract tab sl 12 amb a 1-u • ANTINEOPLASTIC AGENTS ANTINEOPLASTICS ACTIMMUNE - interferon gamma-1b inj 100 mcg/0.5ml (2000000 unit/0.5ml) 5 AFINITOR - everolimus tab 2.5 mg M AFINITOR - everolimus tab 5 mg M AFINITOR - everolimus tab 7.5 mg M AFINITOR - everolimus tab 10 mg M AFINITOR DISPERZ - everolimus tab for oral susp 2 mg M • • • • • AFINITOR DISPERZ - everolimus tab for oral susp 3 mg M • AFINITOR DISPERZ - everolimus tab for oral susp 5 mg M • ALFERON N - interferon alfa-n3 inj 5000000 unit/ml 5 18 COMETRIQ - cabozantinib s-malate cap M 3 x 20 mg (60 mg dose) kit COMETRIQ - cabozantinib s-mal cap 1 M x 80 mg & 1 x 20 mg (100 dose) kit COMETRIQ - cabozantinib s-mal cap 1 M x 80 mg & 3 x 20 mg (140 dose) kit M CYCLOPHOSPHAMIDE cyclophosphamide cap 25 mg M CYCLOPHOSPHAMIDE cyclophosphamide cap 50 mg M CYCLOPHOSPHAMIDE cyclophosphamide tab 25 mg M CYCLOPHOSPHAMIDE cyclophosphamide tab 50 mg 2 cyclophosphamide for inj 1 gm SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare • • • • • • • • • Products January 2015 Quantity Limits M Step Therapy • ALKERAN - melphalan tab 2 mg Prior Authorization SYNAGIS - palivizumab im soln 100 mg/ 4 ml 3 VARIZIG - varicella-zoster immune globulin (human ) for inj 125 unit 3 WINRHO SDF - rho d immune globulin (human) inj 2500 unit/2.2ml 3 WINRHO SDF - rho d immune globulin (human) inj 5000 unit/4.4ml 3 WINRHO SDF - rho d immune globulin (human) inj 1500 unit/1.3ml 3 WINRHO SDF - rho d immune globulin (human) inj 15000 unit/13ml Drug Name Drug Tier • SYNAGIS - palivizumab im soln 50 mg/0.5ml Quantity Limits Prior Authorization 4 Drug Name Step Therapy Drug Tier 2015 4 2 FIRMAGON - degarelix acetate for inj 120 mg (base equiv) CYTARABINE - cytarabine for inj 100 mg 2 floxuridine for inj 0.5 gm 1 flutamide cap 125 mg M CYTARABINE - cytarabine for inj 1 gm 3 M • cytarabine for inj 1 gm 1 GILOTRIF - afatinib dimaleate tab 20 mg (base equivalent) cytarabine for inj 500 mg 1 M • cytarabine inj pf 100 mg/ml 1 GILOTRIF - afatinib dimaleate tab 30 mg (base equivalent) 1 GILOTRIF - afatinib dimaleate tab 40 mg (base equivalent) M cytarabine inj pf 20 mg/ml • cytarabine inj 20 mg/ml 1 • DEPO-PROVERA medroxyprogesterone acetate im susp 400 mg/ml GLEEVEC - imatinib mesylate tab 100 mg (base equivalent) M 2 GLEEVEC - imatinib mesylate tab 400 mg (base equivalent) M • DEPOCYT - cytarabine liposome inj 50 mg/5ml 2 2 ELIGARD - leuprolide acetate for subcutaneous inj kit 7.5 mg 5 GLIADEL WAFER - carmustine in polifeprosan intracranial implant wafer 7.7 mg HEXALEN - altretamine cap 50 mg M ELIGARD - leuprolide acetate (3 month) for subcutaneous inj kit 22.5mg 5 ELIGARD - leuprolide acetate (4 month) for subcutaneous inj kit 30 mg 5 ELIGARD - leuprolide acetate (6 month) for subcutaneous inj kit 45 mg 5 ELSPAR - asparaginase for inj 10000 unit 2 EMCYT - estramustine phosphate sodium cap 140 mg M ERIVEDGE - vismodegib cap 150 mg M ERWINAZE - asparaginase erwinia chrysanthemi for im inj 10000 unit 2 ETOPOSIDE - etoposide cap 50 mg HYCAMTIN - topotecan hcl cap 0.25 mg M (base equiv) M HYCAMTIN - topotecan hcl cap 1 mg (base equiv) M HYDREA - hydroxyurea cap 500 mg • M ICLUSIG - ponatinib hcl tab 15 mg (base equiv) M • ICLUSIG - ponatinib hcl tab 45 mg (base equiv) M • IMBRUVICA - ibrutinib cap 140 mg M INLYTA - axitinib tab 1 mg M M INLYTA - axitinib tab 5 mg M • • • exemestane tab 25 mg (Aromasin) M 4 FARESTON - toremifene citrate tab 60 mg (base equivalent) M INTRON A - interferon alfa-2b for inj 10000000 unit 4 FASLODEX - fulvestrant inj 250 mg/5ml 2 INTRON A - interferon alfa-2b for inj 18000000 unit M INTRON A - interferon alfa-2b for inj 50000000 unit 4 FEMARA - letrozole tab 2.5 mg FIRMAGON - degarelix acetate for inj 80 mg (base equiv) 4 INTRON-A - interferon alfa-2b inj 6000000 unit/ml 4 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits • • hydroxyurea cap 500 mg (Hydrea) • Step Therapy Prior Authorization Drug Name Drug Tier cyclophosphamide for inj 500 mg Quantity Limits 2 Step Therapy cyclophosphamide for inj 2 gm Prior Authorization Drug Name Drug Tier 2015 19 INTRON-A - interferon alfa-2b inj 10000000 unit/ml 4 LUPRON DEPOT - leuprolide acetate for inj kit 7.5 mg INTRON-A W/DILUENT - interferon alfa-2b for inj 10000000 unit 4 INTRON-A W/DILUENT - interferon alfa-2b for inj 18000000 unit 4 INTRON-A W/DILUENT - interferon alfa-2b for inj 50000000 unit 4 JAKAFI - ruxolitinib phosphate tab 5 mg (base equivalent) M • JAKAFI - ruxolitinib phosphate tab 10 mg (base equivalent) M • LUPRON DEPOT - leuprolide acetate (3 4 month) for inj kit 11.25 mg LUPRON DEPOT - leuprolide acetate (3 4 month) for inj kit 22.5 mg LUPRON DEPOT - leuprolide acetate (4 4 month) for inj kit 30 mg LUPRON DEPOT - leuprolide acetate (6 4 month) for inj kit 45 mg M LYSODREN - mitotane tab 500 mg JAKAFI - ruxolitinib phosphate tab 15 mg (base equivalent) • MATULANE - procarbazine hcl cap 50 mg M M JAKAFI - ruxolitinib phosphate tab 20 mg (base equivalent) • MEGACE ORAL - megestrol acetate susp 40 mg/ml M M M • megestrol acetate susp 40 mg/ml (Megace oral) M JAKAFI - ruxolitinib phosphate tab 25 mg (base equivalent) megestrol acetate tab 20 mg M letrozole tab 2.5 mg (Femara) M megestrol acetate tab 40 mg M LEUCOVORIN CALCIUM - leucovorin calcium tab 10 mg 2 M • LEUCOVORIN CALCIUM - leucovorin calcium tab 15 mg 2 MEKINIST - trametinib dimethyl sulfoxide tab 0.5 mg (base equivalent) • LEUCOVORIN CALCIUM - leucovorin calcium for inj 500 mg MEKINIST - trametinib dimethyl sulfoxide tab 2 mg (base equivalent) M 2 1 mercaptopurine tab 50 mg (Purinethol) M leucovorin calcium for inj 100 mg leucovorin calcium for inj 200 mg 1 MESNEX - mesna tab 400 mg 2 leucovorin calcium for inj 350 mg 1 methotrexate sodium for inj 1 gm 1 leucovorin calcium for inj 50 mg 1 methotrexate sodium inj pf 25 mg/ml 1 leucovorin calcium tab 25 mg 1 methotrexate sodium inj 25 mg/ml 1 leucovorin calcium tab 5 mg 1 M LEUKERAN - chlorambucil tab 2 mg 2 methotrexate sodium tab 2.5 mg (base equiv) leuprolide acetate inj kit 5 mg/ml 4 LOMUSTINE - lomustine cap 10 mg M LOMUSTINE - lomustine cap 40 mg M LOMUSTINE - lomustine cap 100 mg M LUPRON DEPOT - leuprolide acetate for inj kit 3.75 mg 4 20 4 • • MUSTARGEN - mechlorethamine hcl for 2 inj 10 mg M MYLERAN - busulfan tab 2 mg NEXAVAR - sorafenib tosylate tab 200 mg (base equivalent) M NILANDRON - nilutamide tab 150 mg M SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare • Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 ONCASPAR - pegaspargase inj 750 unit/ml 2 POMALYST - pomalidomide cap 1 mg M POMALYST - pomalidomide cap 2 mg M POMALYST - pomalidomide cap 3 mg M POMALYST - pomalidomide cap 4 mg M PURINETHOL - mercaptopurine tab 50 mg M PURIXAN - mercaptopurine susp 2000 mg/100ml (20 mg/ml) M SOLTAMOX - tamoxifen citrate oral soln M 10 mg/5ml (base equivalent) M SPRYCEL - dasatinib tab 20 mg • • • • • SYNRIBO - omacetaxine mepesuccinate for inj 3.5 mg 4 TABLOID - thioguanine tab 40 mg M TAFINLAR - dabrafenib mesylate cap 50 mg (base equivalent) M • TAFINLAR - dabrafenib mesylate cap 75 mg (base equivalent) M • tamoxifen citrate tab 10 mg (base equivalent) M tamoxifen citrate tab 20 mg (base equivalent) M TARCEVA - erlotinib hcl tab 25 mg (base equivalent) M • TARCEVA - erlotinib hcl tab 100 mg (base equivalent) M • TARCEVA - erlotinib hcl tab 150 mg (base equivalent) M • TARGRETIN - bexarotene cap 75 mg M TASIGNA - nilotinib hcl cap 150 mg (base equivalent) M • • TASIGNA - nilotinib hcl cap 200 mg (base equivalent) M • TEMODAR - temozolomide cap 5 mg M TEMODAR - temozolomide cap 20 mg M TEMODAR - temozolomide cap 100 mg M TEMODAR - temozolomide cap 140 mg M TEMODAR - temozolomide cap 180 mg M • • • • • • • • • • • • SPRYCEL - dasatinib tab 50 mg M SPRYCEL - dasatinib tab 70 mg M SPRYCEL - dasatinib tab 80 mg M SPRYCEL - dasatinib tab 100 mg M SPRYCEL - dasatinib tab 140 mg M STIVARGA - regorafenib tab 40 mg M SUTENT - sunitinib malate cap 12.5 mg (base equivalent) M • • • • • • • • SUTENT - sunitinib malate cap 25 mg (base equivalent) M • SUTENT - sunitinib malate cap 37.5 mg (base equivalent) M • SUTENT - sunitinib malate cap 50 mg (base equivalent) M • 4 • TEMODAR - temozolomide cap 250 mg M SYLATRON - peginterferon alfa-2b for inj kit 296 mcg temozolomide cap 100 mg (Temodar) M SYLATRON - peginterferon alfa-2b for inj kit 444 mcg 4 • temozolomide cap 140 mg (Temodar) M temozolomide cap 180 mg (Temodar) M SYLATRON - peginterferon alfa-2b for inj kit 888 mcg 4 • temozolomide cap 20 mg (Temodar) M M 4 • temozolomide cap 250 mg (Temodar) SYLATRON - peginterferon alfa-2b for inj kit 4 x 296 mcg temozolomide cap 5 mg (Temodar) M 4 • THERACYS - bcg live intravesical for susp 81 mg/vial 2 SYLATRON - peginterferon alfa-2b for inj kit 4 x 444 mcg 4 • TICE BCG - bcg live intravesical for susp 50 mg 2 SYLATRON - peginterferon alfa-2b for inj kit 4 x 888 mcg SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 21 TRELSTAR DEPOT MIXJECT triptorelin pamoate for im susp 3.75 mg 4 ZOLADEX - goserelin acetate implant 3.6 mg 3 TRELSTAR LA - triptorelin pamoate for im susp 11.25 mg ZOLADEX - goserelin acetate implant 10.8 mg 3 4 ZOLINZA - vorinostat cap 100 mg M TRELSTAR LA MIXJECT - triptorelin pamoate for im susp 11.25 mg 4 ZYDELIG - idelalisib tab 100 mg M 4 ZYDELIG - idelalisib tab 150 mg M TRELSTAR MIXJECT - triptorelin pamoate for im susp 22.5 mg ZYKADIA - ceritinib cap 150 mg M tretinoin cap 10 mg M M TREXALL - methotrexate sodium tab 5 mg (base equiv) M ZYTIGA - abiraterone acetate tab 250 mg TREXALL - methotrexate sodium tab 7.5 mg (base equiv) M • ENDOCRINE AND METABOLIC DRUGS TREXALL - methotrexate sodium tab 10 M mg (base equiv) TREXALL - methotrexate sodium tab 15 M mg (base equiv) M TYKERB - lapatinib ditosylate tab 250 mg (base equiv) UVADEX - methoxsalen (photopheresis) 2 soln 20 mcg/ml 2 VALSTAR - valrubicin soln for intravesical instillation 40 mg/ml VANDETANIB - vandetanib tab 100 mg M CORTICOSTEROIDS • • • A-HYDROCORT - hydrocortisone sodium succinate for inj 100 mg 3 ARISTOSPAN INTRA-ARTICULA triamcinolone hexacetonide inj susp 20 mg/ml 3 ARISTOSPAN INTRALESIONAL triamcinolone hexacetonide inj susp 5 mg/ml 3 BETALIDO - betamethasone sod phos & ace inj 6 mg/ml & lido inj 1% kit 3 betamethasone sod phosphate & acetate inj susp 6 (3-3) mg/ml (Celestone-soluspan) 1 VANDETANIB - vandetanib tab 300 mg M VANTAS - histrelin acetate implant kit 50 mg budesonide cap sr 24hr 3 mg (Entocort ec) 1 3 VIDAZA - azacitidine for inj 100 mg BUPIVILOG KIT - triamcinolone inj 40 mg/ml & bupivacaine hcl inj 0.5% kit 3 3 VOTRIENT - pazopanib hcl tab 200 mg (base equiv) M • CELESTONE - betamethasone soln 0.6 mg/5ml 3 XALKORI - crizotinib cap 200 mg M M XELODA - capecitabine tab 150 mg M CELESTONE-SOLUSPAN betamethasone sod phosphate & acetate inj susp 6 (3-3) mg/ml 3 XALKORI - crizotinib cap 250 mg M CORTEF - hydrocortisone tab 5 mg 3 XELODA - capecitabine tab 500 mg M CORTEF - hydrocortisone tab 10 mg 3 XTANDI - enzalutamide cap 40 mg • • • • • CORTEF - hydrocortisone tab 20 mg 3 22 • • • • • SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Prior Authorization • Drug Name Step Therapy Drug Tier M Quantity Limits ZELBORAF - vemurafenib tab 240 mg (base equivalent) Step Therapy 4 Drug Tier TRELSTAR DEPOT - triptorelin pamoate for im susp 3.75 mg Drug Name Prior Authorization 2015 CORTISONE ACETATE - cortisone acetate tab 25 mg 2 DEXPAK 10 DAY - dexamethasone tab 1.5 mg taper pack 3 DEPO-MEDROL - methylprednisolone acetate inj susp 20 mg/ml 3 DEXPAK 13 DAY - dexamethasone tab 1.5 mg taper pack 3 DEPO-MEDROL - methylprednisolone acetate inj susp 40 mg/ml 3 DEXPAK 6 DAY - dexamethasone tab 1.5 mg taper pack 3 DEPO-MEDROL - methylprednisolone acetate inj susp 80 mg/ml 3 DOUBLEDEX - dexamethasone sodium phosphate pf inj 10 mg/ml kit 3 DEXAMETHASONE - dexamethasone tab 1 mg 2 DYURAL-L - methylprednisolone inj 40 mg/ml & lidocaine inj 1% kit 3 DEXAMETHASONE - dexamethasone tab 2 mg 2 DYURAL-LM - methylprednisolone inj 40 mg/ml & bupiv 0.25% &lido 1% kit 3 DEXAMETHASONE - dexamethasone soln 0.5 mg/5ml 2 DYURAL-40 - methylprednisolone inj 40 mg/ml & bupiv 0.25% &lido 1% kit 3 dexamethasone elixir 0.5 mg/5ml 1 3 DEXAMETHASONE INTENSOL dexamethasone conc 1 mg/ml 2 DYURAL-80 - methylprednisolone inj 80 mg/ml & bupiv 0.25% &lido 1% kit 3 DEXAMETHASONE SODIUM PHOS dexamethasone sodium phosphate inj 10 mg/ml 3 ENTOCORT EC - budesonide cap sr 24hr 3 mg FLO-PRED - prednisolone acetate oral susp 16.7 mg/5ml (15 mg/5ml base) 3 DEXAMETHASONE SODIUM PHOS dexamethasone sod phosphate preservative free inj 10 mg/ml 3 fludrocortisone acetate tab 0.1 mg 1 hydrocortisone tab 10 mg (Cortef) 1 1 hydrocortisone tab 20 mg (Cortef) 1 dexamethasone sodium phosphate inj 100 mg/10ml hydrocortisone tab 5 mg (Cortef) 1 dexamethasone sodium phosphate inj 120 mg/30ml 1 3 dexamethasone sodium phosphate inj 20 mg/5ml 1 INTERARTICULAR JOINT KIT triamcinolone inj 40 mg/ml & lidocaine 1% & ammonia inh kit 3 dexamethasone sodium phosphate inj 4 mg/ml 1 KENALOG-10 - triamcinolone acetonide inj susp 10 mg/ml 3 dexamethasone tab 0.5 mg 1 KENALOG-40 - triamcinolone acetonide inj susp 40 mg/ml 1 LIDOLOG KIT - triamcinolone inj 40 mg/ ml & lidocaine hcl inj 2% kit 3 dexamethasone tab 0.75 mg dexamethasone tab 1.5 mg 1 1 MARBETA-L - betameth na pho&ace inj 6 mg/ml & bupiv 0.25% & lido1% kit 3 dexamethasone tab 4 mg dexamethasone tab 6 mg 1 MARBETA-25 - betamethasone sod phos & ace inj 6 mg/ml & bupiv 0.25% kit 3 DEXLIDO - dexamethasone sod phos pf 3 inj 10 mg/ml & lidocaine 1% kit DEXLIDO-M - dexamethasone pf inj 10 3 mg/ml & bupiv 0.25% & lido 1% kit SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 23 MARDEX-25 - dexamethasone sod phos pf inj 10 mg/ml & bupiv 0.25% kit 3 MILLIPRED - prednisolone sod phosphate oral soln 10 mg/5ml (base equiv) 3 MEDROL - methylprednisolone tab 2 mg 3 MILLIPRED DP - prednisolone tab 5 mg dose pack 3 MEDROL - methylprednisolone tab 4 mg 3 MEDROL - methylprednisolone tab 8 mg 3 MEDROL - methylprednisolone tab 16 mg 3 MEDROL - methylprednisolone tab 32 mg 3 MEDROL DOSEPAK methylprednisolone tab 4 mg dose pack 3 methylprednisolone acetate inj susp 40 mg/ml (Depo-medrol) 1 methylprednisolone acetate inj susp 80 mg/ml (Depo-medrol) 1 methylprednisolone sodium succinate for inj 1000 mg (Solumedrol) 1 methylprednisolone sodium succinate for inj 125 mg (Solumedrol) 1 methylprednisolone sodium succinate for inj 40 mg (Solumedrol) 1 methylprednisolone tab 16 mg (Medrol) 1 methylprednisolone tab 32 mg (Medrol) 1 methylprednisolone tab 4 mg (Medrol) 1 methylprednisolone tab 4 mg dose pack (Medrol dosepak) 1 methylprednisolone tab 8 mg (Medrol) 1 MILLIPRED - prednisolone tab 5 mg 3 MLK F1 KIT - triamcinolone inj 40 mg/ml 3 & bupiv 0.5% & lido 2% kit MLK F2 KIT - triamcinolone inj 40 mg/ml 3 & bupiv 0.5% & lido 2% kit MLK F3 KIT - triamcinolone inj 40 mg/ml 3 & bupiv 0.5% & lido 2% kit MLK F4 KIT - triamcinolone inj 40 mg/ml 3 & bupiv 0.5% & lido 2% kit 3 MULTI-SPECIALTY KIT methylprednisolone inj 40 mg/ml & lidocaine inj 1% kit 3 ORAPRED - prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) 3 ORAPRED ODT - prednisolone sod phos orally disintegr tab 10 mg (base eq) 3 ORAPRED ODT - prednisolone sod phos orally disintegr tab 15 mg (base eq) 3 ORAPRED ODT - prednisolone sod phos orally disintegr tab 30 mg (base eq) PEDIAPRED - prednisolone sod phosph 3 oral soln 6.7 mg/5ml (5 mg/5ml base) 3 PHYSICIANS EZ USE JOINT T triamcinolone inj 40 mg/ml & lidocaine 1% & ammonia inh kit 3 PHYSICIANS EZ USE M-PRED methylprednisolone ace 40 mg/ml & bupivacaine inj 0.5% kit 1 prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) (Pediapred) 1 prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) 24 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 PREDNISOLONE SODIUM PHOSP prednisolone sodium phosphate oral soln 25 mg/5ml (base eq) 3 SOLU-MEDROL - methylprednisolone sodium succinate for inj 125 mg 3 prednisolone syrup 15 mg/5ml (usp solution equivalent) (Prelone) SOLU-MEDROL - methylprednisolone sodium succinate for inj 500 mg 3 1 PREDNISONE - prednisone tab 50 mg SOLU-MEDROL - methylprednisolone sodium succinate for inj 1000 mg 3 2 PREDNISONE - prednisone oral soln 5 mg/5ml 2 SOLU-MEDROL - methylprednisolone sodium succinate for inj 2000 mg 3 PREDNISONE - prednisone tab 5 mg dose pack 3 UCERIS - budesonide tab sr 24hr 9 mg 3 PREDNISONE - prednisone tab 10 mg dose pack VERIPRED 20 - prednisolone sod phosphate oral soln 20 mg/5ml (base equiv) 3 3 PREDNISONE INTENSOL - prednisone conc 5 mg/ml 3 ANDROGEN-ANABOLIC • prednisone tab 1 mg ANADROL-50 - oxymetholone tab 50 mg 3 1 prednisone tab 10 mg 1 2 • prednisone tab 10 mg dose pack 1 ANDRODERM - testosterone td patch 24hr 2 mg/24hr prednisone tab 2.5 mg 1 2 • prednisone tab 20 mg 1 ANDRODERM - testosterone td patch 24hr 4 mg/24hr 1 ANDROGEL - testosterone td gel 25 mg/2.5gm (1%) 2 prednisone tab 5 mg • prednisone tab 5 mg dose pack 1 • PRELONE - prednisolone syrup 15 mg/5ml (usp solution equivalent) ANDROGEL - testosterone td gel 50 mg/5gm (1%) 2 3 2 • RAYOS - prednisone tab delayed release 1 mg 3 ANDROGEL - testosterone td gel 20.25 mg/1.25gm (1.62%) • 3 ANDROGEL - testosterone td gel 40.5 mg/2.5gm (1.62%) 2 RAYOS - prednisone tab delayed release 2 mg RAYOS - prednisone tab delayed release 5 mg SOLU-CORTEF - hydrocortisone sodium succinate pf for inj 100 mg 3 SOLU-CORTEF - hydrocortisone sodium succinate pf for inj 250 mg 3 ANDROGEL PUMP - testosterone td gel 2 12.5 mg/act (1%) ANDROGEL PUMP - testosterone td gel 2 20.25 mg/act (1.62%) 3 ANDROID - methyltestosterone cap 10 mg ANDROXY - fluoxymesterone tab 10 mg 2 • 3 SOLU-CORTEF - hydrocortisone sodium succinate pf for inj 500 mg 3 SOLU-CORTEF - hydrocortisone sodium succinate pf for inj 1000 mg 3 SOLU-MEDROL - methylprednisolone sodium succinate for inj 40 mg 3 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Quantity Limits • • • • AVEED - testosterone undecanoate im inj in oil 750 mg/3ml (250mg/ml) 3 • • AXIRON - testosterone td soln 30 mg/ act 3 • danazol cap 100 mg 1 danazol cap 200 mg 1 • • Products January 2015 Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 25 1 DEPO-TESTOSTERONE - testosterone cypionate im inj in oil 100 mg/ml 3 DEPO-TESTOSTERONE - testosterone cypionate im inj in oil 200 mg/ml 3 • ACTIVELLA - estradiol & norethindrone acetate tab 0.5-0.1 mg 3 FIRST-TESTOSTERONE - testosterone propionate td ointment 2% 3 • ACTIVELLA - estradiol & norethindrone acetate tab 1-0.5 mg 3 FIRST-TESTOSTERONE MC COM testosterone propionate td cream 2% 3 • ALORA - estradiol td patch biweekly 0.025 mg/24hr 3 FORTESTA - testosterone td gel 10mg/ act (2%) 3 • ALORA - estradiol td patch biweekly 0.05 mg/24hr 3 METHITEST - methyltestosterone oral tab 10 mg 3 • ALORA - estradiol td patch biweekly 0.075 mg/24hr 3 OXANDRIN - oxandrolone tab 2.5 mg 3 3 ALORA - estradiol td patch biweekly 0.1 mg/24hr 3 OXANDRIN - oxandrolone tab 10 mg oxandrolone tab 10 mg (Oxandrin) 1 1 ANGELIQ - drospirenone-estradiol tab 0.25-0.5 mg 3 oxandrolone tab 2.5 mg (Oxandrin) 3 ANGELIQ - drospirenone-estradiol tab 0.5-1 mg 3 STRIANT - testosterone buccal mucoadhesive system 30 mg • • • • • 3 • CENESTIN - estrogens, conjugated synthetic a tab 0.3 mg 3 TESTIM - testosterone td gel 50 mg/5gm (1%) 3 • CENESTIN - estrogens, conjugated synthetic a tab 0.45 mg 3 TESTOPEL - testosterone implant pellets 75 mg 3 • CENESTIN - estrogens, conjugated synthetic a tab 0.625 mg 3 TESTOSTERONE - testosterone td gel 50 mg/5gm (1%) 3 • CENESTIN - estrogens, conjugated synthetic a tab 0.9 mg 3 TESTOSTERONE - testosterone td gel 10mg/act (2%) 1 • CENESTIN - estrogens, conjugated synthetic a tab 1.25 mg 3 testosterone cypionate im inj in oil 100 mg/ml (Depo-testosterone) 1 • CLIMARA - estradiol td patch weekly 0.025 mg/24hr 3 testosterone cypionate im inj in oil 200 mg/ml (Depo-testosterone) 1 • CLIMARA - estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) 3 testosterone enanthate im inj in oil 200 mg/ml 3 • CLIMARA - estradiol td patch weekly 0.05 mg/24hr 3 TESTOSTERONE PUMP - testosterone td gel 12.5 mg/act (1%) 3 • CLIMARA - estradiol td patch weekly 0.06 mg/24hr 3 TESTRED - methyltestosterone cap 10 mg 3 • CLIMARA - estradiol td patch weekly 0.075 mg/24hr 3 VOGELXO - testosterone td gel 50 mg/5gm (1%) 26 • • VOGELXO PUMP - testosterone td gel 12.5 mg/act (1%) ESTROGENS • • • • SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Prior Authorization • danazol cap 50 mg Drug Name Step Therapy Drug Tier Quantity Limits Step Therapy 3 Drug Name Drug Tier Prior Authorization 2015 • CLIMARA - estradiol td patch weekly 0.1 3 mg/24hr 2 CLIMARA PRO - estradiollevonorgestrel td patch weekly 0.045-0.015 mg/day COMBIPATCH - estradiol-norethindrone 3 ace td pttw 0.05-0.14 mg/day COMBIPATCH - estradiol-norethindrone 3 ace td pttw 0.05-0.25 mg/day DELESTROGEN - estradiol valerate im 3 in oil 10 mg/ml DELESTROGEN - estradiol valerate im 3 in oil 20 mg/ml DELESTROGEN - estradiol valerate im 3 in oil 40 mg/ml 3 DEPO-ESTRADIOL - estradiol cypionate im in oil 5 mg/ml 2 DIVIGEL - estradiol td gel 0.25 mg/0.25gm (0.1%) DIVIGEL - estradiol td gel 0.5 mg/0.5gm 2 (0.1%) 2 DIVIGEL - estradiol td gel 1 mg/gm (0.1%) 3 DUAVEE - conjugated estrogensbazedoxifene tab 0.45-20 mg 3 ELESTRIN - estradiol gel 0.06% (0.52 mg/0.87 gm metered-dose pump) 3 ENJUVIA - estrogens, conjugated synthetic b tab 0.3 mg 3 ENJUVIA - estrogens, conjugated synthetic b tab 0.45 mg 3 ENJUVIA - estrogens, conjugated synthetic b tab 0.625 mg 3 ENJUVIA - estrogens, conjugated synthetic b tab 0.9 mg 3 ENJUVIA - estrogens, conjugated synthetic b tab 1.25 mg 1 esterified estrogens & methyltestosterone tab 0.625-1.25 mg SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare esterified estrogens & methyltestosterone tab 1.25-2.5 mg 1 ESTRACE - estradiol tab 0.5 mg 3 ESTRACE - estradiol tab 1 mg 3 ESTRACE - estradiol tab 2 mg 3 estradiol & norethindrone acetate tab 0.5-0.1 mg (Activella) 1 estradiol & norethindrone acetate tab 1-0.5 mg (Activella) 1 estradiol tab 0.5 mg (Estrace) 1 estradiol tab 1 mg (Estrace) 1 estradiol tab 2 mg (Estrace) 1 estradiol td patch weekly 0.025 mg/24hr (Climara) 1 estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) (Climara) 1 estradiol td patch weekly 0.05 mg/24hr (Climara) 1 estradiol td patch weekly 0.06 mg/24hr (Climara) 1 estradiol td patch weekly 0.075 mg/24hr (Climara) 1 estradiol td patch weekly 0.1 mg/24hr (Climara) 1 estradiol valerate im in oil 10 mg/ml 1 estradiol valerate im in oil 20 mg/ml (Delestrogen) 1 estradiol valerate im in oil 40 mg/ml (Delestrogen) 1 ESTRASORB - estradiol transdermal emulsion 4.35 mg/1.74gm 3 ESTROGEL - estradiol gel 0.06% (0.75 mg/1.25 gm metered-dose pump) 3 ESTROPIPATE - estropipate tab 3 mg 2 estropipate tab 0.75 mg 1 estropipate tab 1.5 mg 1 EVAMIST - estradiol transdermal spray 1.53 mg/spray 3 Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 27 FEMHRT LOW DOSE - norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg 2 FEMHRT 1/5 - norethindrone acetateethinyl estradiol tab 1 mg-5 mcg 3 JINTELI - norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg 2 MENEST - esterified estrogens tab 0.3 mg 3 MENEST - esterified estrogens tab 0.625 mg 3 MENEST - esterified estrogens tab 1.25 mg 3 MENEST - esterified estrogens tab 2.5 mg 3 MENOSTAR - estradiol td patch weekly 14 mcg/24hr 3 MINIVELLE - estradiol td patch biweekly 3 0.0375 mg/24hr MINIVELLE - estradiol td patch biweekly 3 0.05 mg/24hr MINIVELLE - estradiol td patch biweekly 3 0.075 mg/24hr MINIVELLE - estradiol td patch biweekly 3 0.1 mg/24hr 3 PREFEST - estradiol tab 1 mg(15)/estrad-norgestimate tab 1-0.09mg(15) PREMARIN - estrogens, conjugated tab 2 0.3 mg PREMARIN - estrogens, conjugated tab 2 0.45 mg PREMARIN - estrogens, conjugated tab 2 0.625 mg PREMARIN - estrogens, conjugated tab 2 0.9 mg PREMARIN - estrogens, conjugated tab 2 1.25 mg PREMARIN - estrogens, conjugated for 3 inj 25 mg 28 PREMPHASE - conj est 0.625(14)/conj est-medroxypro ac tab 0.625-5mg(14) 2 PREMPRO - conjugated estrogenmedroxyprogest acetate tab 0.3-1.5 mg 2 PREMPRO - conjugated estrogenmedroxyprogest acetate tab 0.45-1.5 mg 2 PREMPRO - conjugated estrogenmedroxyprogest acetate tab 0.625-2.5 mg 2 PREMPRO - conjugated estrogenmedroxyprogest acetate tab 0.625-5 mg 2 VIVELLE-DOT - estradiol td patch biweekly 0.025 mg/24hr 2 VIVELLE-DOT - estradiol td patch biweekly 0.0375 mg/24hr 2 VIVELLE-DOT - estradiol td patch biweekly 0.05 mg/24hr 2 VIVELLE-DOT - estradiol td patch biweekly 0.075 mg/24hr 2 VIVELLE-DOT - estradiol td patch biweekly 0.1 mg/24hr 2 CONTRACEPTIVES AMETHYST - levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg 3 BEYAZ - drospirenone-ethinyl estradlevomefolate tab 3-0.02-0.451 mg 3 BREVICON-28 - norethindrone & ethinyl 3 estradiol tab 0.5 mg-35 mcg 3 CYCLESSA - desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mgmg 3 DEPO-PROVERA CONTRACEPTIV medroxyprogesterone acetate im susp 150 mg/ml 3 DEPO-SUBQ PROVERA 104 medroxyprogesterone acetate subcutaneous susp 104 mg/0.65ml SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 DESOGEN - desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg 3 levonorgestrel tab 1.5 mg (Plan b one-step) 1 desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5) (Mircette) 1 levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg 1 desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mgmg (Cyclessa) 1 LO LOESTRIN FE - norethin-eth estradiol-fe tab 1 mg-10 mcg (24)/10 mcg (2) 3 desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg (Desogen) 1 3 drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz) 1 LO MINASTRIN FE - norethin-eth estrad-fe chew/tab 1 mg-10 mcg/10 mcg ther pack 3 drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin 28) 1 LOESTRIN FE 1.5/30 - norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg ELLA - ulipristal acetate tab 30 mg 2 3 ESTROSTEP FE - norethindrone acethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg 3 LOESTRIN FE 1/20 - norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg 3 ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg 1 LOESTRIN 1.5/30-21 - norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg 3 LOESTRIN 1/20-21 - norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg 3 FALESSA - levonorgest-eth estrad tab 0.1 mg-20 mcg & fa tab 1 mg kit 3 LOESTRIN 24 FE - norethindrone aceethinyl estradiol-fe tab 1 mg-20 mcg (24) 3 FEMCON FE - norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg GENERESS FE - norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg 3 LOMEDIA 24 FE - norethindrone aceethinyl estradiol-fe tab 1 mg-20 mcg (24) 3 IMPLANON - etonogestrel subdermal implant 68 mg 3 3 levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) (Loseasonique) 1 LOSEASONIQUE - levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) 1 levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) (Seasonique) 1 medroxyprogesterone acetate im susp 150 mg/ml (Depo-provera contrac) 3 levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg 1 MINASTRIN 24 FE - norethindrone aceeth estradiol-fe chew tab 1 mg-20 mcg (24) 3 levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg 1 MIRCETTE - desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5) 1 MIRENA - levonorgestrel releasing iud 20 mcg/24hr (52 mg total) 2 levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg levonorgestrel tab 0.75 mg (Plan b) MODICON - norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg 3 1 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 29 NATAZIA - estradiol valerate-dienogest tab 3 mg /2-2 mg/2-3 mg/1 mg 3 NECON 1/50-28 - norethindrone & mestranol tab 1 mg-50 mcg 2 NECON 10/11-28 - norethindrone-eth estradiol tab 0.5-35/1-35 mg-mcg (10/11) 2 NEXPLANON - etonogestrel subdermal implant 68 mg 3 NOR-QD - norethindrone tab 0.35 mg 3 NORDETTE-28 - levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg 3 norelgestromin-ethinyl estradiol td ptwk 150-35 mcg/24hr (Ortho evra) 1 norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg (Ovcon-35) 1 norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg (Brevicon-28) 1 norethindrone & ethinyl estradiol tab 1 mg-35 mcg (Norinyl 1+35) 1 norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg (Femcon fe) 1 norethindrone ac-ethinyl estradfe tab 1-20/1-30/1-35 mg-mcg (Estrostep fe) norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg (Orthonovum 7/7/7) 1 norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg (Trinorinyl 28) 1 norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg (Ortho-cyclen) 1 norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg (Ortho tri-cyclen) 1 norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg 1 NORINYL 1+35 - norethindrone & ethinyl estradiol tab 1 mg-35 mcg 3 NORINYL 1+50 - norethindrone & mestranol tab 1 mg-50 mcg 3 NUVARING - etonogestrel-ethinyl estradiol va ring 0.120-0.015 mg/24hr 2 OGESTREL - norgestrel & ethinyl estradiol tab 0.5 mg-50 mcg 2 ORTHO EVRA - norelgestromin-ethinyl estradiol td ptwk 150-35 mcg/24hr 3 1 ORTHO MICRONOR - norethindrone tab 0.35 mg 3 3 norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg (Loestrin 1/20-21) 1 ORTHO TRI-CYCLEN norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg (Loestrin 1.5/30-21) 1 ORTHO TRI-CYCLEN LO norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg 2 norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg (Loestrin fe 1/20) 1 ORTHO-CEPT - desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg 3 3 norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg (Loestrin fe 1.5/30) 1 ORTHO-CYCLEN - norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg norethindrone ace-ethinyl estradiolfe tab 1 mg-20 mcg (24) (Lomedia 24 fe) 1 norethindrone tab 0.35 mg (Nor-qd) 1 30 ORTHO-NOVUM 1/35 - norethindrone & 3 ethinyl estradiol tab 1 mg-35 mcg ORTHO-NOVUM 7/7/7 - norethindrone- 3 eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 OVCON-35 - norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg 3 norethindrone acetate tab 5 mg (Aygestin) 1 PARAGARD INTRAUTERINE COP copper iud 3 progesterone im in oil 50 mg/ml 1 PLAN B - levonorgestrel tab 0.75 mg progesterone micronized cap 100 mg (Prometrium) 1 3 PLAN B ONE-STEP - levonorgestrel tab 1.5 mg 3 progesterone micronized cap 200 mg (Prometrium) 1 QUARTETTE - levonor-eth est tab 0.15-0.02/0.025/0.03 mg ð est 0.01 mg 3 PROMETRIUM - progesterone micronized cap 100 mg 3 PROMETRIUM - progesterone micronized cap 200 mg 3 PROVERA - medroxyprogesterone acetate tab 2.5 mg 3 PROVERA - medroxyprogesterone acetate tab 5 mg 3 PROVERA - medroxyprogesterone acetate tab 10 mg 3 SAFYRAL - drospirenone-ethinyl estrad- 3 levomefolate tab 3-0.03-0.451 mg 3 SEASONIQUE - levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) 2 SKYLA - levonorgestrel releasing iud 13.5 mg 3 TRI-NORINYL 28 - norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mgmcg 3 YASMIN 28 - drospirenone-ethinyl estradiol tab 3-0.03 mg YAZ - drospirenone-ethinyl estradiol tab 3 3-0.02 mg 2 ZOVIA 1/50E - ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 ANTIDIABETICS Antidiabetics PROGESTINS acarbose tab 100 mg (Precose) 1 acarbose tab 25 mg (Precose) 1 acarbose tab 50 mg (Precose) 1 ACTOPLUS MET - pioglitazone hclmetformin hcl tab 15-500 mg 3 ACTOPLUS MET - pioglitazone hclmetformin hcl tab 15-850 mg 3 AYGESTIN - norethindrone acetate tab 5 mg 3 ACTOPLUS MET XR - pioglitazone hclmetformin hcl tab sr 24hr 15-1000 mg 3 MAKENA - hydroxyprogesterone caproate im in oil 250 mg/ml 4 ACTOPLUS MET XR - pioglitazone hclmetformin hcl tab sr 24hr 30-1000 mg 3 medroxyprogesterone acetate tab 10 mg (Provera) 1 ACTOS - pioglitazone hcl tab 15 mg (base equiv) 3 medroxyprogesterone acetate tab 2.5 mg (Provera) 1 ACTOS - pioglitazone hcl tab 30 mg (base equiv) 3 medroxyprogesterone acetate tab 5 mg (Provera) 1 ACTOS - pioglitazone hcl tab 45 mg (base equiv) 3 MEGACE ES - megestrol acetate susp 625 mg/5ml 3 AMARYL - glimepiride tab 1 mg 3 AMARYL - glimepiride tab 2 mg 3 AMARYL - glimepiride tab 4 mg 3 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 31 APPFORMIN - metformin hcl tab 500 mg & dietary management cap pack 3 CYCLOSET - bromocriptine mesylate tab 0.8 mg (base equivalent) 3 APPFORMIN-D - metformin hcl tab 500 mg & dietary management cap pack 3 DIABETA - glyburide tab 1.25 mg 3 DIABETA - glyburide tab 2.5 mg 3 AVANDAMET - rosiglitazone maleatemetformin hcl tab 2-500 mg 3 DIABETA - glyburide tab 5 mg 3 3 DUETACT - pioglitazone hcl-glimepiride tab 30-2 mg 3 AVANDAMET - rosiglitazone maleatemetformin hcl tab 2-1000 mg 3 DUETACT - pioglitazone hcl-glimepiride tab 30-4 mg 3 AVANDAMET - rosiglitazone maleatemetformin hcl tab 4-500 mg 3 FARXIGA - dapagliflozin propanediol tab 5 mg (base equivalent) 3 AVANDAMET - rosiglitazone maleatemetformin hcl tab 4-1000 mg 3 FARXIGA - dapagliflozin propanediol tab 10 mg (base equivalent) 3 AVANDARYL - rosiglitazone maleateglimepiride tab 4-1 mg 3 FORTAMET - metformin hcl tab sr 24hr osmotic 500 mg 3 AVANDARYL - rosiglitazone maleateglimepiride tab 4-2 mg 3 FORTAMET - metformin hcl tab sr 24hr osmotic 1000 mg 3 AVANDARYL - rosiglitazone maleateglimepiride tab 4-4 mg 3 glimepiride tab 1 mg (Amaryl) 1 AVANDARYL - rosiglitazone maleateglimepiride tab 8-2 mg glimepiride tab 2 mg (Amaryl) 1 AVANDARYL - rosiglitazone maleateglimepiride tab 8-4 mg 3 glimepiride tab 4 mg (Amaryl) 1 1 AVANDIA - rosiglitazone maleate tab 2 mg (base equiv) 3 glipizide tab sr 24hr 10 mg (Glucotrol xl) 1 AVANDIA - rosiglitazone maleate tab 4 mg (base equiv) 3 glipizide tab sr 24hr 2.5 mg (Glucotrol xl) 1 AVANDIA - rosiglitazone maleate tab 8 mg (base equiv) 3 glipizide tab sr 24hr 5 mg (Glucotrol xl) glipizide tab 10 mg (Glucotrol) 1 BYDUREON - exenatide extended release for susp pen-injector 2 mg 2 glipizide tab 5 mg (Glucotrol) 1 BYDUREON - exenatide extended release for inj susp 2 mg glipizide-metformin hcl tab 2.5-250 mg 1 2 BYETTA - exenatide soln pen-injector 5 mcg/0.02ml glipizide-metformin hcl tab 2.5-500 mg 1 2 1 2 glipizide-metformin hcl tab 5-500 mg BYETTA - exenatide soln pen-injector 10 mcg/0.04ml 3 CHLORPROPAMIDE - chlorpropamide tab 100 mg 3 GLUCAGEN - glucagon hcl (rdna) for inj 1 mg (base equiv) 3 CHLORPROPAMIDE - chlorpropamide tab 250 mg 3 GLUCAGEN HYPOKIT - glucagon hcl (rdna) for inj 1 mg (base equiv) GLUCAGON EMERGENCY KIT glucagon (rdna) for inj kit 1 mg 2 32 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 GLUCOPHAGE - metformin hcl tab 500 mg 3 glyburide tab 5 mg 1 GLUCOPHAGE - metformin hcl tab 850 mg glyburide-metformin tab 1.25-250 mg (Glucovance) 1 3 GLUCOPHAGE - metformin hcl tab 1000 mg glyburide-metformin tab 2.5-500 mg (Glucovance) 1 3 3 glyburide-metformin tab 5-500 mg (Glucovance) 1 GLUCOPHAGE XR - metformin hcl tab sr 24hr 500 mg 3 GLYNASE - glyburide micronized tab 1.5 mg 3 GLUCOPHAGE XR - metformin hcl tab sr 24hr 750 mg GLUCOTROL - glipizide tab 5 mg GLYNASE - glyburide micronized tab 3 mg 3 3 GLUCOTROL - glipizide tab 10 mg 3 3 GLUCOTROL XL - glipizide tab sr 24hr 2.5 mg 3 GLYNASE - glyburide micronized tab 6 mg GLYSET - miglitol tab 25 mg 3 GLUCOTROL XL - glipizide tab sr 24hr 5 mg 3 GLYSET - miglitol tab 50 mg 3 GLYSET - miglitol tab 100 mg 3 GLUCOTROL XL - glipizide tab sr 24hr 10 mg 3 INVOKAMET - canagliflozin-metformin hcl tab 50-500 mg 2 GLUCOVANCE - glyburide-metformin tab 1.25-250 mg 3 INVOKAMET - canagliflozin-metformin hcl tab 50-1000 mg 2 GLUCOVANCE - glyburide-metformin tab 2.5-500 mg 3 INVOKAMET - canagliflozin-metformin hcl tab 150-500 mg 2 GLUCOVANCE - glyburide-metformin tab 5-500 mg 3 INVOKAMET - canagliflozin-metformin hcl tab 150-1000 mg 2 GLUMETZA - metformin hcl tab sr 24hr modified release 500 mg 3 INVOKANA - canagliflozin tab 100 mg 2 3 INVOKANA - canagliflozin tab 300 mg 2 GLUMETZA - metformin hcl tab sr 24hr modified release 1000 mg 2 GLYBURIDE - glyburide tab 1.25 mg 2 JANUMET - sitagliptin-metformin hcl tab 50-500 mg 2 JANUMET - sitagliptin-metformin hcl tab 50-1000 mg 2 GLYBURIDE - glyburide tab 2.5 mg GLYBURIDE - glyburide tab 5 mg 2 glyburide micronized tab 1.5 mg (Glynase) JANUMET XR - sitagliptin-metformin hcl tab sr 24hr 50-500 mg 2 1 1 JANUMET XR - sitagliptin-metformin hcl tab sr 24hr 50-1000 mg 2 glyburide micronized tab 3 mg (Glynase) 1 JANUMET XR - sitagliptin-metformin hcl tab sr 24hr 100-1000 mg 2 glyburide micronized tab 6 mg (Glynase) glyburide tab 1.25 mg JANUVIA - sitagliptin phosphate tab 25 mg (base equiv) 2 1 glyburide tab 2.5 mg 1 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 33 2 metformin hcl tab sr 24hr 500 mg (Glucophage xr) 1 JANUVIA - sitagliptin phosphate tab 100 2 mg (base equiv) 3 JARDIANCE - empagliflozin tab 10 mg metformin hcl tab sr 24hr 750 mg (Glucophage xr) 1 metformin hcl tab 1000 mg (Glucophage) 1 JANUVIA - sitagliptin phosphate tab 50 mg (base equiv) JARDIANCE - empagliflozin tab 25 mg 3 JENTADUETO - linagliptin-metformin hcl tab 2.5-500 mg 3 metformin hcl tab 500 mg (Glucophage) 1 JENTADUETO - linagliptin-metformin hcl tab 2.5-850 mg 3 metformin hcl tab 850 mg (Glucophage) 1 JENTADUETO - linagliptin-metformin hcl tab 2.5-1000 mg 3 nateglinide tab 120 mg (Starlix) 1 nateglinide tab 60 mg (Starlix) 1 JUVISYNC - sitagliptin-simvastatin tab 50-10 mg 2 NESINA - alogliptin benzoate tab 6.25 mg (base equiv) 3 JUVISYNC - sitagliptin-simvastatin tab 50-20 mg 2 NESINA - alogliptin benzoate tab 12.5 mg (base equiv) 3 JUVISYNC - sitagliptin-simvastatin tab 50-40 mg 2 NESINA - alogliptin benzoate tab 25 mg (base equiv) 3 JUVISYNC - sitagliptin-simvastatin tab 100-10 mg 2 ONGLYZA - saxagliptin hcl tab 2.5 mg (base equiv) 2 JUVISYNC - sitagliptin-simvastatin tab 100-20 mg 2 ONGLYZA - saxagliptin hcl tab 5 mg (base equiv) 2 JUVISYNC - sitagliptin-simvastatin tab 100-40 mg 2 OSENI - alogliptin-pioglitazone tab 12.5-15 mg 3 KAZANO - alogliptin-metformin hcl tab 12.5-500 mg 3 OSENI - alogliptin-pioglitazone tab 12.5-30 mg 3 KAZANO - alogliptin-metformin hcl tab 12.5-1000 mg 3 OSENI - alogliptin-pioglitazone tab 12.5-45 mg 3 KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr 24hr 2.5-1000 mg 2 OSENI - alogliptin-pioglitazone tab 25-15 mg 3 KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr 24hr 5-500 mg OSENI - alogliptin-pioglitazone tab 25-30 mg 3 2 KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr 24hr 5-1000 mg OSENI - alogliptin-pioglitazone tab 25-45 mg 3 2 5 pioglitazone hcl tab 15 mg (base equiv) (Actos) 1 KORLYM - mifepristone tab 300 mg metformin hcl tab sr 24hr osmotic 1000 mg (Fortamet) 1 pioglitazone hcl tab 30 mg (base equiv) (Actos) 1 metformin hcl tab sr 24hr osmotic 500 mg (Fortamet) 1 pioglitazone hcl tab 45 mg (base equiv) (Actos) 1 34 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 pioglitazone hcl-glimepiride tab 30-2 mg (Duetact) 1 TOLBUTAMIDE - tolbutamide tab 500 mg 3 pioglitazone hcl-glimepiride tab 30-4 mg (Duetact) 1 TRADJENTA - linagliptin tab 5 mg 3 pioglitazone hcl-metformin hcl tab 15-500 mg (Actoplus met) TRULICITY - dulaglutide soln peninjector 0.75 mg/0.5ml 3 1 1 TRULICITY - dulaglutide soln peninjector 1.5 mg/0.5ml 3 pioglitazone hcl-metformin hcl tab 15-850 mg (Actoplus met) 3 VICTOZA - liraglutide soln pen-injector 18 mg/3ml (6 mg/ml) 2 PRANDIMET - repaglinide-metformin hcl tab 1-500 mg PRANDIMET - repaglinide-metformin hcl tab 2-500 mg XIGDUO XR - dapagliflozin-metformin hcl tab sr 24hr 5-500 mg 3 3 PRANDIN - repaglinide tab 0.5 mg XIGDUO XR - dapagliflozin-metformin hcl tab sr 24hr 5-1000 mg 3 3 PRANDIN - repaglinide tab 1 mg 3 3 PRANDIN - repaglinide tab 2 mg 3 XIGDUO XR - dapagliflozin-metformin hcl tab sr 24hr 10-500 mg PRECOSE - acarbose tab 25 mg 3 3 PRECOSE - acarbose tab 50 mg 3 XIGDUO XR - dapagliflozin-metformin hcl tab sr 24hr 10-1000 mg PRECOSE - acarbose tab 100 mg 3 PROGLYCEM - diazoxide susp 50 mg/ ml 3 repaglinide tab 0.5 mg (Prandin) 1 repaglinide tab 1 mg (Prandin) 1 repaglinide tab 2 mg (Prandin) 1 RIOMET - metformin hcl oral soln 500 mg/5ml Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 Rapid-Acting Insulins APIDRA - insulin glulisine inj 100 unit/ml 3 APIDRA SOLOSTAR - insulin glulisine soln pen-injector inj 100 unit/ml 3 • • HUMALOG - insulin lispro (human) soln cartridge 100 unit/ml 3 • 3 • 3 HUMALOG - insulin lispro (human) inj 100 unit/ml • STARLIX - nateglinide tab 60 mg HUMALOG KWIKPEN - insulin lispro (human) soln pen-injector 100 unit/ml 3 3 STARLIX - nateglinide tab 120 mg 3 2 SYMLINPEN 120 - pramlintide acetate pen-inj 2700 mcg/2.7ml (1000 mcg/ ml) 3 NOVOLOG - insulin aspart inj 100 unit/ ml NOVOLOG FLEXPEN - insulin aspart soln pen-injector 100 unit/ml 2 SYMLINPEN 60 - pramlintide acetate pen-inj 1500 mcg/1.5ml (1000 mcg/ ml) 3 NOVOLOG PENFILL - insulin aspart soln cartridge 100 unit/ml 2 3 NOVOLOG PENFILL - insulin aspart inj 100 unit/ml 2 TANZEUM - albiglutide for soln peninjector 30 mg TANZEUM - albiglutide for soln peninjector 50 mg 3 TOLAZAMIDE - tolazamide tab 500 mg 3 tolazamide tab 250 mg 1 Short-Acting Insulins HUMULIN R - insulin regular (human) inj 3 100 unit/ml 2 HUMULIN R U-500 (CONCENTR insulin regular (human) inj 500 unit/ml SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 • 35 NOVOLIN R - insulin regular (human) inj 2 100 unit/ml 2 NOVOLIN R RELION - insulin regular (human) inj 100 unit/ml 2 RELION R - insulin regular (human) inj 100 unit/ml NOVOLIN 70/30 - insulin isophane & regular (human) inj 100 unit/ml (70-30) 2 NOVOLIN 70/30 RELION - insulin isophane & regular (human) inj 100 unit/ml (70-30) 2 Intermediate-Acting Insulins 2 • NOVOLOG MIX 70/30 - insulin aspart prot & aspart (human) inj 100 unit/ml (70-30) • NOVOLOG MIX 70/30 PREFILL - insulin 2 aspart prot & aspart sus pen-inj 100 unit/ml (70-30) HUMALOG MIX 50/50 - insulin lispro prot & lispro (human) inj 100 unit/ml (50-50) 3 HUMALOG MIX 50/50 KWIKPEN insulin lispro prot & lispro sus pen-inj 100 unit/ml (50-50) 3 HUMALOG MIX 75/25 - insulin lispro prot & lispro (human) inj 100 unit/ml (75-25) 3 • HUMALOG MIX 75/25 KWIKPEN insulin lispro prot & lispro sus pen-inj 100 unit/ml (75-25) 3 • HUMULIN N - insulin isophane (human) inj 100 unit/ml 3 • HUMULIN N KWIKPEN - insulin isophane (human) susp pen-injector 100 unit/ml 3 • HUMULIN N U-100 PEN - insulin isophane (human) susp pen-injector 100 unit/ml 3 • HUMULIN 70/30 - insulin isophane & regular (human) inj 100 unit/ml (70-30) 3 • HUMULIN 70/30 KWIKPEN - insulin isophane & regular susp pen-inj 100 unit/ml (70-30) 3 • HUMULIN 70/30 PEN - insulin isophane & regular susp pen-inj 100 unit/ml (70-30) 3 • NOVOLIN N - insulin isophane (human) inj 100 unit/ml 2 NOVOLIN N RELION - insulin isophane (human) inj 100 unit/ml 2 36 Basal Insulins LANTUS - insulin glargine inj 100 unit/ml 2 2 LANTUS SOLOSTAR - insulin glargine soln pen-injector 100 unit/ml 2 LEVEMIR - insulin detemir inj 100 unit/ ml 2 LEVEMIR FLEXPEN - insulin detemir soln pen-injector 100 unit/ml 2 LEVEMIR FLEXTOUCH - insulin detemir soln pen-injector 100 unit/ml THYROID AGENTS ARMOUR THYROID - thyroid tab 15 mg 3 (1/4 grain) ARMOUR THYROID - thyroid tab 30 mg 3 (1/2 grain) ARMOUR THYROID - thyroid tab 60 mg 3 (1 grain) ARMOUR THYROID - thyroid tab 90 mg 3 (1 1/2 grain) 3 ARMOUR THYROID - thyroid tab 120 mg (2 grain) 3 ARMOUR THYROID - thyroid tab 180 mg (3 grain) 3 ARMOUR THYROID - thyroid tab 240 mg (4 grain) 3 ARMOUR THYROID - thyroid tab 300 mg (5 grain) SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 CYTOMEL - liothyronine sodium tab 5 mcg 3 NATURE-THROID - thyroid tab 32.5 mg 3 CYTOMEL - liothyronine sodium tab 25 mcg NATURE-THROID - thyroid tab 48.75 mg (3/4 grain) 3 3 NATURE-THROID - thyroid tab 65 mg 3 CYTOMEL - liothyronine sodium tab 50 mcg 3 NATURE-THROID - thyroid tab 81.25 mg 3 levothyroxine sodium tab 100 mcg (Synthroid) 1 NATURE-THROID - thyroid tab 97.5 mg 3 1 NATURE-THROID - thyroid tab 113.75 mg 3 levothyroxine sodium tab 112 mcg (Synthroid) 1 NATURE-THROID - thyroid tab 130 mg 3 levothyroxine sodium tab 125 mcg (Synthroid) NATURE-THROID - thyroid tab 195 mg 3 levothyroxine sodium tab 137 mcg (Synthroid) 1 NATURE-THROID - thyroid tab 260 mg 3 3 levothyroxine sodium tab 150 mcg (Synthroid) 1 NATURE-THROID - thyroid tab 325 mg (5 grain) 3 levothyroxine sodium tab 175 mcg (Synthroid) 1 NATURE-THROID - thyroid tab 146.25 mg 3 levothyroxine sodium tab 200 mcg (Synthroid) 1 NATURE-THROID NT-2.5 - thyroid tab 162.5 mg (2 1/2 grain) propylthiouracil tab 50 mg 1 levothyroxine sodium tab 25 mcg (Synthroid) 1 levothyroxine sodium tab 300 mcg (Synthroid) 1 levothyroxine sodium tab 50 mcg (Synthroid) 1 levothyroxine sodium tab 75 mcg (Synthroid) 1 levothyroxine sodium tab 88 mcg (Synthroid) 1 liothyronine sodium tab 25 mcg (Cytomel) 1 liothyronine sodium tab 5 mcg (Cytomel) 1 liothyronine sodium tab 50 mcg (Cytomel) 1 methimazole tab 10 mg (Tapazole) 1 methimazole tab 5 mg (Tapazole) 1 NATURE-THROID - thyroid tab 16.25 mg 3 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 SYNTHROID - levothyroxine sodium tab 3 25 mcg SYNTHROID - levothyroxine sodium tab 3 50 mcg SYNTHROID - levothyroxine sodium tab 3 75 mcg SYNTHROID - levothyroxine sodium tab 3 88 mcg SYNTHROID - levothyroxine sodium tab 3 100 mcg SYNTHROID - levothyroxine sodium tab 3 112 mcg SYNTHROID - levothyroxine sodium tab 3 125 mcg SYNTHROID - levothyroxine sodium tab 3 137 mcg SYNTHROID - levothyroxine sodium tab 3 150 mcg SYNTHROID - levothyroxine sodium tab 3 175 mcg SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 37 SYNTHROID - levothyroxine sodium tab 3 200 mcg SYNTHROID - levothyroxine sodium tab 3 300 mcg 3 TAPAZOLE - methimazole tab 5 mg TIROSINT - levothyroxine sodium cap 150 mcg 3 WESTHROID - thyroid tab 16.25 mg 3 WESTHROID - thyroid tab 32.5 mg 3 3 TAPAZOLE - methimazole tab 10 mg 3 WESTHROID - thyroid tab 48.75 mg (3/4 grain) thyroid tab 30 mg (1/2 grain) (Armour thyroid) 1 WESTHROID - thyroid tab 65 mg 3 WESTHROID - thyroid tab 81.25 mg 3 thyroid tab 60 mg (1 grain) (Armour thyroid) 1 WESTHROID - thyroid tab 97.5 mg 3 1 WESTHROID - thyroid tab 113.75 mg 3 thyroid tab 90 mg (1 1/2 grain) (Armour thyroid) WESTHROID - thyroid tab 130 mg 3 THYROLAR-1 - liotrix (t3-t4) tab 60 mg (12.5-50 mcg) 3 WESTHROID - thyroid tab 162.5 mg (2 1/2 grain) 3 THYROLAR-1/2 - liotrix (t3-t4) tab 30 mg (6.25-25 mcg) 3 WESTHROID - thyroid tab 195 mg 3 WESTHROID - thyroid tab 260 mg 3 THYROLAR-1/4 - liotrix (t3-t4) tab 15 mg (3.1-12.5 mcg) 3 WESTHROID - thyroid tab 325 mg (5 grain) 3 THYROLAR-2 - liotrix (t3-t4) tab 120 mg (25-100 mcg) 3 WESTHROID - thyroid tab 146.25 mg 3 WESTHROID-P - thyroid tab 16.25 mg 3 THYROLAR-3 - liotrix (t3-t4) tab 180 mg (37.5-150 mcg) 3 WESTHROID-P - thyroid tab 32.5 mg 3 3 WESTHROID-P - thyroid tab 48.75 mg (3/4 grain) 3 TIROSINT - levothyroxine sodium cap 13 mcg 3 WESTHROID-P - thyroid tab 65 mg 3 TIROSINT - levothyroxine sodium cap 25 mcg WESTHROID-P - thyroid tab 97.5 mg 3 TIROSINT - levothyroxine sodium cap 50 mcg 3 WESTHROID-P - thyroid tab 130 mg 3 WP THYROID - thyroid tab 16.25 mg 3 TIROSINT - levothyroxine sodium cap 75 mcg 3 WP THYROID - thyroid tab 32.5 mg 3 TIROSINT - levothyroxine sodium cap 88 mcg WP THYROID - thyroid tab 48.75 mg (3/4 grain) 3 3 3 3 WP THYROID - thyroid tab 65 mg TIROSINT - levothyroxine sodium cap 100 mcg WP THYROID - thyroid tab 81.25 mg 3 3 WP THYROID - thyroid tab 97.5 mg 3 TIROSINT - levothyroxine sodium cap 112 mcg WP THYROID - thyroid tab 113.75 mg 3 TIROSINT - levothyroxine sodium cap 125 mcg 3 WP THYROID - thyroid tab 130 mg 3 TIROSINT - levothyroxine sodium cap 137 mcg 3 38 OXYTOCICS CERVIDIL - dinoprostone vaginal inserts 3 10 mg SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 HEMABATE - carboprost tromethamine im soln 250 mcg/ml 3 BUPHENYL - sodium phenylbutyrate tab 500 mg 5 methylergonovine maleate inj 0.2 mg/ml 1 BUPHENYL - sodium phenylbutyrate oral powder 3 gm/teaspoonful 5 methylergonovine maleate tab 0.2 mg 1 cabergoline tab 0.5 mg 1 1 calcitonin (salmon) nasal soln 200 unit/act (Miacalcin) 1 oxytocin inj 10 unit/ml (Pitocin) PITOCIN - oxytocin inj 10 unit/ml 3 calcitriol cap 0.25 mcg (Rocaltrol) 1 PREPIDIL - dinoprostone cervical gel 0.5 mg/3gm 3 calcitriol cap 0.5 mcg (Rocaltrol) 1 PROSTIN E2 - dinoprostone vaginal suppos 20 mg calcitriol oral soln 1 mcg/ml (Rocaltrol) 1 3 CARBAGLU - carglumic acid tab 200 mg 5 CARNITOR - levocarnitine tab 330 mg 3 CARNITOR - levocarnitine oral soln 1 gm/10ml (10%) 3 CARNITOR SF - levocarnitine oral soln 1 gm/10ml (10%) 3 chorionic gonadotropin for inj 10000 unit 4 CYSTADANE - betaine powder for oral solution 3 DDAVP - desmopressin acetate tab 0.1 mg 3 DDAVP - desmopressin acetate tab 0.2 mg 3 DDAVP - desmopressin acetate inj 4 mcg/ml 3 DDAVP - desmopressin acetate nasal soln 0.01% (refrigerated) 3 ENDOCRINE and METABOLIC AGENTS - MISC. 5 • ACTHAR HP - corticotropin inj gel 80 unit/ml 3 ACTONEL - risedronate sodium tab 5 mg 3 ACTONEL - risedronate sodium tab 30 mg 3 ACTONEL - risedronate sodium tab 35 mg ACTONEL - risedronate sodium tab 150 3 mg ALENDRONATE SODIUM - alendronate 2 sodium tab 40 mg ALENDRONATE SODIUM - alendronate 3 sodium oral soln 70 mg/75ml 1 alendronate sodium tab 10 mg alendronate sodium tab 35 mg 1 alendronate sodium tab 5 mg 1 alendronate sodium tab 70 mg (Fosamax) 1 DDAVP - desmopressin acetate nasal spray soln 0.01% 3 ATELVIA - risedronate sodium tab delayed release 35 mg 3 desmopressin acetate inj 4 mcg/ml (Ddavp) 1 BINOSTO - alendronate sodium effervescent tab 70 mg 3 desmopressin acetate nasal soln 0.01% (refrigerated) (Ddavp) 1 BONIVA - ibandronate sodium tab 150 mg (base equivalent) 3 desmopressin acetate nasal spray soln 0.01% (Ddavp) 1 desmopressin acetate nasal spray soln 0.01% (refrigerated) 1 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 39 desmopressin acetate tab 0.2 mg (Ddavp) 1 GENOTROPIN MINIQUICK somatropin for inj 0.8 mg 5 • DIDRONEL - etidronate disodium tab 400 mg 3 GENOTROPIN MINIQUICK somatropin for inj 1 mg 5 • doxercalciferol cap 0.5 mcg (Hectorol) 1 GENOTROPIN MINIQUICK somatropin for inj 1.2 mg 5 • doxercalciferol cap 1 mcg (Hectorol) 1 5 • doxercalciferol cap 2.5 mcg (Hectorol) 1 GENOTROPIN MINIQUICK somatropin for inj 1.4 mg 5 • EGRIFTA - tesamorelin acetate for inj 1 mg (base equiv) 5 GENOTROPIN MINIQUICK somatropin for inj 1.6 mg 5 • EGRIFTA - tesamorelin acetate for inj 2 mg (base equiv) 5 GENOTROPIN MINIQUICK somatropin for inj 1.8 mg 5 • ETIDRONATE DISODIUM - etidronate disodium tab 200 mg 2 GENOTROPIN MINIQUICK somatropin for inj 2 mg 5 • ETIDRONATE DISODIUM - etidronate disodium tab 400 mg 3 H.P. ACTHAR - corticotropin inj gel 80 unit/ml 3 EVISTA - raloxifene hcl tab 60 mg 3 HECTOROL - doxercalciferol cap 0.5 mcg FORTEO - teriparatide (recombinant) inj 600 mcg/2.4ml 5 HECTOROL - doxercalciferol cap 1 mcg 3 3 FORTICAL - calcitonin (salmon) nasal soln 200 unit/act 3 HECTOROL - doxercalciferol cap 2.5 mcg HUMATROPE - somatropin for inj 5 mg 5 FOSAMAX - alendronate sodium tab 70 mg 3 HUMATROPE - somatropin for inj 6 mg (18 unit) 5 • • FOSAMAX PLUS D - alendronate sodium-cholecalciferol tab 70-2800 mg-unit 3 HUMATROPE - somatropin for inj 12 mg (36 unit) 5 • • FOSAMAX PLUS D - alendronate sodium-cholecalciferol tab 70-5600 mg-unit HUMATROPE - somatropin for inj 24 mg 5 3 5 • GENOTROPIN - somatropin for subcutaneous inj 5 mg 5 • HUMATROPE COMBO PACK somatropin for inj 5 mg 1 GENOTROPIN - somatropin for inj 12 mg (13.8 mg overfill) 5 • ibandronate sodium tab 150 mg (base equivalent) (Boniva) 4 GENOTROPIN MINIQUICK somatropin for inj 0.2 mg 5 • INCRELEX - mecasermin inj 40 mg/4ml (10 mg/ml) 5 GENOTROPIN MINIQUICK somatropin for inj 0.4 mg 5 • KUVAN - sapropterin dihydrochloride powder packet 100 mg KUVAN - sapropterin dihydrochloride soluble tab 100 mg 5 40 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Prior Authorization • Drug Name Step Therapy Drug Tier 5 Quantity Limits GENOTROPIN MINIQUICK somatropin for inj 0.6 mg Step Therapy 1 Drug Tier desmopressin acetate tab 0.1 mg (Ddavp) Drug Name Prior Authorization 2015 levocarnitine tab 330 mg (Carnitor) 1 5 • LUPANETA PACK - leuprolide (1 mon) inj 3.75 mg & norethindrone tab 5 mg kit 3 NUTROPIN AQ NUSPIN 5 - somatropin inj 5 mg/2ml NUTROPIN AQ PEN - somatropin inj 10 mg/2ml 5 • LUPANETA PACK - leuprolide (3 mon) inj 11.25 mg & norethindrone tab 5 mg kit 3 NUTROPIN AQ PEN - somatropin inj 20 mg/2ml 5 • LUPRON DEPOT-PED - leuprolide acetate for inj pediatric kit 7.5 mg octreotide acetate inj 100 mcg/ml (0.1 mg/ml) (Sandostatin) 4 4 LUPRON DEPOT-PED - leuprolide acetate for inj pediatric kit 11.25 mg octreotide acetate inj 1000 mcg/ml (1 mg/ml) (Sandostatin) 4 4 LUPRON DEPOT-PED - leuprolide acetate for inj pediatric kit 15 mg octreotide acetate inj 200 mcg/ml (0.2 mg/ml) (Sandostatin) 4 4 4 LUPRON DEPOT-PED - leuprolide acetate (3 month) for inj pediatric kit 11.25 mg 4 octreotide acetate inj 50 mcg/ml (0.05 mg/ml) (Sandostatin) octreotide acetate inj 500 mcg/ml (0.5 mg/ml) (Sandostatin) 4 LUPRON DEPOT-PED - leuprolide acetate (3 month) for inj pediatric kit 30 mg 4 OMNITROPE - somatropin inj 5 mg/1.5ml 4 • OMNITROPE - somatropin inj 10 mg/1.5ml 4 • OMNITROPE - somatropin for inj 5.8 mg 4 4 ORFADIN - nitisinone cap 2 mg • MIACALCIN - calcitonin (salmon) inj 200 3 unit/ml MIACALCIN - calcitonin (salmon) nasal 3 soln 200 unit/act 5 MYALEPT - metreleptin for subcutaneous inj 11.3 mg 5 NORDITROPIN CARTRIDGE somatropin inj 5 mg/1.5ml NORDITROPIN FLEXPRO - somatropin 5 inj 5 mg/1.5ml NORDITROPIN FLEXPRO - somatropin 5 inj 10 mg/1.5ml NORDITROPIN FLEXPRO - somatropin 5 inj 15 mg/1.5ml 5 NORDITROPIN NORDIFLEX PEN somatropin inj 30 mg/3ml 5 NUTROPIN - somatropin for inj 10 mg NUTROPIN AQ NUSPIN 10 somatropin inj 10 mg/2ml 5 • • • • • • • SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare ORFADIN - nitisinone cap 5 mg 4 ORFADIN - nitisinone cap 10 mg 4 OSPHENA - ospemifene tab 60 mg 3 paricalcitol cap 1 mcg (Zemplar) 1 paricalcitol cap 2 mcg (Zemplar) 1 paricalcitol cap 4 mcg (Zemplar) 1 PITRESSIN SYNTHETIC - vasopressin inj 20 unit/ml 3 PROLIA - denosumab inj 60 mg/ml 2 raloxifene hcl tab 60 mg (Evista) 1 RAVICTI - glycerol phenylbutyrate liquid 1.1 gm/ml 5 risedronate sodium tab 150 mg (Actonel) 1 ROCALTROL - calcitriol cap 0.25 mcg 3 Products January 2015 Quantity Limits Prior Authorization • Drug Name Step Therapy Drug Tier 5 Quantity Limits NUTROPIN AQ NUSPIN 20 somatropin inj 20 mg/2ml Step Therapy 1 Drug Tier levocarnitine oral soln 1 gm/10ml (10%) (Carnitor) Drug Name Prior Authorization 2015 • 41 • • SIGNIFOR - pasireotide diaspartate inj 0.3 mg/ml (base equiv) 5 • SIGNIFOR - pasireotide diaspartate inj 0.6 mg/ml (base equiv) 5 • SIGNIFOR - pasireotide diaspartate inj 0.9 mg/ml (base equiv) 5 sodium phenylbutyrate oral powder 3 gm/teaspoonful (Buphenyl) 4 SOMATULINE DEPOT - lanreotide acetate extended release inj 60 mg/0.2ml 5 SOMATULINE DEPOT - lanreotide acetate extended release inj 90 mg/0.3ml 5 SOMATULINE DEPOT - lanreotide acetate extended release inj 120 mg/0.5ml 5 SAMSCA - tolvaptan tab 30 mg 5 SANDOSTATIN - octreotide acetate inj 50 mcg/ml (0.05 mg/ml) 5 SANDOSTATIN - octreotide acetate inj 100 mcg/ml (0.1 mg/ml) 5 SANDOSTATIN - octreotide acetate inj 200 mcg/ml (0.2 mg/ml) 5 SANDOSTATIN - octreotide acetate inj 500 mcg/ml (0.5 mg/ml) 5 SANDOSTATIN - octreotide acetate inj 1000 mcg/ml (1 mg/ml) 5 SANDOSTATIN LAR DEPOT octreotide acetate for im inj kit 10 mg 4 SANDOSTATIN LAR DEPOT octreotide acetate for im inj kit 20 mg 4 SANDOSTATIN LAR DEPOT octreotide acetate for im inj kit 30 mg 4 SENSIPAR - cinacalcet hcl tab 30 mg (base equiv) 2 SENSIPAR - cinacalcet hcl tab 60 mg (base equiv) 2 SENSIPAR - cinacalcet hcl tab 90 mg (base equiv) 2 SEROSTIM - somatropin (nonrefrigerated) for subcutaneous inj 4 mg 5 • SEROSTIM - somatropin (nonrefrigerated) for subcutaneous inj 5 mg 5 • 42 SOMAVERT - pegvisomant for inj 10 mg 5 (as protein) SOMAVERT - pegvisomant for inj 15 mg 5 (as protein) SOMAVERT - pegvisomant for inj 20 mg 5 (as protein) SOMAVERT - pegvisomant for inj 25 mg 5 (as protein) SOMAVERT - pegvisomant for inj 30 mg 5 (as protein) STIMATE - desmopressin acetate nasal 2 soln 1.5 mg/ml SUPPRELIN LA - histrelin acetate (cpp) 3 implant kit 50 mg SYNAREL - nafarelin acetate nasal soln 3 2 mg/ml 5 TEV-TROPIN - somatropin for subcutaneous inj 5 mg 1 vasopressin inj 20 unit/ml (Pitressin synthetic) 5 XGEVA - denosumab inj 120 mg/1.7ml SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare • • Products January 2015 Quantity Limits Prior Authorization 5 Drug Name Step Therapy Drug Tier ROCALTROL - calcitriol oral soln 1 mcg/ 3 ml SAIZEN - somatropin (non-refrigerated) 5 for inj 5 mg SAIZEN - somatropin (non-refrigerated) 5 for inj 8.8 mg 5 SAIZEN CLICK.EASY - somatropin (non-refrigerated) for inj 8.8 mg 5 SAMSCA - tolvaptan tab 15 mg SEROSTIM - somatropin (nonrefrigerated) for subcutaneous inj 6 mg Quantity Limits 3 Step Therapy ROCALTROL - calcitriol cap 0.5 mcg Prior Authorization Drug Name Drug Tier 2015 ZORBTIVE - somatropin (nonrefrigerated) for subcutaneous inj 8.8 mg 5 ISOSORBIDE DINITRATE - isosorbide dinitrate sl tab 2.5 mg 3 isosorbide dinitrate tab cr 40 mg 1 isosorbide dinitrate tab 10 mg 1 CARDIOVASCULAR AGENTS isosorbide dinitrate tab 20 mg 1 CARDIOTONICS isosorbide dinitrate tab 30 mg 1 isosorbide dinitrate tab 5 mg (Isordil titradose) 1 • DIGOXIN - digoxin oral soln 0.05 mg/ml 2 digoxin inj 0.25 mg/ml (Lanoxin) 1 digoxin tab 125 mcg (0.125 mg) (Lanoxin) 1 isosorbide mononitrate tab sr 24hr 120 mg (Imdur) 1 digoxin tab 250 mcg (0.25 mg) (Lanoxin) 1 isosorbide mononitrate tab sr 24hr 30 mg (Imdur) 1 LANOXIN - digoxin tab 62.5 mcg (0.0625 mg) 3 isosorbide mononitrate tab sr 24hr 60 mg (Imdur) 1 LANOXIN - digoxin tab 125 mcg (0.125 mg) 3 isosorbide mononitrate tab 10 mg 1 isosorbide mononitrate tab 20 mg 1 LANOXIN - digoxin tab 187.5 mcg (0.1875 mg) 3 NITRO-BID - nitroglycerin oint 2% 2 LANOXIN - digoxin tab 250 mcg (0.25 mg) NITRO-DUR - nitroglycerin td patch 24hr 0.1 mg/hr 3 3 LANOXIN - digoxin inj 0.25 mg/ml NITRO-DUR - nitroglycerin td patch 24hr 0.2 mg/hr 3 3 LANOXIN PEDIATRIC - digoxin inj 0.1 mg/ml 3 NITRO-DUR - nitroglycerin td patch 24hr 0.3 mg/hr 3 3 ANTIANGINAL AGENTS DILATRATE SR - isosorbide dinitrate cap cr 40 mg 3 NITRO-DUR - nitroglycerin td patch 24hr 0.4 mg/hr 3 IMDUR - isosorbide mononitrate tab sr 24hr 30 mg 3 NITRO-DUR - nitroglycerin td patch 24hr 0.6 mg/hr 3 IMDUR - isosorbide mononitrate tab sr 24hr 60 mg 3 NITRO-DUR - nitroglycerin td patch 24hr 0.8 mg/hr nitroglycerin cap cr 2.5 mg 1 IMDUR - isosorbide mononitrate tab sr 24hr 120 mg 3 nitroglycerin cap cr 6.5 mg 1 nitroglycerin cap cr 9 mg 1 ISORDIL TITRADOSE - isosorbide dinitrate tab 5 mg 3 3 ISORDIL TITRADOSE - isosorbide dinitrate tab 40 mg 3 NITROGLYCERIN LINGUAL nitroglycerin lingual aerosol 400 mcg/ spray nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur) 1 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits 3 3 Step Therapy ZEMPLAR - paricalcitol cap 4 mcg ISOSORBIDE DINITRATE - isosorbide dinitrate tab 30 mg Prior Authorization 3 Drug Name Drug Tier ZEMPLAR - paricalcitol cap 2 mcg Quantity Limits 3 Step Therapy ZEMPLAR - paricalcitol cap 1 mcg Prior Authorization Drug Name Drug Tier 2015 43 nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur) 1 bisoprolol fumarate tab 10 mg (Zebeta) 1 nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur) 1 bisoprolol fumarate tab 5 mg (Zebeta) 1 nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur) 1 BYSTOLIC - nebivolol hcl tab 2.5 mg (base equivalent) 3 nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray) (Nitrolingual pumpspr) 1 BYSTOLIC - nebivolol hcl tab 5 mg (base equivalent) 3 NITROLINGUAL PUMPSPRAY nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray) BYSTOLIC - nebivolol hcl tab 10 mg (base equivalent) 3 3 BYSTOLIC - nebivolol hcl tab 20 mg (base equivalent) 3 NITROMIST - nitroglycerin lingual aerosol 400 mcg/spray 3 carvedilol tab 12.5 mg (Coreg) 1 carvedilol tab 25 mg (Coreg) 1 carvedilol tab 3.125 mg (Coreg) 1 carvedilol tab 6.25 mg (Coreg) 1 COREG - carvedilol tab 3.125 mg 3 COREG - carvedilol tab 6.25 mg 3 COREG - carvedilol tab 12.5 mg 3 COREG - carvedilol tab 25 mg 3 COREG CR - carvedilol phosphate cap sr 24hr 10 mg 3 COREG CR - carvedilol phosphate cap sr 24hr 20 mg 3 COREG CR - carvedilol phosphate cap sr 24hr 40 mg 3 NITROSTAT - nitroglycerin sl tab 0.3 mg 2 NITROSTAT - nitroglycerin sl tab 0.4 mg 2 NITROSTAT - nitroglycerin sl tab 0.6 mg 2 3 RANEXA - ranolazine tab sr 12hr 500 mg 3 RANEXA - ranolazine tab sr 12hr 1000 mg BETA BLOCKERS acebutolol hcl cap 200 mg (Sectral) 1 acebutolol hcl cap 400 mg (Sectral) 1 atenolol tab 100 mg (Tenormin) 1 atenolol tab 25 mg (Tenormin) 1 atenolol tab 50 mg (Tenormin) 1 BETAPACE - sotalol hcl tab 80 mg COREG CR - carvedilol phosphate cap sr 24hr 80 mg 3 3 BETAPACE - sotalol hcl tab 120 mg 3 CORGARD - nadolol tab 20 mg 3 BETAPACE - sotalol hcl tab 160 mg 3 CORGARD - nadolol tab 40 mg 3 BETAPACE AF - sotalol hcl (afib/afl) tab 80 mg 3 CORGARD - nadolol tab 80 mg 3 BETAPACE AF - sotalol hcl (afib/afl) tab 120 mg 3 BETAPACE AF - sotalol hcl (afib/afl) tab 160 mg 3 betaxolol hcl tab 10 mg (Kerlone) 1 betaxolol hcl tab 20 mg (Kerlone) 1 44 HEMANGEOL - propranolol hcl oral soln 3 4.28 mg/ml HYPERTENEVIDE-12.5 - carvedilol tab 3 12.5 mg & dietary management cap pack 3 INDERAL LA - propranolol hcl cap sr 24hr 60 mg SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 INDERAL LA - propranolol hcl cap sr 24hr 80 mg 3 metoprolol tartrate tab 50 mg (Lopressor) 1 INDERAL LA - propranolol hcl cap sr 24hr 120 mg 3 nadolol tab 20 mg (Corgard) 1 nadolol tab 40 mg (Corgard) 1 INDERAL LA - propranolol hcl cap sr 24hr 160 mg 3 nadolol tab 80 mg (Corgard) 1 3 pindolol tab 10 mg 1 INDERAL XL - propranolol hcl sustained-release beads cap sr 24hr 80 mg pindolol tab 5 mg 1 2 INDERAL XL - propranolol hcl sustained-release beads cap sr 24hr 120 mg 3 PROPRANOLOL HCL - propranolol hcl oral soln 20 mg/5ml PROPRANOLOL HCL - propranolol hcl oral soln 40 mg/5ml 2 INNOPRAN XL - propranolol hcl sustained-release beads cap sr 24hr 80 mg 3 propranolol hcl cap sr 24hr 120 mg (Inderal la) 1 INNOPRAN XL - propranolol hcl sustained-release beads cap sr 24hr 120 mg propranolol hcl cap sr 24hr 160 mg (Inderal la) 1 3 1 KERLONE - betaxolol hcl tab 10 mg 3 propranolol hcl cap sr 24hr 60 mg (Inderal la) KERLONE - betaxolol hcl tab 20 mg propranolol hcl cap sr 24hr 80 mg (Inderal la) 1 3 labetalol hcl tab 100 mg (Trandate) 1 propranolol hcl tab 10 mg 1 labetalol hcl tab 200 mg (Trandate) 1 propranolol hcl tab 20 mg 1 labetalol hcl tab 300 mg (Trandate) 1 propranolol hcl tab 40 mg 1 LEVATOL - penbutolol sulfate tab 20 mg 3 3 LOPRESSOR - metoprolol tartrate tab 50 mg 3 LOPRESSOR - metoprolol tartrate tab 100 mg 1 metoprolol succinate tab sr 24hr 100 mg (Toprol xl) 1 metoprolol succinate tab sr 24hr 200 mg (Toprol xl) 1 metoprolol succinate tab sr 24hr 25 mg (Toprol xl) 1 metoprolol succinate tab sr 24hr 50 mg (Toprol xl) 1 metoprolol tartrate tab 100 mg (Lopressor) 1 metoprolol tartrate tab 25 mg propranolol hcl tab 60 mg 1 propranolol hcl tab 80 mg 1 SECTRAL - acebutolol hcl cap 200 mg 3 SECTRAL - acebutolol hcl cap 400 mg 3 sotalol hcl (afib/afl) tab 120 mg (Betapace af) 1 sotalol hcl (afib/afl) tab 160 mg (Betapace af) 1 sotalol hcl (afib/afl) tab 80 mg (Betapace af) 1 sotalol hcl tab 120 mg (Betapace) 1 sotalol hcl tab 160 mg (Betapace) 1 sotalol hcl tab 240 mg 1 sotalol hcl tab 80 mg (Betapace) 1 TENORMIN - atenolol tab 25 mg 3 TENORMIN - atenolol tab 50 mg 3 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 45 3 2 CALAN SR - verapamil hcl tab cr 180 mg 3 TIMOLOL MALEATE - timolol maleate tab 10 mg 2 CALAN SR - verapamil hcl tab cr 240 mg 3 TIMOLOL MALEATE - timolol maleate tab 20 mg 2 CARDENE SR - nicardipine hcl cap sr 12hr 30 mg 3 TOPROL XL - metoprolol succinate tab sr 24hr 25 mg 3 CARDENE SR - nicardipine hcl cap sr 12hr 60 mg CARDIZEM - diltiazem hcl tab 30 mg 3 TOPROL XL - metoprolol succinate tab sr 24hr 50 mg 3 CARDIZEM - diltiazem hcl tab 60 mg 3 CARDIZEM - diltiazem hcl tab 90 mg 3 TOPROL XL - metoprolol succinate tab sr 24hr 100 mg 3 CARDIZEM - diltiazem hcl tab 120 mg 3 3 CARDIZEM CD - diltiazem hcl coated beads cap sr 24hr 120 mg 3 TOPROL XL - metoprolol succinate tab sr 24hr 200 mg 3 CARDIZEM CD - diltiazem hcl coated beads cap sr 24hr 180 mg 3 TRANDATE - labetalol hcl tab 100 mg TRANDATE - labetalol hcl tab 200 mg 3 3 CARDIZEM CD - diltiazem hcl coated beads cap sr 24hr 240 mg 3 TRANDATE - labetalol hcl tab 300 mg ZEBETA - bisoprolol fumarate tab 5 mg 3 3 ZEBETA - bisoprolol fumarate tab 10 mg 3 CARDIZEM CD - diltiazem hcl coated beads cap sr 24hr 300 mg CARDIZEM CD - diltiazem hcl coated beads cap sr 24hr 360 mg 3 CALCIUM CHANNEL BLOCKERS ADALAT CC - nifedipine tab sr 24hr 30 mg 3 CARDIZEM LA - diltiazem hcl coated beads tab sr 24hr 120 mg 3 ADALAT CC - nifedipine tab sr 24hr 60 mg 3 CARDIZEM LA - diltiazem hcl coated beads tab sr 24hr 180 mg 3 ADALAT CC - nifedipine tab sr 24hr 90 mg 3 CARDIZEM LA - diltiazem hcl coated beads tab sr 24hr 240 mg 3 amlodipine besylate tab 10 mg (Norvasc) 1 CARDIZEM LA - diltiazem hcl coated beads tab sr 24hr 300 mg 3 amlodipine besylate tab 2.5 mg (Norvasc) 1 CARDIZEM LA - diltiazem hcl coated beads tab sr 24hr 360 mg 3 amlodipine besylate tab 5 mg (Norvasc) 1 CARDIZEM LA - diltiazem hcl coated beads tab sr 24hr 420 mg 3 CALAN - verapamil hcl tab 80 mg 3 3 CALAN - verapamil hcl tab 120 mg 3 DILACOR XR - diltiazem hcl cap sr 24hr 240 mg 3 diltiazem hcl cap sr 12hr 120 mg 1 CALAN SR - verapamil hcl tab cr 120 mg diltiazem hcl cap sr 12hr 60 mg 1 diltiazem hcl cap sr 12hr 90 mg 1 46 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier TIMOLOL MALEATE - timolol maleate tab 5 mg Quantity Limits 3 Step Therapy TENORMIN - atenolol tab 100 mg Prior Authorization Drug Name Drug Tier 2015 1 diltiazem hcl cap sr 24hr 180 mg 1 felodipine tab sr 24hr 2.5 mg 1 diltiazem hcl cap sr 24hr 240 mg 1 felodipine tab sr 24hr 5 mg 1 diltiazem hcl coated beads cap sr 24hr 120 mg (Cardizem cd) 1 3 diltiazem hcl coated beads cap sr 24hr 180 mg (Cardizem cd) 1 HYPERTENIPINE-2.5 - amlodipine tab 2.5 mg & dietary management cap pack 3 diltiazem hcl coated beads cap sr 24hr 240 mg (Cardizem cd) 1 ISOPTIN SR - verapamil hcl tab cr 120 mg 3 diltiazem hcl coated beads cap sr 24hr 300 mg (Cardizem cd) 1 ISOPTIN SR - verapamil hcl tab cr 180 mg 3 diltiazem hcl coated beads cap sr 24hr 360 mg (Cardizem cd) 1 ISOPTIN SR - verapamil hcl tab cr 240 mg ISRADIPINE - isradipine cap 2.5 mg 3 diltiazem hcl coated beads tab sr 24hr 180 mg (Cardizem la) 1 ISRADIPINE - isradipine cap 5 mg 3 nicardipine hcl cap 20 mg 1 diltiazem hcl coated beads tab sr 24hr 240 mg (Cardizem la) 1 nicardipine hcl cap 30 mg 1 1 nifedipine cap 10 mg (Procardia) 1 diltiazem hcl coated beads tab sr 24hr 300 mg (Cardizem la) nifedipine cap 20 mg 1 diltiazem hcl coated beads tab sr 24hr 360 mg (Cardizem la) 1 nifedipine tab sr 24hr osmotic 30 mg (Procardia xl) 1 diltiazem hcl coated beads tab sr 24hr 420 mg (Cardizem la) 1 nifedipine tab sr 24hr osmotic 60 mg (Procardia xl) 1 diltiazem hcl extended release beads cap sr 24hr 120 mg (Tiazac) 1 nifedipine tab sr 24hr osmotic 90 mg (Procardia xl) 1 diltiazem hcl extended release beads cap sr 24hr 180 mg (Tiazac) 1 nifedipine tab sr 24hr 30 mg (Adalat cc) 1 diltiazem hcl extended release beads cap sr 24hr 240 mg (Tiazac) 1 nifedipine tab sr 24hr 60 mg (Adalat cc) 1 diltiazem hcl extended release beads cap sr 24hr 300 mg (Tiazac) 1 nifedipine tab sr 24hr 90 mg (Adalat cc) 1 diltiazem hcl extended release beads cap sr 24hr 360 mg (Tiazac) 1 nimodipine cap 30 mg 1 3 diltiazem hcl extended release beads cap sr 24hr 420 mg (Tiazac) 1 NISOLDIPINE - nisoldipine tab sr 24hr 20 mg 3 diltiazem hcl tab 120 mg (Cardizem) 1 NISOLDIPINE - nisoldipine tab sr 24hr 30 mg diltiazem hcl tab 30 mg (Cardizem) 1 3 diltiazem hcl tab 60 mg (Cardizem) 1 NISOLDIPINE - nisoldipine tab sr 24hr 40 mg 1 NISOLDIPINE ER - nisoldipine tab sr 24hr 25.5 mg 3 diltiazem hcl tab 90 mg SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits felodipine tab sr 24hr 10 mg Step Therapy 1 Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy diltiazem hcl cap sr 24hr 120 mg Prior Authorization Drug Name Drug Tier 2015 47 NORVASC - amlodipine besylate tab 2.5 mg 3 NORVASC - amlodipine besylate tab 5 mg 3 NORVASC - amlodipine besylate tab 10 mg 3 NYMALIZE - nimodipine oral soln 60 mg/20ml 3 PROCARDIA - nifedipine cap 10 mg 3 PROCARDIA XL - nifedipine tab sr 24hr osmotic 30 mg 1 verapamil hcl cap sr 24hr 200 mg (Verelan pm) 1 verapamil hcl cap sr 24hr 240 mg (Verelan) 1 verapamil hcl cap sr 24hr 300 mg (Verelan pm) 1 verapamil hcl cap sr 24hr 360 mg (Verelan) 1 verapamil hcl tab cr 120 mg (Calan sr) 1 3 verapamil hcl tab cr 180 mg (Calan sr) 1 3 verapamil hcl tab cr 240 mg (Calan sr) 1 PROCARDIA XL - nifedipine tab sr 24hr osmotic 60 mg 3 verapamil hcl tab 120 mg (Calan) 1 PROCARDIA XL - nifedipine tab sr 24hr osmotic 90 mg verapamil hcl tab 80 mg (Calan) 1 SULAR - nisoldipine tab sr 24hr 8.5 mg 3 3 SULAR - nisoldipine tab sr 24hr 17 mg 3 VERELAN - verapamil hcl cap sr 24hr 120 mg 3 VERELAN - verapamil hcl cap sr 24hr 180 mg 3 SULAR - nisoldipine tab sr 24hr 34 mg VERELAN - verapamil hcl cap sr 24hr 240 mg 3 VERELAN - verapamil hcl cap sr 24hr 360 mg 3 VERELAN PM - verapamil hcl cap sr 24hr 100 mg 3 VERELAN PM - verapamil hcl cap sr 24hr 200 mg 3 VERELAN PM - verapamil hcl cap sr 24hr 300 mg 3 TIAZAC - diltiazem hcl extended release 3 beads cap sr 24hr 120 mg TIAZAC - diltiazem hcl extended release 3 beads cap sr 24hr 180 mg TIAZAC - diltiazem hcl extended release 3 beads cap sr 24hr 240 mg TIAZAC - diltiazem hcl extended release 3 beads cap sr 24hr 300 mg TIAZAC - diltiazem hcl extended release 3 beads cap sr 24hr 360 mg TIAZAC - diltiazem hcl extended release 3 beads cap sr 24hr 420 mg VERAPAMIL HCL - verapamil hcl tab 40 2 mg 1 verapamil hcl cap sr 24hr 100 mg (Verelan pm) 1 verapamil hcl cap sr 24hr 120 mg (Verelan) 48 ANTIARRHYTHMICS amiodarone hcl tab 100 mg 1 amiodarone hcl tab 200 mg (Cordarone) 1 amiodarone hcl tab 400 mg 1 CORDARONE - amiodarone hcl tab 200 3 mg SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits 1 verapamil hcl cap sr 24hr 180 mg (Verelan) Step Therapy nisoldipine tab sr 24hr 8.5 mg (Sular) Drug Name Prior Authorization 1 Drug Tier nisoldipine tab sr 24hr 34 mg (Sular) Quantity Limits 1 Step Therapy nisoldipine tab sr 24hr 17 mg (Sular) Prior Authorization Drug Name Drug Tier 2015 disopyramide phosphate cap 100 mg (Norpace) 1 QUINIDINE SULFATE - quinidine sulfate tab 200 mg 3 disopyramide phosphate cap 150 mg (Norpace) 1 QUINIDINE SULFATE ER - quinidine sulfate tab cr 300 mg 2 flecainide acetate tab 100 mg 1 quinidine sulfate tab 200 mg 1 flecainide acetate tab 150 mg 1 quinidine sulfate tab 300 mg 1 flecainide acetate tab 50 mg 1 3 mexiletine hcl cap 150 mg 1 RYTHMOL - propafenone hcl tab 150 mg mexiletine hcl cap 200 mg 1 3 mexiletine hcl cap 250 mg 1 RYTHMOL - propafenone hcl tab 225 mg 2 RYTHMOL SR - propafenone hcl cap sr 12hr 225 mg 3 MULTAQ - dronedarone hcl tab 400 mg (base equivalent) 3 RYTHMOL SR - propafenone hcl cap sr 12hr 325 mg 3 NORPACE - disopyramide phosphate cap 100 mg 3 RYTHMOL SR - propafenone hcl cap sr 12hr 425 mg 3 NORPACE - disopyramide phosphate cap 150 mg 3 TAMBOCOR - flecainide acetate tab 50 mg 3 NORPACE CR - disopyramide phosphate cap sr 12hr 100 mg 3 TAMBOCOR - flecainide acetate tab 100 mg 3 NORPACE CR - disopyramide phosphate cap sr 12hr 150 mg 3 TAMBOCOR - flecainide acetate tab 150 mg 3 PROCAINAMIDE HCL - procainamide hcl inj 100 mg/ml 3 TIKOSYN - dofetilide cap 125 mcg (0.125 mg) 3 PROCAINAMIDE HCL - procainamide hcl inj 500 mg/ml propafenone hcl cap sr 12hr 225 mg (Rythmol sr) 1 propafenone hcl cap sr 12hr 325 mg (Rythmol sr) 1 propafenone hcl cap sr 12hr 425 mg (Rythmol sr) 1 propafenone hcl tab 150 mg (Rythmol) 1 propafenone hcl tab 225 mg (Rythmol) Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 TIKOSYN - dofetilide cap 250 mcg (0.25 3 mg) 3 TIKOSYN - dofetilide cap 500 mcg (0.5 mg) ANTIHYPERTENSIVES ACCUPRIL - quinapril hcl tab 5 mg 3 ACCUPRIL - quinapril hcl tab 10 mg 3 ACCUPRIL - quinapril hcl tab 20 mg 3 1 ACCUPRIL - quinapril hcl tab 40 mg 3 1 ACCURETIC - quinaprilhydrochlorothiazide tab 10-12.5 mg 3 propafenone hcl tab 300 mg QUINIDINE GLUCONATE - quinidine gluconate inj 80 mg/ml 3 ACCURETIC - quinaprilhydrochlorothiazide tab 20-12.5 mg 3 quinidine gluconate tab cr 324 mg 1 ACCURETIC - quinaprilhydrochlorothiazide tab 20-25 mg 3 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 49 ALTACE - ramipril cap 2.5 mg 3 ALTACE - ramipril cap 5 mg 3 ALTACE - ramipril cap 10 mg 3 amlodipine besylate-benazepril hcl cap 10-20 mg (Lotrel) ATACAND - candesartan cilexetil tab 4 mg 3 • ATACAND - candesartan cilexetil tab 8 mg 3 • ATACAND - candesartan cilexetil tab 16 mg 3 • ATACAND - candesartan cilexetil tab 32 mg 3 • 1 • amlodipine besylate-benazepril hcl cap 10-40 mg (Lotrel) ATACAND HCT - candesartan cilexetilhydrochlorothiazide tab 16-12.5 mg 3 1 • amlodipine besylate-benazepril hcl cap 2.5-10 mg (Lotrel) ATACAND HCT - candesartan cilexetilhydrochlorothiazide tab 32-12.5 mg 3 1 • amlodipine besylate-benazepril hcl cap 5-10 mg (Lotrel) ATACAND HCT - candesartan cilexetilhydrochlorothiazide tab 32-25 mg 3 1 1 amlodipine besylate-benazepril hcl cap 5-20 mg (Lotrel) 1 atenolol & chlorthalidone tab 100-25 mg (Tenoretic 100) 1 atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50) 1 amlodipine besylate-benazepril hcl cap 5-40 mg (Lotrel) • amlodipine besylate-valsartan tab 10-160 mg (Exforge) AVALIDE - irbesartanhydrochlorothiazide tab 150-12.5 mg 3 1 • amlodipine besylate-valsartan tab 10-320 mg (Exforge) AVALIDE - irbesartanhydrochlorothiazide tab 300-12.5 mg 3 1 AVAPRO - irbesartan tab 75 mg 3 amlodipine besylate-valsartan tab 5-160 mg (Exforge) 1 AVAPRO - irbesartan tab 150 mg 3 1 AVAPRO - irbesartan tab 300 mg 3 amlodipine besylate-valsartan tab 5-320 mg (Exforge) 3 AMTURNIDE - aliskiren-amlodipinehydrochlorothiazide tab 150-5-12.5 mg 3 AZOR - amlodipine besylate-olmesartan medoxomil tab 5-20 mg • • • • AZOR - amlodipine besylate-olmesartan medoxomil tab 5-40 mg 3 • AMTURNIDE - aliskiren-amlodipinehydrochlorothiazide tab 300-5-12.5 mg 3 AZOR - amlodipine besylate-olmesartan medoxomil tab 10-20 mg 3 • 3 • AMTURNIDE - aliskiren-amlodipinehydrochlorothiazide tab 300-5-25 mg 3 • AZOR - amlodipine besylate-olmesartan medoxomil tab 10-40 mg 1 AMTURNIDE - aliskiren-amlodipinehydrochlorothiazide tab 300-10-12.5 mg 3 • benazepril & hydrochlorothiazide tab 10-12.5 mg (Lotensin hct) benazepril & hydrochlorothiazide tab 20-12.5 mg (Lotensin hct) 1 AMTURNIDE - aliskiren-amlodipinehydrochlorothiazide tab 300-10-25 mg 3 benazepril & hydrochlorothiazide tab 20-25 mg (Lotensin hct) 1 50 • • • SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits 3 Step Therapy ALTACE - ramipril cap 1.25 mg Drug Name Prior Authorization 3 Drug Tier ACEON - perindopril erbumine tab 8 mg Quantity Limits 3 Step Therapy ACEON - perindopril erbumine tab 4 mg Prior Authorization Drug Name Drug Tier 2015 benazepril & hydrochlorothiazide tab 5-6.25 mg 1 benazepril hcl tab 10 mg (Lotensin) 1 benazepril hcl tab 20 mg (Lotensin) 1 benazepril hcl tab 40 mg (Lotensin) 1 benazepril hcl tab 5 mg 1 BENICAR - olmesartan medoxomil tab 5 3 mg 3 BENICAR - olmesartan medoxomil tab 20 mg 3 BENICAR - olmesartan medoxomil tab 40 mg 3 BENICAR HCT - olmesartan medoxomil-hydrochlorothiazide tab 20-12.5 mg 3 BENICAR HCT - olmesartan medoxomil-hydrochlorothiazide tab 40-12.5 mg 3 BENICAR HCT - olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg bisoprolol & hydrochlorothiazide tab 1 10-6.25 mg (Ziac) bisoprolol & hydrochlorothiazide tab 1 2.5-6.25 mg (Ziac) bisoprolol & hydrochlorothiazide tab 1 5-6.25 mg (Ziac) 1 candesartan cilexetil tab 16 mg (Atacand) 1 candesartan cilexetil tab 32 mg (Atacand) 1 candesartan cilexetil tab 4 mg (Atacand) 1 candesartan cilexetil tab 8 mg (Atacand) 1 candesartan cilexetilhydrochlorothiazide tab 16-12.5 mg (Atacand hct) candesartan cilexetilhydrochlorothiazide tab 32-12.5 mg (Atacand hct) 1 candesartan cilexetilhydrochlorothiazide tab 32-25 mg (Atacand hct) 1 captopril tab 100 mg 1 captopril tab 12.5 mg 1 • captopril tab 25 mg 1 captopril tab 50 mg 1 • CAPTOPRIL/HYDROCHLOROTHIA captopril & hydrochlorothiazide tab 25-15 mg 2 CAPTOPRIL/HYDROCHLOROTHIA captopril & hydrochlorothiazide tab 25-25 mg 2 CAPTOPRIL/HYDROCHLOROTHIA captopril & hydrochlorothiazide tab 50-15 mg 2 CAPTOPRIL/HYDROCHLOROTHIA captopril & hydrochlorothiazide tab 50-25 mg 2 CARDURA - doxazosin mesylate tab 1 mg 3 CARDURA - doxazosin mesylate tab 2 mg 3 CARDURA - doxazosin mesylate tab 4 mg 3 CARDURA - doxazosin mesylate tab 8 mg 3 CATAPRES - clonidine hcl tab 0.1 mg 3 CATAPRES - clonidine hcl tab 0.2 mg 3 CATAPRES - clonidine hcl tab 0.3 mg 3 CATAPRES-TTS-1 - clonidine hcl td patch weekly 0.1 mg/24hr 3 CATAPRES-TTS-2 - clonidine hcl td patch weekly 0.2 mg/24hr 3 CATAPRES-TTS-3 - clonidine hcl td patch weekly 0.3 mg/24hr 3 clonidine hcl tab 0.1 mg (Catapres) 1 • • • • SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 51 • DIOVAN HCT - valsartanhydrochlorothiazide tab 320-25 mg 3 1 doxazosin mesylate tab 1 mg (Cardura) 1 clonidine hcl td patch weekly 0.2 mg/24hr (Catapres-tts-2) 1 doxazosin mesylate tab 2 mg (Cardura) 1 clonidine hcl td patch weekly 0.3 mg/24hr (Catapres-tts-3) 1 doxazosin mesylate tab 4 mg (Cardura) 1 CLORPRES - clonidine & chlorthalidone tab 0.1-15 mg 3 doxazosin mesylate tab 8 mg (Cardura) 1 CLORPRES - clonidine & chlorthalidone tab 0.2-15 mg 3 2 CLORPRES - clonidine & chlorthalidone tab 0.3-15 mg 3 DUTOPROL - metoprolol & hydrochlorothiazide tab sr 24hr 25-12.5 mg 2 CORZIDE - nadolol & bendroflumethiazide tab 40-5 mg 3 DUTOPROL - metoprolol & hydrochlorothiazide tab sr 24hr 50-12.5 mg 3 COZAAR - losartan potassium tab 25 mg 3 • DUTOPROL - metoprolol & hydrochlorothiazide tab sr 24hr 100-12.5 mg 2 CORZIDE - nadolol & bendroflumethiazide tab 80-5 mg 3 • COZAAR - losartan potassium tab 50 mg 3 • EDARBI - azilsartan medoxomil tab 40 mg 3 • COZAAR - losartan potassium tab 100 mg 3 • EDARBI - azilsartan medoxomil tab 80 mg EDARBYCLOR - azilsartan medoxomilchlorthalidone tab 40-12.5 mg 3 • DEMSER - metyrosine cap 250 mg 3 • 2 EDARBYCLOR - azilsartan medoxomilchlorthalidone tab 40-25 mg 3 DIBENZYLINE - phenoxybenzamine hcl cap 10 mg DIOVAN - valsartan tab 40 mg DIOVAN - valsartan tab 80 mg 3 DIOVAN - valsartan tab 160 mg 3 3 enalapril maleate & hydrochlorothiazide tab 5-12.5 mg 1 DIOVAN - valsartan tab 320 mg DIOVAN HCT - valsartanhydrochlorothiazide tab 80-12.5 mg 3 • • • • • enalapril maleate & hydrochlorothiazide tab 10-25 mg (Vaseretic) 1 3 DIOVAN HCT - valsartanhydrochlorothiazide tab 160-12.5 mg 3 • DIOVAN HCT - valsartanhydrochlorothiazide tab 160-25 mg 3 • enalapril maleate tab 5 mg (Vasotec) 1 3 DIOVAN HCT - valsartanhydrochlorothiazide tab 320-12.5 mg 3 • EPANED - enalapril maleate for oral soln 1 mg/ml eplerenone tab 25 mg (Inspra) 1 52 enalapril maleate tab 10 mg (Vasotec) 1 1 enalapril maleate tab 2.5 mg (Vasotec) enalapril maleate tab 20 mg (Vasotec) 1 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy clonidine hcl td patch weekly 0.1 mg/24hr (Catapres-tts-1) Drug Name Prior Authorization 1 Drug Tier clonidine hcl tab 0.3 mg (Catapres) Quantity Limits 1 Step Therapy clonidine hcl tab 0.2 mg (Catapres) Prior Authorization Drug Name Drug Tier 2015 3 1 HYPERTENSOLOL - metoprolol tab 50 mg & dietary management cap pack 3 • EXFORGE - amlodipine besylatevalsartan tab 5-160 mg 3 • HYZAAR - losartan potassium & hydrochlorothiazide tab 50-12.5 mg 3 • EXFORGE - amlodipine besylatevalsartan tab 5-320 mg 3 • HYZAAR - losartan potassium & hydrochlorothiazide tab 100-12.5 mg 3 • EXFORGE - amlodipine besylatevalsartan tab 10-160 mg 3 • HYZAAR - losartan potassium & hydrochlorothiazide tab 100-25 mg INSPRA - eplerenone tab 25 mg 3 EXFORGE - amlodipine besylatevalsartan tab 10-320 mg 3 • INSPRA - eplerenone tab 50 mg 3 1 EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 5-160-12.5 mg • irbesartan tab 150 mg (Avapro) 2 irbesartan tab 300 mg (Avapro) 1 irbesartan tab 75 mg (Avapro) 1 EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 5-160-25 mg 2 • irbesartan-hydrochlorothiazide tab 150-12.5 mg (Avalide) 1 EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 10-160-12.5 mg 2 • irbesartan-hydrochlorothiazide tab 300-12.5 mg (Avalide) 1 1 EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 10-160-25 mg 2 lisinopril & hydrochlorothiazide tab 10-12.5 mg (Zestoretic) lisinopril & hydrochlorothiazide tab 20-12.5 mg (Zestoretic) 1 EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 10-320-25 mg 2 lisinopril & hydrochlorothiazide tab 20-25 mg (Zestoretic) 1 1 1 lisinopril tab 10 mg (Prinivil) fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg lisinopril tab 2.5 mg (Zestril) 1 1 lisinopril tab 20 mg (Prinivil) 1 fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg lisinopril tab 30 mg (Zestril) 1 fosinopril sodium tab 10 mg 1 lisinopril tab 40 mg (Zestril) 1 fosinopril sodium tab 20 mg 1 lisinopril tab 5 mg (Prinivil) 1 fosinopril sodium tab 40 mg 1 3 guanfacine hcl tab 1 mg (Tenex) 1 LOPRESSOR HCT - metoprolol & hydrochlorothiazide tab 50-25 mg 1 hydralazine hcl inj 20 mg/ml 1 LOPRESSOR HCT - metoprolol & hydrochlorothiazide tab 100-25 mg 3 guanfacine hcl tab 2 mg (Tenex) 1 hydralazine hcl tab 100 mg 1 losartan potassium & hydrochlorothiazide tab 100-12.5 mg (Hyzaar) 1 hydralazine hcl tab 10 mg hydralazine hcl tab 25 mg 1 1 hydralazine hcl tab 50 mg 1 losartan potassium & hydrochlorothiazide tab 100-25 mg (Hyzaar) • • SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier eprosartan mesylate tab 600 mg (Teveten) Quantity Limits 1 Step Therapy eplerenone tab 50 mg (Inspra) Prior Authorization Drug Name Drug Tier 2015 53 methyldopa tab 500 mg 1 METHYLDOPA/HYDROCHLOROTHI methyldopa & hydrochlorothiazide tab 250-15 mg 3 3 losartan potassium & hydrochlorothiazide tab 50-12.5 mg (Hyzaar) 1 losartan potassium tab 100 mg (Cozaar) 1 losartan potassium tab 25 mg (Cozaar) 1 losartan potassium tab 50 mg (Cozaar) 1 METHYLDOPA/HYDROCHLOROTHI methyldopa & hydrochlorothiazide tab 250-25 mg LOTENSIN - benazepril hcl tab 10 mg metoprolol & hydrochlorothiazide tab 100-25 mg (Lopressor hct) 1 3 LOTENSIN - benazepril hcl tab 20 mg 3 1 LOTENSIN - benazepril hcl tab 40 mg 3 metoprolol & hydrochlorothiazide tab 100-50 mg LOTENSIN HCT - benazepril & hydrochlorothiazide tab 10-12.5 mg 3 metoprolol & hydrochlorothiazide tab 50-25 mg (Lopressor hct) 1 LOTENSIN HCT - benazepril & hydrochlorothiazide tab 20-12.5 mg 3 MICARDIS - telmisartan tab 20 mg 3 MICARDIS - telmisartan tab 40 mg 3 LOTENSIN HCT - benazepril & hydrochlorothiazide tab 20-25 mg 3 MICARDIS - telmisartan tab 80 mg 3 3 LOTREL - amlodipine besylatebenazepril hcl cap 2.5-10 mg 3 MICARDIS HCT - telmisartanhydrochlorothiazide tab 40-12.5 mg • • • • • LOTREL - amlodipine besylatebenazepril hcl cap 5-10 mg MICARDIS HCT - telmisartanhydrochlorothiazide tab 80-12.5 mg 3 3 • LOTREL - amlodipine besylatebenazepril hcl cap 5-20 mg MICARDIS HCT - telmisartanhydrochlorothiazide tab 80-25 mg 3 3 MINIPRESS - prazosin hcl cap 1 mg 3 LOTREL - amlodipine besylatebenazepril hcl cap 5-40 mg 3 MINIPRESS - prazosin hcl cap 2 mg 3 3 MINIPRESS - prazosin hcl cap 5 mg 3 LOTREL - amlodipine besylatebenazepril hcl cap 10-20 mg minoxidil tab 10 mg 1 LOTREL - amlodipine besylatebenazepril hcl cap 10-40 mg 3 minoxidil tab 2.5 mg 1 moexipril hcl tab 15 mg (Univasc) 1 LYTENSOPRIL KIT - lisinopril tab 20 mg 3 & dietary management cap pack LYTENSOPRIL-90 - lisinopril tab 20 mg 3 & dietary management cap pack LYTENSOPRIL-90 KIT - lisinopril tab 20 3 mg & dietary management cap pack 3 MAVIK - trandolapril tab 1 mg moexipril hcl tab 7.5 mg (Univasc) 1 moexipril-hydrochlorothiazide tab 15-12.5 mg (Uniretic) 1 moexipril-hydrochlorothiazide tab 15-25 mg 1 moexipril-hydrochlorothiazide tab 7.5-12.5 mg 1 MAVIK - trandolapril tab 2 mg 3 1 MAVIK - trandolapril tab 4 mg 3 nadolol & bendroflumethiazide tab 40-5 mg (Corzide) 54 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits 1 Step Therapy methyldopa tab 250 mg Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 ramipril cap 5 mg (Altace) 1 RESERPINE - reserpine tab 0.1 mg 3 RESERPINE - reserpine tab 0.25 mg 3 nadolol & bendroflumethiazide tab 80-5 mg (Corzide) 1 perindopril erbumine tab 2 mg 1 perindopril erbumine tab 4 mg (Aceon) 1 1 TARKA - trandolapril-verapamil hcl tab cr 1-240 mg 3 perindopril erbumine tab 8 mg (Aceon) 3 TARKA - trandolapril-verapamil hcl tab cr 2-180 mg 3 PHENTOLAMINE MESYLATE phentolamine mesylate inj 5 mg/ml 3 TARKA - trandolapril-verapamil hcl tab cr 2-240 mg 3 PHENTOLAMINE MESYLATE phentolamine mesylate for inj 5 mg 1 TARKA - trandolapril-verapamil hcl tab cr 4-240 mg 3 prazosin hcl cap 1 mg (Minipress) prazosin hcl cap 2 mg (Minipress) 1 • prazosin hcl cap 5 mg (Minipress) TEKAMLO - aliskiren-amlodipine tab 150-5 mg 3 1 PRINIVIL - lisinopril tab 5 mg 3 3 • PRINIVIL - lisinopril tab 10 mg 3 TEKAMLO - aliskiren-amlodipine tab 150-10 mg PRINIVIL - lisinopril tab 20 mg 3 3 • PRINZIDE - lisinopril & hydrochlorothiazide tab 10-12.5 mg 3 TEKAMLO - aliskiren-amlodipine tab 300-5 mg 3 • PRINZIDE - lisinopril & hydrochlorothiazide tab 20-12.5 mg 3 TEKAMLO - aliskiren-amlodipine tab 300-10 mg 3 • PROPRANOLOL/HYDROCHLOROTH propranolol & hydrochlorothiazide tab 40-25 mg 2 TEKTURNA - aliskiren fumarate tab 150 mg (base equivalent) TEKTURNA - aliskiren fumarate tab 300 mg (base equivalent) 3 • PROPRANOLOL/HYDROCHLOROTH propranolol & hydrochlorothiazide tab 80-25 mg 2 TEKTURNA HCT - aliskirenhydrochlorothiazide tab 150-12.5 mg 3 • 3 • quinapril hcl tab 10 mg (Accupril) 1 TEKTURNA HCT - aliskirenhydrochlorothiazide tab 150-25 mg quinapril hcl tab 20 mg (Accupril) 1 3 • quinapril hcl tab 40 mg (Accupril) 1 TEKTURNA HCT - aliskirenhydrochlorothiazide tab 300-12.5 mg 1 TEKTURNA HCT - aliskirenhydrochlorothiazide tab 300-25 mg 3 quinapril hcl tab 5 mg (Accupril) • quinapril-hydrochlorothiazide tab 10-12.5 mg (Accuretic) 1 telmisartan tab 20 mg (Micardis) 1 1 telmisartan tab 40 mg (Micardis) 1 quinapril-hydrochlorothiazide tab 20-12.5 mg (Accuretic) telmisartan tab 80 mg (Micardis) 1 quinapril-hydrochlorothiazide tab 20-25 mg (Accuretic) 1 telmisartan-amlodipine tab 40-10 mg (Twynsta) 1 ramipril cap 1.25 mg (Altace) 1 1 ramipril cap 10 mg (Altace) 1 telmisartan-amlodipine tab 40-5 mg (Twynsta) SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits 1 Step Therapy ramipril cap 2.5 mg (Altace) Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 55 3 • 1 TRIBENZOR - olmesartan-amlodipinehydrochlorothiazide tab 40-10-12.5 mg 3 • telmisartan-hydrochlorothiazide tab 40-12.5 mg (Micardis hct) 1 TRIBENZOR - olmesartan-amlodipinehydrochlorothiazide tab 40-10-25 mg 3 • telmisartan-hydrochlorothiazide tab 80-12.5 mg (Micardis hct) 1 TWYNSTA - telmisartan-amlodipine tab 40-5 mg 3 • telmisartan-hydrochlorothiazide tab 80-25 mg (Micardis hct) 1 TWYNSTA - telmisartan-amlodipine tab 40-10 mg 3 • TENEX - guanfacine hcl tab 1 mg 3 TWYNSTA - telmisartan-amlodipine tab 80-5 mg TENEX - guanfacine hcl tab 2 mg 3 3 • TENORETIC 100 - atenolol & chlorthalidone tab 100-25 mg 3 TWYNSTA - telmisartan-amlodipine tab 80-10 mg 3 TENORETIC 50 - atenolol & chlorthalidone tab 50-25 mg 3 UNIRETIC - moexiprilhydrochlorothiazide tab 7.5-12.5 mg 3 terazosin hcl cap 1 mg 1 UNIRETIC - moexiprilhydrochlorothiazide tab 15-12.5 mg 1 UNIRETIC - moexiprilhydrochlorothiazide tab 15-25 mg 3 terazosin hcl cap 10 mg terazosin hcl cap 2 mg 1 UNIVASC - moexipril hcl tab 7.5 mg 3 terazosin hcl cap 5 mg 1 3 TEVETEN - eprosartan mesylate tab 400 mg • UNIVASC - moexipril hcl tab 15 mg 3 valsartan tab 160 mg (Diovan) 1 3 • valsartan tab 320 mg (Diovan) 1 TEVETEN - eprosartan mesylate tab 600 mg valsartan tab 40 mg (Diovan) 1 TEVETEN HCT - eprosartan mesylatehydrochlorothiazide tab 600-12.5 mg 3 • valsartan tab 80 mg (Diovan) 1 1 TEVETEN HCT - eprosartan mesylatehydrochlorothiazide tab 600-25 mg 3 • valsartan-hydrochlorothiazide tab 160-12.5 mg (Diovan hct) 1 trandolapril tab 1 mg (Mavik) 1 valsartan-hydrochlorothiazide tab 160-25 mg (Diovan hct) trandolapril tab 2 mg (Mavik) 1 1 trandolapril tab 4 mg (Mavik) 1 valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovan hct) 3 • valsartan-hydrochlorothiazide tab 320-25 mg (Diovan hct) 1 TRIBENZOR - olmesartan-amlodipinehydrochlorothiazide tab 20-5-12.5 mg 3 • valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan hct) 1 TRIBENZOR - olmesartan-amlodipinehydrochlorothiazide tab 40-5-12.5 mg 3 • VASERETIC - enalapril maleate & hydrochlorothiazide tab 10-25 mg 3 TRIBENZOR - olmesartan-amlodipinehydrochlorothiazide tab 40-5-25 mg VASOTEC - enalapril maleate tab 2.5 mg 3 telmisartan-amlodipine tab 80-10 mg (Twynsta) 1 telmisartan-amlodipine tab 80-5 mg (Twynsta) 56 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 3 3 ALDACTONE - spironolactone tab 50 mg 3 VASOTEC - enalapril maleate tab 20 mg 3 ALDACTONE - spironolactone tab 100 mg 1 VECAMYL - mecamylamine hcl tab 2.5 mg 3 amiloride & hydrochlorothiazide tab 5-50 mg amiloride hcl tab 5 mg 1 ZESTORETIC - lisinopril & hydrochlorothiazide tab 10-12.5 mg 3 bumetanide inj 0.25 mg/ml 1 bumetanide tab 0.5 mg 1 ZESTORETIC - lisinopril & hydrochlorothiazide tab 20-12.5 mg 3 bumetanide tab 1 mg 1 3 bumetanide tab 2 mg 1 ZESTORETIC - lisinopril & hydrochlorothiazide tab 20-25 mg 3 ZESTRIL - lisinopril tab 2.5 mg 3 CHLOROTHIAZIDE - chlorothiazide tab 250 mg 3 chlorothiazide tab 250 mg 1 ZESTRIL - lisinopril tab 5 mg 3 chlorothiazide tab 500 mg 1 ZESTRIL - lisinopril tab 10 mg 3 CHLORTHALIDONE - chlorthalidone tab 25 mg 3 ZESTRIL - lisinopril tab 20 mg ZESTRIL - lisinopril tab 30 mg 3 ZESTRIL - lisinopril tab 40 mg CHLORTHALIDONE - chlorthalidone tab 50 mg 2 3 ZIAC - bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg 3 CHLORTHALIDONE - chlorthalidone tab 100 mg 3 ZIAC - bisoprolol & hydrochlorothiazide tab 5-6.25 mg 3 DEMADEX - torsemide tab 5 mg 3 DEMADEX - torsemide tab 10 mg 3 ZIAC - bisoprolol & hydrochlorothiazide tab 10-6.25 mg 3 DEMADEX - torsemide tab 20 mg 3 DEMADEX - torsemide tab 100 mg 3 DIURETICS 2 DIAMOX - acetazolamide cap sr 12hr 500 mg 3 ACETAZOLAMIDE - acetazolamide tab 125 mg 1 DIURIL - chlorothiazide susp 250 mg/5ml 3 acetazolamide cap sr 12hr 500 mg (Diamox) 1 DYAZIDE - triamterene & hydrochlorothiazide cap 37.5-25 mg 3 acetazolamide sodium for inj 500 mg acetazolamide tab 250 mg 1 DYRENIUM - triamterene cap 50 mg 3 ALDACTAZIDE - spironolactone & hydrochlorothiazide tab 25-25 mg 3 DYRENIUM - triamterene cap 100 mg 3 3 EDECRIN - ethacrynic acid tab 25 mg 3 ALDACTAZIDE - spironolactone & hydrochlorothiazide tab 50-50 mg 3 ALDACTONE - spironolactone tab 25 mg 3 FUROSEMIDE - furosemide oral soln 8 mg/ml furosemide inj 10 mg/ml 1 furosemide oral soln 10 mg/ml 1 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier VASOTEC - enalapril maleate tab 10 mg Quantity Limits 3 Step Therapy VASOTEC - enalapril maleate tab 5 mg Prior Authorization Drug Name Drug Tier 2015 57 1 furosemide tab 40 mg (Lasix) 1 spironolactone tab 50 mg (Aldactone) 1 furosemide tab 80 mg (Lasix) 1 torsemide tab 10 mg (Demadex) 1 hydrochlorothiazide cap 12.5 mg (Microzide) 1 torsemide tab 100 mg (Demadex) 1 torsemide tab 20 mg (Demadex) 1 hydrochlorothiazide tab 12.5 mg 1 torsemide tab 5 mg (Demadex) 1 hydrochlorothiazide tab 25 mg 1 1 triamterene & hydrochlorothiazide cap 37.5-25 mg (Dyazide) 1 hydrochlorothiazide tab 50 mg indapamide tab 1.25 mg 1 1 indapamide tab 2.5 mg 1 triamterene & hydrochlorothiazide tab 37.5-25 mg (Maxzide-25) INTROL - glycerin soln 75% 3 1 LASIX - furosemide tab 20 mg 3 triamterene & hydrochlorothiazide tab 75-50 mg (Maxzide) 3 LASIX - furosemide tab 80 mg 3 TRIAMTERENE/HYDROCHLOROTH triamterene & hydrochlorothiazide cap 50-25 mg 3 LASIX - furosemide tab 40 mg MAXZIDE - triamterene & hydrochlorothiazide tab 75-50 mg 3 ZAROXOLYN - metolazone tab 2.5 mg 3 ZAROXOLYN - metolazone tab 5 mg 3 MAXZIDE-25 - triamterene & hydrochlorothiazide tab 37.5-25 mg 3 1 ADRENACLICK - epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000) 3 methazolamide tab 25 mg (Neptazane) 1 ADRENACLICK - epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) 3 methazolamide tab 50 mg (Neptazane) 3 ADRENALIN - epinephrine inj 1 mg/ml (1:1000) 3 METHYCLOTHIAZIDE methyclothiazide tab 5 mg 1 ADRENALIN - epinephrine inj 30 mg/30ml (1 mg/ml) (1:1000) 3 metolazone tab 10 mg metolazone tab 2.5 mg (Zaroxolyn) 1 metolazone tab 5 mg (Zaroxolyn) AUVI-Q - epinephrine solution autoinjector 0.15 mg/0.15ml (1:1000) 3 1 MICROZIDE - hydrochlorothiazide cap 12.5 mg 3 AUVI-Q - epinephrine solution autoinjector 0.3 mg/0.3ml (1:1000) 3 NEPTAZANE - methazolamide tab 25 mg 3 ephedrine sulfate inj 50 mg/ml 1 3 EPINEPHRINE - epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000) 3 NEPTAZANE - methazolamide tab 50 mg spironolactone & hydrochlorothiazide tab 25-25 mg (Aldactazide) EPINEPHRINE - epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) 3 1 EPIPEN 2-PAK - epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) 2 spironolactone tab 100 mg (Aldactone) 1 58 VASOPRESSORS SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits spironolactone tab 25 mg (Aldactone) Step Therapy 1 Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy furosemide tab 20 mg (Lasix) Prior Authorization Drug Name Drug Tier 2015 EPIPEN-JR 2-PAK - epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000) 2 ANTARA - fenofibrate micronized cap 130 mg 3 • LEVOPHED - norepinephrine bitartrate inj 1 mg/ml atorvastatin calcium tab 10 mg (base equivalent) (Lipitor) 1 3 • midodrine hcl tab 10 mg atorvastatin calcium tab 20 mg (base equivalent) (Lipitor) 1 1 midodrine hcl tab 2.5 mg 1 1 • midodrine hcl tab 5 mg 1 atorvastatin calcium tab 40 mg (base equivalent) (Lipitor) NEO-SYNEPHRINE - phenylephrine hcl inj 10 mg/ml 3 atorvastatin calcium tab 80 mg (base equivalent) (Lipitor) 1 • norepinephrine bitartrate inj 1 mg/ml (Levophed) 1 cholestyramine light powder packets 4 gm 1 NORTHERA - droxidopa cap 100 mg 3 1 NORTHERA - droxidopa cap 200 mg 3 cholestyramine light powder 4 gm/ dose (Questran light) 3 cholestyramine powder packets 4 gm (Questran) 1 NORTHERA - droxidopa cap 300 mg cholestyramine powder 4 gm/dose (Questran) 1 choline fenofibrate cap dr 135 mg (fenofibric acid equiv) (Trilipix) 1 PHENYLEPHRINE HCL - phenylephrine 3 hcl inj 10 mg/ml 1 phenylephrine hcl inj 10 mg/ml ANTIHYPERLIPIDEMICS ADVICOR - niacin-lovastatin tab sr 24hr 500-20 mg 3 • choline fenofibrate cap dr 45 mg (fenofibric acid equiv) (Trilipix) 1 ADVICOR - niacin-lovastatin tab sr 24hr 750-20 mg 3 • COLESTID - colestipol hcl tab 1 gm 3 3 ADVICOR - niacin-lovastatin tab sr 24hr 1000-20 mg 3 • COLESTID - colestipol hcl granules 5 gm 3 • COLESTID - colestipol hcl granule packets 5 gm 3 ADVICOR - niacin-lovastatin tab sr 24hr 1000-40 mg ALTOPREV - lovastatin tab sr 24hr 20 mg • COLESTID FLAVORED - colestipol hcl granules 5 gm 3 3 ALTOPREV - lovastatin tab sr 24hr 40 mg • COLESTID FLAVORED - colestipol hcl granule packets 5 gm 3 3 ALTOPREV - lovastatin tab sr 24hr 60 mg • colestipol hcl granule packets 5 gm (Colestid flavored) 1 3 ANTARA - fenofibrate micronized cap 30 mg 3 ANTARA - fenofibrate micronized cap 43 mg 3 ANTARA - fenofibrate micronized cap 90 mg 3 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 colestipol hcl granules 5 gm (Colestid 1 flavored) 1 colestipol hcl tab 1 gm (Colestid) 2 • CRESTOR - rosuvastatin calcium tab 10 2 mg • CRESTOR - rosuvastatin calcium tab 5 mg SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 59 CRESTOR - rosuvastatin calcium tab 20 2 mg CRESTOR - rosuvastatin calcium tab 40 2 mg FENOFIBRATE - fenofibrate cap 50 mg 3 • KYNAMRO - mipomersen sodium soln prefilled syringe 200 mg/ml 5 • LESCOL XL - fluvastatin sodium tab sr 24 hr 80 mg 3 LIPOFEN - fenofibrate cap 50 mg 3 • FENOFIBRATE - fenofibrate cap 150 mg 3 LIPOFEN - fenofibrate cap 150 mg 3 • 1 LIPTRUZET - ezetimibe-atorvastatin tab 10-10 mg 3 fenofibrate micronized cap 130 mg fenofibrate micronized cap 134 mg (Lofibra) 1 LIPTRUZET - ezetimibe-atorvastatin tab 10-20 mg 3 • fenofibrate micronized cap 200 mg (Lofibra) 1 LIPTRUZET - ezetimibe-atorvastatin tab 10-40 mg 3 • fenofibrate micronized cap 43 mg 1 3 • fenofibrate micronized cap 67 mg (Lofibra) 1 LIPTRUZET - ezetimibe-atorvastatin tab 10-80 mg 3 • fenofibrate tab 145 mg (Tricor) 1 LIVALO - pitavastatin calcium tab 1 mg (base equiv) fenofibrate tab 160 mg (Lofibra) 1 3 • fenofibrate tab 48 mg (Tricor) 1 LIVALO - pitavastatin calcium tab 2 mg (base equiv) 1 LIVALO - pitavastatin calcium tab 4 mg (base equiv) 3 fenofibrate tab 54 mg (Lofibra) • FENOFIBRIC ACID - fenofibric acid tab 35 mg 3 LOFIBRA - fenofibrate tab 54 mg 3 3 LOFIBRA - fenofibrate tab 160 mg 3 FENOFIBRIC ACID - fenofibric acid tab 105 mg 3 FENOGLIDE - fenofibrate tab 40 mg 3 LOFIBRA - fenofibrate micronized cap 67 mg 3 LOFIBRA - fenofibrate micronized cap 134 mg 3 FENOGLIDE - fenofibrate tab 120 mg FIBRICOR - fenofibric acid tab 35 mg 3 FIBRICOR - fenofibric acid tab 105 mg LOFIBRA - fenofibrate micronized cap 200 mg 3 3 fluvastatin sodium cap 20 mg (Lescol) 1 LOPID - gemfibrozil tab 600 mg 3 lovastatin tab 10 mg 1 fluvastatin sodium cap 40 mg (Lescol) 1 lovastatin tab 20 mg (Mevacor) 1 1 lovastatin tab 40 mg (Mevacor) 1 gemfibrozil tab 600 mg (Lopid) 5 LOVAZA - omega-3-acid ethyl esters cap 1 gm 3 JUXTAPID - lomitapide mesylate cap 5 mg (base equiv) niacin tab cr 1000 mg (antihyperlipidemic) (Niaspan) 1 niacin tab cr 500 mg (antihyperlipidemic) (Niaspan) 1 JUXTAPID - lomitapide mesylate cap 10 5 mg (base equiv) JUXTAPID - lomitapide mesylate cap 20 5 mg (base equiv) 60 • • SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare • • • Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 simvastatin tab 80 mg (Zocor) 1 TRICOR - fenofibrate tab 48 mg 3 TRICOR - fenofibrate tab 145 mg 3 TRIGLIDE - fenofibrate tab 50 mg 3 • • niacin tab cr 750 mg (antihyperlipidemic) (Niaspan) 1 NIACOR - niacin (antihyperlipidemic) tab 500 mg 3 NIASPAN - niacin tab cr 500 mg (antihyperlipidemic) 3 NIASPAN - niacin tab cr 750 mg (antihyperlipidemic) 3 TRIGLIDE - fenofibrate tab 160 mg 3 3 NIASPAN - niacin tab cr 1000 mg (antihyperlipidemic) 3 TRILIPIX - choline fenofibrate cap dr 45 mg (fenofibric acid equiv) 3 omega-3-acid ethyl esters cap 1 gm (Lovaza) 1 TRILIPIX - choline fenofibrate cap dr 135 mg (fenofibric acid equiv) VASCEPA - icosapent ethyl cap 1 gm 3 pravastatin sodium tab 10 mg 1 • pravastatin sodium tab 20 mg (Pravachol) VYTORIN - ezetimibe-simvastatin tab 10-10 mg 3 1 • • 3 • pravastatin sodium tab 40 mg (Pravachol) 1 • VYTORIN - ezetimibe-simvastatin tab 10-20 mg 3 • pravastatin sodium tab 80 mg (Pravachol) 1 • VYTORIN - ezetimibe-simvastatin tab 10-40 mg 3 • QUESTRAN - cholestyramine powder 4 gm/dose 3 VYTORIN - ezetimibe-simvastatin tab 10-80 mg 2 QUESTRAN - cholestyramine powder packets 4 gm 3 WELCHOL - colesevelam hcl tab 625 mg 2 QUESTRAN LIGHT - cholestyramine light powder 4 gm/dose 3 WELCHOL - colesevelam hcl packet for susp 3.75 gm ZETIA - ezetimibe tab 10 mg 3 QUESTRAN LIGHT - cholestyramine light powder packets 4 gm 3 SIMCOR - niacin-simvastatin tab sr 24hr 3 500-20 mg SIMCOR - niacin-simvastatin tab sr 24hr 3 500-40 mg SIMCOR - niacin-simvastatin tab sr 24hr 3 750-20 mg SIMCOR - niacin-simvastatin tab sr 24hr 3 1000-20 mg SIMCOR - niacin-simvastatin tab sr 24hr 3 1000-40 mg 1 simvastatin tab 10 mg (Zocor) simvastatin tab 20 mg (Zocor) 1 simvastatin tab 40 mg (Zocor) 1 Quantity Limits 1 Step Therapy simvastatin tab 5 mg (Zocor) Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 CARDIOVASCULAR AGENTS - MISC. ADCIRCA - tadalafil tab 20 mg (pah) 4 ADEMPAS - riociguat tab 0.5 mg 5 • ADEMPAS - riociguat tab 1 mg 5 ADEMPAS - riociguat tab 1.5 mg 5 • ADEMPAS - riociguat tab 2 mg 5 ADEMPAS - riociguat tab 2.5 mg 5 amlodipine besylate-atorvastatin calcium tab 10-10 mg (Caduet) 1 amlodipine besylate-atorvastatin calcium tab 10-20 mg (Caduet) 1 amlodipine besylate-atorvastatin calcium tab 10-40 mg (Caduet) 1 • • • • • • SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 61 CIALIS - tadalafil tab 5 mg 2 ISOXSUPRINE HCL - isoxsuprine hcl tab 20 mg 3 isoxsuprine hcl tab 10 mg 1 LETAIRIS - ambrisentan tab 5 mg 4 LETAIRIS - ambrisentan tab 10 mg 4 amlodipine besylate-atorvastatin calcium tab 2.5-10 mg (Caduet) 1 amlodipine besylate-atorvastatin calcium tab 2.5-20 mg (Caduet) 1 amlodipine besylate-atorvastatin calcium tab 2.5-40 mg (Caduet) 1 amlodipine besylate-atorvastatin calcium tab 5-10 mg (Caduet) 1 OPSUMIT - macitentan tab 10 mg 4 5 amlodipine besylate-atorvastatin calcium tab 5-20 mg (Caduet) 1 ORENITRAM - treprostinil diolamine tab cr 0.125 mg (base equiv) 5 amlodipine besylate-atorvastatin calcium tab 5-40 mg (Caduet) 1 ORENITRAM - treprostinil diolamine tab cr 0.25 mg (base equiv) 5 amlodipine besylate-atorvastatin calcium tab 5-80 mg (Caduet) 1 ORENITRAM - treprostinil diolamine tab cr 1 mg (base equiv) 5 BIDIL - isosorbide dinitrate-hydralazine hcl tab 20-37.5 mg 3 ORENITRAM - treprostinil diolamine tab cr 2.5 mg (base equiv) papaverine hcl inj 30 mg/ml 1 CADUET - amlodipine besylateatorvastatin calcium tab 2.5-10 mg 3 REMODULIN - treprostinil sodium inj 1 mg/ml (base equiv) 5 CADUET - amlodipine besylateatorvastatin calcium tab 2.5-20 mg 3 CADUET - amlodipine besylateatorvastatin calcium tab 2.5-40 mg 3 CADUET - amlodipine besylateatorvastatin calcium tab 5-10 mg 3 CADUET - amlodipine besylateatorvastatin calcium tab 5-20 mg 3 REMODULIN - treprostinil sodium inj 2.5 5 mg/ml (base equiv) 5 REMODULIN - treprostinil sodium inj 5 mg/ml (base equiv) REMODULIN - treprostinil sodium inj 10 5 mg/ml (base equiv) 5 REVATIO - sildenafil citrate tab 20 mg CADUET - amlodipine besylateatorvastatin calcium tab 5-40 mg REVATIO - sildenafil citrate for suspension 10 mg/ml 5 3 sildenafil citrate tab 20 mg (Revatio) 4 CADUET - amlodipine besylateatorvastatin calcium tab 5-80 mg 3 TRACLEER - bosentan tab 62.5 mg 4 3 TRACLEER - bosentan tab 125 mg 4 CADUET - amlodipine besylateatorvastatin calcium tab 10-10 mg CADUET - amlodipine besylateatorvastatin calcium tab 10-20 mg 3 CADUET - amlodipine besylateatorvastatin calcium tab 10-40 mg 3 CADUET - amlodipine besylateatorvastatin calcium tab 10-80 mg 3 62 TYVASO - treprostinil inhalation solution 5 0.6 mg/ml TYVASO REFILL - treprostinil inhalation 5 solution 0.6 mg/ml 5 TYVASO STARTER - treprostinil inhalation solution 0.6 mg/ml VENTAVIS - iloprost inhalation solution 5 10 mcg/ml SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits 2 1 Step Therapy CIALIS - tadalafil tab 2.5 mg amlodipine besylate-atorvastatin calcium tab 10-80 mg (Caduet) Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 • • VENTAVIS - iloprost inhalation solution 20 mcg/ml 5 2 CIALIS - tadalafil tab 5 mg 2 • • RESPIRATORY AGENTS ANTIHISTAMINES brompheniramine maleate tab sr 12hr 6 mg 1 BROMPHENIRAMINE TANNATE brompheniramine tannate chew tab 12 mg 3 carbinoxamine maleate soln 4 mg/5ml 1 carbinoxamine maleate tab 4 mg 1 CLEMASTINE FUMARATE - clemastine 3 fumarate syrup 0.67 mg/5ml (0.5 mg/5ml base eq) 1 clemastine fumarate tab 2.68 mg cyproheptadine hcl syrup 2 mg/5ml 1 cyproheptadine hcl tab 4 mg 1 desloratadine tab orally disintegrating 2.5 mg (Clarinex reditabs) 1 desloratadine tab orally disintegrating 5 mg (Clarinex reditabs) 1 desloratadine tab 5 mg (Clarinex) 1 DEXCHLORPHENIRAMINE MALEA dexchlorpheniramine maleate syrup 2 mg/5ml 3 DICOPANOL FUSEPAQ diphenhydramine hcl for oral susp 5 mg/ml (compound kit) 3 diphenhydramine hcl cap 50 mg 1 diphenhydramine hcl elixir 12.5 mg/5ml 1 diphenhydramine hcl inj 50 mg/ml 1 Quantity Limits Step Therapy DOXYTEX - doxylamine succinate liquid 3 2.5 mg/2.5ml KARBINAL ER - carbinoxamine maleate 3 er susp 4 mg/5ml 1 levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) (Xyzal) 1 levocetirizine dihydrochloride tab 5 mg (Xyzal) PALGIC - carbinoxamine maleate tab 4 3 mg PALGIC - carbinoxamine maleate soln 4 3 mg/5ml 3 PBZ - tripelennamine hcl tab 50 mg ERECTLIE DYSFUNCTION CIALIS - tadalafil tab 2.5 mg Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 PHENERGAN - promethazine hcl inj 25 mg/ml 3 PHENERGAN - promethazine hcl inj 50 mg/ml 3 promethazine hcl inj 25 mg/ml (Phenergan) 1 promethazine hcl inj 50 mg/ml (Phenergan) 1 promethazine hcl suppos 12.5 mg 1 promethazine hcl suppos 25 mg 1 promethazine hcl suppos 50 mg 1 promethazine hcl syrup 6.25 mg/5ml 1 promethazine hcl tab 12.5 mg 1 promethazine hcl tab 25 mg 1 promethazine hcl tab 50 mg 1 RESPA-BR - brompheniramine maleate tab sr 12hr 11 mg 3 NASAL AGENTS - SYSTEMIC and TOPICAL 3 ADRENALIN - epinephrine hcl nasal soln 0.1% 3 ASTELIN - azelastine hcl nasal spray 137 mcg/spray (1 mg/ml) 2 ASTEPRO - azelastine hcl nasal spray 0.15% (205.5 mcg/spray) ATROVENT - ipratropium bromide nasal 3 soln 0.03% (21 mcg/spray) SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 63 ATROVENT - ipratropium bromide nasal 3 soln 0.06% (42 mcg/spray) 1 azelastine hcl nasal spray 0.15% (205.5 mcg/spray) (Astepro) 1 azelastine hcl nasal spray 137 mcg/ spray (1 mg/ml) 2 BACTROBAN NASAL - mupirocin calcium nasal oint 2% 1 budesonide nasal susp 32 mcg/act (Rhinocort aqua) 3 DYMISTA - azelastine hcl-fluticasone prop nasal spray 137-50 mcg/act 1 flunisolide nasal soln 25 mcg/act (0.025%) (Flunisolide) 1 fluticasone propionate nasal susp 50 mcg/act (Flonase) 1 ipratropium bromide nasal soln 0.03% (21 mcg/spray) (Atrovent) 1 ipratropium bromide nasal soln 0.06% (42 mcg/spray) (Atrovent) 1 olopatadine hcl nasal soln 0.6% (Patanase) PATANASE - olopatadine hcl nasal soln 3 0.6% 1 triamcinolone acetonide nasal aerosol suspension 55 mcg/act (Nasacort aq) TYZINE - tetrahydrozoline hcl nasal soln 3 0.1% 3 TYZINE PEDIATRIC NASAL DR tetrahydrozoline hcl nasal soln 0.05% ALBATUSSIN NN - phenyleph-dm-pyrilpot guai-sod cit-cit acid liquid 3 ALLFEN CD - guaifenesin-codeine tab 400-10 mg 3 ALLFEN CDX - guaifenesin-codeine tab 400-20 mg 3 ALLFEN CDX - guaifenesin-codeine liquid 200-20 mg/5ml 3 AMBIFED CD - pseudoephedrine w/ cod-gg tab 30-10-400 mg 3 AMBIFED CDX - pseudoephedrine w/ cod-gg tab 30-20-400 mg 3 AMBIFED-G CD - pseudoephedrine w/ cod-gg tab 20-10-400 mg 3 COUGH/COLD/ALLERGY AMBIFED-G CDX - pseudoephedrine w/ 3 cod-gg tab 20-20-400 mg 1 benzonatate cap 100 mg (Tessalon perles) 1 benzonatate cap 200 mg brompheniramine & pseudoephedrine tab sr 12hr 6-45 mg 1 BRONCOPECTOL - phenylephchlorphen w/ dm-gg syrup 5-2-5-75 mg/5ml 3 CARBAPHEN 12 - phenylephchlorphen-carbetapentane liqd 10-4-27.5 mg/5ml 3 CARBAPHEN 12 PED - phenylephchlorphen-carbetapentane susp 2.5-1.25-7.5 mg/ml 3 COTAB A - chlorpheniramine w/ codeine tab 4-10 mg 3 COTAB AX - chlorpheniramine w/ codeine tab 4-20 mg 3 3 3 acetylcysteine inhal soln 10% 1 acetylcysteine inhal soln 20% 1 ALAHIST AC - phenylephrine w/ codeine liqd 7.5-10 mg/5ml 3 ALAHIST DHC - phenylephrinedihydrocodeine liqd 7.5-3 mg/5ml 3 COTABFLU - codeinechlorpheniramine-acetaminophen tab 20-4-500 mg ALBATUSSIN - phenylephrinecarbetapentane-gg cap 10-25-400 mg 3 CPB WC - pseudoephedrine-bromphencodeine liq 10-1.3-6.3 mg/5ml 64 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 DECON-A - brompheniramine & phenylephrine elixir 2-5 mg/5ml 3 J-COF DHC - pseudoephed-bromphendihydrocodeine liqd 15-3-7.5 mg/5ml 3 DECON-G - phenylephrinebrompheniramine-guaifenesin liqd 2-1-40 mg/ml 3 J-MAX DHC - dihydrocodeineguaifenesin liquid 7.5-100 mg/5ml 3 DEXTROMETHORPHAN HBR/CHLO phenylephrine-chlorphen-dm liquid 1.75-0.75-2.75 mg/ml LARTUS - phenyleph-chlorphen w/ dmgg liquid 5-2-15-150 mg/5ml 3 3 MAXIFED CD - pseudoephedrine w/ cod-gg tab 60-10-400 mg 3 DONATUSS DC - phenylephrinedihydrocodeine-gg syrup 7.5-7.5-50 mg/5ml 3 MAXIFED CDX - pseudoephedrine w/ cod-gg tab 60-20-400 mg 3 3 MAXIFED-G CD - pseudoephedrine w/ cod-gg tab 40-10-400 mg 3 EXACTUSS - phenylephrine w/ dm-gg liqd 10-28-388 mg/5ml GILPHEX TR - phenylephrineguaifenesin tab 10-388 mg 3 GILTUSS - phenylephrine w/ dm-gg liqd 10-28-388 mg/5ml 3 GILTUSS PED-C - phenylephrine w/ codeine-gg liquid 2.5-3-50 mg/ml 3 GILTUSS TR - phenylephrine w/ dm-gg cap 7-14-288 mg 3 GILTUSS TR - phenylephrine w/ dm-gg tab 10-28-388 mg 3 GILTUSS TR - phenylephrine w/ dm-gg tab sr 12hr 20-30-600 mg 3 guaifenesin-codeine soln 100-10 mg/5ml 1 hydrocod polst-chlorphen polst cr susp 10-8 mg/5ml (Tussionex pennkineti) 1 hydrocodone w/ homatropine syrup 5-1.5 mg/5ml 1 hydrocodone w/ homatropine tab 5-1.5 mg 1 HYPER-SAL - sodium chloride soln nebu 7% 3 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 MAXIFED-G CDX - pseudoephedrine w/ 3 cod-gg tab 40-20-400 mg 3 MAXIFLU CD - pseudoephed-codeineguaifenesin-apap tab 40-10-400-500 mg MAXIFLU CDX - pseudoephed-codeine- 3 guaifenesin-apap tab 60-20-400-500 mg 3 MAXIPHEN CD - phenylephrine w/ codeine-gg tab 10-10-400 mg 3 MAXIPHEN CDX - phenylephrine w/ codeine-gg tab 10-20-400 mg 3 NEBUSAL - sodium chloride soln nebu 6% 3 NEOTUSS PLUS - phenylephrinechlorphen-dm liquid 7.5-4-30 mg/5ml NEOTUSS-D - pseudoephed-chlorphen 3 w/ dm-gg liqd 30-2-30-200 mg/5ml 3 NORTUSS-EX - dextromethorphanguaifenesin liquid 20-200 mg/5ml 3 PANATUSS DXP - phenylephrinedexbromphen-dm-gg liquid 5-1-15-100 mg/5ml 3 PEDIATEX TD - triprolidine & pseudoephedrine liquid 0.938-10 mg/ ml 3 PEDIATEX TDM - pseudoephedtriprolidine-dm susp 10-0.938-4 mg/ ml HYPERSAL - sodium chloride soln nebu 3 3.5% HYPERSAL - sodium chloride soln nebu 3 7% SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 65 PHENFLU CD - phenylephrine-codeineguaifenesin-apap tab 10-10-400-500 mg 3 promethazine w/ codeine syrup 6.25-10 mg/5ml 1 PHENFLU CDX - phenylephrinecodeine-guaifenesin-apap tab 10-20-400-500 mg promethazine-dm syrup 6.25-15 mg/5ml 1 3 1 phenylephrine w/ dm-gg liqd 10-15-300 mg/5ml 1 pseudoeph-chlorphen w/ hydrocodone soln 60-4-5 mg/5ml (Zutripro) 1 pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml 1 phenylephrine w/ dm-gg liqd 10-30-200 mg/5ml phenylephrine w/ dm-gg liqd 2.5-5-50 mg/ml 1 phenylephrine w/ dm-gg liqd 2.5-7.5-88 mg/ml 1 phenylephrine-brompheniramine-dm liquid 7.5-4-15 mg/5ml 1 phenylephrine-guaifenesin liqd 7.5-100 mg/5ml (1.5-20 mg/ml) 1 phenylephrine-promethazine w/ codeine syrup 5-6.25-10 mg/5ml 1 POLY HIST DHC - phenylephrinepyrilamine-dihydrocod liqd 5-7.5-7.5 mg/5ml 3 POLY HIST NC - pseudoephedrinetriprolidine w/ cod liquid 15-1.25-10 mg/5ml 3 POLY-TUSSIN DHC - phenylephrinebromphen-dihydrocodeine liqd 7.5-4-3 mg/5ml 3 POLY-TUSSIN EX - phenylephrinedihydrocodeine-gg syrup 5-7.5-50 mg/5ml 3 promethazine & phenylephrine syrup 6.25-5 mg/5ml 1 PROMETHAZINE VC PLAIN promethazine & phenylephrine syrup 6.25-5 mg/5ml 3 PROMETHAZINE VC/CODEINE phenylephrine-promethazine w/ codeine syrup 5-6.25-10 mg/5ml 3 66 RELHIST - bromphen tan-phenyleph tan 3 chew tab 6-15 mg 3 RESCON-JR - chlorpheniramine & phenylephrine tab sr 12hr 4-20 mg 3 RESCON-JR - dexchlorpheniraminephenylephrine tab sr 12hr 3-20 mg 3 RESCON-MX - dexchlorpheniraminephenylephrine tab sr 12hr 6-40 mg 3 REZIRA - pseudoephedrine w/ hydrocodone soln 60-5 mg/5ml 3 SEMPREX-D - acrivastine & pseudoephedrine cap 8-60 mg 1 sodium chloride soln nebu 0.9% sodium chloride soln nebu 10% 1 sodium chloride soln nebu 3% 1 sodium chloride soln nebu 7% (Hyper-sal) 1 SUTTAR-SF - pseudoephedrine w/ codgg syrup 30-10-100 mg/5ml 3 SUTTAR-2 - pseudoephedrine w/ codgg syrup 30-10-100 mg/5ml 3 TESSALON PERLES - benzonatate cap 3 100 mg 3 TGQ 15DM/5PEH/2CPM phenylephrine-chlorphen-dm syrup 5-2-15 mg/5ml 3 TGQ 30PSE/150GFN/15DM pseudoephedrine w/ dm-gg syrup 30-15-150 mg/5ml SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 TGQ 30PSE/3BRM/15DM pseudoephed-bromphen-dm syrup 30-3-15 mg/5ml 3 TGQ 50PSE/3BRM/30DM pseudoephed-bromphen-dm syrup 50-3-30 mg/5ml 3 TUSNEL - brompheniramine w/ dm-gg cap 2-15-200 mg 3 TUSSICAPS - hydrocod polst-chlorphen polst cap sr 12hr 5-4 mg 3 TUSSICAPS - hydrocod polst-chlorphen polst cap sr 12hr 10-8 mg 3 TUSSIONEX PENNKINETIC EXT hydrocod polst-chlorphen polst cr susp 10-8 mg/5ml 3 VITUZ - hydrocodone-chlorpheniramine soln 5-4 mg/5ml 3 ZONATUSS - benzonatate cap 150 mg 3 ZUTRIPRO - pseudoeph-chlorphen w/ hydrocodone soln 60-4-5 mg/5ml 3 ANTIASTHMATIC and BRONCHODILATOR AGENTS 3 ACCOLATE - zafirlukast tab 10 mg ACCOLATE - zafirlukast tab 20 mg 3 ACCUNEB - albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) 3 ACCUNEB - albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) 3 ADRENALIN - epinephrine hcl inj 1 mg/ ml 3 ADVAIR DISKUS - fluticasonesalmeterol aer powder ba 100-50 mcg/dose 2 ADVAIR DISKUS - fluticasonesalmeterol aer powder ba 250-50 mcg/dose 2 ADVAIR DISKUS - fluticasonesalmeterol aer powder ba 500-50 mcg/dose 2 ADVAIR HFA - fluticasone-salmeterol inhal aerosol 45-21 mcg/act 2 ADVAIR HFA - fluticasone-salmeterol inhal aerosol 115-21 mcg/act 2 ADVAIR HFA - fluticasone-salmeterol inhal aerosol 230-21 mcg/act 2 AEROSPAN - flunisolide hfa inhal aerosol 80 mcg/act 3 albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) 1 albuterol sulfate soln nebu 0.5% (5 mg/ml) 1 albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) 1 albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) 1 albuterol sulfate syrup 2 mg/5ml 1 albuterol sulfate tab sr 12hr 4 mg (Vospire er) 1 albuterol sulfate tab sr 12hr 8 mg (Vospire er) 1 albuterol sulfate tab 2 mg 1 albuterol sulfate tab 4 mg 1 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 ALVESCO - ciclesonide inhal aerosol 80 3 mcg/act 3 ALVESCO - ciclesonide inhal aerosol 160 mcg/act 2 ANORO ELLIPTA - umeclidiniumvilanterol aero powd ba 62.5-25 mcg/ inh 3 ARCAPTA NEOHALER - indacaterol maleate inhal powder cap 75 mcg (base equiv) 2 ASMANEX TWISTHALER 120 ME mometasone furoate inhal powd 220 mcg/inh (breath activated) 2 ASMANEX TWISTHALER 14 MET mometasone furoate inhal powd 220 mcg/inh (breath activated) 2 ASMANEX TWISTHALER 30 ME mometasone furoate inhal powd 220 mcg/inh (breath activated) SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 67 ASMANEX TWISTHALER 30 MET mometasone furoate inhal powd 110 mcg/inh (breath activated) 2 ASMANEX TWISTHALER 60 MET mometasone furoate inhal powd 220 mcg/inh (breath activated) 2 ASMANEX TWISTHALER 7 METE mometasone furoate inhal powd 110 mcg/inh (breath activated) 2 ATROVENT HFA - ipratropium bromide hfa inhal aerosol 17 mcg/act 2 BREO ELLIPTA - fluticasone furoatevilanterol aero powd ba 100-25 mcg/ inh 2 BRONCOMAR-1 - theophylline-pse-gg elixir 150-30-150 mg/15ml 3 BRONDIL - dyphylline-guaifenesin liqd 100-100 mg/15ml dyphylline-guaifenesin liqd 100-100 mg/5ml 1 ELIXOPHYLLIN - theophylline elixir 80 mg/15ml 3 epinephrine hcl inj 1 mg/ml 1 epinephrine hcl soln prefilled syringe 0.1 mg/ml 1 FLOVENT DISKUS - fluticasone propionate aer pow ba 50 mcg/blister 2 FLOVENT DISKUS - fluticasone propionate aer pow ba 100 mcg/ blister 2 FLOVENT DISKUS - fluticasone propionate aer pow ba 250 mcg/ blister 2 3 FLOVENT HFA - fluticasone propionate hfa inhal aero 44 mcg/act (50/valve) 2 3 FLOVENT HFA - fluticasone propionate hfa inhal aer 110 mcg/act (125/valve) 2 BROVANA - arformoterol tartrate soln nebu 15 mcg/2ml (base equiv) 1 FLOVENT HFA - fluticasone propionate hfa inhal aer 220 mcg/act (250/valve) 2 budesonide inhalation susp 0.25 mg/2ml (Pulmicort) 1 FORADIL AEROLIZER - formoterol fumarate inhal cap 12 mcg 2 budesonide inhalation susp 0.5 mg/2ml (Pulmicort) 2 ipratropium bromide inhal soln 0.02% 1 COMBIVENT - ipratropium-albuterol aerosol 18-103 mcg/act (20-120mcg/ act) 1 COMBIVENT RESPIMAT - ipratropiumalbuterol inhal aerosol soln 20-100 mcg/act 2 ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml ISUPREL - isoproterenol hcl inj 0.2 mg/ ml 3 cromolyn sodium soln nebu 20 mg/2ml 1 3 DALIRESP - roflumilast tab 500 mcg 3 LEVALBUTEROL - levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) DULERA - mometasone furoateformoterol fumarate aerosol 100-5 mcg/act 2 DULERA - mometasone furoateformoterol fumarate aerosol 200-5 mcg/act 2 DUONEB - ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml 3 68 1 levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv) (Xopenex) 1 levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv) (Xopenex) 1 levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) (Xopenex) 3 LUFYLLIN - dyphylline tab 200 mg LUFYLLIN - dyphylline tab 400 mg SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare 3 Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 MAXAIR AUTOHALER - pirbuterol acetate breath activated inhal aerosol 200mcg/inh 3 QVAR - beclomethasone dipropionate inhal aero soln 80 mcg/act 2 METAPROTERENOL SULFATE metaproterenol sulfate tab 10 mg SENOPHYLLINE - theophylline tab 200 mg & dietary management cap pack 3 3 METAPROTERENOL SULFATE metaproterenol sulfate tab 20 mg SEREVENT DISKUS - salmeterol xinafoate aer pow ba 50 mcg/dose (base equiv) 2 3 METAPROTERENOL SULFATE metaproterenol sulfate syrup 10 mg/5ml 3 SINGULAIR - montelukast sodium tab 10 mg (base equiv) 3 montelukast sodium chew tab 4 mg (base equiv) (Singulair) SINGULAIR - montelukast sodium chew tab 4 mg (base equiv) 3 1 montelukast sodium chew tab 5 mg (base equiv) (Singulair) SINGULAIR - montelukast sodium chew tab 5 mg (base equiv) 3 1 montelukast sodium oral granules packet 4 mg (base equiv) (Singulair) SINGULAIR - montelukast sodium oral granules packet 4 mg (base equiv) 3 1 1 SPIRIVA HANDIHALER - tiotropium bromide monohydrate inhal cap 18 mcg (base equiv) 2 montelukast sodium tab 10 mg (base equiv) (Singulair) PERFOROMIST - formoterol fumarate soln nebu 20 mcg/2ml 3 2 PROAIR HFA - albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv) 2 SPIRIVA RESPIMAT - tiotropium bromide monohydrate inhal aerosol 2.5 mcg/act 3 PROVENTIL HFA - albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv) 3 STRIVERDI RESPIMAT - olodaterol hcl inhal aerosol soln 2.5 mcg/act (base equiv) 2 PULMICORT - budesonide inhalation susp 0.25 mg/2ml 3 SYMBICORT - budesonide-formoterol fumarate dihyd aerosol 80-4.5 mcg/ act PULMICORT - budesonide inhalation susp 0.5 mg/2ml 3 2 PULMICORT - budesonide inhalation susp 1 mg/2ml 2 SYMBICORT - budesonide-formoterol fumarate dihyd aerosol 160-4.5 mcg/ act terbutaline sulfate inj 1 mg/ml 1 PULMICORT FLEXHALER budesonide inhal aero powd 90 mcg/ act (breath activated) 3 terbutaline sulfate tab 2.5 mg 1 terbutaline sulfate tab 5 mg 1 PULMICORT FLEXHALER budesonide inhal aero powd 180 mcg/act (breath activated) THEO-24 - theophylline cap sr 24hr 100 mg 3 3 THEO-24 - theophylline cap sr 24hr 200 mg 3 PULMOPHYLLINE - theophylline tab 50 mg & dietary management cap pack 3 THEO-24 - theophylline cap sr 24hr 300 mg 3 QVAR - beclomethasone dipropionate inhal aero soln 40 mcg/act 2 THEO-24 - theophylline cap sr 24hr 400 mg 3 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 69 KALYDECO - ivacaftor tab 150 mg 4 theophylline tab sr 12hr 100 mg 1 3 theophylline tab sr 12hr 200 mg 1 OFEV - nintedanib esylate cap 100 mg (base equivalent) • • theophylline tab sr 12hr 300 mg 1 3 • theophylline tab sr 12hr 450 mg 1 OFEV - nintedanib esylate cap 150 mg (base equivalent) 1 PULMOZYME - dornase alfa inhal soln 1 mg/ml 4 theophylline tab sr 24hr 400 mg theophylline tab sr 24hr 600 mg 1 TUDORZA PRESSAIR - aclidinium bromide aerosol powd breath activated 400 mcg/act SCLEROSOL INTRAPLEURAL - talc intrapleural aerosol powder 4 gm (0.4 gm/second) 3 3 VENTOLIN HFA - albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv) STERILE TALC POWDER - talc intrapleural powder for susp 5 gm 3 2 VOSPIRE ER - albuterol sulfate tab sr 12hr 4 mg SURFAXIN - lucinactant intratracheal susp 30 mg/ml 3 3 3 VOSPIRE ER - albuterol sulfate tab sr 12hr 8 mg 3 SURVANTA INTRATRACHEAL beractant in nacl 0.9% intratracheal susp 25 mg/ml XOLAIR - omalizumab for inj 150 mg 5 XOPENEX - levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv) 3 LAXATIVES XOPENEX - levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv) CASCARA SAGRADA - cascara sagrada fl ext 1 gm/ml 3 3 XOPENEX - levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) COLYTE-FLAVOR PACKS - peg 3350kcl-na bicarb-nacl-na sulfate for soln 227.1 gm 3 3 XOPENEX CONCENTRATE levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) 3 COLYTE-FLAVOR PACKS - peg 3350kcl-na bicarb-nacl-na sulfate for soln 240 gm 3 XOPENEX HFA - levalbuterol tartrate inhal aerosol 45 mcg/act (base equiv) 3 GOLYTELY - peg 3350-kcl-na bicarbnacl-na sulfate for soln 236 gm 3 zafirlukast tab 10 mg (Accolate) 1 3 zafirlukast tab 20 mg (Accolate) 1 GOLYTELY - peg 3350-kcl-na bicarbnacl-na sulfate packet 227.1 gm ZYFLO - zileuton tab 600 mg 3 HALFLYTELY BOWEL PREP/FLA bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for soln kit 3 KRISTALOSE - lactulose oral crystal packet 10 gm 3 KRISTALOSE - lactulose oral crystal packet 20 gm 3 lactulose solution 10 gm/15ml 1 MINERAL OIL HEAVY - mineral oil 3 • ZYFLO CR - zileuton tab sr 12hr 600 mg 3 RESPIRATORY AGENTS - MISC. CUROSURF - poractant alfa intratracheal susp 80 mg/ml 3 ESBRIET - pirfenidone cap 267 mg 3 INFASURF - calfactant in nacl 0.9% intratracheal susp 35 mg/ml 3 70 • GASTROINTESTINAL AGENTS SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits 1 Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy theophylline soln 80 mg/15ml Prior Authorization Drug Name Drug Tier 2015 MOVIPREP - peg 3350-kcl-nacl-na sulfate-na acorbate-c for soln 100 gm 3 OPIUM TINCTURE (PAREGORIC paregoric 2 mg/5ml 3 NULYTELY/FLAVOR PACKS - peg 3350-kcl-sod bicarb-nacl for soln 420 gm 3 opium tincture 1% (10 mg/ml) (morphine equiv) 1 RESTORA RX - lactobacillus casei-folic acid cap 60-1.25 mg 3 REZYST IM - probiotic product - chew tab 3 REZYST SB - saccharomyces boulardii chew tab 250 mg 3 VSL#3 DS - probiotic product - packet 3 OSMOPREP - sod phos mono-sod phos 3 di tabs 1.102-0.398 gm(1.5gm na phos) 1 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm (Golytely) 1 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm (Colyteflavor packs) peg 3350-kcl-sod bicarb-nacl for soln 1 420 gm (Nulytely/flavor pack) polyethylene glycol 3350 oral packet 1 polyethylene glycol 3350 oral powder 1 PREPOPIK - sod picosulfate-mg oxidecitric acid pack 10 mg-3.5 gm-12 gm 3 SENNA - senna powder 3 SENNA LEAVES - senna leaves 3 SUCLEAR - na sulf-k sulf-mg sulf & peg 3350-nacl-na bicarb-kcl kit 3 SUPREP BOWEL PREP - sodium sulfate-potassium sulfate-magnesium sulfate oral soln 3 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 ANTACIDS SODIUM BICARBONATE - sodium bicarbonate powder 3 ULCER DRUGS ANTIDIARRHEALS amoxicillin cap-clarithro tablansopraz cap dr therapy pack (Prevpac) 1 ANASPAZ - hyoscyamine sulfate tab disp 0.125 mg 3 ATROPEN - atropine sulfate im inj device 0.25 mg/0.3ml 3 ATROPEN - atropine sulfate im inj device 0.5 mg/0.7ml 3 ATROPEN - atropine sulfate im inj device 1 mg/0.7ml 3 ATROPEN - atropine sulfate im inj device 2 mg/0.7ml 3 ATROPINE SULFATE - atropine sulfate inj 0.05 mg/ml 3 ATROPINE SULFATE - atropine sulfate inj 0.8 mg/ml 3 atropine sulfate inj 0.1 mg/ml 1 atropine sulfate inj 0.4 mg/ml 1 atropine sulfate inj 1 mg/ml 1 AXID - nizatidine cap 300 mg 3 diphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil) 1 DIPHENOXYLATE/ATROPINE diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml 2 FULYZAQ - crofelemer tab delayed release 125 mg 3 LOMOTIL - diphenoxylate w/ atropine tab 2.5-0.025 mg 3 loperamide hcl cap 2 mg 1 AXID - nizatidine oral soln 15 mg/ml 3 MOTOFEN - difenoxin w/ atropine tab 1-0.025 mg 3 BELLADONNA & OPIUM - belladonna alkaloids & opium suppos 16.2-30 mg 3 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 71 BELLADONNA ALKALOIDS & OP belladonna alkaloids & opium suppos 16.2-60 mg 3 DONNATAL EXTENTABS - pbhyoscy-atrop-scopol tab cr 48.6-0.3111-0.0582-0.0195 mg 3 BENTYL - dicyclomine hcl cap 10 mg 3 1 BENTYL - dicyclomine hcl tab 20 mg 3 famotidine for susp 40 mg/5ml (Pepcid) BENTYL - dicyclomine hcl inj 10 mg/ml 3 famotidine tab 20 mg (Pepcid) 1 BENTYL - dicyclomine hcl oral soln 10 mg/5ml 3 famotidine tab 40 mg (Pepcid) 1 3 CANTIL - mepenzolate bromide tab 25 mg 3 GABITIDINE - ranitidine hcl tab 150 mg & dietary management cap pack 3 CARAFATE - sucralfate tab 1 gm 3 GASTRINEX NF - hyoscyaminephenyltoloxamine cap 0.0625-15 mg GLYCATE - glycopyrrolate tab 1.5 mg 3 CARAFATE - sucralfate susp 1 gm/10ml 2 1 cimetidine hcl soln 300 mg/5ml cimetidine tab 200 mg 1 cimetidine tab 300 mg 1 cimetidine tab 400 mg 1 cimetidine tab 800 mg 1 clidinium & chlordiazepoxide cap 2.5-5 mg (Librax) 1 CUVPOSA - glycopyrrolate oral soln 1 mg/5ml 3 CYTOTEC - misoprostol tab 100 mcg 3 CYTOTEC - misoprostol tab 200 mcg 3 DEPRIZINE FUSEPAQ - ranitidine hcl for oral susp 22.4 mg/ml (compound kit) 3 DICYCLOMINE HCL - dicyclomine hcl oral soln 10 mg/5ml 2 dicyclomine hcl cap 10 mg (Bentyl) 1 dicyclomine hcl tab 20 mg (Bentyl) 1 DIGEX NF - hyoscyaminephenyltoloxamine cap 0.0625-15 mg 3 DONNATAL - pb-hyoscy-atrop-scopol tab 16.2-0.1037-0.0194-0.0065 mg 3 DONNATAL - pb-hyoscy-atrop-scopol elix 16.2-0.1037-0.0194-0.0065 mg/5ml 3 72 glycopyrrolate inj 0.2 mg/ml (Robinul) 1 1 glycopyrrolate inj 0.4 mg/2ml (0.2 mg/ml) (Robinul) 1 glycopyrrolate inj 1 mg/5ml (0.2 mg/ ml) (Robinul) glycopyrrolate inj 4 mg/20ml (0.2 mg/ 1 ml) (Robinul) 1 glycopyrrolate tab 1 mg (Robinul) glycopyrrolate tab 2 mg (Robinul forte) 1 HELIDAC - metronidaz tab-tetracyc cap- 3 bis subsal chew tab therapy pack 1 hyoscyamine sulfate elixir 0.125 mg/5ml 1 hyoscyamine sulfate soln 0.125 mg/ ml 1 hyoscyamine sulfate tab disp 0.125 mg (Anaspaz) 1 hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl) 1 hyoscyamine sulfate tab sr 12hr 0.375 mg (Levbid) 1 hyoscyamine sulfate tab 0.125 mg (Levsin) 1 lansoprazole cap delayed release 15 mg (Prevacid) 1 lansoprazole cap delayed release 30 mg (Prevacid) SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 LEVBID - hyoscyamine sulfate tab sr 12hr 0.375 mg 3 LEVSIN - hyoscyamine sulfate tab 0.125 3 mg 3 LEVSIN - hyoscyamine sulfate inj 0.5 mg/ml LEVSIN/SL - hyoscyamine sulfate tab sl 3 0.125 mg 3 LIBRAX - clidinium & chlordiazepoxide cap 2.5-5 mg 1 methscopolamine bromide tab 2.5 mg (Pamine) 1 methscopolamine bromide tab 5 mg (Pamine forte) 1 misoprostol tab 100 mcg (Cytotec) pantoprazole sodium ec tab 40 mg (base equiv) (Protonix) 1 PEPCID - famotidine tab 20 mg 3 PEPCID - famotidine tab 40 mg 3 PEPCID - famotidine for susp 40 mg/5ml 3 PREVPAC - amoxicillin cap-clarithro tab-lansopraz cap dr therapy pack 3 PROPANTHELINE BROMIDE propantheline bromide tab 15 mg 2 PROTONIX - pantoprazole sodium for delayed release susp packet 40 mg 2 PYLERA - bismuth subcitmetronidazole-tetracycline cap 140-125-125 mg 3 1 misoprostol tab 200 mcg (Cytotec) 1 nizatidine cap 150 mg 1 rabeprazole sodium ec tab 20 mg (Aciphex) nizatidine cap 300 mg (Axid) 1 ranitidine hcl cap 150 mg 1 nizatidine oral soln 15 mg/ml (Axid) 1 ranitidine hcl cap 300 mg 1 OMECLAMOX-PAK - amoxicillin capclarithro tab w/ omepraz cap dr therapy pack 3 ranitidine hcl inj 1000 mg/40ml (25 mg/ml) (Zantac) 1 1 omeprazole cap delayed release 10 mg (Prilosec) 1 ranitidine hcl inj 150 mg/6ml (25 mg/ ml) (Zantac) 1 omeprazole cap delayed release 20 mg (Prilosec) 1 ranitidine hcl inj 50 mg/2ml (25 mg/ ml) (Zantac) 1 omeprazole cap delayed release 40 mg (Prilosec) 1 ranitidine hcl syrup 15 mg/ml (75 mg/5ml) ranitidine hcl tab 150 mg (Zantac) 1 omeprazole-sodium bicarbonate cap 20-1100 mg (Zegerid) 1 ranitidine hcl tab 300 mg (Zantac) 1 ROBINUL - glycopyrrolate tab 1 mg 3 omeprazole-sodium bicarbonate cap 40-1100 mg (Zegerid) 1 ROBINUL - glycopyrrolate inj 0.2 mg/ml 3 3 ROBINUL - glycopyrrolate inj 0.4 mg/2ml (0.2 mg/ml) 3 PAMINE - methscopolamine bromide tab 2.5 mg 3 ROBINUL - glycopyrrolate inj 1 mg/5ml (0.2 mg/ml) 3 PAMINE FORTE - methscopolamine bromide tab 5 mg 3 ROBINUL - glycopyrrolate inj 4 mg/20ml (0.2 mg/ml) 3 PAMINE FQ - methscopolamine tab 5 mg & misc intestinal flora reg cap 1 ROBINUL FORTE - glycopyrrolate tab 2 mg 3 pantoprazole sodium ec tab 20 mg (base equiv) (Protonix) SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 73 SCOPOLAMINE HYDROBROMIDE scopolamine hbr inj 0.4 mg/ml 3 EMEND - aprepitant capsule therapy pack 80 & 125 mg 2 SENTRADINE - ranitidine hcl tab 150 mg & dietary management cap pack 3 granisetron hcl tab 1 mg 1 sucralfate tab 1 gm (Carafate) GRANISOL - granisetron hcl oral soln 2 mg/10ml (base equivalent) 3 1 MARINOL - dronabinol cap 2.5 mg 3 MARINOL - dronabinol cap 5 mg 3 MARINOL - dronabinol cap 10 mg 3 meclizine hcl tab 12.5 mg 1 meclizine hcl tab 25 mg 1 meclizine hcl tab 32 mg 1 ondansetron hcl inj 4 mg/2ml (2 mg/ ml) 1 ondansetron hcl inj 40 mg/20ml (2 mg/ml) (Zofran) 1 ondansetron hcl oral soln 4 mg/5ml (Zofran) 1 ondansetron hcl tab 24 mg 1 ondansetron hcl tab 4 mg (Zofran) 1 SYMAX DUOTAB - hyoscyamine sulfate 3 tab cr 0.375 mg (0.125 mg ir/0.25 mg cr) 3 ZANTAC - ranitidine hcl tab 150 mg ZANTAC - ranitidine hcl tab 300 mg 3 ZANTAC - ranitidine hcl effer tab 25 mg 3 ZANTAC - ranitidine hcl syrup 15 mg/ml (75 mg/5ml) 3 ZANTAC - ranitidine hcl inj 50 mg/2ml (25 mg/ml) 3 ZANTAC - ranitidine hcl inj 150 mg/6ml (25 mg/ml) 3 ZANTAC - ranitidine hcl inj 1000 mg/40ml (25 mg/ml) 3 ANTIEMETICS AKYNZEO - netupitant-palonosetron cap 300-0.5 mg 3 ondansetron hcl tab 8 mg (Zofran) 1 1 ANZEMET - dolasetron mesylate tab 50 mg 3 ondansetron orally disintegrating tab 4 mg (Zofran odt) 1 ANZEMET - dolasetron mesylate tab 100 mg 3 ondansetron orally disintegrating tab 8 mg (Zofran odt) 3 CESAMET - nabilone cap 1 mg 3 SANCUSO - granisetron td patch 3.1 mg/24hr (contains 34.3 mg) COCA COLA SYURP - phosphorated carbohydrate w/ caffeine syrup 3 DICLEGIS - doxylamine-pyridoxine tab delayed release 10-10 mg 3 DIMENHYDRINATE - dimenhydrinate inj 50 mg/ml 3 dronabinol cap 10 mg (Marinol) 1 dronabinol cap 2.5 mg (Marinol) 1 dronabinol cap 5 mg (Marinol) 1 EMEND - aprepitant capsule 40 mg 2 EMEND - aprepitant capsule 80 mg 2 EMEND - aprepitant capsule 125 mg 2 74 TIGAN - trimethobenzamide hcl cap 300 3 mg 3 TIGAN - trimethobenzamide hcl inj 100 mg/ml 3 TRANSDERM-SCOP - scopolamine td patch 72hr 1.5 mg 1 trimethobenzamide hcl cap 300 mg (Tigan) trimethobenzamide hcl inj 100 mg/ml 1 ZOFRAN - ondansetron hcl tab 4 mg 3 ZOFRAN - ondansetron hcl tab 8 mg 3 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 ZOFRAN - ondansetron hcl inj 40 mg/20ml (2 mg/ml) 3 ULTRESA - pancrelipase (lip-prot-amyl) dr cap 13800-27600-27600 unit 3 ZOFRAN - ondansetron hcl oral soln 4 mg/5ml 3 ULTRESA - pancrelipase (lip-prot-amyl) dr cap 20700-41400-41400 unit 3 ZOFRAN ODT - ondansetron orally disintegrating tab 4 mg 3 ULTRESA - pancrelipase (lip-prot-amyl) dr cap 23000-46000-46000 unit 3 ZOFRAN ODT - ondansetron orally disintegrating tab 8 mg 3 VIOKACE - pancrelipase (lip-prot-amyl) tab 10440-39150-39150 unit 3 ZUPLENZ - ondansetron oral soluble film 4 mg 3 VIOKACE - pancrelipase (lip-prot-amyl) tab 20880-78300-78300 unit 3 ZUPLENZ - ondansetron oral soluble film 8 mg 3 ZENPEP - pancrelipase (lip-prot-amyl) dr cap 3000-10000-16000 unit 2 2 DIGESTIVE AIDS CREON - pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000 unit 2 ZENPEP - pancrelipase (lip-prot-amyl) dr cap 5000-17000-27000 unit 2 CREON - pancrelipase (lip-prot-amyl) dr cap 6000-19000-30000 unit 2 ZENPEP - pancrelipase (lip-prot-amyl) dr cap 10000-34000-55000 unit 2 CREON - pancrelipase (lip-prot-amyl) dr cap 12000-38000-60000 unit 2 ZENPEP - pancrelipase (lip-prot-amyl) dr cap 15000-51000-82000 unit 2 CREON - pancrelipase (lip-prot-amyl) dr cap 24000-76000-120000 unit 2 ZENPEP - pancrelipase (lip-prot-amyl) dr cap 20000-68000-109000 unit 2 CREON - pancrelipase (lip-prot-amyl) dr cap 36000-114000-180000 unit 2 ZENPEP - pancrelipase (lip-prot-amyl) dr cap 25000-85000-136000 unit 2 PANCREAZE - pancrelipase (lip-protamyl) dr cap 4200-10000-17500 unit 3 ZENPEP - pancrelipase (lip-prot-amyl) dr cap 40000-136000-218000 unit PANCREAZE - pancrelipase (lip-protamyl) dr cap 10500-25000-43750 unit 3 mesalamine rectal enema 4 gm & cleanser wipe kit (Rowasa) 1 PANCREAZE - pancrelipase (lip-protamyl) dr cap 16800-40000-70000 unit 3 ACTIGALL - ursodiol cap 300 mg 3 AMITIZA - lubiprostone cap 8 mcg 3 PANCREAZE - pancrelipase (lip-protamyl) dr cap 21000-37000-61000 unit 3 AMITIZA - lubiprostone cap 24 mcg 3 3 APRISO - mesalamine cap sr 24hr 0.375 gm 3 PANCRELIPASE - pancrelipase (lipprot-amyl) dr cap 5000-17000-27000 unit 2 PERTZYE - pancrelipase (lip-prot-amyl) dr cap 8000-28750-30250 unit 3 ASACOL - mesalamine tab delayed release 400 mg 2 PERTZYE - pancrelipase (lip-prot-amyl) dr cap 16000-57500-60500 unit 3 ASACOL HD - mesalamine tab delayed release 800 mg AZULFIDINE - sulfasalazine tab 500 mg 3 SUCRAID - sacrosidase soln 8500 unit/ ml 5 AZULFIDINE EN-TABS - sulfasalazine tab delayed release 500 mg 3 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 GASTROINTESTINAL AGENTS- MISC. SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 75 balsalazide disodium cap 750 mg (Colazal) 1 GIAZO - balsalazide disodium tab 1.1 gm 3 calcium acetate (phosphate binder) cap 667 mg (169 mg ca) (Phoslo) 1 lactulose (encephalopathy) solution 10 gm/15ml 1 calcium acetate (phosphate binder) tab 667 mg (Eliphos) 1 LIALDA - mesalamine tab delayed release 1.2 gm 2 CANASA - mesalamine suppos 1000 mg 2 LINZESS - linaclotide cap 145 mcg 2 LINZESS - linaclotide cap 290 mcg 2 CHENODAL - chenodiol tab 250 mg 4 CIMZIA - certolizumab pegol for inj kit 2 x 200 mg • • LOTRONEX - alosetron hcl tab 0.5 mg (base equiv) 3 5 CIMZIA - certolizumab pegol inj kit 2 x 200 mg/ml • • LOTRONEX - alosetron hcl tab 1 mg (base equiv) 3 5 mesalamine enema 4 gm 1 CIMZIA STARTER KIT - certolizumab pegol inj kit 6 x 200 mg/ml 5 metoclopramide hcl inj 5 mg/ml 1 3 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) 1 COLAZAL - balsalazide disodium cap 750 mg 1 metoclopramide hcl tab 10 mg (Reglan) 1 cromolyn sodium oral conc 100 mg/5ml (Gastrocrom) metoclopramide hcl tab 5 mg (Reglan) 1 METOZOLV ODT - metoclopramide hcl orally disintegrating tab 5 mg 3 PENTASA - mesalamine cap cr 250 mg 2 PENTASA - mesalamine cap cr 500 mg 2 PHOSLO - calcium acetate (phosphate binder) cap 667 mg (169 mg ca) 3 PHOSLYRA - calcium acetate (phosphate binder) oral soln 667 mg/5ml 3 DELZICOL - mesalamine cap dr 400 mg 2 3 DEXPANTHENOL - dexpanthenol inj 250 mg/ml DIPENTUM - olsalazine sodium cap 250 3 mg ELIPHOS - calcium acetate (phosphate 3 binder) tab 667 mg 3 ENTEREG - alvimopan cap 12 mg FERRIC CITRATE - ferric citrate tab 1 gm (210 mg ferric iron) 3 FOSRENOL - lanthanum carbonate chew tab 500 mg 3 FOSRENOL - lanthanum carbonate chew tab 750 mg 3 FOSRENOL - lanthanum carbonate chew tab 1000 mg 3 GASTROCROM - cromolyn sodium oral conc 100 mg/5ml 3 GATTEX - teduglutide (rdna) for inj kit 5 mg 5 76 • • REGLAN - metoclopramide hcl tab 5 mg 3 3 REGLAN - metoclopramide hcl tab 10 mg RELISTOR - methylnaltrexone bromide 3 inj 8 mg/0.4ml (20 mg/ml) RELISTOR - methylnaltrexone bromide 3 inj 12 mg/0.6ml (20 mg/ml) RELISTOR - methylnaltrexone bromide 3 inj kit 12 mg/0.6ml 3 RENAGEL - sevelamer hcl tab 400 mg SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 2 2 MACRODANTIN - nitrofurantoin macrocrystalline cap 25 mg 3 RENVELA - sevelamer carbonate packet 0.8 gm 2 MACRODANTIN - nitrofurantoin macrocrystalline cap 50 mg 3 RENVELA - sevelamer carbonate packet 2.4 gm 2 MACRODANTIN - nitrofurantoin macrocrystalline cap 100 mg 1 ROWASA - mesalamine rectal enema 4 gm & cleanser wipe kit 3 methenamine hippurate tab 1 gm (Hiprex) 3 SEVELAMER CARBONATE sevelamer carbonate tab 800 mg 3 METHENAMINE MANDELATE methenamine mandelate tab 0.5 gm methenamine mandelate tab 1 gm 1 SFROWASA - mesalamine sulfite-free (sf) enema 4 gm/60ml 3 sulfasalazine tab delayed release 500 mg (Azulfidine en-tabs) 1 sulfasalazine tab 500 mg (Azulfidine) 1 URSO FORTE - ursodiol tab 500 mg 3 URSO 250 - ursodiol tab 250 mg 3 ursodiol cap 300 mg (Actigall) 1 ursodiol tab 250 mg (Urso 250) 1 ursodiol tab 500 mg (Urso forte) 1 VELPHORO - sucroferric oxyhydroxide chew tab 500 mg 3 URINARY ANTI-INFECTIVES 1 methenamine-hyosamine-meth bluesod phos tab 81.6 mg (Urogesicblue) 1 methenamine-hyosc-meth blue-sod phos-phen sal cap 120 mg 1 FURADANTIN - nitrofurantoin susp 25 mg/5ml 3 HIPREX - methenamine hippurate tab 1 gm 3 MACROBID - nitrofurantoin monohydrate macrocrystalline cap 100 mg 3 Quantity Limits Step Therapy methenamine-hyosc-meth blue-benz 1 acid-phenyl sal tab 81.6mg (Prosed/ ds) 3 MONUROL - fosfomycin tromethamine powd pack 3 gm (base equivalent) 1 nitrofurantoin macrocrystalline cap 100 mg (Macrodantin) 1 nitrofurantoin macrocrystalline cap 50 mg (Macrodantin) 1 nitrofurantoin monohydrate macrocrystalline cap 100 mg (Macrobid) 1 nitrofurantoin susp 25 mg/5ml (Furadantin) 3 PROSED/DS - methenamine-hyoscmeth blue-benz acid-phenyl sal tab 81.6mg 3 URELLE - methenamine-hyosc-meth blue-sod phos-phen sal tab 81 mg 3 URETRON D/S - methenamine-hyoscmeth blue-sod phos-phen sal tab 120 mg 3 UREX - methenamine hippurate tab 1 gm 3 URIBEL - methenamine-hyosc-meth blue-sod phos-phen sal cap 118 mg URIMAR-T - methenamine-hyosc-meth 3 blue-sod phos-phen sal tab 120 mg GENITOURINARY AGENTS methenamine-hyos-meth blue-sod phos-phen sal tab 81.6 mg Prior Authorization Drug Name Drug Tier RENVELA - sevelamer carbonate tab 800 mg Quantity Limits 3 Step Therapy RENAGEL - sevelamer hcl tab 800 mg Prior Authorization Drug Name Drug Tier 2015 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 77 UROGESIC-BLUE - methenaminehyosamine-meth blue-sod phos tab 81.6 mg 3 UROQID #2 - methenamine mandelatesod phosphate monobasic tab 500-500 mg 3 UTA - methenamine-hyoscyamine-meth blue-sod phos cap 120 mg 3 URINARY ANTISPASMODICS MYRBETRIQ - mirabegron tab sr 24 hr 50 mg 2 oxybutynin chloride syrup 5 mg/5ml 1 oxybutynin chloride tab sr 24hr 10 mg (Ditropan xl) 1 oxybutynin chloride tab sr 24hr 15 mg (Ditropan xl) 1 oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl) 1 oxybutynin chloride tab 5 mg 1 bethanechol chloride tab 10 mg (Urecholine) 1 1 OXYTROL - oxybutynin td patch biweekly 3.9 mg/24hr 3 bethanechol chloride tab 25 mg (Urecholine) 1 SANCTURA - trospium chloride tab 20 mg 3 bethanechol chloride tab 5 mg (Urecholine) 1 SANCTURA XR - trospium chloride cap sr 24hr 60 mg 3 bethanechol chloride tab 50 mg (Urecholine) 3 tolterodine tartrate cap sr 24hr 2 mg (Detrol la) 1 DETROL - tolterodine tartrate tab 1 mg DETROL - tolterodine tartrate tab 2 mg 3 DETROL LA - tolterodine tartrate cap sr 24hr 2 mg tolterodine tartrate cap sr 24hr 4 mg (Detrol la) 1 3 tolterodine tartrate tab 1 mg (Detrol) 1 DETROL LA - tolterodine tartrate cap sr 24hr 4 mg 3 tolterodine tartrate tab 2 mg (Detrol) 1 3 TOVIAZ - fesoterodine fumarate tab sr 24hr 4 mg 3 DITROPAN XL - oxybutynin chloride tab sr 24hr 5 mg 3 TOVIAZ - fesoterodine fumarate tab sr 24hr 8 mg 3 DITROPAN XL - oxybutynin chloride tab sr 24hr 10 mg 3 trospium chloride cap sr 24hr 60 mg 1 DITROPAN XL - oxybutynin chloride tab sr 24hr 15 mg trospium chloride tab 20 mg 1 ENABLEX - darifenacin hydrobromide tab sr 24hr 7.5 mg (base equiv) 3 URECHOLINE - bethanechol chloride tab 5 mg 3 ENABLEX - darifenacin hydrobromide tab sr 24hr 15 mg (base equiv) 3 URECHOLINE - bethanechol chloride tab 10 mg 3 flavoxate hcl tab 100 mg 1 3 GELNIQUE - oxybutynin td gel 3% (28 mg/act metered-dose pump) 3 URECHOLINE - bethanechol chloride tab 25 mg 3 GELNIQUE - oxybutynin chloride td gel 10% 3 URECHOLINE - bethanechol chloride tab 50 mg 2 MYRBETRIQ - mirabegron tab sr 24 hr 25 mg 2 VESICARE - solifenacin succinate tab 5 mg 78 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 2 FIRST-PROGESTERONE VGS 40 progesterone vaginal suppository 400 mg 3 AVC - sulfanilamide vaginal cream 15% 3 3 CLEOCIN - clindamycin phosphate vaginal cream 2% 3 FIRST-PROGESTERONE VGS 50 progesterone vaginal suppository 50 mg 2 GYNAZOLE-1 - butoconazole nitrate (one dose) vaginal cream 2% 3 CLEOCIN - clindamycin phosphate vaginal suppos 100 mg 1 METROGEL-VAGINAL - metronidazole vaginal gel 0.75% 3 clindamycin phosphate vaginal cream 2% (Cleocin) 3 metronidazole vaginal gel 0.75% (Metrogel-vaginal) 1 CLINDESSE - clindamycin phosphate (one dose) vaginal cream 2% 3 miconazole nitrate vaginal supp 200 mg & 2% cream 9 gm kit 1 CRINONE - progesterone vaginal gel 4% 3 MICONAZOLE 3 - miconazole nitrate vaginal suppos 200 mg 3 CRINONE - progesterone vaginal gel 8% 3 OPTIONS CONCEPTROL VAGINA nonoxynol-9 gel 4% 3 ENCARE - nonoxynol-9 vaginal suppos 100 mg 3 OPTIONS GYNOL II VAGINAL nonoxynol-9 gel 3% 3 ENDOMETRIN - progesterone vaginal insert 100 mg 2 PREMARIN - estrogens, conjugated vaginal cream 0.625 mg/gm 3 ESTRACE - estradiol vaginal cream 0.1 mg/gm 3 RELAGARD - acetic acid-oxyquinoline vaginal gel 0.9-0.025% 3 ESTRING - estradiol vaginal ring 2 mg (7.5 mcg/24hrs) 3 SHUR-SEAL - nonoxynol-9 gel 2% 3 FEM PH - acetic acid-oxyquinoline vaginal gel 0.9-0.025% 3 FEMRING - estradiol acetate vaginal ring 0.05 mg/24hr 3 TERAZOL 3 - terconazole vaginal cream 0.8% 3 FEMRING - estradiol acetate vaginal ring 0.1 mg/24hr 3 TERAZOL 3 - terconazole vaginal suppos 80 mg 3 FIRST-PROGESTERONE VGS 10 progesterone vaginal suppository 100 mg 3 TERAZOL 7 - terconazole vaginal cream 0.4% terconazole vaginal cream 0.4% (Terazol 7) 1 FIRST-PROGESTERONE VGS 20 progesterone vaginal suppository 200 mg 3 terconazole vaginal cream 0.8% (Terazol 3) 1 terconazole vaginal suppos 80 mg 1 FIRST-PROGESTERONE VGS 25 progesterone vaginal suppository 25 mg 3 TODAY SPONGE - nonoxynol-9 vaginal sponge 1000 mg 3 VESICARE - solifenacin succinate tab 10 mg VAGINAL PRODUCTS Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 VAGIFEM - estradiol vaginal tab 10 mcg 2 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 79 VCF VAGINAL CONTRACEPTIVE nonoxynol-9 foam 12.5% 3 phenazopyridine hcl tab 100 mg (Pyridium) 1 VCF VAGINAL CONTRACEPTIVE nonoxynol-9 film 28% 3 phenazopyridine hcl tab 200 mg (Pyridium) 1 pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml 1 GENITOURINARY AGENTS - MISC. acetic acid irrigation soln 0.25% 1 alfuzosin hcl tab sr 24hr 10 mg (Uroxatral) 1 potassium citrate & citric acid powder pack 3300-1002 mg 1 AVODART - dutasteride cap 0.5 mg 2 1 CARDURA XL - doxazosin mesylate tab sr 24 hr 4 mg (base equiv) 3 potassium citrate & citric acid soln 1100-334 mg/5ml 1 CARDURA XL - doxazosin mesylate tab sr 24 hr 8 mg (base equiv) 3 potassium citrate tab cr 10 meq (1080 mg) (Urocit-k 10) 1 CITROLITH - potassium & sodium citrates tab 50-950 mg 3 potassium citrate tab cr 15 meq (1620 mg) (Urocit-k 15) 1 CYSTAGON - cysteamine bitartrate cap 50 mg 4 potassium citrate tab cr 5 meq (540 mg) (Urocit-k 5) 5 CYSTAGON - cysteamine bitartrate cap 150 mg 4 PROCYSBI - cysteamine bitartrate cap delayed release 25 mg (base equiv) 5 CYTRA-3 - pot & sod citrates w/ cit ac syrup 550-500-334 mg/5ml 2 PROCYSBI - cysteamine bitartrate cap delayed release 75 mg (base equiv) PROSCAR - finasteride tab 5 mg 3 ELMIRON - pentosan polysulfate sodium caps 100 mg 3 PYRIDIUM - phenazopyridine hcl tab 100 mg 3 finasteride tab 5 mg (Proscar) 1 3 FLOMAX - tamsulosin hcl cap 0.4 mg 3 PYRIDIUM - phenazopyridine hcl tab 200 mg 1 RAPAFLO - silodosin cap 4 mg 3 glycine irrigation soln 1.5% 3 RAPAFLO - silodosin cap 8 mg 3 JALYN - dutasteride-tamsulosin hcl cap 0.5-0.4 mg 3 K-PHOS NO 2 - potassium & sodium acid phosphates tab 305-700 mg 2 RENACIDIN - citric acid & d-gluconic acid soln LITHOSTAT - acetohydroxamic acid tab 250 mg 3 neomycin-polymyxin b gu irrigation soln (Neosporin gu irrigan) 1 NEOSPORIN GU IRRIGANT neomycin-polymyxin b gu irrigation soln 3 sodium citrate & citric acid soln 500-334 mg/5ml (Shohls solution modi) 1 ORACIT - sodium citrate & citric acid soln 490-640 mg/5ml 3 SORBITOL - sorbitol irrigation soln 3% 3 80 RIMSO-50 - dimethyl sulfoxide soln 50% 3 3 SHOHLS SOLUTION MODIFIED sodium citrate & citric acid soln 500-334 mg/5ml 1 sodium chloride irrigation soln 0.9% SORBITOL - sorbitol irrigation soln 3.3% 3 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 3 tamsulosin hcl cap 0.4 mg 1 THIOLA - tiopronin tab 100 mg 3 UROCIT-K 10 - potassium citrate tab cr 10 meq (1080 mg) 3 UROCIT-K 15 - potassium citrate tab cr 15 meq (1620 mg) 3 UROCIT-K 5 - potassium citrate tab cr 5 meq (540 mg) 3 UROXATRAL - alfuzosin hcl tab sr 24hr 10 mg 3 ANTIANXIETY AGENTS ATIVAN - lorazepam inj 2 mg/ml 3 ATIVAN - lorazepam inj 4 mg/ml 3 buspirone hcl tab 10 mg 1 buspirone hcl tab 15 mg 1 buspirone hcl tab 30 mg 1 buspirone hcl tab 5 mg 1 buspirone hcl tab 7.5 mg 1 chlordiazepoxide hcl cap 10 mg 1 chlordiazepoxide hcl cap 25 mg 1 chlordiazepoxide hcl cap 5 mg 1 clorazepate dipotassium tab 15 mg (Tranxene t) 1 3 clorazepate dipotassium tab 3.75 mg (Tranxene t) 1 ALPRAZOLAM INTENSOL - alprazolam conc 1 mg/ml 1 clorazepate dipotassium tab 7.5 mg (Tranxene t) 1 alprazolam orally disintegrating tab 0.25 mg (Niravam) DIAZEPAM - diazepam soln 1 mg/ml 2 alprazolam orally disintegrating tab 0.5 mg 1 DIAZEPAM - diazepam inj 5 mg/ml 3 1 DIAZEPAM - diazepam im inj device 10 mg/2ml 3 alprazolam orally disintegrating tab 1 mg 1 DIAZEPAM INTENSOL - diazepam conc 5 mg/ml 3 alprazolam orally disintegrating tab 2 mg 1 diazepam tab 10 mg (Valium) 1 alprazolam tab sr 24hr 0.5 mg (Xanax xr) diazepam tab 2 mg (Valium) 1 alprazolam tab sr 24hr 1 mg (Xanax xr) 1 diazepam tab 5 mg (Valium) 1 droperidol inj 2.5 mg/ml 1 alprazolam tab sr 24hr 2 mg (Xanax xr) 1 GABAVALE-5 - diazepam tab 5 mg & dietary management cap pack 3 alprazolam tab sr 24hr 3 mg (Xanax xr) 1 GABAZOLAMINE - alprazolam tab 0.25 mg & dietary management cap pack 3 alprazolam tab 0.25 mg (Xanax) 1 3 alprazolam tab 0.5 mg (Xanax) 1 alprazolam tab 1 mg (Xanax) 1 GABAZOLAMINE-0.5 - alprazolam tab 0.5 mg & dietary management cap pack 1 ATIVAN - lorazepam tab 0.5 mg 3 HYDROXYZINE HCL - hydroxyzine hcl im soln 25 mg/ml 3 alprazolam tab 2 mg (Xanax) hydroxyzine hcl im soln 50 mg/ml 1 ATIVAN - lorazepam tab 1 mg 3 hydroxyzine hcl syrup 10 mg/5ml 1 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits 3 Step Therapy ATIVAN - lorazepam tab 2 mg Prior Authorization Quantity Limits Step Therapy CENTRAL NERVOUS SYSTEM DRUGS Drug Name Drug Tier SORBITOL-MANNITOL - sorbitolmannitol irrigation soln 2.7-0.54 gm/100ml Prior Authorization Drug Name Drug Tier 2015 81 3 1 TRANXENE T - clorazepate dipotassium tab 15 mg hydroxyzine hcl tab 50 mg 1 VALIUM - diazepam tab 2 mg 3 HYDROXYZINE PAMOATE hydroxyzine pamoate cap 100 mg 2 VALIUM - diazepam tab 5 mg 3 VALIUM - diazepam tab 10 mg 3 hydroxyzine pamoate cap 25 mg (Vistaril) 1 VISTARIL - hydroxyzine pamoate cap 25 mg 3 hydroxyzine pamoate cap 50 mg (Vistaril) 1 VISTARIL - hydroxyzine pamoate cap 50 mg 3 lorazepam conc 2 mg/ml (Lorazepam intensol) 1 XANAX - alprazolam tab 0.25 mg 3 XANAX - alprazolam tab 0.5 mg 3 lorazepam inj 2 mg/ml (Ativan) 1 XANAX - alprazolam tab 1 mg 3 lorazepam inj 4 mg/ml (Ativan) 1 XANAX - alprazolam tab 2 mg 3 LORAZEPAM INTENSOL - lorazepam conc 2 mg/ml 3 XANAX XR - alprazolam tab sr 24hr 0.5 mg 3 lorazepam tab 0.5 mg (Ativan) 1 1 XANAX XR - alprazolam tab sr 24hr 1 mg 3 lorazepam tab 1 mg (Ativan) lorazepam tab 2 mg (Ativan) 1 3 meprobamate tab 200 mg 1 XANAX XR - alprazolam tab sr 24hr 2 mg meprobamate tab 400 mg 1 3 NIRAVAM - alprazolam orally disintegrating tab 0.25 mg 3 XANAX XR - alprazolam tab sr 24hr 3 mg NIRAVAM - alprazolam orally disintegrating tab 0.5 mg 3 NIRAVAM - alprazolam orally disintegrating tab 1 mg 3 NIRAVAM - alprazolam orally disintegrating tab 2 mg 3 oxazepam cap 10 mg 1 oxazepam cap 15 mg 1 oxazepam cap 30 mg 1 SENTRAZOLAM AM 0.25 - alprazolam tab 0.25 mg & dietary management cap pack 3 TRANXENE T - clorazepate dipotassium tab 3.75 mg TRANXENE T - clorazepate dipotassium tab 7.5 mg 82 ANTIDEPRESSANTS amitriptyline hcl tab 10 mg 1 amitriptyline hcl tab 100 mg 1 amitriptyline hcl tab 150 mg 1 amitriptyline hcl tab 25 mg 1 amitriptyline hcl tab 50 mg 1 amitriptyline hcl tab 75 mg 1 AMOXAPINE - amoxapine tab 25 mg 3 AMOXAPINE - amoxapine tab 50 mg 3 AMOXAPINE - amoxapine tab 100 mg 3 AMOXAPINE - amoxapine tab 150 mg 3 3 3 ANAFRANIL - clomipramine hcl cap 25 mg 3 3 ANAFRANIL - clomipramine hcl cap 50 mg ANAFRANIL - clomipramine hcl cap 75 mg 3 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier hydroxyzine hcl tab 25 mg Quantity Limits 1 Step Therapy hydroxyzine hcl tab 10 mg Prior Authorization Drug Name Drug Tier 2015 APLENZIN - bupropion hbr tab sr 24hr 174 mg 3 • citalopram hydrobromide tab 20 mg (base equiv) (Celexa) 1 APLENZIN - bupropion hbr tab sr 24hr 348 mg 3 • citalopram hydrobromide tab 40 mg (base equiv) (Celexa) 1 APLENZIN - bupropion hbr tab sr 24hr 522 mg 3 • clomipramine hcl cap 25 mg (Anafranil) 1 APPBUTAMONE - bupropion hcl tab 75 mg & dietary management cap pack 3 clomipramine hcl cap 50 mg (Anafranil) 1 APPBUTAMONE-D - bupropion hcl tab 75 mg & dietary management cap pack 3 clomipramine hcl cap 75 mg (Anafranil) 1 • BRINTELLIX - vortioxetine hbr tab 5 mg (base equiv) • CYMBALTA - duloxetine hcl enteric coated pellets cap 20 mg 3 3 • • BRINTELLIX - vortioxetine hbr tab 10 mg (base equiv) CYMBALTA - duloxetine hcl enteric coated pellets cap 30 mg 3 3 3 3 • • BRINTELLIX - vortioxetine hbr tab 20 mg (base equiv) CYMBALTA - duloxetine hcl enteric coated pellets cap 60 mg 1 desipramine hcl tab 10 mg (Norpramin) 1 bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr) bupropion hcl tab sr 12hr 150 mg (Wellbutrin sr) desipramine hcl tab 100 mg (Norpramin) 1 1 bupropion hcl tab sr 12hr 200 mg (Wellbutrin sr) desipramine hcl tab 150 mg (Norpramin) 1 1 bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl) desipramine hcl tab 25 mg (Norpramin) 1 1 1 desipramine hcl tab 50 mg (Norpramin) 1 bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl) desipramine hcl tab 75 mg (Norpramin) 1 3 • • DESVENLAFAXINE ER desvenlafaxine tab sr 24hr 50 mg 3 • • DESVENLAFAXINE ER desvenlafaxine tab sr 24hr 100 mg DESVENLAFAXINE ER desvenlafaxine fumarate tab sr 24hr 50 mg (base equiv) 3 • DESVENLAFAXINE ER desvenlafaxine fumarate tab sr 24hr 100 mg (base equiv) 3 • DOXEPIN HCL - doxepin hcl cap 75 mg 2 doxepin hcl cap 10 mg 1 bupropion hcl tab 100 mg (Wellbutrin) 1 1 bupropion hcl tab 75 mg (Wellbutrin) CELEXA - citalopram hydrobromide tab 10 mg (base equiv) 3 CELEXA - citalopram hydrobromide tab 20 mg (base equiv) 3 CELEXA - citalopram hydrobromide tab 40 mg (base equiv) 3 citalopram hydrobromide oral soln 10 mg/5ml 1 citalopram hydrobromide tab 10 mg (base equiv) (Celexa) 1 • SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 83 doxepin hcl cap 50 mg 1 doxepin hcl conc 10 mg/ml 1 duloxetine hcl enteric coated pellets cap 20 mg (Cymbalta) 1 duloxetine hcl enteric coated pellets cap 30 mg (Cymbalta) 1 duloxetine hcl enteric coated pellets cap 60 mg (Cymbalta) 1 EFFEXOR XR - venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) 3 EFFEXOR XR - venlafaxine hcl cap sr 24hr 75 mg (base equivalent) 3 EFFEXOR XR - venlafaxine hcl cap sr 24hr 150 mg (base equivalent) 3 EMSAM - selegiline td patch 24hr 6 mg/24hr 3 EMSAM - selegiline td patch 24hr 9 mg/24hr 3 EMSAM - selegiline td patch 24hr 12 mg/24hr 3 escitalopram oxalate soln 5 mg/5ml (base equiv) (Lexapro) 1 escitalopram oxalate tab 10 mg (base equiv) (Lexapro) 1 escitalopram oxalate tab 20 mg (base equiv) (Lexapro) FETZIMA TITRATION PACK levomilnacipran hcl cap sr 24hr 20 & 40 mg therapy pack 3 • FLUOXETINE HCL - fluoxetine hcl tab 60 mg 3 • fluoxetine hcl cap delayed release 90 mg (Prozac weekly) 1 fluoxetine hcl cap 10 mg (Prozac) 1 fluoxetine hcl cap 20 mg (Prozac) 1 fluoxetine hcl cap 40 mg (Prozac) 1 fluoxetine hcl solution 20 mg/5ml 1 fluoxetine hcl tab 10 mg 1 fluoxetine hcl tab 20 mg 1 • fluvoxamine maleate cap sr 24hr 100 mg (Luvox cr) 1 • fluvoxamine maleate cap sr 24hr 150 mg (Luvox cr) 1 fluvoxamine maleate tab 100 mg 1 fluvoxamine maleate tab 25 mg 1 fluvoxamine maleate tab 50 mg 1 • FORFIVO XL - bupropion hcl tab sr 24hr 3 450 mg 3 GABOXETINE - fluoxetine hcl cap 10 mg & dietary management cap pack 1 imipramine hcl tab 10 mg (Tofranil) imipramine hcl tab 25 mg (Tofranil) 1 1 imipramine hcl tab 50 mg (Tofranil) 1 1 escitalopram oxalate tab 5 mg (base equiv) (Lexapro) 1 imipramine pamoate cap 100 mg (Tofranil-pm) 1 FETZIMA - levomilnacipran hcl cap sr 24hr 20 mg (base equivalent) 3 • imipramine pamoate cap 125 mg (Tofranil-pm) 1 FETZIMA - levomilnacipran hcl cap sr 24hr 40 mg (base equivalent) 3 • imipramine pamoate cap 150 mg (Tofranil-pm) 1 FETZIMA - levomilnacipran hcl cap sr 24hr 80 mg (base equivalent) 3 • imipramine pamoate cap 75 mg (Tofranil-pm) FETZIMA - levomilnacipran hcl cap sr 24hr 120 mg (base equivalent) 3 84 • KHEDEZLA - desvenlafaxine tab sr 24hr 3 50 mg KHEDEZLA - desvenlafaxine tab sr 24hr 3 100 mg SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare • • • Products January 2015 Quantity Limits 1 Step Therapy doxepin hcl cap 25 mg Drug Name Prior Authorization 1 Drug Tier doxepin hcl cap 150 mg Quantity Limits 1 Step Therapy doxepin hcl cap 100 mg Prior Authorization Drug Name Drug Tier 2015 3 • NORPRAMIN - desipramine hcl tab 10 mg 3 LEXAPRO - escitalopram oxalate tab 10 3 mg (base equiv) LEXAPRO - escitalopram oxalate tab 20 3 mg (base equiv) LEXAPRO - escitalopram oxalate soln 5 3 mg/5ml (base equiv) 3 LUVOX CR - fluvoxamine maleate cap sr 24hr 100 mg 3 LUVOX CR - fluvoxamine maleate cap sr 24hr 150 mg 3 MAPROTILINE HCL - maprotiline hcl tab 25 mg 3 MAPROTILINE HCL - maprotiline hcl tab 50 mg 3 MAPROTILINE HCL - maprotiline hcl tab 75 mg 3 MARPLAN - isocarboxazid tab 10 mg • NORPRAMIN - desipramine hcl tab 25 mg 3 • NORPRAMIN - desipramine hcl tab 50 mg 3 • NORPRAMIN - desipramine hcl tab 75 mg 3 • NORPRAMIN - desipramine hcl tab 100 mg 3 • NORPRAMIN - desipramine hcl tab 150 mg 3 • NORTRIPTYLINE HCL - nortriptyline hcl 2 soln 10 mg/5ml nortriptyline hcl cap 10 mg (Pamelor) 1 LEXAPRO - escitalopram oxalate tab 5 mg (base equiv) • • nortriptyline hcl cap 25 mg (Pamelor) 1 nortriptyline hcl cap 50 mg (Pamelor) 1 nortriptyline hcl cap 75 mg (Pamelor) 1 1 OLEPTRO - trazodone hcl tab sr 24hr 150 mg 3 mirtazapine orally disintegrating tab 15 mg (Remeron soltab) • 1 OLEPTRO - trazodone hcl tab sr 24hr 300 mg 3 mirtazapine orally disintegrating tab 30 mg (Remeron soltab) • 1 PAMELOR - nortriptyline hcl cap 10 mg 3 mirtazapine orally disintegrating tab 45 mg (Remeron soltab) PAMELOR - nortriptyline hcl cap 25 mg 3 mirtazapine tab 15 mg (Remeron) 1 PAMELOR - nortriptyline hcl cap 50 mg 3 mirtazapine tab 30 mg (Remeron) 1 PAMELOR - nortriptyline hcl cap 75 mg 3 mirtazapine tab 45 mg (Remeron) 1 3 mirtazapine tab 7.5 mg 1 PARNATE - tranylcypromine sulfate tab 10 mg 3 paroxetine hcl tab sr 24hr 12.5 mg (Paxil cr) 1 NARDIL - phenelzine sulfate tab 15 mg NEFAZODONE HCL - nefazodone hcl tab 50 mg 3 paroxetine hcl tab sr 24hr 25 mg (Paxil cr) 1 NEFAZODONE HCL - nefazodone hcl tab 100 mg 3 paroxetine hcl tab sr 24hr 37.5 mg (Paxil cr) 1 NEFAZODONE HCL - nefazodone hcl tab 150 mg 3 paroxetine hcl tab 10 mg (Paxil) 1 3 paroxetine hcl tab 20 mg (Paxil) 1 NEFAZODONE HCL - nefazodone hcl tab 200 mg paroxetine hcl tab 30 mg (Paxil) 1 nefazodone hcl tab 250 mg 1 paroxetine hcl tab 40 mg (Paxil) 1 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 85 PAXIL - paroxetine hcl tab 30 mg 3 PAXIL - paroxetine hcl tab 40 mg 3 PAXIL - paroxetine hcl oral susp 10 mg/5ml (base equiv) 3 PAXIL CR - paroxetine hcl tab sr 24hr 12.5 mg 3 • PAXIL CR - paroxetine hcl tab sr 24hr 25 mg 3 • PAXIL CR - paroxetine hcl tab sr 24hr 37.5 mg 3 • PEXEVA - paroxetine mesylate tab 10 mg (base equiv) 3 PEXEVA - paroxetine mesylate tab 20 mg (base equiv) REMERON SOLTAB - mirtazapine orally disintegrating tab 30 mg 3 • REMERON SOLTAB - mirtazapine orally disintegrating tab 45 mg 3 • SENTRAFLOX AM-10 - fluoxetine hcl cap 10 mg & dietary management cap pack 3 SENTRALOPRAM AM-10 - citalopram tab 10 mg & dietary management cap pack 3 SENTRAVIL PM-25 - amitriptyline hcl tab 25 mg & diet manage prod cap pack 3 • SENTROXATINE - fluoxetine hcl cap 10 mg & dietary management cap pack 3 3 • sertraline hcl oral conc 20 mg/ml (Zoloft) 1 PEXEVA - paroxetine mesylate tab 30 mg (base equiv) 3 • sertraline hcl tab 100 mg (Zoloft) 1 1 PEXEVA - paroxetine mesylate tab 40 mg (base equiv) • sertraline hcl tab 25 mg (Zoloft) 3 sertraline hcl tab 50 mg (Zoloft) 1 1 PRISTIQ - desvenlafaxine succinate tab sr 24hr 50 mg (base equiv) 3 • SURMONTIL - trimipramine maleate cap 25 mg 3 phenelzine sulfate tab 15 mg (Nardil) 3 PRISTIQ - desvenlafaxine succinate tab sr 24hr 100 mg (base equiv) 3 • SURMONTIL - trimipramine maleate cap 50 mg SURMONTIL - trimipramine maleate cap 100 mg 3 protriptyline hcl tab 10 mg (Vivactil) 1 TOFRANIL - imipramine hcl tab 10 mg 3 protriptyline hcl tab 5 mg (Vivactil) 1 TOFRANIL - imipramine hcl tab 25 mg 3 PROZAC - fluoxetine hcl cap 10 mg 3 TOFRANIL - imipramine hcl tab 50 mg 3 PROZAC - fluoxetine hcl cap 20 mg 3 PROZAC - fluoxetine hcl cap 40 mg TOFRANIL-PM - imipramine pamoate cap 75 mg 3 3 PROZAC WEEKLY - fluoxetine hcl cap delayed release 90 mg 3 TOFRANIL-PM - imipramine pamoate cap 100 mg 3 REMERON - mirtazapine tab 15 mg 3 3 REMERON - mirtazapine tab 30 mg 3 TOFRANIL-PM - imipramine pamoate cap 125 mg REMERON - mirtazapine tab 45 mg 3 3 REMERON SOLTAB - mirtazapine orally disintegrating tab 15 mg 3 TOFRANIL-PM - imipramine pamoate cap 150 mg tranylcypromine sulfate tab 10 mg (Parnate) 1 86 • • • • • • • • SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits 3 Step Therapy PAXIL - paroxetine hcl tab 20 mg • • • • • Drug Name Prior Authorization 3 Drug Tier PAXIL - paroxetine hcl tab 10 mg Quantity Limits Step Therapy Drug Name Drug Tier Prior Authorization 2015 VIIBRYD - vilazodone hcl tab 10 mg 3 VIIBRYD - vilazodone hcl tab 20 mg 3 VIIBRYD - vilazodone hcl tab 40 mg 3 TRAZAMINE - trazodone hcl tab 50 mg & dietary management cap pack 3 trazodone hcl tab 100 mg 1 trazodone hcl tab 150 mg 1 trazodone hcl tab 300 mg 1 1 VIIBRYD - vilazodone hcl tab starter kit 10 (7) & 20 (7) & 40 (16) mg 3 trazodone hcl tab 50 mg trimipramine maleate cap 100 mg 1 VIVACTIL - protriptyline hcl tab 5 mg 3 trimipramine maleate cap 25 mg 1 VIVACTIL - protriptyline hcl tab 10 mg 3 trimipramine maleate cap 50 mg 1 3 • venlafaxine hcl cap sr 24hr 150 mg (base equivalent) (Effexor xr) 1 WELLBUTRIN - bupropion hcl tab 75 mg 3 • venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) (Effexor xr) 1 WELLBUTRIN - bupropion hcl tab 100 mg 3 • venlafaxine hcl cap sr 24hr 75 mg (base equivalent) (Effexor xr) 1 WELLBUTRIN SR - bupropion hcl tab sr 12hr 100 mg 3 • VENLAFAXINE HCL ER - venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent) 3 WELLBUTRIN SR - bupropion hcl tab sr 12hr 150 mg WELLBUTRIN SR - bupropion hcl tab sr 12hr 200 mg 3 • VENLAFAXINE HCL ER - venlafaxine hcl tab sr 24hr 75 mg (base equivalent) 3 WELLBUTRIN XL - bupropion hcl tab sr 24hr 150 mg 3 • • VENLAFAXINE HCL ER - venlafaxine hcl tab sr 24hr 150 mg (base equivalent) WELLBUTRIN XL - bupropion hcl tab sr 24hr 300 mg 3 3 ZOLOFT - sertraline hcl tab 25 mg 3 3 ZOLOFT - sertraline hcl tab 50 mg 3 VENLAFAXINE HCL ER - venlafaxine hcl tab sr 24hr 225 mg (base equivalent) ZOLOFT - sertraline hcl tab 100 mg 3 3 venlafaxine hcl tab sr 24hr 150 mg (base equivalent) (Venlafaxine hcl er) 1 ZOLOFT - sertraline hcl oral conc 20 mg/ml • • • • venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent) (Venlafaxine hcl er) 1 venlafaxine hcl tab sr 24hr 75 mg (base equivalent) (Venlafaxine hcl er) 1 venlafaxine hcl tab 100 mg 1 venlafaxine hcl tab 25 mg 1 venlafaxine hcl tab 37.5 mg 1 venlafaxine hcl tab 50 mg 1 • • • • Quantity Limits 1 Step Therapy venlafaxine hcl tab 75 mg Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 • • • • ANTIPSYCHOTICS SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare ABILIFY - aripiprazole tab 2 mg 3 ABILIFY - aripiprazole tab 5 mg 3 ABILIFY - aripiprazole tab 10 mg 3 ABILIFY - aripiprazole tab 15 mg 3 ABILIFY - aripiprazole tab 20 mg 3 ABILIFY - aripiprazole tab 30 mg 3 ABILIFY - aripiprazole oral solution 1 mg/ml 3 ABILIFY - aripiprazole im inj 9.75 mg/1.3ml (7.5 mg/ml) 3 Products January 2015 87 FANAPT - iloperidone tab 2 mg 3 FANAPT - iloperidone tab 4 mg 3 FANAPT - iloperidone tab 6 mg 3 FANAPT - iloperidone tab 8 mg 3 FANAPT - iloperidone tab 10 mg 3 FANAPT - iloperidone tab 12 mg 3 3 ABILIFY DISCMELT - aripiprazole orally disintegrating tab 15 mg 3 ABILIFY MAINTENA - aripiprazole im for extended release susp 300 mg 3 ABILIFY MAINTENA - aripiprazole im for extended release susp 400 mg 3 ADASUVE - loxapine aerosol powder breath activated 10 mg 3 CHLORPROMAZINE HCL chlorpromazine hcl inj 25 mg/ml 3 FANAPT TITRATION PACK iloperidone tab 1 mg & 2 mg & 4 mg & 6 mg titration pak 3 chlorpromazine hcl tab 10 mg 1 FAZACLO - clozapine orally disintegrating tab 12.5 mg chlorpromazine hcl tab 100 mg 1 3 chlorpromazine hcl tab 200 mg 1 FAZACLO - clozapine orally disintegrating tab 25 mg 1 FAZACLO - clozapine orally disintegrating tab 100 mg 3 chlorpromazine hcl tab 25 mg chlorpromazine hcl tab 50 mg 1 CLOZAPINE ODT - clozapine orally disintegrating tab 12.5 mg FAZACLO - clozapine orally disintegrating tab 150 mg 3 3 CLOZAPINE ODT - clozapine orally disintegrating tab 25 mg FAZACLO - clozapine orally disintegrating tab 200 mg 3 3 fluphenazine decanoate inj 25 mg/ml 1 CLOZAPINE ODT - clozapine orally disintegrating tab 100 mg 3 FLUPHENAZINE HCL - fluphenazine hcl elixir 2.5 mg/5ml 2 clozapine tab 100 mg (Clozaril) 1 1 FLUPHENAZINE HCL - fluphenazine hcl oral conc 5 mg/ml 2 clozapine tab 200 mg clozapine tab 25 mg (Clozaril) 1 3 clozapine tab 50 mg 1 FLUPHENAZINE HCL - fluphenazine hcl inj 2.5 mg/ml CLOZARIL - clozapine tab 25 mg 3 fluphenazine hcl tab 1 mg 1 CLOZARIL - clozapine tab 100 mg 3 fluphenazine hcl tab 10 mg 1 COMPAZINE - prochlorperazine maleate tab 5 mg 3 fluphenazine hcl tab 2.5 mg 1 fluphenazine hcl tab 5 mg 1 COMPAZINE - prochlorperazine maleate tab 10 mg 3 GEODON - ziprasidone hcl cap 20 mg 3 GEODON - ziprasidone hcl cap 40 mg 3 EQUETRO - carbamazepine (antipsychotic) cap sr 12hr 100 mg 3 GEODON - ziprasidone hcl cap 60 mg 3 3 GEODON - ziprasidone hcl cap 80 mg 3 EQUETRO - carbamazepine (antipsychotic) cap sr 12hr 200 mg 3 EQUETRO - carbamazepine (antipsychotic) cap sr 12hr 300 mg 3 GEODON - ziprasidone mesylate for inj 20 mg (base equivalent) 88 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits 3 3 Step Therapy FANAPT - iloperidone tab 1 mg ABILIFY DISCMELT - aripiprazole orally disintegrating tab 10 mg Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 LATUDA - lurasidone hcl tab 40 mg 3 LATUDA - lurasidone hcl tab 60 mg 3 LATUDA - lurasidone hcl tab 80 mg 3 HALDOL DECANOATE 100 haloperidol decanoate im soln 100 mg/ml 3 HALDOL DECANOATE 50 - haloperidol decanoate im soln 50 mg/ml 3 LATUDA - lurasidone hcl tab 120 mg 3 2 haloperidol decanoate im soln 100 mg/ml (Haldol decanoate 100) 1 LITHIUM - lithium oral solution 8 meq/5ml 2 haloperidol decanoate im soln 50 mg/ml (Haldol decanoate 50) 1 LITHIUM CARBONATE - lithium carbonate cap 150 mg 3 haloperidol lactate inj 5 mg/ml (Haldol) 1 LITHIUM CARBONATE - lithium carbonate cap 600 mg 1 haloperidol lactate oral conc 2 mg/ml 1 lithium carbonate cap 150 mg (Lithium carbonate) haloperidol tab 0.5 mg 1 lithium carbonate cap 300 mg 1 haloperidol tab 1 mg 1 1 haloperidol tab 10 mg 1 lithium carbonate cap 600 mg (Lithium carbonate) 1 lithium carbonate tab cr 300 mg (Lithobid) 1 haloperidol tab 2 mg haloperidol tab 20 mg 1 lithium carbonate tab cr 450 mg 1 haloperidol tab 5 mg 1 lithium carbonate tab 300 mg 1 INVEGA - paliperidone tab sr 24hr 1.5 mg 3 INVEGA - paliperidone tab sr 24hr 3 mg 3 INVEGA - paliperidone tab sr 24hr 6 mg 3 INVEGA - paliperidone tab sr 24hr 9 mg 3 INVEGA SUSTENNA - paliperidone palmitate im extended-release susp 39 mg/0.25ml 3 INVEGA SUSTENNA - paliperidone palmitate im extended-release susp 78 mg/0.5ml 3 INVEGA SUSTENNA - paliperidone palmitate im extend-release susp 117 mg/0.75ml 3 INVEGA SUSTENNA - paliperidone palmitate im extended-release susp 156 mg/ml 3 INVEGA SUSTENNA - paliperidone palmitate im extended-release susp 234 mg/1.5ml 3 Quantity Limits 3 3 Step Therapy LATUDA - lurasidone hcl tab 20 mg HALDOL - haloperidol lactate inj 5 mg/ ml Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 LITHOBID - lithium carbonate tab cr 300 3 mg 1 loxapine succinate cap 10 mg SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare loxapine succinate cap 25 mg 1 loxapine succinate cap 5 mg 1 loxapine succinate cap 50 mg 1 LOXITANE - loxapine succinate cap 5 mg 3 LOXITANE - loxapine succinate cap 10 mg 3 LOXITANE - loxapine succinate cap 25 mg 3 LOXITANE - loxapine succinate cap 50 mg 3 olanzapine for im inj 10 mg (Zyprexa) 1 olanzapine orally disintegrating tab 10 mg (Zyprexa zydis) 1 Products January 2015 89 RISPERDAL - risperidone tab 3 mg 3 RISPERDAL - risperidone tab 4 mg 3 RISPERDAL - risperidone soln 1 mg/ml 3 RISPERDAL CONSTA - risperidone microspheres for inj 12.5 mg 3 RISPERDAL CONSTA - risperidone microspheres for inj 25 mg 3 RISPERDAL CONSTA - risperidone microspheres for inj 37.5 mg 3 RISPERDAL CONSTA - risperidone microspheres for inj 50 mg 3 RISPERDAL M-TAB - risperidone orally disintegrating tab 0.5 mg 3 RISPERDAL M-TAB - risperidone orally disintegrating tab 1 mg 3 olanzapine orally disintegrating tab 20 mg (Zyprexa zydis) 1 olanzapine orally disintegrating tab 5 mg (Zyprexa zydis) 1 olanzapine tab 10 mg (Zyprexa) 1 olanzapine tab 15 mg (Zyprexa) 1 olanzapine tab 2.5 mg (Zyprexa) 1 olanzapine tab 20 mg (Zyprexa) 1 olanzapine tab 5 mg (Zyprexa) 1 olanzapine tab 7.5 mg (Zyprexa) 1 perphenazine tab 16 mg 1 perphenazine tab 2 mg 1 perphenazine tab 4 mg 1 perphenazine tab 8 mg 1 prochlorperazine edisylate inj 5 mg/ ml RISPERDAL M-TAB - risperidone orally disintegrating tab 2 mg 3 1 prochlorperazine maleate tab 10 mg (Compazine) RISPERDAL M-TAB - risperidone orally disintegrating tab 3 mg 3 1 prochlorperazine maleate tab 5 mg (Compazine) RISPERDAL M-TAB - risperidone orally disintegrating tab 4 mg 3 1 1 prochlorperazine suppos 25 mg 1 risperidone orally disintegrating tab 0.25 mg quetiapine fumarate tab 100 mg (Seroquel) 1 risperidone orally disintegrating tab 0.5 mg (Risperdal m-tab) 1 quetiapine fumarate tab 200 mg (Seroquel) 1 risperidone orally disintegrating tab 1 mg (Risperdal m-tab) 1 quetiapine fumarate tab 25 mg (Seroquel) 1 risperidone orally disintegrating tab 2 mg (Risperdal m-tab) 1 quetiapine fumarate tab 300 mg (Seroquel) 1 risperidone orally disintegrating tab 3 mg (Risperdal m-tab) 1 quetiapine fumarate tab 400 mg (Seroquel) 1 risperidone orally disintegrating tab 4 mg (Risperdal m-tab) 1 quetiapine fumarate tab 50 mg (Seroquel) 1 risperidone soln 1 mg/ml (Risperdal) 1 risperidone tab 0.25 mg (Risperdal) 1 RISPERDAL - risperidone tab 0.25 mg 3 risperidone tab 0.5 mg (Risperdal) 1 RISPERDAL - risperidone tab 0.5 mg 3 risperidone tab 1 mg (Risperdal) 1 RISPERDAL - risperidone tab 1 mg 3 risperidone tab 2 mg (Risperdal) 1 90 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits 3 1 Step Therapy RISPERDAL - risperidone tab 2 mg olanzapine orally disintegrating tab 15 mg (Zyprexa zydis) Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 1 risperidone tab 4 mg (Risperdal) 1 trifluoperazine hcl tab 5 mg 1 SAPHRIS - asenapine maleate sl tab 5 mg (base equiv) 3 VERSACLOZ - clozapine susp 50 mg/ml 3 1 ziprasidone hcl cap 20 mg (Geodon) SAPHRIS - asenapine maleate sl tab 10 mg (base equiv) 3 SEROQUEL - quetiapine fumarate tab 25 mg 3 SEROQUEL - quetiapine fumarate tab 50 mg 3 SEROQUEL - quetiapine fumarate tab 100 mg 3 SEROQUEL - quetiapine fumarate tab 200 mg 3 SEROQUEL - quetiapine fumarate tab 300 mg 3 SEROQUEL - quetiapine fumarate tab 400 mg 3 SEROQUEL XR - quetiapine fumarate tab sr 24hr 50 mg 2 SEROQUEL XR - quetiapine fumarate tab sr 24hr 150 mg 2 SEROQUEL XR - quetiapine fumarate tab sr 24hr 200 mg 2 SEROQUEL XR - quetiapine fumarate tab sr 24hr 300 mg 2 SEROQUEL XR - quetiapine fumarate tab sr 24hr 400 mg 2 thioridazine hcl tab 10 mg 1 thioridazine hcl tab 100 mg 1 thioridazine hcl tab 25 mg 1 thioridazine hcl tab 50 mg ziprasidone hcl cap 40 mg (Geodon) 1 ziprasidone hcl cap 60 mg (Geodon) 1 ziprasidone hcl cap 80 mg (Geodon) 1 ZYPREXA - olanzapine tab 2.5 mg 3 ZYPREXA - olanzapine tab 5 mg 3 ZYPREXA - olanzapine tab 7.5 mg 3 ZYPREXA - olanzapine tab 10 mg 3 ZYPREXA - olanzapine tab 15 mg 3 ZYPREXA - olanzapine tab 20 mg 3 ZYPREXA - olanzapine for im inj 10 mg 3 ZYPREXA RELPREVV - olanzapine pamoate for extended rel im susp 210 mg (base eq) 3 ZYPREXA RELPREVV - olanzapine pamoate for extended rel im susp 300 mg (base eq) 3 ZYPREXA RELPREVV - olanzapine pamoate for extended rel im susp 405 mg (base eq) 3 ZYPREXA ZYDIS - olanzapine orally disintegrating tab 5 mg 3 ZYPREXA ZYDIS - olanzapine orally disintegrating tab 10 mg 3 ZYPREXA ZYDIS - olanzapine orally disintegrating tab 15 mg 3 3 1 ZYPREXA ZYDIS - olanzapine orally disintegrating tab 20 mg thiothixene cap 1 mg 1 HYPNOTICS thiothixene cap 10 mg 1 AMBIEN - zolpidem tartrate tab 5 mg 3 thiothixene cap 2 mg 1 AMBIEN - zolpidem tartrate tab 10 mg 3 thiothixene cap 5 mg 1 3 trifluoperazine hcl tab 1 mg 1 AMBIEN CR - zolpidem tartrate tab cr 6.25 mg 1 AMBIEN CR - zolpidem tartrate tab cr 12.5 mg 3 trifluoperazine hcl tab 10 mg SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits trifluoperazine hcl tab 2 mg Step Therapy 1 Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy risperidone tab 3 mg (Risperdal) Prior Authorization Drug Name Drug Tier 2015 91 AMYTAL SODIUM - amobarbital sodium 3 for inj 500 mg 3 BUTISOL SODIUM - butabarbital sodium tab 30 mg 3 BUTISOL SODIUM - butabarbital sodium tab 50 mg 3 BUTISOL SODIUM - butabarbital sodium elixir 30 mg/5ml 3 DORAL - quazepam tab 15 mg NEMBUTAL SODIUM - pentobarbital sodium inj 50 mg/ml 3 PHENOBARBITAL - phenobarbital tab 15 mg 3 PHENOBARBITAL - phenobarbital tab 30 mg 3 PHENOBARBITAL - phenobarbital tab 60 mg 3 PHENOBARBITAL - phenobarbital tab 64.8 mg 3 EDLUAR - zolpidem tartrate sl tab 5 mg 3 EDLUAR - zolpidem tartrate sl tab 10 mg 3 PHENOBARBITAL - phenobarbital tab 97.2 mg 3 estazolam tab 1 mg 1 3 estazolam tab 2 mg 1 PHENOBARBITAL - phenobarbital tab 100 mg 1 phenobarbital elixir 20 mg/5ml 1 eszopiclone tab 1 mg (Lunesta) 1 PHENOBARBITAL SODIUM phenobarbital sodium inj 65 mg/ml 3 eszopiclone tab 2 mg (Lunesta) eszopiclone tab 3 mg (Lunesta) 1 FLURAZEPAM HCL - flurazepam hcl cap 15 mg PHENOBARBITAL SODIUM phenobarbital sodium inj 130 mg/ml 3 3 phenobarbital tab 16.2 mg 1 FLURAZEPAM HCL - flurazepam hcl cap 30 mg 3 phenobarbital tab 32.4 mg 1 1 QUAZEPAM - quazepam tab 15 mg 3 flurazepam hcl cap 15 mg 1 RESTORIL - temazepam cap 7.5 mg 3 flurazepam hcl cap 30 mg RESTORIL - temazepam cap 15 mg 3 RESTORIL - temazepam cap 22.5 mg 3 RESTORIL - temazepam cap 30 mg 3 GABAZOLPIDEM-5 - zolpidem tab 5 mg 3 & dietary management cap pack 3 HALCION - triazolam tab 0.25 mg HETLIOZ - tasimelteon capsule 20 mg 3 ROZEREM - ramelteon tab 8 mg 3 INTERMEZZO - zolpidem tartrate sl tab 1.75 mg 3 SECONAL - secobarbital sodium cap 100 mg 3 INTERMEZZO - zolpidem tartrate sl tab 3.5 mg 3 3 LUMINAL - phenobarbital sodium inj 130 mg/ml 3 SENTRAZOLPIDEM PM-5 - zolpidem tab 5 mg & dietary management cap pack LUNESTA - eszopiclone tab 1 mg 3 LUNESTA - eszopiclone tab 2 mg 3 LUNESTA - eszopiclone tab 3 mg 3 NEMBUTAL - pentobarbital sodium inj 50 mg/ml 3 92 SILENOR - doxepin hcl (sleep) tab 3 mg 3 (base equiv) SILENOR - doxepin hcl (sleep) tab 6 mg 3 (base equiv) 3 SONATA - zaleplon cap 5 mg SONATA - zaleplon cap 10 mg SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare 3 Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 STRAZEPAM - temazepam cap 15mg & 3 dietary management cap pack 1 temazepam cap 15 mg (Restoril) ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr 15 mg 3 temazepam cap 22.5 mg (Restoril) 1 3 temazepam cap 30 mg (Restoril) 1 ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr 20 mg temazepam cap 7.5 mg (Restoril) 1 1 triazolam tab 0.25 mg (Halcion) 1 ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr 25 mg 3 triazolam tab 0.125 mg zaleplon cap 10 mg (Sonata) 1 3 zaleplon cap 5 mg (Sonata) 1 ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr 30 mg zolpidem tartrate tab cr 12.5 mg (Ambien cr) 1 amphetamine-dextroamphetamine cap sr 24hr 10 mg (Adderall xr) 1 zolpidem tartrate tab cr 6.25 mg (Ambien cr) 1 amphetamine-dextroamphetamine cap sr 24hr 15 mg (Adderall xr) 1 zolpidem tartrate tab 10 mg (Ambien) 1 1 amphetamine-dextroamphetamine cap sr 24hr 20 mg (Adderall xr) 1 zolpidem tartrate tab 5 mg (Ambien) ZOLPIMIST - zolpidem tartrate oral spray 5 mg/act 3 amphetamine-dextroamphetamine cap sr 24hr 25 mg (Adderall xr) 1 amphetamine-dextroamphetamine cap sr 24hr 30 mg (Adderall xr) 1 amphetamine-dextroamphetamine cap sr 24hr 5 mg (Adderall xr) 1 amphetamine-dextroamphetamine tab 10 mg (Adderall) 1 amphetamine-dextroamphetamine tab 12.5 mg (Adderall) 1 amphetamine-dextroamphetamine tab 15 mg (Adderall) 1 amphetamine-dextroamphetamine tab 20 mg (Adderall) 1 amphetamine-dextroamphetamine tab 30 mg (Adderall) 1 amphetamine-dextroamphetamine tab 5 mg (Adderall) 1 amphetamine-dextroamphetamine tab 7.5 mg (Adderall) 1 CAFCIT - caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv) 3 ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ ANOREXIANTS 3 ADDERALL - amphetaminedextroamphetamine tab 5 mg 3 ADDERALL - amphetaminedextroamphetamine tab 7.5 mg 3 ADDERALL - amphetaminedextroamphetamine tab 10 mg 3 ADDERALL - amphetaminedextroamphetamine tab 12.5 mg 3 ADDERALL - amphetaminedextroamphetamine tab 15 mg 3 ADDERALL - amphetaminedextroamphetamine tab 20 mg 3 ADDERALL - amphetaminedextroamphetamine tab 30 mg 3 ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr 5 mg 3 ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr 10 mg SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 93 caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv) (Cafcit) 1 dexmethylphenidate hcl tab 2.5 mg (Focalin) 1 CAFFEINE/SODIUM BENZOATE caffeine & sodium benzoate inj 125-125 mg/ml (500 mg/2ml) 3 dexmethylphenidate hcl tab 5 mg (Focalin) 1 clonidine hcl tab sr 12hr 0.1 mg (Kapvay) dextroamphetamine sulfate cap sr 24hr 10 mg (Dexedrine) 1 1 3 dextroamphetamine sulfate cap sr 24hr 15 mg (Dexedrine) 1 CONCERTA - methylphenidate hcl tab sa osm 18 mg CONCERTA - methylphenidate hcl tab sa osm 27 mg dextroamphetamine sulfate cap sr 24hr 5 mg (Dexedrine) 1 3 CONCERTA - methylphenidate hcl tab sa osm 36 mg dextroamphetamine sulfate oral solution 5 mg/5ml (Procentra) 1 3 CONCERTA - methylphenidate hcl tab sa osm 54 mg dextroamphetamine sulfate tab 10 mg 1 3 dextroamphetamine sulfate tab 5 mg 1 DAYTRANA - methylphenidate td patch 10 mg/9hr 3 FOCALIN - dexmethylphenidate hcl tab 2.5 mg 3 DAYTRANA - methylphenidate td patch 15 mg/9hr 3 FOCALIN - dexmethylphenidate hcl tab 5 mg 3 DAYTRANA - methylphenidate td patch 20 mg/9hr 3 FOCALIN - dexmethylphenidate hcl tab 10 mg 3 DAYTRANA - methylphenidate td patch 30 mg/9hr 3 FOCALIN XR - dexmethylphenidate hcl cap sr 24 hr 5 mg 3 DESOXYN - methamphetamine hcl tab 5 mg 3 FOCALIN XR - dexmethylphenidate hcl cap sr 24 hr 10 mg 3 DEXEDRINE - dextroamphetamine sulfate cap sr 24hr 5 mg 3 FOCALIN XR - dexmethylphenidate hcl cap sr 24 hr 15 mg 3 DEXEDRINE - dextroamphetamine sulfate cap sr 24hr 10 mg 3 FOCALIN XR - dexmethylphenidate hcl cap sr 24 hr 20 mg 3 DEXEDRINE - dextroamphetamine sulfate cap sr 24hr 15 mg 3 FOCALIN XR - dexmethylphenidate hcl cap sr 24 hr 25 mg 3 dexmethylphenidate hcl cap sr 24 hr 15 mg (Focalin xr) 1 FOCALIN XR - dexmethylphenidate hcl cap sr 24 hr 30 mg 3 dexmethylphenidate hcl cap sr 24 hr 30 mg (Focalin xr) 1 FOCALIN XR - dexmethylphenidate hcl cap sr 24 hr 35 mg 3 dexmethylphenidate hcl cap sr 24 hr 40 mg (Focalin xr) 1 FOCALIN XR - dexmethylphenidate hcl cap sr 24 hr 40 mg 3 dexmethylphenidate hcl tab 10 mg (Focalin) 1 INTUNIV - guanfacine hcl tab sr 24hr 1 mg (base equiv) 2 94 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 INTUNIV - guanfacine hcl tab sr 24hr 2 mg (base equiv) 2 methylphenidate hcl cap cr 40 mg (Metadate cd) 1 INTUNIV - guanfacine hcl tab sr 24hr 3 mg (base equiv) 2 methylphenidate hcl cap cr 50 mg (Metadate cd) 1 INTUNIV - guanfacine hcl tab sr 24hr 4 mg (base equiv) 2 methylphenidate hcl cap cr 60 mg (Metadate cd) 1 KAPVAY - clonidine hcl tab sr 12hr 0.1 mg 3 methylphenidate hcl cap sr 24hr 20 mg (Ritalin la) 1 KAPVAY DOSE PACK - clonidine hcl tab sr 12hr therapy pack 0.1 & 0.2 mg 3 methylphenidate hcl cap sr 24hr 30 mg (Ritalin la) 1 METADATE CD - methylphenidate hcl cap cr 10 mg 3 methylphenidate hcl cap sr 24hr 40 mg (Ritalin la) 1 METADATE CD - methylphenidate hcl cap cr 20 mg 3 METHYLPHENIDATE HCL ER methylphenidate hcl tab cr 10 mg 3 METADATE CD - methylphenidate hcl cap cr 30 mg 3 methylphenidate hcl soln 10 mg/5ml (Methylin) 1 METADATE CD - methylphenidate hcl cap cr 40 mg 3 methylphenidate hcl soln 5 mg/5ml (Methylin) 1 METADATE CD - methylphenidate hcl cap cr 50 mg 3 methylphenidate hcl tab cr 20 mg (Ritalin sr) 1 METADATE CD - methylphenidate hcl cap cr 60 mg 3 methylphenidate hcl tab sa osm 18 mg (Concerta) 1 methamphetamine hcl tab 5 mg (Desoxyn) 1 methylphenidate hcl tab sa osm 27 mg (Concerta) 1 METHYLIN - methylphenidate hcl chew tab 2.5 mg 3 methylphenidate hcl tab sa osm 36 mg (Concerta) 1 METHYLIN - methylphenidate hcl chew tab 5 mg 3 methylphenidate hcl tab sa osm 54 mg (Concerta) 1 METHYLIN - methylphenidate hcl chew tab 10 mg 3 methylphenidate hcl tab 10 mg (Ritalin) 1 METHYLIN - methylphenidate hcl soln 5 mg/5ml 3 methylphenidate hcl tab 20 mg (Ritalin) 1 METHYLIN - methylphenidate hcl soln 10 mg/5ml 3 methylphenidate hcl tab 5 mg (Ritalin) 1 methylphenidate hcl cap cr 10 mg (Metadate cd) 1 modafinil tab 100 mg (Provigil) 1 modafinil tab 200 mg (Provigil) 1 methylphenidate hcl cap cr 20 mg (Metadate cd) 1 NUVIGIL - armodafinil tab 50 mg 3 1 NUVIGIL - armodafinil tab 150 mg 3 methylphenidate hcl cap cr 30 mg (Metadate cd) NUVIGIL - armodafinil tab 200 mg 3 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 95 2 3 VYVANSE - lisdexamfetamine dimesylate cap 20 mg 2 PROVIGIL - modafinil tab 100 mg 3 VYVANSE - lisdexamfetamine dimesylate cap 30 mg PROVIGIL - modafinil tab 200 mg 3 2 QUILLIVANT XR - methylphenidate hcl for er susp 25 mg/5ml (5 mg/ml) 3 VYVANSE - lisdexamfetamine dimesylate cap 40 mg 2 RITALIN - methylphenidate hcl tab 5 mg 3 VYVANSE - lisdexamfetamine dimesylate cap 50 mg 3 VYVANSE - lisdexamfetamine dimesylate cap 60 mg 2 RITALIN - methylphenidate hcl tab 10 mg 3 VYVANSE - lisdexamfetamine dimesylate cap 70 mg 2 RITALIN - methylphenidate hcl tab 20 mg 3 ZENZEDI - dextroamphetamine sulfate tab 2.5 mg 3 RITALIN LA - methylphenidate hcl cap sr 24hr 10 mg 3 ZENZEDI - dextroamphetamine sulfate tab 7.5 mg 3 RITALIN LA - methylphenidate hcl cap sr 24hr 20 mg 3 ZENZEDI - dextroamphetamine sulfate tab 15 mg 3 RITALIN LA - methylphenidate hcl cap sr 24hr 30 mg 3 ZENZEDI - dextroamphetamine sulfate tab 20 mg 3 RITALIN LA - methylphenidate hcl cap sr 24hr 40 mg 3 ZENZEDI - dextroamphetamine sulfate tab 30 mg 3 RITALIN SR - methylphenidate hcl tab cr 20 mg SENTRAMODAFIN AM-100 - modafinil tab 100 mg & dietary management cap pack 3 STRATTERA - atomoxetine hcl cap 10 mg (base equiv) 3 STRATTERA - atomoxetine hcl cap 18 mg (base equiv) 3 STRATTERA - atomoxetine hcl cap 25 mg (base equiv) 3 STRATTERA - atomoxetine hcl cap 40 mg (base equiv) 3 STRATTERA - atomoxetine hcl cap 60 mg (base equiv) PSYCHOTHERAPEUTIC and NEUROLOGICAL AGENTS - MISC. 1 acamprosate calcium tab delayed release 333 mg (Campral) 3 ACTIVE-PAC/GABAPENTIN gabapentin oral cap 300 mg & lidocaine-menthol gel ther pk AMPYRA - dalfampridine tab sr 12hr 10 5 • mg 3 ANTABUSE - disulfiram tab 250 mg ANTABUSE - disulfiram tab 500 mg 3 3 ARICEPT - donepezil hydrochloride tab 5 mg 3 STRATTERA - atomoxetine hcl cap 80 mg (base equiv) 3 ARICEPT - donepezil hydrochloride tab 10 mg 3 STRATTERA - atomoxetine hcl cap 100 mg (base equiv) 3 ARICEPT - donepezil hydrochloride tab 23 mg 3 96 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier PROCENTRA - dextroamphetamine sulfate oral solution 5 mg/5ml Quantity Limits 3 Step Therapy NUVIGIL - armodafinil tab 250 mg Prior Authorization Drug Name Drug Tier 2015 ARICEPT ODT - donepezil hydrochloride orally disintegrating tab 5 mg 3 ARICEPT ODT - donepezil hydrochloride orally disintegrating tab 10 mg 3 AUBAGIO - teriflunomide tab 7 mg 5 AUBAGIO - teriflunomide tab 14 mg 5 AVONEX - interferon beta-1a for im inj kit 30mcg (33mcg(6.6 mu)/vial) 5 • • • AVONEX - interferon beta-1a im inj kit 30 mcg/0.5ml 5 AVONEX PEN - interferon beta-1a im inj 5 kit 30 mcg/0.5ml BETASERON - interferon beta-1b for inj 4 kit 0.3 mg 3 BRISDELLE - paroxetine mesylate cap 7.5 mg (base equiv) 1 bupropion hcl (smoking deterrent) tab sr 12hr 150 mg (Zyban) 3 CAMPRAL - acamprosate calcium tab delayed release 333 mg 2 CHANTIX - varenicline tartrate tab 0.5 mg (base equiv) CHANTIX - varenicline tartrate tab 1 mg 2 (base equiv) 2 CHANTIX CONTINUING MONTH varenicline tartrate tab 1 mg (base equiv) 2 CHANTIX STARTING MONTH PA varenicline tartrate tab 0.5 mg x 11 & tab 1 mg x 42 pack 3 CHLORDIAZEPOXIDE/AMITRIPT chlordiazepoxide-amitriptyline tab 5-12.5 mg 3 CHLORDIAZEPOXIDE/AMITRIPT chlordiazepoxide-amitriptyline tab 10-25 mg COMMIT - nicotine polacrilex lozenge 2 3 mg COMMIT - nicotine polacrilex lozenge 4 mg 3 COPAXONE - glatiramer acetate soln prefilled syringe 40 mg/ml 4 • COPAXONE - glatiramer acetate inj kit 20 mg/ml 4 • disulfiram tab 250 mg (Antabuse) 1 disulfiram tab 500 mg (Antabuse) 1 1 • donepezil hydrochloride orally disintegrating tab 10 mg (Aricept odt) 1 • donepezil hydrochloride orally disintegrating tab 5 mg 1 • donepezil hydrochloride tab 10 mg (Aricept) donepezil hydrochloride tab 23 mg (Aricept) 1 donepezil hydrochloride tab 5 mg (Aricept) 1 ergoloid mesylates tab 1 mg 1 EXELON - rivastigmine td patch 24hr 4.6 mg/24hr 3 EXELON - rivastigmine td patch 24hr 9.5 mg/24hr 3 EXELON - rivastigmine td patch 24hr 13.3 mg/24hr 3 EXELON - rivastigmine tartrate cap 1.5 mg 3 EXELON - rivastigmine tartrate cap 3 mg 3 EXELON - rivastigmine tartrate cap 4.5 mg 3 EXELON - rivastigmine tartrate cap 6 mg 3 EXELON - rivastigmine tartrate soln 2 mg/ml 3 EXTAVIA - interferon beta-1b for inj kit 0.3 mg 5 fluoxetine hcl (pmdd) cap 10 mg 1 fluoxetine hcl (pmdd) cap 20 mg 1 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 • 97 galantamine hydrobromide cap sr 24hr 16 mg (Razadyne er) 1 NAMENDA XR - memantine hcl cap sr 24hr 28 mg 2 galantamine hydrobromide cap sr 24hr 24 mg (Razadyne er) 1 2 galantamine hydrobromide cap sr 24hr 8 mg (Razadyne er) 1 NAMENDA XR TITRATION PACK memantine hcl cap sr 24hr 7 mg & 14 mg & 21 mg & 28 mg pack 3 galantamine hydrobromide oral soln 4 mg/ml (Razadyne) 1 NICODERM CQ - nicotine td patch 24hr 7 mg/24hr 3 galantamine hydrobromide tab 12 mg (Razadyne) 1 NICODERM CQ - nicotine td patch 24hr 14 mg/24hr 3 galantamine hydrobromide tab 4 mg (Razadyne) 1 NICODERM CQ - nicotine td patch 24hr 21 mg/24hr 3 galantamine hydrobromide tab 8 mg (Razadyne) 1 NICORETTE - nicotine polacrilex gum 2 mg 3 GILENYA - fingolimod hcl cap 0.5 mg (base equiv) 5 NICORETTE - nicotine polacrilex gum 4 mg 3 GRALISE - gabapentin (phn) tab 300 mg 3 NICORETTE - nicotine polacrilex lozenge 2 mg 3 GRALISE - gabapentin (phn) tab 600 mg 3 NICORETTE - nicotine polacrilex lozenge 4 mg 3 GRALISE STARTER - gabapentin (phn) tab starter pack 300 mg (9) & 600 mg (69) 3 NICORETTE MINI - nicotine polacrilex lozenge 2 mg NICORETTE MINI - nicotine polacrilex lozenge 4 mg 3 HORIZANT - gabapentin enacarbil tab cr 300 mg 3 NICORETTE STARTER KIT - nicotine polacrilex gum 2 mg 3 HORIZANT - gabapentin enacarbil tab cr 600 mg 3 NICORETTE STARTER KIT - nicotine polacrilex gum 4 mg 3 NAMENDA - memantine hcl tab 5 mg 2 nicotine polacrilex gum 2 mg 1 NAMENDA - memantine hcl tab 10 mg 2 nicotine polacrilex gum 4 mg 1 NAMENDA - memantine hcl oral solution 2 mg/ml 2 nicotine polacrilex lozenge 2 mg 1 nicotine polacrilex lozenge 4 mg 1 NAMENDA TITRATION PAK memantine hcl tab 5 mg (28) & 10 mg (21) titration pak 2 nicotine td patch 24hr 14 mg/24hr 1 nicotine td patch 24hr 21 mg/24hr 1 NAMENDA XR - memantine hcl cap sr 24hr 7 mg 2 nicotine td patch 24hr 7 mg/24hr 1 3 NAMENDA XR - memantine hcl cap sr 24hr 14 mg 2 NICOTINE TRANSDERMAL SYST nicotine td patch 24 hr kit 21-14-7 mg/24hr NAMENDA XR - memantine hcl cap sr 24hr 21 mg 2 NICOTROL INHALER - nicotine inhaler system 10 mg (4 mg delivered) 2 98 • SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 NICOTROL NS - nicotine nasal spray 10 2 mg/ml (0.5 mg/spray) 2 NUEDEXTA - dextromethorphan hbrquinidine sulfate cap 20-10 mg 1 olanzapine-fluoxetine hcl cap 12-25 mg (Symbyax) 1 olanzapine-fluoxetine hcl cap 12-50 mg (Symbyax) 1 olanzapine-fluoxetine hcl cap 3-25 mg (Symbyax) 1 olanzapine-fluoxetine hcl cap 6-25 mg (Symbyax) 1 olanzapine-fluoxetine hcl cap 6-50 mg (Symbyax) 2 ORAP - pimozide tab 1 mg RAZADYNE - galantamine hydrobromide tab 4 mg 3 RAZADYNE - galantamine hydrobromide tab 8 mg 3 RAZADYNE - galantamine hydrobromide tab 12 mg 3 RAZADYNE - galantamine hydrobromide oral soln 4 mg/ml 3 RAZADYNE ER - galantamine hydrobromide cap sr 24hr 8 mg 3 RAZADYNE ER - galantamine hydrobromide cap sr 24hr 16 mg 3 RAZADYNE ER - galantamine hydrobromide cap sr 24hr 24 mg 3 REBIF - interferon beta-1a inj 22 mcg/0.5ml (12mu/ml) (44 mcg/ml) 4 • ORAP - pimozide tab 2 mg 2 PERPHENAZINE/AMITRIPTYLIN perphenazine-amitriptyline tab 2-10 mg 3 REBIF - interferon beta-1a inj 44 mcg/0.5ml (24mu/ml) (88 mcg/ml) 4 • 4 • PERPHENAZINE/AMITRIPTYLIN perphenazine-amitriptyline tab 2-25 mg 3 REBIF REBIDOSE - interferon beta-1a inj 22 mcg/0.5ml (12mu/ml) (44 mcg/ ml) 4 • PERPHENAZINE/AMITRIPTYLIN perphenazine-amitriptyline tab 4-10 mg 3 REBIF REBIDOSE - interferon beta-1a inj 44 mcg/0.5ml (24mu/ml) (88 mcg/ ml) 4 • PERPHENAZINE/AMITRIPTYLIN perphenazine-amitriptyline tab 4-25 mg 3 REBIF REBIDOSE TITRATION interferon beta-1a inj 6 x 8.8 mcg/0.2ml & 6 x 22 mcg/0.5ml 4 • PERPHENAZINE/AMITRIPTYLIN perphenazine-amitriptyline tab 4-50 mg 3 REBIF TITRATION PACK - interferon beta-1a inj 6 x 8.8 mcg/0.2ml & 6 x 22 mcg/0.5ml 1 PLEGRIDY - peginterferon beta-1a soln pen-injector 125 mcg/0.5ml 4 • rivastigmine tartrate cap 1.5 mg (Exelon) 1 PLEGRIDY - peginterferon beta-1a soln prefilled syringe 125 mcg/0.5ml 4 • rivastigmine tartrate cap 3 mg (Exelon) 1 PLEGRIDY STARTER PACK peginterferon beta-1a soln pen-inj 63 & 94 mcg/0.5ml pack 4 • rivastigmine tartrate cap 4.5 mg (Exelon) rivastigmine tartrate cap 6 mg (Exelon) 1 PLEGRIDY STARTER PACK peginterferon beta-1a soln pref syr 63 & 94 mcg/0.5ml pack 4 SARAFEM - fluoxetine hcl (pmdd) tab 10 mg 3 • SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 99 SARAFEM - fluoxetine hcl (pmdd) tab 20 mg 3 SAVELLA - milnacipran hcl tab 12.5 mg 3 SAVELLA - milnacipran hcl tab 25 mg 3 SAVELLA - milnacipran hcl tab 50 mg 3 SAVELLA - milnacipran hcl tab 100 mg 3 SAVELLA TITRATION PACK milnacipran hcl tab 12.5 mg (5) & 25 mg (8) & 50 mg (42) pak 3 SYMBYAX - olanzapine-fluoxetine hcl cap 3-25 mg 3 SYMBYAX - olanzapine-fluoxetine hcl cap 6-25 mg 3 SYMBYAX - olanzapine-fluoxetine hcl cap 6-50 mg ALAGESIC LQ - butalbitalacetaminophen-caffeine soln 50-325-40 mg/15ml 3 ALPAIN - phenyltoloxamineacetaminophen tab 60-500 mg 3 aspirin buffered (ca carb-mg carbmg ox) tab 325 mg 1 aspirin chew tab 81 mg 1 ASPIRIN LOW DOSE - aspirin tab 81 mg 3 aspirin tab delayed release 325 mg 1 aspirin tab delayed release 81 mg 1 aspirin tab 325 mg 1 3 aspirin tab 81 mg 1 3 BIOREGESIC - phenyltoloxamineacetaminophen tab 50-650 mg 3 SYMBYAX - olanzapine-fluoxetine hcl cap 12-25 mg 3 BUFFERIN - aspirin buffered (ca carbmg carb-mg ox) tab 325 mg 3 SYMBYAX - olanzapine-fluoxetine hcl cap 12-50 mg TECFIDERA - dimethyl fumarate capsule delayed release 120 mg • BUFFERIN LOW DOSE - aspirin buffered (ca carb-mg carb-mg ox) tab 81 mg 3 4 TECFIDERA - dimethyl fumarate capsule delayed release 240 mg 4 • BUPAP - butalbital-acetaminophen tab 50-300 mg 3 TECFIDERA STARTER PACK dimethyl fumarate capsule dr starter pack 120 mg & 240 mg 4 • BUPAP - butalbital-acetaminophen tab 50-650 mg 3 4 butalbital-acetaminophen tab 50-325 mg 1 XENAZINE - tetrabenazine tab 12.5 mg XENAZINE - tetrabenazine tab 25 mg 4 1 XYREM - sodium oxybate oral solution 500 mg/ml 5 butalbital-acetaminophen tab 50-650 mg 1 ZYBAN - bupropion hcl (smoking deterrent) tab sr 12hr 150 mg 3 butalbital-acetaminophen-caffeine cap 50-300-40 mg (Fioricet) butalbital-acetaminophen-caffeine cap 50-325-40 mg 1 butalbital-acetaminophen-caffeine cap 50-500-40 mg 1 butalbital-acetaminophen-caffeine tab 50-325-40 mg (Esgic) 1 butalbital-acetaminophen-caffeine tab 50-500-40 mg 1 ANALGESICS AND ANESTHETICS ANALGESICS - NON-NARCOTIC acetaminophen-salicylamidephenyltoloxamine cap 300-200-20mg 1 ADULT ASPIRIN LOW STRENGT aspirin dispersible tab 81 mg 3 100 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal) 1 butalbital-aspirin-caffeine tab 50-325-40 mg 3 1 ESGIC-PLUS - butalbitalacetaminophen-caffeine tab 50-500-40 mg 3 BUTALBITAL/ASPIRIN/CAFFEI butalbital-aspirin-caffeine tab 50-325-40 mg 3 FIORICET - butalbital-acetaminophencaffeine cap 50-300-40 mg FIORICET - butalbital-acetaminophencaffeine tab 50-325-40 mg 3 choline & magnesium salicylates liq 500 mg/5ml 1 FIORINAL - butalbital-aspirin-caffeine cap 50-325-40 mg 3 choline & magnesium salicylates tab 1000 mg 1 LEVACET - aspirin-apap-salicylamidecaffeine tab 500-250-150-32.5 mg 3 clonidine hcl inj (for epidural infusion) 100 mcg/ml (Duraclon) 1 ORBIVAN - butalbital-acetaminophencaffeine cap 50-300-40 mg 3 clonidine hcl inj (for epidural infusion) 500 mcg/ml (Duraclon) 1 ORBIVAN CF - butalbitalacetaminophen tab 50-300 mg 3 diflunisal tab 500 mg 1 1 DISALCID - salsalate tab 500 mg 3 phenyltoloxamine-acetaminophen tab 30-500 mg DISALCID - salsalate tab 750 mg 3 1 DOLGIC PLUS - butalbitalacetaminophen-caffeine tab 50-750-40 mg 3 phenyltoloxamine-acetaminophen tab 50-500 mg phenyltoloxamine-acetaminophen tab 55-500 mg 1 DOLOGESIC - phenyltoloxamineacetaminophen liquid 30-500 mg/15ml 3 PHRENILIN FORTE - butalbitalacetaminophen cap 50-650 mg 3 3 DURACLON - clonidine hcl inj (for epidural infusion) 100 mcg/ml 3 PRIALT - ziconotide acetate intrathecal inj 500 mcg/20ml (25 mcg/ml) 3 DURACLON - clonidine hcl inj (for epidural infusion) 500 mcg/ml 3 PRIALT - ziconotide acetate intrathecal inj 100 mcg/ml 3 ECOTRIN REGULAR STRENGTH aspirin tab delayed release 325 mg 3 PRIALT - ziconotide acetate intrathecal inj 500 mcg/5ml RELAGESIC - phenyltoloxamineacetaminophen tab 50-650 mg 3 RHINOFLEX-650 - phenyltoloxamineacetaminophen tab 50-650 mg 3 salsalate tab 500 mg 1 salsalate tab 750 mg 1 STAFLEX - phenyltoloxamineacetaminophen tab 55-500 mg 3 EQUAGESIC - meprobamate-aspirin tab 3 200-325 mg 3 ESGIC - butalbital-acetaminophencaffeine cap 50-325-40 mg 3 ESGIC - butalbital-acetaminophencaffeine tab 50-325-40 mg 3 ESGIC-PLUS - butalbitalacetaminophen-caffeine cap 50-500-40 mg Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 TENCON - butalbital-acetaminophen tab 3 50-650 mg SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 101 ZGESIC - phenyltoloxamineacetaminophen tab cr 66-600 mg 3 ANALGESICS - NARCOTIC ABSTRAL - fentanyl citrate sl tab 100 mcg (base equiv) 3 ABSTRAL - fentanyl citrate sl tab 200 mcg (base equiv) 3 ABSTRAL - fentanyl citrate sl tab 300 mcg (base equiv) 3 ABSTRAL - fentanyl citrate sl tab 400 mcg (base equiv) 3 ABSTRAL - fentanyl citrate sl tab 600 mcg (base equiv) 3 ABSTRAL - fentanyl citrate sl tab 800 mcg (base equiv) 3 acetaminophen w/ codeine soln 120-12 mg/5ml 1 acetaminophen w/ codeine tab 300-15 mg (Tylenol/codeine) 1 acetaminophen w/ codeine tab 300-30 mg (Tylenol/codeine #3) 1 acetaminophen w/ codeine tab 300-60 mg (Tylenol/codeine #4) 1 ACETAMINOPHEN/CAFFEINE/ DI - acetaminophen-caffeinedihydrocodeine tab 712.8-60-32 mg 3 ACTIQ - fentanyl citrate lollipop 200 mcg 3 ACTIQ - fentanyl citrate lollipop 400 mcg 3 ACTIQ - fentanyl citrate lollipop 600 mcg 3 ACTIQ - fentanyl citrate lollipop 800 mcg 3 ACTIQ - fentanyl citrate lollipop 1200 mcg 3 ACTIQ - fentanyl citrate lollipop 1600 mcg 3 ALFENTA - alfentanil inj 500 mcg/ml 3 alfentanil inj 500 mcg/ml (Alfenta) 1 ASPIRIN-CAFFEINE-DIHYDROC aspirin-caffeine-dihydrocodeine cap 356.4-30-16 mg 3 102 AVINZA - morphine sulfate beads cap sr 3 24hr 30 mg AVINZA - morphine sulfate beads cap sr 3 24hr 45 mg AVINZA - morphine sulfate beads cap sr 3 24hr 60 mg AVINZA - morphine sulfate beads cap sr 3 24hr 75 mg AVINZA - morphine sulfate beads cap sr 3 24hr 90 mg AVINZA - morphine sulfate beads cap sr 3 24hr 120 mg 3 BUNAVAIL - buprenorphine-naloxone buccal film 2.1-0.3 mg (base equiv) 3 BUNAVAIL - buprenorphine-naloxone buccal film 4.2-0.7 mg (base equiv) 3 BUNAVAIL - buprenorphine-naloxone buccal film 6.3-1 mg (base equiv) BUPRENEX - buprenorphine hcl inj 0.3 3 mg/ml (base equiv) 1 buprenorphine hcl inj 0.3 mg/ml (base equiv) (Buprenex) 1 buprenorphine hcl sl tab 2 mg (base equiv) 1 buprenorphine hcl sl tab 8 mg (base equiv) 1 buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv) 1 buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) 1 butalbital-acetaminophen-caff w/ cod cap 50-300-40-30 mg (Fioricet/ codeine) butalbital-acetaminophen-caff w/ cod 1 cap 50-325-40-30 mg butalbital-aspirin-caff w/ codeine cap 1 50-325-40-30 mg (Fiorinal/codeine #3) 1 butorphanol tartrate inj 1 mg/ml butorphanol tartrate inj 2 mg/ml SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare 1 Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 butorphanol tartrate nasal soln 10 mg/ml 1 BUTRANS - buprenorphine td patch weekly 5 mcg/hr 3 BUTRANS - buprenorphine td patch weekly 7.5 mcg/hr • DEMEROL - meperidine hcl inj 100 mg/ ml 3 3 3 DEPODUR - morphine sulfate extrelease liposome epidural inj 10 mg/ ml 3 BUTRANS - buprenorphine td patch weekly 10 mcg/hr 3 DEPODUR - morphine sulfate ext-rel liposome epidural inj 15 mg/1.5ml 3 BUTRANS - buprenorphine td patch weekly 15 mcg/hr 3 DILAUDID - hydromorphone hcl tab 2 mg 3 BUTRANS - buprenorphine td patch weekly 20 mcg/hr 3 DILAUDID - hydromorphone hcl tab 4 mg 3 CAPITAL/CODEINE - acetaminophen w/ codeine susp 120-12 mg/5ml 3 DILAUDID - hydromorphone hcl tab 8 mg 3 CODEINE SULFATE - codeine sulfate tab 15 mg 2 DILAUDID - hydromorphone hcl liqd 1 mg/ml 3 CODEINE SULFATE - codeine sulfate oral soln 30 mg/5ml 3 DILAUDID - hydromorphone hcl preservative free (pf) inj 1 mg/ml 3 codeine sulfate tab 30 mg 1 DILAUDID - hydromorphone hcl preservative free (pf) inj 2 mg/ml codeine sulfate tab 60 mg 1 3 CONZIP - tramadol hcl cap sr 24hr biphasic release 100 mg 3 DILAUDID - hydromorphone hcl preservative free (pf) inj 4 mg/ml 3 CONZIP - tramadol hcl cap sr 24hr biphasic release 200 mg 3 DILAUDID-HP - hydromorphone hcl preservative free (pf) inj 10 mg/ml 3 CONZIP - tramadol hcl cap sr 24hr biphasic release 300 mg 3 DILAUDID-HP - hydromorphone hcl for inj 250 mg 3 DEMEROL - meperidine hcl tab 50 mg 3 DOLOPHINE - methadone hcl tab 10 mg 3 DOLOPHINE HCL - methadone hcl tab 5 mg 3 DEMEROL - meperidine hcl tab 100 mg DEMEROL - meperidine hcl inj 25 mg/ ml 3 DEMEROL - meperidine hcl inj 25 mg/0.5ml (50 mg/ml) 3 DEMEROL - meperidine hcl inj 50 mg/ ml 3 DEMEROL - meperidine hcl inj 75 mg/1.5ml (50 mg/ml) 3 DEMEROL - meperidine hcl inj 100 mg/2ml (50 mg/ml) 3 DEMEROL - meperidine hcl inj 75 mg/ ml 3 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 DURAGESIC - fentanyl td patch 72hr 12 3 mcg/hr DURAGESIC - fentanyl td patch 72hr 25 3 mcg/hr DURAGESIC - fentanyl td patch 72hr 50 3 mcg/hr DURAGESIC - fentanyl td patch 72hr 75 3 mcg/hr 3 DURAGESIC - fentanyl td patch 72hr 100 mcg/hr SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 103 EXALGO - hydromorphone hcl tab er 24hr deter 8 mg 3 EXALGO - hydromorphone hcl tab er 24hr deter 12 mg 3 EXALGO - hydromorphone hcl tab er 24hr deter 16 mg 3 EXALGO - hydromorphone hcl tab er 24hr deter 32 mg 3 fentanyl citrate lollipop 1200 mcg (Actiq) 1 fentanyl citrate lollipop 1600 mcg (Actiq) 1 fentanyl citrate lollipop 200 mcg (Actiq) 1 fentanyl citrate lollipop 400 mcg (Actiq) 1 fentanyl citrate lollipop 600 mcg (Actiq) 1 fentanyl citrate lollipop 800 mcg (Actiq) 1 fentanyl td patch 72hr 100 mcg/hr (Duragesic) 1 fentanyl td patch 72hr 12 mcg/hr (Duragesic) 1 fentanyl td patch 72hr 25 mcg/hr (Duragesic) 1 fentanyl td patch 72hr 50 mcg/hr (Duragesic) 1 fentanyl td patch 72hr 75 mcg/hr (Duragesic) 1 FENTORA - fentanyl citrate buccal tab 100 mcg (base equiv) 3 FENTORA - fentanyl citrate buccal tab 200 mcg (base equiv) 3 FENTORA - fentanyl citrate buccal tab 400 mcg (base equiv) 3 FENTORA - fentanyl citrate buccal tab 600 mcg (base equiv) 3 FENTORA - fentanyl citrate buccal tab 800 mcg (base equiv) 3 104 FIORICET/CODEINE - butalbitalacetaminophen-caff w/ cod cap 50-300-40-30 mg 3 FIORICET/CODEINE - butalbitalacetaminophen-caff w/ cod cap 50-325-40-30 mg 3 FIORINAL/CODEINE #3 - butalbitalaspirin-caff w/ codeine cap 50-325-40-30 mg 3 HYCET - hydrocodone-acetaminophen soln 7.5-325 mg/15ml 3 hydrocodone-acetaminophen cap 5-500 mg 1 hydrocodone-acetaminophen soln 10-325 mg/15ml 1 hydrocodone-acetaminophen soln 7.5-325 mg/15ml (Hycet) 1 hydrocodone-acetaminophen soln 7.5-500 mg/15ml 1 hydrocodone-acetaminophen tab 10-300 mg (Xodol) 1 hydrocodone-acetaminophen tab 10-325 mg (Norco) 1 hydrocodone-acetaminophen tab 10-500 mg 1 hydrocodone-acetaminophen tab 10-650 mg 1 hydrocodone-acetaminophen tab 10-660 mg 1 hydrocodone-acetaminophen tab 10-750 mg 1 hydrocodone-acetaminophen tab 2.5-325 mg 1 hydrocodone-acetaminophen tab 2.5-500 mg 1 hydrocodone-acetaminophen tab 5-300 mg (Xodol) 1 hydrocodone-acetaminophen tab 5-325 mg (Norco) 1 hydrocodone-acetaminophen tab 5-500 mg 1 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 hydrocodone-acetaminophen tab 7.5-300 mg (Xodol) 1 hydromorphone hcl preservative free (pf) inj 1 mg/ml (Dilaudid) 1 hydrocodone-acetaminophen tab 7.5-325 mg (Norco) 1 hydromorphone hcl preservative free (pf) inj 10 mg/ml (Dilaudid-hp) 1 hydrocodone-acetaminophen tab 7.5-500 mg 1 hydromorphone hcl preservative free (pf) inj 2 mg/ml (Dilaudid) 1 hydrocodone-acetaminophen tab 7.5-650 mg 1 hydromorphone hcl preservative free (pf) inj 4 mg/ml (Dilaudid) 1 hydrocodone-acetaminophen tab 7.5-750 mg 1 hydromorphone hcl tab er 24hr deter 12 mg (Exalgo) 1 hydrocodone-ibuprofen tab 10-200 mg (Ibudone) 1 hydromorphone hcl tab er 24hr deter 16 mg (Exalgo) 1 hydrocodone-ibuprofen tab 2.5-200 mg (Reprexain) 1 hydromorphone hcl tab er 24hr deter 8 mg (Exalgo) 1 hydrocodone-ibuprofen tab 5-200 mg (Reprexain) 1 hydromorphone hcl tab 2 mg (Dilaudid) 1 hydrocodone-ibuprofen tab 7.5-200 mg (Vicoprofen) 1 hydromorphone hcl tab 4 mg (Dilaudid) 1 HYDROCODONE/ACETAMINOPHEN hydrocodone-acetaminophen tab 7.5-500 mg 3 hydromorphone hcl tab 8 mg (Dilaudid) 1 HYDROCODONE/ACETAMINOPHEN hydrocodone-acetaminophen tab 7.5-650 mg IBUDONE - hydrocodone-ibuprofen tab 10-200 mg 3 3 3 HYDROCODONE/ACETAMINOPHEN hydrocodone-acetaminophen tab 7.5-750 mg 3 INFUMORPH 200 - morphine sulfate for microinfusion inj 200 mg/20ml (10mg/ ml) 3 HYDROCODONE/ACETAMINOPHEN hydrocodone-acetaminophen soln 10-325 mg/15ml 3 INFUMORPH 500 - morphine sulfate for microinfusion inj 500 mg/20ml (25mg/ ml) KADIAN - morphine sulfate cap sr 24hr 10 mg 3 HYDROMORPHONE HCL hydromorphone hcl inj 2 mg/ml 3 KADIAN - morphine sulfate cap sr 24hr 20 mg 3 HYDROMORPHONE HCL hydromorphone hcl suppos 3 mg 2 KADIAN - morphine sulfate cap sr 24hr 30 mg 3 HYDROMORPHONE HCL DOSETTE hydromorphone hcl inj 2 mg/ml 3 KADIAN - morphine sulfate cap sr 24hr 40 mg 3 HYDROMORPHONE HCL ER hydromorphone hcl tab er 24hr deter 32 mg 3 KADIAN - morphine sulfate cap sr 24hr 50 mg 3 1 KADIAN - morphine sulfate cap sr 24hr 60 mg 3 hydromorphone hcl liqd 1 mg/ml (Dilaudid) SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 105 KADIAN - morphine sulfate cap sr 24hr 70 mg 3 MAXIDONE - hydrocodoneacetaminophen tab 10-750 mg 3 KADIAN - morphine sulfate cap sr 24hr 80 mg 3 MEPERIDINE HCL - meperidine hcl inj 10 mg/ml 3 KADIAN - morphine sulfate cap sr 24hr 100 mg 3 KADIAN - morphine sulfate cap sr 24hr 130 mg 3 KADIAN - morphine sulfate cap sr 24hr 150 mg 3 KADIAN - morphine sulfate cap sr 24hr 200 mg 3 LAZANDA - fentanyl citrate nasal spray 100 mcg/act (base equiv) 3 MEPERIDINE HCL - meperidine hcl oral 3 soln 50 mg/5ml 1 meperidine hcl inj 100 mg/ml (Demerol) 1 meperidine hcl inj 25 mg/ml (Demerol) 1 meperidine hcl inj 50 mg/ml (Demerol) meperidine hcl tab 100 mg (Demerol) 1 LAZANDA - fentanyl citrate nasal spray 400 mcg/act (base equiv) 3 LEVORPHANOL TARTRATE levorphanol tartrate tab 2 mg meperidine hcl tab 50 mg (Demerol) 1 3 3 MEPERIDINE HCL/PROMETHAZI meperidine w/ promethazine cap 50-25 mg 3 METHADONE HCL - methadone hcl inj 10 mg/ml 3 LIQUICET - hydrocodoneacetaminophen soln 10-500 mg/15ml LORCET PLUS - hydrocodoneacetaminophen tab 7.5-650 mg METHADONE HCL - methadone hcl soln 5 mg/5ml 3 3 LORCET 10/650 - hydrocodoneacetaminophen tab 10-650 mg METHADONE HCL - methadone hcl soln 10 mg/5ml 3 3 methadone hcl conc 10 mg/ml (Methadose) 1 methadone hcl soln 10 mg/5ml (Methadone hcl) 1 methadone hcl soln 5 mg/5ml (Methadone hcl) 1 methadone hcl tab for oral susp 40 mg 1 methadone hcl tab 10 mg (Dolophine) 1 methadone hcl tab 5 mg (Dolophine hcl) 1 METHADOSE - methadone hcl conc 10 mg/ml 3 METHADOSE SUGAR-FREE methadone hcl conc 10 mg/ml 3 MORPHINE SULFATE - morphine sulfate tab 15 mg 2 LORTAB - hydrocodone-acetaminophen 3 tab 5-500 mg LORTAB - hydrocodone-acetaminophen 3 tab 7.5-500 mg LORTAB - hydrocodone-acetaminophen 3 tab 10-500 mg LORTAB - hydrocodone-acetaminophen 3 soln 7.5-500 mg/15ml LORTAB - hydrocodone-acetaminophen 3 soln 10-300 mg/15ml 3 MAGNACET - oxycodone w/ acetaminophen tab 5-400 mg 3 MAGNACET - oxycodone w/ acetaminophen tab 7.5-400 mg 3 MAGNACET - oxycodone w/ acetaminophen tab 10-400 mg 106 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 MORPHINE SULFATE - morphine sulfate tab 30 mg 2 morphine sulfate cap sr 24hr 50 mg (Kadian) 1 MORPHINE SULFATE - morphine sulfate inj 2 mg/ml 3 morphine sulfate cap sr 24hr 60 mg (Kadian) 1 MORPHINE SULFATE - morphine sulfate inj 4 mg/ml 3 morphine sulfate cap sr 24hr 80 mg (Kadian) 1 MORPHINE SULFATE - morphine sulfate inj 5 mg/ml 3 morphine sulfate inj pf 0.5 mg/ml 1 morphine sulfate inj pf 1 mg/ml 1 MORPHINE SULFATE - morphine sulfate suppos 5 mg 2 morphine sulfate inj 10 mg/ml 1 2 morphine sulfate inj 15 mg/ml 1 MORPHINE SULFATE - morphine sulfate suppos 10 mg morphine sulfate inj 8 mg/ml 1 MORPHINE SULFATE - morphine sulfate suppos 20 mg 2 morphine sulfate oral soln 10 mg/5ml 1 morphine sulfate oral soln 20 mg/5ml 1 MORPHINE SULFATE - morphine sulfate suppos 30 mg 2 morphine sulfate tab cr 100 mg (Ms contin) 1 MORPHINE SULFATE - morphine sulfate im inj device 10 mg/0.7ml 3 morphine sulfate tab cr 15 mg (Ms contin) 1 morphine sulfate (concentrate) oral soln 20 mg/ml 1 morphine sulfate tab cr 200 mg (Ms contin) 1 morphine sulfate beads cap sr 24hr 120 mg (Avinza) 1 morphine sulfate tab cr 30 mg (Ms contin) 1 morphine sulfate beads cap sr 24hr 30 mg (Avinza) 1 morphine sulfate tab cr 60 mg (Ms contin) 1 morphine sulfate beads cap sr 24hr 45 mg (Avinza) 1 MS CONTIN - morphine sulfate tab cr 15 mg 3 morphine sulfate beads cap sr 24hr 60 mg (Avinza) 1 MS CONTIN - morphine sulfate tab cr 30 mg 3 morphine sulfate beads cap sr 24hr 75 mg (Avinza) 1 MS CONTIN - morphine sulfate tab cr 60 mg 3 morphine sulfate beads cap sr 24hr 90 mg (Avinza) 1 MS CONTIN - morphine sulfate tab cr 100 mg 3 morphine sulfate cap sr 24hr 10 mg (Kadian) 1 MS CONTIN - morphine sulfate tab cr 200 mg 3 morphine sulfate cap sr 24hr 100 mg (Kadian) 1 nalbuphine hcl inj 10 mg/ml 1 1 1 nalbuphine hcl inj 20 mg/ml morphine sulfate cap sr 24hr 20 mg (Kadian) 3 morphine sulfate cap sr 24hr 30 mg (Kadian) 1 NORCO - hydrocodone-acetaminophen tab 10-325 mg NORCO - hydrocodone-acetaminophen tab 5-325 mg 3 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 107 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 NORCO - hydrocodone-acetaminophen tab 7.5-325 mg 3 OXECTA - oxycodone hcl tab abuse deter 5 mg 3 NUCYNTA - tapentadol hcl tab 50 mg 3 3 NUCYNTA - tapentadol hcl tab 75 mg 3 OXECTA - oxycodone hcl tab abuse deter 7.5 mg NUCYNTA - tapentadol hcl tab 100 mg 3 2 NUCYNTA ER - tapentadol hcl tab sr 12hr 50 mg 2 OXYCODONE HCL - oxycodone hcl conc 100 mg/5ml (20 mg/ml) 3 NUCYNTA ER - tapentadol hcl tab sr 12hr 100 mg 2 OXYCODONE HCL - oxycodone hcl soln 5 mg/5ml oxycodone hcl cap 5 mg 1 NUCYNTA ER - tapentadol hcl tab sr 12hr 150 mg 2 oxycodone hcl conc 100 mg/5ml (20 mg/ml) (Oxycodone hcl) 1 NUCYNTA ER - tapentadol hcl tab sr 12hr 200 mg 2 OXYCODONE HCL ER - oxycodone hcl tab er 12hr deter 10 mg 3 • NUCYNTA ER - tapentadol hcl tab sr 12hr 250 mg 2 OXYCODONE HCL ER - oxycodone hcl tab er 12hr deter 20 mg 3 • OPANA - oxymorphone hcl tab 5 mg 3 3 • OPANA - oxymorphone hcl tab 10 mg 3 OXYCODONE HCL ER - oxycodone hcl tab er 12hr deter 40 mg 3 OXYCODONE HCL ER - oxycodone hcl tab er 12hr deter 80 mg 3 OPANA - oxymorphone hcl inj 1 mg/ml • OPANA ER (CRUSH RESISTANT oxymorphone hcl tab er 12hr deter 5 mg 3 oxycodone hcl soln 5 mg/5ml (Oxycodone hcl) 1 3 oxycodone hcl tab 10 mg 1 OPANA ER (CRUSH RESISTANT oxymorphone hcl tab er 12hr deter 7.5 mg oxycodone hcl tab 15 mg (Roxicodone) 1 OPANA ER (CRUSH RESISTANT oxymorphone hcl tab er 12hr deter 10 mg 3 oxycodone hcl tab 20 mg 1 oxycodone hcl tab 30 mg (Roxicodone) 1 OPANA ER (CRUSH RESISTANT oxymorphone hcl tab er 12hr deter 15 mg 3 OPANA ER (CRUSH RESISTANT oxymorphone hcl tab er 12hr deter 20 mg 3 OPANA ER (CRUSH RESISTANT oxymorphone hcl tab er 12hr deter 30 mg 3 OPANA ER (CRUSH RESISTANT oxymorphone hcl tab er 12hr deter 40 mg 3 108 oxycodone hcl tab 5 mg (Roxicodone) 1 1 oxycodone w/ acetaminophen cap 5-500 mg 1 oxycodone w/ acetaminophen tab 10-325 mg (Percocet) 1 oxycodone w/ acetaminophen tab 10-650 mg 1 oxycodone w/ acetaminophen tab 2.5-325 mg (Percocet) 1 oxycodone w/ acetaminophen tab 5-325 mg (Percocet) 1 oxycodone w/ acetaminophen tab 7.5-325 mg (Percocet) SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 oxycodone w/ acetaminophen tab 7.5-500 mg 1 PERCOCET - oxycodone w/ acetaminophen tab 7.5-500 mg 3 oxycodone-aspirin tab 4.8355-325 mg (Percodan) 1 PERCOCET - oxycodone w/ acetaminophen tab 10-325 mg 3 oxycodone-ibuprofen tab 5-400 mg 1 3 OXYCONTIN - oxycodone hcl tab er 12hr deter 10 mg 2 • PERCOCET - oxycodone w/ acetaminophen tab 10-650 mg 3 OXYCONTIN - oxycodone hcl tab er 12hr deter 15 mg 2 • PERCODAN - oxycodone-aspirin tab 4.8355-325 mg 3 OXYCONTIN - oxycodone hcl tab er 12hr deter 20 mg 2 • PRIMLEV - oxycodone w/ acetaminophen tab 5-300 mg 3 OXYCONTIN - oxycodone hcl tab er 12hr deter 30 mg 2 • PRIMLEV - oxycodone w/ acetaminophen tab 7.5-300 mg 3 OXYCONTIN - oxycodone hcl tab er 12hr deter 40 mg 2 • PRIMLEV - oxycodone w/ acetaminophen tab 10-300 mg 3 OXYCONTIN - oxycodone hcl tab er 12hr deter 60 mg 2 • REPREXAIN - hydrocodone-ibuprofen tab 2.5-200 mg 3 OXYCONTIN - oxycodone hcl tab er 12hr deter 80 mg 2 • REPREXAIN - hydrocodone-ibuprofen tab 5-200 mg 3 oxymorphone hcl tab sr 12hr 10 mg 1 ROXICET - oxycodone w/ acetaminophen soln 5-325 mg/5ml oxymorphone hcl tab sr 12hr 15 mg 1 3 oxymorphone hcl tab sr 12hr 20 mg 1 ROXICODONE - oxycodone hcl tab 5 mg 1 ROXICODONE - oxycodone hcl tab 15 mg 3 oxymorphone hcl tab sr 12hr 30 mg oxymorphone hcl tab sr 12hr 40 mg 1 1 ROXICODONE - oxycodone hcl tab 30 mg 3 oxymorphone hcl tab sr 12hr 5 mg oxymorphone hcl tab sr 12hr 7.5 mg 1 3 oxymorphone hcl tab 10 mg (Opana) 1 RYBIX ODT - tramadol hcl orally disintegrating tab 50 mg oxymorphone hcl tab 5 mg (Opana) 1 3 pentazocine w/ naloxone tab 50-0.5 mg 1 SUBOXONE - buprenorphine hclnaloxone hcl sl tab 2-0.5 mg (base equiv) 1 SUBOXONE - buprenorphine hclnaloxone hcl sl tab 8-2 mg (base equiv) 3 pentazocine-acetaminophen tab 25-650 mg PERCOCET - oxycodone w/ acetaminophen tab 2.5-325 mg 3 2 PERCOCET - oxycodone w/ acetaminophen tab 5-325 mg 3 SUBOXONE - buprenorphine hclnaloxone hcl sl film 2-0.5 mg (base equiv) PERCOCET - oxycodone w/ acetaminophen tab 7.5-325 mg SUBOXONE - buprenorphine hclnaloxone hcl sl film 4-1 mg (base equiv) 2 3 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 109 SUBOXONE - buprenorphine hclnaloxone hcl sl film 8-2 mg (base equiv) 2 THERATRAMADOL-60 - tramadol hcl tab 50 mg & dietary management cap pack 3 SUBOXONE - buprenorphine hclnaloxone hcl sl film 12-3 mg (base equiv) 2 THERATRAMADOL-90 - tramadol hcl tab 50 mg & dietary management cap pack 3 SUBSYS - fentanyl sublingual spray 100 3 mcg SUBSYS - fentanyl sublingual spray 200 3 mcg SUBSYS - fentanyl sublingual spray 400 3 mcg SUBSYS - fentanyl sublingual spray 600 3 mcg SUBSYS - fentanyl sublingual spray 800 3 mcg 3 SUBSYS - fentanyl sublingual spray 1200 mcg (600 mcg x 2) 3 SUBSYS - fentanyl sublingual spray 1600 mcg (800 mcg x 2) 3 SYNALGOS-DC - aspirin-caffeinedihydrocodeine cap 356.4-30-16 mg 3 SYNAPRYN FUSEPAQ - tramadol hcl for oral susp 10 mg/ml (compound kit) TALWIN - pentazocine lactate inj 30 mg/ 3 ml 3 THERACODEINE-300 - apap-codeine tab 300-30 mg & dietary management cap pack 3 THERACODOPHEN-LOW-90 hydrocodone-apap tab 5-500 mg & dietary manage cap pack 3 THERACODOPHEN-325 hydrocodone-apap tab 10-325 mg & dietary manage cap pack 3 THERACODOPHEN-650 hydrocodone-apap tab 10-650 mg & dietary manage cap pack 3 THERACODOPHEN-750 hydrocodone-apap tab 7.5-750 mg & dietary manage cap pack TRAMADOL HCL ER - tramadol hcl cap sr 24hr biphasic release 150 mg 3 tramadol hcl tab sr 24hr biphasic release 100 mg 1 tramadol hcl tab sr 24hr biphasic release 200 mg 1 tramadol hcl tab sr 24hr biphasic release 300 mg 1 tramadol hcl tab sr 24hr 100 mg (Ultram er) 1 tramadol hcl tab sr 24hr 200 mg (Ultram er) 1 tramadol hcl tab sr 24hr 300 mg (Ultram er) 1 tramadol hcl tab 50 mg (Ultram) 1 tramadol-acetaminophen tab 37.5-325 mg (Ultracet) 1 TREZIX - acetaminophen-caffeinedihydrocodeine cap 356.4-30-16 mg 3 TYLENOL/CODEINE - acetaminophen w/ codeine tab 300-15 mg 3 TYLENOL/CODEINE #3 acetaminophen w/ codeine tab 300-30 mg 3 TYLENOL/CODEINE #4 acetaminophen w/ codeine tab 300-60 mg 3 ULTRACET - tramadol-acetaminophen tab 37.5-325 mg 3 ULTRAM - tramadol hcl tab 50 mg 3 ULTRAM ER - tramadol hcl tab sr 24hr 100 mg 3 ULTRAM ER - tramadol hcl tab sr 24hr 200 mg 3 110 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 ULTRAM ER - tramadol hcl tab sr 24hr 300 mg 3 ACTEMRA - tocilizumab subcutaneous soln prefilled syringe 162 mg/0.9ml 5 VICOPROFEN - hydrocodone-ibuprofen tab 7.5-200 mg 3 ANAPROX - naproxen sodium tab 275 mg 3 XARTEMIS XR - oxycodone w/ acetaminophen tab cr 7.5-325 mg 3 ANAPROX DS - naproxen sodium tab 550 mg 3 XODOL - hydrocodone-acetaminophen tab 5-300 mg 3 ARAVA - leflunomide tab 10 mg 3 ARAVA - leflunomide tab 20 mg 3 XODOL - hydrocodone-acetaminophen tab 7.5-300 mg 3 ARCALYST - rilonacept for inj 220 mg 5 3 ARTHROTEC 50 - diclofenac w/ misoprostol tab delayed release 50-0.2 mg 3 XODOL - hydrocodone-acetaminophen tab 10-300 mg XOLOX - oxycodone w/ acetaminophen tab 10-500 mg 3 3 ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr 10 mg 3 ARTHROTEC 75 - diclofenac w/ misoprostol tab delayed release 75-0.2 mg 3 CATAFLAM - diclofenac potassium tab 50 mg 3 ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr 15 mg CELEBREX - celecoxib cap 50 mg 3 ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr 20 mg 3 CELEBREX - celecoxib cap 100 mg 3 3 CELEBREX - celecoxib cap 200 mg 3 ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr 30 mg CELEBREX - celecoxib cap 400 mg 3 ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr 40 mg 3 DAYPRO - oxaprozin tab 600 mg 3 1 ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr 50 mg 3 diclofenac potassium tab 50 mg (Cataflam) 1 ZOLVIT - hydrocodone-acetaminophen soln 10-300 mg/15ml 3 diclofenac sodium tab delayed release 25 mg diclofenac sodium tab delayed release 50 mg 1 diclofenac sodium tab delayed release 75 mg 1 diclofenac sodium tab sr 24hr 100 mg (Voltaren-xr) 1 diclofenac w/ misoprostol tab delayed release 50-0.2 mg (Arthrotec 50) 1 diclofenac w/ misoprostol tab delayed release 75-0.2 mg (Arthrotec 75) 1 DUEXIS - ibuprofen-famotidine tab 800-26.6 mg 3 ZUBSOLV - buprenorphine hcl-naloxone 3 hcl sl tab 1.4-0.36 mg (base eq) ZUBSOLV - buprenorphine hcl-naloxone 3 hcl sl tab 5.7-1.4 mg (base eq) 3 ZYDONE - hydrocodoneacetaminophen tab 5-400 mg 3 ZYDONE - hydrocodoneacetaminophen tab 7.5-400 mg 3 ZYDONE - hydrocodoneacetaminophen tab 10-400 mg ANALGESICS - ANTI-INFLAMMATORY SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 • • • • • • 111 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 HUMIRA PEN-CROHNS DISEASE adalimumab inj kit 40 mg/0.8ml (50 mg/ml) 4 • • HUMIRA PEN-PSORIASIS STAR adalimumab inj kit 40 mg/0.8ml (50 mg/ml) 4 • • IBUPROFEN COMFORT PAC ibuprofen tab 800 mg & liniment topical gel kit 3 ibuprofen susp 100 mg/5ml 1 ibuprofen tab 400 mg 1 ibuprofen tab 600 mg 1 ibuprofen tab 800 mg 1 IC 400 - ibuprofen tab 400 mg & caffeine-vitamins cap kit 3 3 1 IC 800 - ibuprofen tab 800 mg & caffeine-vitamins cap kit etodolac tab sr 24hr 600 mg 1 ILARIS - canakinumab for inj 180 mg 4 etodolac tab 400 mg 1 3 etodolac tab 500 mg 1 INDOCIN - indomethacin susp 25 mg/5ml 3 INDOCIN - indomethacin suppos 50 mg 3 FELDENE - piroxicam cap 10 mg 3 indomethacin cap cr 75 mg 1 FELDENE - piroxicam cap 20 mg 3 indomethacin cap 25 mg 1 FENOPROFEN CALCIUM - fenoprofen calcium cap 400 mg indomethacin cap 50 mg 1 FENOPROFEN CALCIUM - fenoprofen calcium tab 600 mg 3 ketoprofen cap 50 mg 1 ketoprofen cap 75 mg 1 flurbiprofen tab 100 mg 1 3 flurbiprofen tab 50 mg 1 KETOPROFEN ER - ketoprofen cap sr 24hr 200 mg HUMIRA - adalimumab prefilled syringe kit 10 mg/0.2ml 4 • • KETOROCAINE-L - ketorolac trometh inj 30 mg/ml & lidocaine hcl 1% kit 3 HUMIRA - adalimumab inj kit 20 mg/0.4ml 4 • • 3 HUMIRA - adalimumab inj kit 40 mg/0.8ml (50 mg/ml) 4 • • KETOROCAINE-LM - ketorolac inj 30 mg/ml & bupivacaine 0.25% & lido 1% kit 3 HUMIRA PEDIATRIC CROHNS D adalimumab inj kit 40 mg/0.8ml (50 mg/ml) 4 • • KETOROLAC TROMETHAMINE ketorolac tromethamine inj 300 mg/10ml (30 mg/ml) 3 HUMIRA PEN - adalimumab inj kit 40 mg/0.8ml (50 mg/ml) 4 • • KETOROLAC TROMETHAMINE ketorolac tromethamine im inj 30 mg/ ml EC-NAPROSYN - naproxen tab ec 375 mg 3 EC-NAPROSYN - naproxen tab ec 500 mg 3 ENBREL - etanercept subcutaneous soln prefilled syringe 25 mg/0.5ml 4 • • ENBREL - etanercept subcutaneous soln prefilled syringe 50 mg/ml 4 • • ENBREL - etanercept for subcutaneous inj kit 25 mg 4 • • ENBREL SURECLICK - etanercept subcutaneous solution auto-injector 50 mg/ml 4 etodolac cap 200 mg 1 etodolac cap 300 mg 1 etodolac tab sr 24hr 400 mg 1 etodolac tab sr 24hr 500 mg 112 • • SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 NAPROSYN - naproxen tab 375 mg 3 NAPROSYN - naproxen tab 500 mg 3 Quantity Limits 3 Step Therapy NAPROSYN - naproxen tab 250 mg Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 ketorolac tromethamine im inj 60 mg/2ml (30 mg/ml) 1 ketorolac tromethamine inj 15 mg/ml 1 ketorolac tromethamine inj 30 mg/ml 1 ketorolac tromethamine inj 60 mg/2ml (30 mg/ml) NAPROSYN - naproxen susp 125 mg/5ml 3 1 1 KINERET - anakinra subcutaneous soln prefilled syringe 100 mg/0.67ml 5 NAPROXEN COMFORT PAC naproxen tab 500 mg & liniment topical gel kit 3 ketorolac tromethamine tab 10 mg 1 leflunomide tab 10 mg (Arava) 1 naproxen sodium tab 275 mg (Anaprox) leflunomide tab 20 mg (Arava) 1 1 MECLOFENAMATE SODIUM meclofenamate sodium cap 50 mg 3 naproxen sodium tab 550 mg (Anaprox ds) 1 MECLOFENAMATE SODIUM meclofenamate sodium cap 100 mg 3 naproxen susp 125 mg/5ml (Naprosyn) 1 mefenamic acid cap 250 mg (Ponstel) 1 naproxen tab ec 375 mg (Ecnaprosyn) 3 naproxen tab ec 500 mg (Ecnaprosyn) 1 MELOXICAM - meloxicam susp 7.5 mg/5ml 3 naproxen tab 250 mg (Naprosyn) 1 MELOXICAM COMFORT PAC meloxicam tab 15 mg & liniment topical gel kit naproxen tab 375 mg (Naprosyn) 1 naproxen tab 500 mg (Naprosyn) 1 meloxicam tab 15 mg (Mobic) 1 5 • • meloxicam tab 7.5 mg (Mobic) 1 ORENCIA - abatacept subcutaneous soln prefilled syringe 125 mg/ml MOBIC - meloxicam tab 7.5 mg 3 5 • • MOBIC - meloxicam tab 15 mg 3 OTEZLA - apremilast tab starter therapy pack 10 mg & 20 mg & 30 mg 3 OTEZLA - apremilast tab 30 mg 5 MOBIC - meloxicam susp 7.5 mg/5ml • • 1 OTREXUP - methotrexate soln pf autoinjector 10mg/0.4ml 3 nabumetone tab 500 mg nabumetone tab 750 mg 1 NALFON - fenoprofen calcium cap 400 mg OTREXUP - methotrexate soln pf autoinjector 15mg/0.4ml 3 3 3 NAPRELAN - naproxen sodium tab sr 24hr 375 mg (base equiv) 3 OTREXUP - methotrexate soln pf autoinjector 20mg/0.4ml 3 OTREXUP - methotrexate soln pf autoinjector 25mg/0.4ml 3 NAPRELAN - naproxen sodium tab sr 24hr 500 mg (base equiv) oxaprozin tab 600 mg (Daypro) 1 NAPRELAN - naproxen sodium tab sr 24hr 750 mg (base equiv) 3 piroxicam cap 10 mg (Feldene) 1 3 piroxicam cap 20 mg (Feldene) 1 NAPRELAN - naproxen sodium tab sr 24hr 500 mg (14) & 750 mg (6) pack PONSTEL - mefenamic acid cap 250 mg 3 • • SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 113 PRASTERA - prasterone cap 200 mg & ibuprofen tab 400 mg kit 3 THERAPROFEN-60 - ibuprofen tab 600 mg & dietary management cap pack 3 RASUVO - methotrexate soln pf autoinjector 7.5 mg/0.15ml 3 3 RASUVO - methotrexate soln pf autoinjector 10 mg/0.2ml 3 THERAPROFEN-800 - ibuprofen tab 800 mg & dietary management cap pack 3 RASUVO - methotrexate soln pf autoinjector 12.5 mg/0.25ml 3 THERAPROFEN-90 - ibuprofen tab 600 mg & dietary management cap pack 3 RASUVO - methotrexate soln pf autoinjector 15 mg/0.3ml 3 THERAPROXEN-500 - naproxen tab 500 mg & dietary management cap pack RASUVO - methotrexate soln pf autoinjector 17.5 mg/0.35ml 3 THERAPROXEN-60 - naproxen tab 250 mg & dietary management cap pack 3 RASUVO - methotrexate soln pf autoinjector 20 mg/0.4ml 3 THERAPROXEN-90 - naproxen tab 250 mg & dietary management cap pack 3 RASUVO - methotrexate soln pf autoinjector 22.5 mg/0.45ml 3 TOLMETIN SODIUM - tolmetin sodium tab 200 mg 3 RASUVO - methotrexate soln pf autoinjector 25 mg/0.5ml 3 TOLMETIN SODIUM - tolmetin sodium tab 600 mg 3 RASUVO - methotrexate soln pf autoinjector 27.5 mg/0.55ml 3 tolmetin sodium cap 400 mg 1 3 RASUVO - methotrexate soln pf autoinjector 30 mg/0.6ml 3 TREPADICLOFEN-25 - diclofenac tab dr 25 mg & dietary management cap pack RHEUMATREX - methotrexate sodium tab 2.5 mg (antirheumatic) 3 RIDAURA - auranofin cap 3 mg 3 SIMPONI - golimumab subcutaneous soln auto-injector 50 mg/0.5ml 5 • • SIMPONI - golimumab subcutaneous soln auto-injector 100 mg/ml 5 • • SIMPONI - golimumab subcutaneous soln prefilled syringe 50 mg/0.5ml 5 • • SIMPONI - golimumab subcutaneous soln prefilled syringe 100 mg/ml 5 • • SPRIX - ketorolac tromethamine nasal spray 15.75 mg/spray 3 sulindac tab 150 mg 1 sulindac tab 200 mg 1 THERAFELDAMINE - piroxicam cap 20 mg & dietary management cap pack 3 114 TREPOXEN-250 - naproxen tab 250 mg 3 & dietary management cap pack TREPOXICAM-7.5 - meloxicam tab 7.5 3 mg & dietary management cap pack VOLTAREN-XR - diclofenac sodium tab 3 sr 24hr 100 mg 5 XELJANZ - tofacitinib citrate tab 5 mg (base equivalent) 3 ZIPSOR - diclofenac potassium cap 25 mg 3 ZORVOLEX - diclofenac cap 18 mg ZORVOLEX - diclofenac cap 35 mg • • 3 MIGRAINE PRODUCTS acetaminophen-isometheptenecaffeine tab 325-65-20 mg (Prodrin) 1 acetaminophen-isometheptenedichloral cap 325-65-100 mg 1 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 Products January 2015 ALSUMA - sumatriptan succinate solution auto-injector 6 mg/0.5ml 3 • AMERGE - naratriptan hcl tab 1 mg (base equiv) 3 • AMERGE - naratriptan hcl tab 2.5 mg (base equiv) 3 • AXERT - almotriptan malate tab 6.25 mg 3 • AXERT - almotriptan malate tab 12.5 mg 3 • CAFERGOT - ergotamine w/ caffeine tab 1-100 mg 3 CAMBIA - diclofenac potassium packet 50 mg 3 D.H.E. 45 - dihydroergotamine mesylate inj 1 mg/ml 3 DIHYDROERGOTAMINE MESYLAT dihydroergotamine mesylate nasal spray 4 mg/ml 3 dihydroergotamine mesylate inj 1 mg/ml (D.h.e. 45) 1 ERGOMAR - ergotamine tartrate sl tab 2 mg 3 FROVA - frovatriptan succinate tab 2.5 mg (base equivalent) 3 • IMITREX - sumatriptan nasal spray 5 mg/act 2 • IMITREX - sumatriptan nasal spray 20 mg/act 2 • IMITREX - sumatriptan succinate tab 25 mg 3 • IMITREX - sumatriptan succinate tab 50 mg 3 • IMITREX - sumatriptan succinate tab 100 mg 3 • IMITREX - sumatriptan succinate inj 6 mg/0.5ml 3 • IMITREX STATDOSE REFILL sumatriptan succinate solution cartridge 4 mg/0.5ml 3 • • SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Quantity Limits Step Therapy IMITREX STATDOSE REFILL sumatriptan succinate solution cartridge 6 mg/0.5ml 3 • IMITREX STATDOSE SYSTEM sumatriptan succinate solution autoinjector 4 mg/0.5ml 3 • IMITREX STATDOSE SYSTEM sumatriptan succinate solution autoinjector 6 mg/0.5ml 3 • ISOMETHEPTENE/CAFFEINE/AC acetaminophen-isometheptenecaffeine tab 500-130-20 mg 3 MAXALT - rizatriptan benzoate tab 5 mg 3 3 MAXALT - rizatriptan benzoate tab 10 mg 3 MAXALT-MLT - rizatriptan benzoate orally disintegrating tab 5 mg 3 MAXALT-MLT - rizatriptan benzoate orally disintegrating tab 10 mg 3 MIGERGOT - ergotamine w/ caffeine suppos 2-100 mg 3 MIGRAL - isometheptene mucate tab 130 mg 3 MIGRALAM - acetaminophenisometheptene-caffeine cap 325-65-100 mg 2 MIGRANAL - dihydroergotamine mesylate nasal spray 4 mg/ml naratriptan hcl tab 1 mg (base equiv) 1 (Amerge) 1 naratriptan hcl tab 2.5 mg (base equiv) (Amerge) 3 PRODRIN - acetaminophenisometheptene-caffeine tab 325-65-20 mg 3 PRODRIN - acetaminophenisometheptene-caffeine tab 500-130-20 mg 3 RELPAX - eletriptan hydrobromide tab 20 mg (base equivalent) • Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 Products January 2015 • • • • • • • • 115 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 RELPAX - eletriptan hydrobromide tab 40 mg (base equivalent) 3 • sumatriptan succinate tab 50 mg (Imitrex) 1 • rizatriptan benzoate orally disintegrating tab 10 mg (Maxaltmlt) 1 • SUMAVEL DOSEPRO - sumatriptan succinate solution jet-injector 4 mg/0.5ml 3 • rizatriptan benzoate orally disintegrating tab 5 mg (Maxalt-mlt) 1 • 3 • rizatriptan benzoate tab 10 mg (Maxalt) 1 • SUMAVEL DOSEPRO - sumatriptan succinate solution jet-injector 6 mg/0.5ml 3 • rizatriptan benzoate tab 5 mg (Maxalt) 1 • TREXIMET - sumatriptan-naproxen sodium tab 85-500 mg 1 • SUMATRIPTAN - sumatriptan nasal spray 5 mg/act 3 • zolmitriptan orally disintegrating tab 2.5 mg (Zomig zmt) 1 • SUMATRIPTAN - sumatriptan nasal spray 20 mg/act 3 • zolmitriptan orally disintegrating tab 5 mg (Zomig zmt) zolmitriptan tab 2.5 mg (Zomig) 1 SUMATRIPTAN SUCCINATE sumatriptan succinate solution prefilled syringe 6 mg/0.5ml 3 zolmitriptan tab 5 mg (Zomig) 1 ZOMIG - zolmitriptan tab 2.5 mg 3 3 ZOMIG - zolmitriptan tab 5 mg 3 SUMATRIPTAN SUCCINATE sumatriptan succinate inj 4 mg/0.5ml 2 sumatriptan succinate inj 6 mg/0.5ml (Imitrex) 1 ZOMIG - zolmitriptan nasal spray 2.5 mg/spray unit • • • • • ZOMIG NASAL SPRAY - zolmitriptan nasal spray 5 mg/spray unit 2 • ZOMIG ZMT - zolmitriptan orally disintegrating tab 2.5 mg 3 • ZOMIG ZMT - zolmitriptan orally disintegrating tab 5 mg 3 • sumatriptan succinate solution auto- 1 injector 4 mg/0.5ml (Imitrex statdose sys) sumatriptan succinate solution auto- 1 injector 6 mg/0.5ml (Imitrex statdose sys) 1 sumatriptan succinate solution cartridge 4 mg/0.5ml (Imitrex statdose ref) 1 sumatriptan succinate solution cartridge 6 mg/0.5ml (Imitrex statdose ref) 1 sumatriptan succinate solution prefilled syringe 6 mg/0.5ml 1 sumatriptan succinate tab 100 mg (Imitrex) 1 sumatriptan succinate tab 25 mg (Imitrex) 116 • • • • GOUT AGENTS • • • • • allopurinol tab 100 mg (Zyloprim) 1 allopurinol tab 300 mg (Zyloprim) 1 colchicine w/ probenecid tab 0.5-500 mg 1 COLCRYS - colchicine tab 0.6 mg 2 MITIGARE - colchicine cap 0.6 mg 3 probenecid tab 500 mg 1 ULORIC - febuxostat tab 40 mg 3 ULORIC - febuxostat tab 80 mg 3 ZYLOPRIM - allopurinol tab 100 mg 3 ZYLOPRIM - allopurinol tab 300 mg 3 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 LOCAL ANESTHETICS - PARENTERAL 3 ARTICADENT DENTAL - articaineepinephrine inj 4%-1:200000 3 CITANEST FORTE DENTAL prilocaine 4% w/ epinephrine inj 3 ARTICADENT DENTAL - articaineepinephrine inj 4%-1:100000 3 CITANEST PLAIN DENTAL - prilocaine hcl inj 4% 3 BD PUDENDAL/LOCAL BLOCK lidocaine hcl local inj kit 1% 3 DUOCAINE - lidocaine hcl-bupivacaine hcl inj 1-0.375% 3 bupivacaine hcl inj 0.25% (Marcaine) 1 DURASAFE SPINAL/EPIDURAL lidocaine hcl local inj kit 1% bupivacaine hcl inj 0.5% (Marcaine) 1 3 bupivacaine hcl preservative free (pf) inj 0.75% (Marcaine w/o epi) 1 EXPAREL - bupivacaine liposome inj 1.3% (13.3 mg/ml) 3 bupivacaine hcl preservative free (pf) inj 0.25% (Marcaine) 1 LETS KIT - lidocaine & tetracaine w/ epineph kit (compounding kit) 1 bupivacaine hcl preservative free (pf) inj 0.5% (Marcaine) 1 lidocaine hcl local inj 0.5% (Xylocaine) 1 bupivacaine inj 0.25% w/ epinephrine (Marcaine/epinephrine) 1 lidocaine hcl local inj 1.5% (Xylocaine-mpf) lidocaine hcl local inj 1% (Xylocaine) 1 bupivacaine inj 0.25% w/ epinephrine preservative free (pf) (Marcaine/ epinephrine) 1 lidocaine hcl local inj 2% (Xylocaine) 1 lidocaine hcl local inj 4% (Xylocainempf) 1 bupivacaine inj 0.5% w/ epinephrine (Marcaine/epinephrine) 1 lidocaine hcl local preservative free (pf) inj 0.5% (Xylocaine-mpf) 1 bupivacaine inj 0.5% w/ epinephrine preservative free (pf) (Marcaine/ epinephrine) 1 lidocaine hcl local preservative free (pf) inj 1% (Xylocaine-mpf) 1 1 lidocaine hcl local preservative free (pf) inj 2% (Xylocaine-mpf) 1 bupivacaine 0.75% in dextrose inj 8.25% (Marcaine spinal) 3 CARBOCAINE - mepivacaine hcl preservative free (pf) inj 1% 3 lidocaine inj 0.5% w/ epinephrine-1:200000 (Xylocaine/ epinephrin) 1 CARBOCAINE - mepivacaine hcl inj 1% 1 CARBOCAINE - mepivacaine hcl inj 1.5% 3 lidocaine inj 1.5% w/ epinephrine-1:200000 (Xylocainempf/epinep) CARBOCAINE - mepivacaine hcl inj 2% 3 1 CARBOCAINE - mepivacaine hcl preservative free (pf) inj 2% 3 lidocaine inj 1% w/ epinephrine-1:100000 (Xylocaine/ epinephrin) 1 lidocaine inj 2% w/ epinephrine-1:100000 (Xylocaine/ epinephrin) 1 chloroprocaine hcl inj 2% (Nesacaine-mpf) chloroprocaine hcl inj 3% (Nesacaine-mpf) 1 lidocaine inj 2% w/ epinephrine-1:200000 (Xylocainempf/epinep) 1 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 117 lidocaine inj 2% w/ epinephrine-1:50000 1 NAROPIN - ropivacaine hcl inj 7.5 mg/ ml 3 MARCAINE - bupivacaine hcl inj 0.25% 3 NAROPIN - ropivacaine hcl inj 10 mg/ml 3 MARCAINE - bupivacaine hcl preservative free (pf) inj 0.25% 3 NESACAINE - chloroprocaine hcl inj 1% 3 NESACAINE - chloroprocaine hcl inj 2% 3 MARCAINE - bupivacaine hcl inj 0.5% 3 3 NESACAINE-MPF - chloroprocaine hcl inj 2% 3 MARCAINE - bupivacaine hcl preservative free (pf) inj 0.5% 3 NESACAINE-MPF - chloroprocaine hcl inj 3% 3 MARCAINE SPINAL - bupivacaine 0.75% in dextrose inj 8.25% PONTOCAINE - tetracaine hcl inj 1% 3 MARCAINE W/O EPI - bupivacaine hcl preservative free (pf) inj 0.75% 3 ropivacaine hcl inj 10 mg/ml (Naropin) 1 MARCAINE/EPINEPHRINE bupivacaine inj 0.25% w/ epinephrine 3 ropivacaine hcl inj 2 mg/ml (Naropin) 1 3 ropivacaine hcl inj 5 mg/ml (Naropin) 1 MARCAINE/EPINEPHRINE bupivacaine inj 0.25% w/ epinephrine preservative free (pf) ropivacaine hcl inj 7.5 mg/ml (Naropin) 1 MARCAINE/EPINEPHRINE bupivacaine inj 0.5% w/ epinephrine 3 SENSORCAINE-MPF/EPINEPHRI bupivacaine inj 0.75% w/ epinephrine 3 MARCAINE/EPINEPHRINE bupivacaine inj 0.5% w/ epinephrine preservative free (pf) 3 TETRACAINE HCL - tetracaine hcl inj 1% 3 3 MARLIDO KIT - lidocaine hcl inj 2% & bupivacaine hcl inj 0.5% kit 3 TURKEL PARACENTESIS PROCE lidocaine hcl local inj kit 1% 3 MARLIDO-25 - lidocaine hcl inj 1% & bupivacaine hcl inj 0.25% kit 3 TURKEL PNEUMOTHORAX PROCE lidocaine hcl local inj kit 1% 3 MEPIVACAINE HCL - mepivacaine hcl inj 3% 3 XYLOCAINE - lidocaine hcl local inj 0.5% XYLOCAINE - lidocaine hcl local inj 1% 3 mepivacaine hcl inj 1.5% (Carbocaine) 1 XYLOCAINE - lidocaine hcl local inj 2% 3 mepivacaine hcl inj 1% (Carbocaine) XYLOCAINE-MPF - lidocaine hcl local preservative free (pf) inj 0.5% 3 1 mepivacaine hcl inj 2% (Carbocaine) 1 3 mepivacaine hcl preservative free (pf) inj 1% (Carbocaine) 1 XYLOCAINE-MPF - lidocaine hcl local preservative free (pf) inj 1% 3 mepivacaine hcl preservative free (pf) inj 2% (Carbocaine) 1 XYLOCAINE-MPF - lidocaine hcl local inj 1.5% 3 MONOJECT BONE MARROW BIOP lidocaine hcl local inj kit 1% 3 XYLOCAINE-MPF - lidocaine hcl local preservative free (pf) inj 2% 3 NAROPIN - ropivacaine hcl inj 2 mg/ml 3 XYLOCAINE-MPF - lidocaine hcl local inj 4% NAROPIN - ropivacaine hcl inj 5 mg/ml 3 118 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 XYLOCAINE-MPF/EPINEPHRINE lidocaine inj 1% w/ epinephrine-1:200000 3 XYLOCAINE-MPF/EPINEPHRINE lidocaine inj 1.5% w/ epinephrine-1:200000 3 XYLOCAINE-MPF/EPINEPHRINE lidocaine inj 2% w/ epinephrine-1:200000 3 XYLOCAINE/EPINEPHRINE - lidocaine inj 0.5% w/ epinephrine-1:200000 3 XYLOCAINE/EPINEPHRINE - lidocaine inj 1% w/ epinephrine-1:100000 XYLOCAINE/EPINEPHRINE - lidocaine inj 2% w/ epinephrine-1:100000 carbamazepine tab sr 12hr 400 mg (Tegretol-xr) 1 carbamazepine tab 200 mg (Tegretol) 1 CARBATROL - carbamazepine cap sr 12hr 100 mg 3 CARBATROL - carbamazepine cap sr 12hr 200 mg 3 CARBATROL - carbamazepine cap sr 12hr 300 mg 3 CELONTIN - methsuximide cap 300 mg 2 3 CEREBYX - fosphenytoin sodium inj 100 mg/2ml (phenytoin equiv) 3 3 CEREBYX - fosphenytoin sodium inj 500 mg/10ml (phenytoin equiv) 3 clonazepam orally disintegrating tab 0.125 mg 1 NEUROMUSCULAR DRUGS ANTICONVULSANTS 3 clonazepam orally disintegrating tab 0.25 mg 1 APTIOM - eslicarbazepine acetate tab 200 mg 3 clonazepam orally disintegrating tab 0.5 mg 1 APTIOM - eslicarbazepine acetate tab 400 mg 3 clonazepam orally disintegrating tab 1 mg 1 APTIOM - eslicarbazepine acetate tab 600 mg 3 clonazepam orally disintegrating tab 2 mg 1 APTIOM - eslicarbazepine acetate tab 800 mg 2 clonazepam tab 0.5 mg (Klonopin) 1 BANZEL - rufinamide tab 200 mg 2 clonazepam tab 1 mg (Klonopin) 1 BANZEL - rufinamide tab 400 mg 2 clonazepam tab 2 mg (Klonopin) 1 BANZEL - rufinamide susp 40 mg/ml 1 DEPAKENE - valproate sodium syrup 250 mg/5ml (base equiv) 3 carbamazepine cap sr 12hr 100 mg (Carbatrol) 1 DEPAKENE - valproic acid cap 250 mg 3 carbamazepine cap sr 12hr 200 mg (Carbatrol) 3 carbamazepine cap sr 12hr 300 mg (Carbatrol) 1 DEPAKOTE - divalproex sodium tab delayed release 125 mg 3 carbamazepine chew tab 100 mg 1 DEPAKOTE - divalproex sodium tab delayed release 250 mg 1 DEPAKOTE - divalproex sodium tab delayed release 500 mg 3 carbamazepine susp 100 mg/5ml (Tegretol) 1 DEPAKOTE ER - divalproex sodium tab sr 24 hr 250 mg 3 carbamazepine tab sr 12hr 200 mg (Tegretol-xr) SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 119 FELBATOL - felbamate tab 400 mg 3 FELBATOL - felbamate tab 600 mg 3 DEPAKOTE SPRINKLES - divalproex sodium cap sprinkle 125 mg 3 2 FELBATOL - felbamate susp 600 mg/5ml 3 DIASTAT ACUDIAL - diazepam rectal gel delivery system 10 mg 2 fosphenytoin sodium inj 100 mg/2ml (phenytoin equiv) (Cerebyx) 1 DIASTAT ACUDIAL - diazepam rectal gel delivery system 20 mg 2 fosphenytoin sodium inj 500 mg/10ml (phenytoin equiv) (Cerebyx) 1 DIASTAT PEDIATRIC - diazepam rectal gel delivery system 2.5 mg DIAZEPAM - diazepam rectal gel delivery system 2.5 mg 3 FYCOMPA - perampanel tab 2 mg 3 3 FYCOMPA - perampanel tab 4 mg 3 DIAZEPAM - diazepam rectal gel delivery system 10 mg FYCOMPA - perampanel tab 6 mg 3 DIAZEPAM - diazepam rectal gel delivery system 20 mg 3 FYCOMPA - perampanel tab 8 mg 3 FYCOMPA - perampanel tab 10 mg 3 DILANTIN - phenytoin susp 125 mg/5ml 2 FYCOMPA - perampanel tab 12 mg 3 DILANTIN - phenytoin sodium extended cap 30 mg 2 gabapentin cap 100 mg (Neurontin) 1 gabapentin cap 300 mg (Neurontin) 1 DILANTIN - phenytoin sodium extended cap 100 mg 2 gabapentin cap 400 mg (Neurontin) 1 3 gabapentin oral soln 250 mg/5ml (Neurontin) 1 DILANTIN INFATABS - phenytoin chew tab 50 mg 1 gabapentin tab 600 mg (Neurontin) 1 divalproex sodium cap sprinkle 125 mg (Depakote sprinkles) gabapentin tab 800 mg (Neurontin) 1 divalproex sodium tab delayed release 125 mg (Depakote) 1 GABITRIL - tiagabine hcl tab 2 mg 3 GABITRIL - tiagabine hcl tab 4 mg 3 divalproex sodium tab delayed release 250 mg (Depakote) 1 GABITRIL - tiagabine hcl tab 12 mg 3 GABITRIL - tiagabine hcl tab 16 mg 3 divalproex sodium tab delayed release 500 mg (Depakote) 1 KEPPRA - levetiracetam tab 250 mg 3 1 KEPPRA - levetiracetam tab 500 mg 3 divalproex sodium tab sr 24 hr 250 mg (Depakote er) KEPPRA - levetiracetam tab 750 mg 3 divalproex sodium tab sr 24 hr 500 mg (Depakote er) 1 KEPPRA - levetiracetam tab 1000 mg 3 3 ethosuximide cap 250 mg (Zarontin) 1 KEPPRA - levetiracetam oral soln 100 mg/ml ethosuximide soln 250 mg/5ml (Zarontin) 1 KEPPRA XR - levetiracetam tab sr 24hr 500 mg 3 felbamate susp 600 mg/5ml (Felbatol) 1 3 felbamate tab 400 mg (Felbatol) 1 KEPPRA XR - levetiracetam tab sr 24hr 750 mg 120 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits 1 3 Step Therapy felbamate tab 600 mg (Felbatol) DEPAKOTE ER - divalproex sodium tab sr 24 hr 500 mg Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 LAMICTAL - lamotrigine tab 25 mg 3 LAMICTAL - lamotrigine tab 100 mg 3 LAMICTAL - lamotrigine tab 150 mg 3 LAMICTAL - lamotrigine tab 200 mg 3 LAMICTAL - lamotrigine tab chewable dispersible 2 mg LAMICTAL XR - lamotrigine tab sr 24hr 50 (14) & 100 mg(14) & 200 mg(7) kit 3 LAMICTAL XR - lamotrigine tab sr 24hr 25 mg 3 LAMICTAL XR - lamotrigine tab sr 24hr 50 mg 3 3 LAMICTAL XR - lamotrigine tab sr 24hr 100 mg 3 LAMICTAL CHEWABLE DISPERS lamotrigine tab chewable dispersible 5 mg 3 LAMICTAL XR - lamotrigine tab sr 24hr 200 mg 3 LAMICTAL CHEWABLE DISPERS lamotrigine tab chewable dispersible 25 mg LAMICTAL XR - lamotrigine tab sr 24hr 250 mg 3 3 LAMICTAL XR - lamotrigine tab sr 24hr 300 mg 3 LAMICTAL ODT - lamotrigine tab disp 25 mg (21) & 50 mg (7) titration kit 3 lamotrigine tab chewable dispersible 25 mg (Lamictal chewable di) 1 LAMICTAL ODT - lamotrigine tab disp 50 mg (42) & 100 mg (14) titration kit 3 lamotrigine tab chewable dispersible 5 mg (Lamictal chewable di) 1 LAMICTAL ODT - lamotrigine tab disp 25 (14) & 50 mg (14) & 100 mg (7) kit 3 lamotrigine tab sr 24hr 100 mg (Lamictal xr) 1 LAMICTAL ODT - lamotrigine orally disintegrating tab 25 mg 3 lamotrigine tab sr 24hr 200 mg (Lamictal xr) 1 LAMICTAL ODT - lamotrigine orally disintegrating tab 50 mg 3 lamotrigine tab sr 24hr 25 mg (Lamictal xr) 1 LAMICTAL ODT - lamotrigine orally disintegrating tab 100 mg 3 lamotrigine tab sr 24hr 250 mg (Lamictal xr) 1 LAMICTAL ODT - lamotrigine orally disintegrating tab 200 mg 3 lamotrigine tab sr 24hr 300 mg (Lamictal xr) 1 LAMICTAL STARTER/NOT TAKI lamotrigine tab 25 mg (42) & 100 mg (7) starter kit 3 lamotrigine tab sr 24hr 50 mg (Lamictal xr) 1 3 lamotrigine tab 100 mg (Lamictal) 1 LAMICTAL STARTER/TAKING C lamotrigine tab 25 mg (84) & 100 mg (14) starter kit lamotrigine tab 150 mg (Lamictal) 1 lamotrigine tab 200 mg (Lamictal) 1 LAMICTAL STARTER/TAKING V lamotrigine tab 25 mg (35) starter kit 3 lamotrigine tab 25 mg (Lamictal) 1 LAMICTAL XR - lamotrigine tab sr 24hr 25 mg (21) & 50 mg (7) titration kit levetiracetam oral soln 100 mg/ml (Keppra) 1 3 levetiracetam tab sr 24hr 500 mg (Keppra xr) 1 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits 3 3 Step Therapy KLONOPIN - clonazepam tab 2 mg LAMICTAL XR - lamotrigine tab sr 24hr 25 (14) & 50 mg (14) & 100 mg(7) kit Prior Authorization 3 Drug Name Drug Tier KLONOPIN - clonazepam tab 1 mg Quantity Limits 3 Step Therapy KLONOPIN - clonazepam tab 0.5 mg Prior Authorization Drug Name Drug Tier 2015 121 levetiracetam tab sr 24hr 750 mg (Keppra xr) 1 OXTELLAR XR - oxcarbazepine tab sr 24hr 300 mg 3 levetiracetam tab 1000 mg (Keppra) 1 3 levetiracetam tab 250 mg (Keppra) 1 OXTELLAR XR - oxcarbazepine tab sr 24hr 600 mg levetiracetam tab 500 mg (Keppra) 1 PEGANONE - ethotoin tab 250 mg 3 levetiracetam tab 750 mg (Keppra) 1 3 LYRICA - pregabalin cap 25 mg 3 PHENYTEK - phenytoin sodium extended cap 200 mg 3 PHENYTEK - phenytoin sodium extended cap 300 mg 3 LYRICA - pregabalin cap 50 mg LYRICA - pregabalin cap 75 mg 3 LYRICA - pregabalin cap 100 mg phenytoin chew tab 50 mg (Dilantin infatabs) 1 3 LYRICA - pregabalin cap 150 mg 3 1 LYRICA - pregabalin cap 200 mg 3 phenytoin sodium extended cap 100 mg (Dilantin) LYRICA - pregabalin cap 225 mg 3 1 LYRICA - pregabalin cap 300 mg 3 phenytoin sodium extended cap 200 mg (Phenytek) 3 phenytoin sodium extended cap 300 mg (Phenytek) 1 LYRICA - pregabalin soln 20 mg/ml MYSOLINE - primidone tab 50 mg 3 phenytoin sodium inj 50 mg/ml 1 MYSOLINE - primidone tab 250 mg 3 phenytoin susp 125 mg/5ml (Dilantin) 1 NEURONTIN - gabapentin cap 100 mg 3 POTIGA - ezogabine tab 50 mg 3 NEURONTIN - gabapentin cap 300 mg 3 POTIGA - ezogabine tab 200 mg 3 NEURONTIN - gabapentin cap 400 mg 3 POTIGA - ezogabine tab 300 mg 3 NEURONTIN - gabapentin tab 600 mg 3 POTIGA - ezogabine tab 400 mg 3 NEURONTIN - gabapentin tab 800 mg 3 primidone tab 250 mg (Mysoline) 1 NEURONTIN - gabapentin oral soln 250 mg/5ml 3 primidone tab 50 mg (Mysoline) 1 3 QUDEXY XR - topiramate cap er 24hr sprinkle 25 mg 3 ONFI - clobazam tab 5 mg ONFI - clobazam tab 10 mg 3 ONFI - clobazam tab 20 mg QUDEXY XR - topiramate cap er 24hr sprinkle 50 mg 3 3 ONFI - clobazam suspension 2.5 mg/ml 3 3 oxcarbazepine susp 300 mg/5ml (60 mg/ml) (Trileptal) 1 QUDEXY XR - topiramate cap er 24hr sprinkle 100 mg 3 oxcarbazepine tab 150 mg (Trileptal) 1 QUDEXY XR - topiramate cap er 24hr sprinkle 150 mg oxcarbazepine tab 300 mg (Trileptal) 1 3 oxcarbazepine tab 600 mg (Trileptal) 1 QUDEXY XR - topiramate cap er 24hr sprinkle 200 mg 3 SABRIL - vigabatrin tab 500 mg 2 OXTELLAR XR - oxcarbazepine tab sr 24hr 150 mg SABRIL - vigabatrin powd pack 500 mg 2 STAVZOR - valproic acid cap delayed release 125 mg 3 122 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 STAVZOR - valproic acid cap delayed release 250 mg 3 topiramate sprinkle cap 15 mg (Topamax sprinkle) 1 STAVZOR - valproic acid cap delayed release 500 mg 3 topiramate sprinkle cap 25 mg (Topamax sprinkle) 1 TEGRETOL - carbamazepine tab 200 mg 3 topiramate tab 100 mg (Topamax) 1 topiramate tab 200 mg (Topamax) 1 TEGRETOL - carbamazepine susp 100 mg/5ml 3 topiramate tab 25 mg (Topamax) 1 2 topiramate tab 50 mg (Topamax) 1 TEGRETOL-XR - carbamazepine tab sr 12hr 100 mg 3 TEGRETOL-XR - carbamazepine tab sr 12hr 200 mg 3 TRILEPTAL - oxcarbazepine tab 150 mg 3 TEGRETOL-XR - carbamazepine tab sr 12hr 400 mg 3 TRILEPTAL - oxcarbazepine tab 300 mg 3 THERAPENTIN-60 - gabapentin cap 300 mg & dietary management cap pack 3 TRILEPTAL - oxcarbazepine tab 600 mg TRILEPTAL - oxcarbazepine susp 300 mg/5ml (60 mg/ml) 3 THERAPENTIN-90 - gabapentin cap 300 mg & dietary management cap pack 3 TROKENDI XR - topiramate cap sr 24hr 25 mg 3 3 tiagabine hcl tab 2 mg (Gabitril) 1 TROKENDI XR - topiramate cap sr 24hr 50 mg tiagabine hcl tab 4 mg (Gabitril) 1 3 TOPAMAX - topiramate tab 25 mg 3 TROKENDI XR - topiramate cap sr 24hr 100 mg 3 TROKENDI XR - topiramate cap sr 24hr 200 mg 3 TOPAMAX - topiramate tab 50 mg TOPAMAX - topiramate tab 100 mg 3 3 valproate sodium syrup 250 mg/5ml (base equiv) (Depakene) 1 TOPAMAX - topiramate tab 200 mg TOPAMAX SPRINKLE - topiramate sprinkle cap 15 mg 3 valproic acid cap 250 mg (Depakene) 1 VIMPAT - lacosamide tab 50 mg 3 TOPAMAX SPRINKLE - topiramate sprinkle cap 25 mg 3 VIMPAT - lacosamide tab 100 mg 3 3 VIMPAT - lacosamide tab 150 mg 3 TOPIRAMATE ER - topiramate cap er 24hr sprinkle 25 mg VIMPAT - lacosamide tab 200 mg 3 TOPIRAMATE ER - topiramate cap er 24hr sprinkle 50 mg 3 VIMPAT - lacosamide oral solution 10 mg/ml 3 TOPIRAMATE ER - topiramate cap er 24hr sprinkle 100 mg 3 ZARONTIN - ethosuximide cap 250 mg 3 3 TOPIRAMATE ER - topiramate cap er 24hr sprinkle 150 mg 3 ZARONTIN - ethosuximide soln 250 mg/5ml ZONEGRAN - zonisamide cap 25 mg 3 TOPIRAMATE ER - topiramate cap er 24hr sprinkle 200 mg 3 ZONEGRAN - zonisamide cap 100 mg 3 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 123 ANTIPARKINSON AGENTS 2 CARBIDOPA/LEVODOPA/ENTACA carbidopa-levodopa-entacapone tabs 18.75-75-200 mg 2 CARBIDOPA/LEVODOPA/ENTACA carbidopa-levodopa-entacapone tabs 25-100-200 mg 2 CARBIDOPA/LEVODOPA/ENTACA carbidopa-levodopa-entacapone tabs 31.25-125-200 mg 2 CARBIDOPA/LEVODOPA/ENTACA carbidopa-levodopa-entacapone tabs 37.5-150-200 mg 2 CARBIDOPA/LEVODOPA/ENTACA carbidopa-levodopa-entacapone tabs 50-200-200 mg 2 AMANTADINE HCL - amantadine hcl tab 100 mg 3 amantadine hcl cap 100 mg 1 amantadine hcl syrup 50 mg/5ml 1 APOKYN - apomorphine hydrochloride inj 10 mg/ml 5 AZILECT - rasagiline mesylate tab 0.5 mg (base equiv) 2 AZILECT - rasagiline mesylate tab 1 mg (base equiv) 2 benztropine mesylate inj 1 mg/ml (Cogentin) 1 benztropine mesylate tab 0.5 mg 1 benztropine mesylate tab 1 mg COGENTIN - benztropine mesylate inj 1 mg/ml 3 1 benztropine mesylate tab 2 mg 1 COMTAN - entacapone tab 200 mg 3 bromocriptine mesylate cap 5 mg (Parlodel) 1 ELDEPRYL - selegiline hcl cap 5 mg 3 entacapone tab 200 mg (Comtan) 1 bromocriptine mesylate tab 2.5 mg 1 LODOSYN - carbidopa tab 25 mg 3 carbidopa & levodopa orally disintegrating tab 10-100 mg 1 carbidopa & levodopa orally disintegrating tab 25-100 mg 1 carbidopa & levodopa orally disintegrating tab 25-250 mg 1 carbidopa & levodopa tab cr 25-100 mg (Sinemet cr) 1 carbidopa & levodopa tab cr 50-200 mg (Sinemet cr) 1 carbidopa & levodopa tab 10-100 mg (Sinemet) 1 carbidopa & levodopa tab 25-100 mg (Sinemet) 1 carbidopa & levodopa tab 25-250 mg (Sinemet) 1 carbidopa tab 25 mg (Lodosyn) 1 124 MIRAPEX - pramipexole dihydrochloride 3 tab 0.125 mg MIRAPEX - pramipexole dihydrochloride 3 tab 0.25 mg MIRAPEX - pramipexole dihydrochloride 3 tab 0.5 mg MIRAPEX - pramipexole dihydrochloride 3 tab 0.75 mg MIRAPEX - pramipexole dihydrochloride 3 tab 1 mg MIRAPEX - pramipexole dihydrochloride 3 tab 1.5 mg 3 MIRAPEX ER - pramipexole dihydrochloride tab sr 24hr 0.375 mg 3 MIRAPEX ER - pramipexole dihydrochloride tab sr 24hr 0.75 mg SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits 1 CARBIDOPA/LEVODOPA/ENTACA carbidopa-levodopa-entacapone tabs 12.5-50-200 mg Step Therapy zonisamide cap 50 mg Drug Name Prior Authorization 1 Drug Tier zonisamide cap 25 mg (Zonegran) Quantity Limits 1 Step Therapy zonisamide cap 100 mg (Zonegran) Prior Authorization Drug Name Drug Tier 2015 MIRAPEX ER - pramipexole dihydrochloride tab sr 24hr 1.5 mg 3 pramipexole dihydrochloride tab 1 mg (Mirapex) 1 MIRAPEX ER - pramipexole dihydrochloride tab sr 24hr 2.25 mg 3 pramipexole dihydrochloride tab 1.5 mg (Mirapex) 1 MIRAPEX ER - pramipexole dihydrochloride tab sr 24hr 3 mg 3 REQUIP - ropinirole hydrochloride tab 0.25 mg 3 MIRAPEX ER - pramipexole dihydrochloride tab sr 24hr 3.75 mg 3 REQUIP - ropinirole hydrochloride tab 0.5 mg 3 MIRAPEX ER - pramipexole dihydrochloride tab sr 24hr 4.5 mg 3 REQUIP - ropinirole hydrochloride tab 1 mg 3 NEUPRO - rotigotine td patch 24hr 1 mg/24hr 3 REQUIP - ropinirole hydrochloride tab 2 mg 3 NEUPRO - rotigotine td patch 24hr 2 mg/24hr 3 REQUIP - ropinirole hydrochloride tab 3 mg 3 NEUPRO - rotigotine td patch 24hr 3 mg/24hr 3 REQUIP - ropinirole hydrochloride tab 4 mg 3 NEUPRO - rotigotine td patch 24hr 4 mg/24hr 3 REQUIP - ropinirole hydrochloride tab 5 mg 3 NEUPRO - rotigotine td patch 24hr 6 mg/24hr 3 REQUIP XL - ropinirole hydrochloride tab sr 24hr 2 mg (base equivalent) 3 NEUPRO - rotigotine td patch 24hr 8 mg/24hr 3 REQUIP XL - ropinirole hydrochloride tab sr 24hr 4 mg (base equivalent) 3 PARCOPA - carbidopa & levodopa orally disintegrating tab 10-100 mg 3 REQUIP XL - ropinirole hydrochloride tab sr 24hr 6 mg (base equivalent) 3 PARCOPA - carbidopa & levodopa orally disintegrating tab 25-100 mg 3 REQUIP XL - ropinirole hydrochloride tab sr 24hr 8 mg (base equivalent) 3 PARCOPA - carbidopa & levodopa orally disintegrating tab 25-250 mg 3 REQUIP XL - ropinirole hydrochloride tab sr 24hr 12 mg (base equivalent) 3 PARLODEL - bromocriptine mesylate cap 5 mg 3 ropinirole hydrochloride tab sr 24hr 12 mg (base equivalent) (Requip xl) 1 PARLODEL - bromocriptine mesylate tab 2.5 mg 3 ropinirole hydrochloride tab sr 24hr 2 mg (base equivalent) (Requip xl) 1 pramipexole dihydrochloride tab 0.125 mg (Mirapex) 1 ropinirole hydrochloride tab sr 24hr 4 mg (base equivalent) (Requip xl) 1 pramipexole dihydrochloride tab 0.25 mg (Mirapex) 1 ropinirole hydrochloride tab sr 24hr 6 mg (base equivalent) (Requip xl) 1 pramipexole dihydrochloride tab 0.5 mg (Mirapex) 1 ropinirole hydrochloride tab sr 24hr 8 mg (base equivalent) (Requip xl) 1 pramipexole dihydrochloride tab 0.75 mg (Mirapex) 1 ropinirole hydrochloride tab 0.25 mg (Requip) 1 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 125 ropinirole hydrochloride tab 0.5 mg (Requip) 1 trihexyphenidyl hcl tab 5 mg 1 ropinirole hydrochloride tab 1 mg (Requip) ZELAPAR - selegiline hcl orally disintegrating tab 1.25 mg 3 1 ropinirole hydrochloride tab 2 mg (Requip) 1 ropinirole hydrochloride tab 3 mg (Requip) 1 ropinirole hydrochloride tab 4 mg (Requip) 1 ropinirole hydrochloride tab 5 mg (Requip) 1 selegiline hcl cap 5 mg (Eldepryl) 1 selegiline hcl tab 5 mg 1 SINEMET - carbidopa & levodopa tab 10-100 mg 3 BOTOX - onabotulinumtoxina for inj 100 unit 3 BOTOX - onabotulinumtoxina for inj 200 unit 3 DYSPORT - abobotulinumtoxina for inj 300 unit 3 DYSPORT - abobotulinumtoxina for inj 500 unit 3 3 MYOBLOC - rimabotulinumtoxinb inj 2500 unit/0.5ml 3 SINEMET - carbidopa & levodopa tab 25-100 mg 3 MYOBLOC - rimabotulinumtoxinb inj 5000 unit/ml 3 SINEMET - carbidopa & levodopa tab 25-250 mg 3 MYOBLOC - rimabotulinumtoxinb inj 10000 unit/2ml 3 SINEMET CR - carbidopa & levodopa tab cr 25-100 mg 3 QUELICIN - succinylcholine chloride inj 20 mg/ml 3 SINEMET CR - carbidopa & levodopa tab cr 50-200 mg 3 QUELICIN 1000 - succinylcholine chloride inj 100 mg/ml 3 STALEVO 100 - carbidopa-levodopaentacapone tabs 25-100-200 mg 3 RILUTEK - riluzole tab 50 mg 3 riluzole tab 50 mg (Rilutek) 1 STALEVO 125 - carbidopa-levodopaentacapone tabs 31.25-125-200 mg 3 XEOMIN - incobotulinumtoxina for inj 50 unit 3 STALEVO 150 - carbidopa-levodopaentacapone tabs 37.5-150-200 mg 3 XEOMIN - incobotulinumtoxina for inj 100 unit 3 STALEVO 200 - carbidopa-levodopaentacapone tabs 50-200-200 mg 3 STALEVO 50 - carbidopa-levodopaentacapone tabs 12.5-50-200 mg 3 STALEVO 75 - carbidopa-levodopaentacapone tabs 18.75-75-200 mg 3 TASMAR - tolcapone tab 100 mg 3 trihexyphenidyl hcl elixir 0.4 mg/ml 1 trihexyphenidyl hcl tab 2 mg 1 MUSCULOSKELETAL THERAPY AGENTS 3 ACTIVE-CYCLOBENZAPRINE KI cyclobenzaprine hcl td cream 5% (compound kit) 3 AMRIX - cyclobenzaprine hcl cap sr 24hr 15 mg 3 AMRIX - cyclobenzaprine hcl cap sr 24hr 30 mg 1 baclofen tab 10 mg SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy NEUROMUSCULAR AGENTS ANECTINE - succinylcholine chloride inj 20 mg/ml 126 Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 3 3 GABLOFEN - baclofen intrathecal inj 50 mcg/ml 3 carisoprodol tab 350 mg (Soma) 1 GABLOFEN - baclofen intrathecal inj 10000 mcg/20ml (500 mcg/ml) carisoprodol w/ aspirin & codeine tab 200-325-16 mg 1 GABLOFEN - baclofen intrathecal inj 20000 mcg/20ml (1000 mcg/ml) 3 carisoprodol w/ aspirin tab 200-325 mg 1 GABLOFEN - baclofen intrathecal inj 40000 mcg/20ml (2000 mcg/ml) 3 CARTICEL - autologous cultured chondrocytes for implantation 3 LIORESAL INTRATHECAL - baclofen intrathecal inj 0.05 mg/ml (50 mcg/ml) 3 chlorzoxazone tab 500 mg (Parafon forte dsc) 1 3 CYCLOBENZAPRINE COMFORT P cyclobenzaprine hcl tab 10 mg & liniment topical gel kit 3 LIORESAL INTRATHECAL - baclofen intrathecal inj 10 mg/20ml (500 mcg/ ml) 3 cyclobenzaprine hcl tab 10 mg 1 LIORESAL INTRATHECAL - baclofen intrathecal inj 10 mg/5ml (2000 mcg/ ml) 1 cyclobenzaprine hcl tab 7.5 mg (Fexmid) 1 LIORESAL INTRATHECAL - baclofen intrathecal inj 40 mg/20ml (2000 mcg/ ml) 3 cyclobenzaprine hcl tab 5 mg LORZONE - chlorzoxazone tab 375 mg 3 DANTRIUM - dantrolene sodium cap 25 mg 3 LORZONE - chlorzoxazone tab 750 mg 3 3 metaxalone tab 800 mg (Skelaxin) 1 DANTRIUM - dantrolene sodium cap 50 mg DANTRIUM - dantrolene sodium cap 100 mg 3 DANTROLENE SODIUM - dantrolene sodium cap 100 mg 3 dantrolene sodium cap 25 mg (Dantrium) 1 dantrolene sodium cap 50 mg (Dantrium) 1 ENOVARX-CYCLOBENZAPRINE H cyclobenzaprine hcl td cream 20 mg/ gm (compound kit) 3 FEXMID - cyclobenzaprine hcl tab 7.5 mg 3 FLEXERIL - cyclobenzaprine hcl tab 5 mg 3 FLEXERIL - cyclobenzaprine hcl tab 10 mg 3 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier CARISOPRODOL - carisoprodol tab 250 mg Quantity Limits 1 Step Therapy baclofen tab 20 mg Prior Authorization Drug Name Drug Tier 2015 methocarbamol tab 500 mg (Robaxin) 1 1 methocarbamol tab 750 mg (Robaxin-750) 3 NORFLEX - orphenadrine citrate inj 30 mg/ml 1 orphenadrine citrate inj 30 mg/ml (Norflex) 1 orphenadrine citrate tab sr 12hr 100 mg 1 orphenadrine w/ aspirin & caffeine tab 25-385-30 mg 3 PARAFON FORTE DSC chlorzoxazone tab 500 mg 3 PRAZOLAMINE - carisoprodol tab 350 mg & dietary management cap pack ROBAXIN - methocarbamol tab 500 mg 3 ROBAXIN - methocarbamol inj 100 mg/ ml SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 3 127 ROBAXIN-750 - methocarbamol tab 750 3 mg 3 SKELAXIN - metaxalone tab 800 mg neostigmine methylsulfate inj 1 mg/ ml 1 PROSTIGMIN - neostigmine bromide tab 15 mg 3 PROSTIGMIN - neostigmine methylsulfate inj 0.5 mg/ml (1:2000) 3 pyridostigmine bromide tab 60 mg (Mestinon) 1 REGONOL - pyridostigmine bromide inj 5 mg/ml 3 SOMA - carisoprodol tab 250 mg 3 SOMA - carisoprodol tab 350 mg 3 THERABENZAPRINE-60 cyclobenzaprine tab 10 mg & dietary management cap pack 3 THERABENZAPRINE-90 cyclobenzaprine tab 10 mg & dietary management cap pack 3 THERABENZAPRINE-90-5 cyclobenzaprine tab 5 mg & dietary management cap pack 3 VITAMINS 3 TIZANIDINE COMFORT PAC tizanidine tab 4 mg & liniment topical gel pack 3 AMINOBENZOATE POTASSIUM potassium aminobenzoate packet 2 gm AQUASOL A PARENTERAL - vitamin a inj 50000 unit/ml 3 tizanidine hcl cap 2 mg (Zanaflex) 1 1 ASCORBIC ACID - ascorbic acid oral granules 3 tizanidine hcl cap 4 mg (Zanaflex) tizanidine hcl cap 6 mg (Zanaflex) 1 ascorbic acid inj 500 mg/ml 1 tizanidine hcl tab 2 mg 1 3 tizanidine hcl tab 4 mg (Zanaflex) 1 BABY DDROPS - cholecalciferol drops 400 unit/0.03ml (per drop) ZANAFLEX - tizanidine hcl cap 2 mg 3 cholecalciferol chew tab 400 unit 1 ZANAFLEX - tizanidine hcl cap 4 mg 3 1 ZANAFLEX - tizanidine hcl cap 6 mg 3 cholecalciferol drops 400 unit/0.03ml (per drop) 3 cholecalciferol oral liquid 400 unit/ml 1 ZANAFLEX - tizanidine hcl tab 4 mg cholecalciferol tab 400 unit 1 NUTRITIONAL PRODUCTS ANTIMYASTHENIC AGENTS 3 CVS VITAMIN D3 - cholecalciferol cap 400 unit 3 ENLON - edrophonium chloride inj 10 mg/ml 3 D-VI-SOL - cholecalciferol oral liquid 400 unit/ml 3 GUANIDINE HCL - guanidine hcl tab 125 mg 3 DECARA - cholecalciferol cap 25000 unit 3 MESTINON - pyridostigmine bromide tab 60 mg 2 DRISDOL - ergocalciferol cap 50000 unit 3 MESTINON - pyridostigmine bromide syrup 60 mg/5ml 2 D3 - cholecalciferol cap 400 unit 3 MESTINON TIMESPAN pyridostigmine bromide tab cr 180 mg 1 neostigmine methylsulfate inj 0.5 mg/ml (1:2000) (Prostigmin) 1 ergocalciferol cap 50000 unit (Drisdol) MEPHYTON - phytonadione tab 5 mg 2 128 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 phytonadione inj 1 mg/0.5ml (2 mg/ ml) 1 pediatric multiple vitamins w/ fluoride chew tab 0.25 mg 1 POTABA - potassium aminobenzoate cap 500 mg 3 pediatric multiple vitamins w/ fluoride chew tab 0.5 mg 1 POTABA - potassium aminobenzoate tab 500 mg 3 pediatric multiple vitamins w/ fluoride chew tab 1 mg 1 PYRIDOXINE HCL - pyridoxine hcl inj 100 mg/ml 3 pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml 1 sodium ascorbate inj 250 mg/ml 1 1 thiamine hcl inj 100 mg/ml 1 pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml VITAMIN D - cholecalciferol cap 400 unit 3 pediatric vitamins acd w/ fluoride soln 0.25 mg/ml 1 VITAMIN D2 - ergocalciferol tab 400 unit 3 3 VITAMIN D3 - cholecalciferol cap 400 unit 3 VITAMIN D3 400 - cholecalciferol cap 400 unit 3 VITAMIN K1 - phytonadione inj 10 mg/ ml 3 WHEAT GERM - wheat germ - oil pediatric vitamins acd w/ fluoride soln 0.5 mg/ml 1 speciality vitamin product tab 1 ADRENAL C FORMULA - bioflavonoid products tab 3 ADVANCED AM/PM - multiple vitamins w/ calcium therapy pack 3 ALBAFORT - b-complex w/ iron inj 3 MULTIVITAMINS AP-ZEL - multiple vitamins w/ minerals tab 3 BACMIN - multiple vitamins w/ minerals tab 3 COD LIVER OIL - cod liver oil 3 CORVITE - multiple vitamins w/ minerals & fa tab 1.25 mg 3 DIALYVITE SUPREME D - multiple vitamins w/ minerals & fa tab 3 mg 3 DIALYVITE 3000 - b-complex w/ cbiotin-e-minerals & folic acid tab 3 mg 3 DIALYVITE 5000 - b-complex w/ cbiotin-e-minerals & folic acid tab 5 mg 3 b-complex vitamin inj 1 b-complex w/ c & folic acid cap 1 mg (Nephrocaps) 1 b-complex w/ c & folic acid tab 1 mg (Nephro-vite rx) 1 b-complex w/ c & folic acid tab 5 mg 1 b-complex w/ c & folic acid tab 1 b-complex w/ c-biotin-minerals & folic acid tab 5 mg (Diatx zn) 1 multiple vitamins w/ minerals & fa tab 1.25 mg (Corvite) 1 multiple vitamins w/ minerals cap 1 1 DIALYVITE/ZINC - b-complex w/ c-zn & folic acid tab 1 mg 3 multiple vitamins w/ minerals tab (Strovite forte) pediatric multiple vitamin w/ minerals & c drops 45 mg/ml DIATX ZN - b-complex w/ c-biotinminerals & folic acid tab 5 mg 3 1 pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/ml ESCAVITE - pediatric multiple vitamins w/ fl-fe chew tab 0.25-7.5 mg 3 1 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 129 ESCAVITE D - pediatric multiple vitamins w/ fl-fe chew tab 0.25-6 mg 3 POLY-VI-FLOR - ped multiple vit w/ fluoride biphasic chew tab 1 mg 3 FLORIVA - ped multiple vitamins & minerals w/ fl chew tab 0.5 mg 3 POLY-VI-FLOR - ped multiple vit w/ fluoride biphasic susp 0.25 mg/ml 3 FLORIVA - ped multiple vitamins & minerals w/ fl chew tab 1 mg 3 POLY-VI-FLOR/IRON - ped multiple vit w/ fl-fe biphasic chew tab 0.5-10 mg 3 FOLGARD OS - multiple vit w/ min & calcium-folic acid tab 500-1.1 mg 3 3 FORTAVIT - multiple vitamins w/ minerals cap 3 POLY-VI-FLOR/IRON - ped multiple vitamin w/ fl-fe biphasic susp 0.25-7 mg/ml 2 MYKIDZ IRON FL - pediatric vitamins acd fluoride & fe susp 0.25-10 mg/2ml 3 PRENAPLUS - prenatal vit w/ fe fumarate-fa tab 27-1 mg PRENATABS FA - prenatal vit w/ fe fumarate-fa tab 29-1 mg 2 NEPHPLEX RX - b-complex w/ c-zn & folic acid tab 1 mg 3 PRENATABS RX - prenatal vit w/ iron carbonyl-fa tab 29-1 mg 2 NEPHRO-VITE RX - b-complex w/ c & folic acid tab 1 mg 3 NEPHROCAPS - b-complex w/ c & folic acid cap 1 mg 3 NEPHROCAPS QT - b-complex w/ cbiotin-d & folic acid tab disp 1 mg 3 NEURODEP - b-complex w/ c inj 3 NICADAN - multiple vitamins w/ minerals tab 3 PRENATAL AD - prenatal vit w/ dss-iron 2 carbonyl-fa tab 90-1 mg 2 PRENATAL PLUS - prenatal vit w/ fe fumarate-fa tab 27-1 mg PRENATAL VITAMINS PLUS - prenatal 2 vit w/ fe fumarate-fa tab 27-1 mg 2 PRENATAL 19 - prenatal vit w/ fe fumarate-fa chew tab 29-1 mg 2 PRENATAL 19 - prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg 2 PRENATAL-U - prenatal w/o a vit w/ fe fumarate-fa cap 106.5-1 mg 3 PROMAR - iron & b12 w/ vitamin cap NICAZEL - multiple vitamins w/ minerals 3 tab NICAZEL FORTE - multiple vitamins w/ 3 minerals tab 3 NICOMIDE - niacinamide w/ zn-cumethylfolate tab 750-25-1.5-0.5 mg 3 NUTRICAP - multiple vitamins w/ minerals tab NUTRIVIT - b-complex w/ lysine-min-fe 3 & fa liqd 800-15-1 mg/15ml OCUVEL - multiple vitamins w/ minerals 3 & fa cap 1 mg 3 POLY-VI-FLOR - ped multiple vit w/ fluoride biphasic chew tab 0.25 mg 3 POLY-VI-FLOR - ped multiple vit w/ fluoride biphasic chew tab 0.5 mg 130 PROTECT CARDIO - speciality vitamin product cap 3 PROTECT PLUS - multiple vitamins w/ minerals cap 3 PROTECT PLUS - multiple vitamins w/ minerals liquid 3 PROTECT PLUS NR - multiple vitamins w/ minerals cap 3 PROTECTBONE - multiple vit w/ min & calcium-folic acid wafer 500-1 mg 3 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 QUFLORA PEDIATRIC - pediatric multiple vitamins w/ fluoride chew tab 0.25 mg 3 QUFLORA PEDIATRIC - pediatric multiple vitamins w/ fluoride chew tab 0.5 mg 3 QUFLORA PEDIATRIC - pediatric multiple vitamins w/ fluoride chew tab 1 mg 3 QUFLORA PEDIATRIC - pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml 3 QUFLORA PEDIATRIC - pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml 3 RENATABS - b-complex w/ c-biotin-vit e 3 & folic acid tab 1 mg RENATABS WITH IRON - b complex-c- 3 biotin-e-fa tab 1mg & fe cbn tab 100 mg pack 3 RENAX - multiple vitamins w/ minerals & fa tab 2.5 mg REQ 49+ - multiple vitamins w/ minerals 3 tab 3 SIDEROL - multiple vitamins w/ minerals tab 3 SM B-COMPLEX/VITAMIN C - bcomplex w/ c & folic acid tab STROVITE - b-complex w/ c & folic acid 3 tab 3 STROVITE FORTE - multiple vitamins w/ minerals tab 3 STROVITE FORTE - multiple vitamins w/ minerals & fa syrup 1 mg/15ml 3 STROVITE ONE - multiple vitamins w/ minerals tab SUPERVITE - b-complex w/ lysine-zn & 3 folic acid liquid 3 SUPERVITE EC - multiple vitamins w/ minerals & fa tab dr 1 mg SUPPORT - multiple vitamins w/ minerals liquid 3 SUPPORT-500 - speciality vitamin product cap 3 SYNAGEX - multiple vitamins w/ minerals & fa cap 1.25 mg 3 SYNATEK - multiple vitamins w/ minerals & fa cap 1.25 mg 3 TL G-FOL OS - multiple vit w/ min & calcium-folic acid tab 500-1.1 mg 3 TL-FLUORIVITE - pediatric multiple vitamins w/ fl-fe chew tab 0.25-7.5 mg 3 TRI-VI-FLOR - ped vit acd & l-methylfol w/ fl biphasic susp 0.25 mg/ml 3 TRI-VI-FLOR - ped vit acd & l-methylfol w/ fl biphasic susp 0.5 mg/ml 3 TRI-VI-FLORO - ped vit acd & lmethylfol w/ fl biphasic susp 0.25 mg/ ml 3 TRI-VI-FLORO - ped vit acd & lmethylfol w/ fl biphasic susp 0.5 mg/ ml 3 TRI-VIT/FLUORIDE/IRON - pediatric vitamins acd fluoride & fe drops 0.25-10 mg/ml 2 TRI-ZEL - multiple vitamins w/ minerals tab 3 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 TRINATE - prenatal vit w/ fe fumarate-fa 2 tab 28-1 mg UDAMIN - multiple vitamins w/ minerals 3 & fa tab 2 mg 3 UDAMIN SP - multiple vitamins w/ minerals & fa tab 1 mg 3 VITAFOL - iron w/ vitamin tab SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare VITAJECT - b-complex w/ c inj 3 VITAL-D RX - b-complex w/ c-biotin-dzinc & folic acid tab 1 mg 3 VITAROCA PLUS - multiple vitamins w/ minerals tab 3 Products January 2015 131 3 K-PHOS NEUTRAL - pot phos monobasic w/sod phos di & monobas tab 155-852-130mg 3 CALCIFOL - ca carb-folic acid-vit d-b6b12-boron-mag wafer 1342-1.6 mg 3 K-TAB - potassium chloride tab cr 10 meq 3 CALCIUM-FOLIC ACID PLUS D - ca carb-folic acid-vit d-b6-b12-boronmag wafer 1342-1 mg 3 K-TAB - potassium chloride tab cr 20 meq (1500 mg) 3 3 EFFER-K - potassium bicarbonate-citric acid effer tab 10 meq 3 KLOR-CON M15 - potassium chloride microencapsulated crys cr tab 15 meq EFFER-K - potassium bicarbonate-citric acid effer tab 20 meq 3 KLOR-CON 25 - potassium chloride powder packet 25 meq 3 ELLIOTTS B - intrathecal electrolytes w/ dextrose 3 LOZI-FLUR - sodium fluoride lozenge 1 mg f (from 2.2 mg naf) 3 FLORIVA - sodium fluoride-vitamin d liqd drops 0.25 mg/ml-400 unit/ml 3 FLUOR-A-DAY - sodium fluoride-xylitol chew tab 0.55 (0.25 mg f)-236.79 mg 2 FLUOR-A-DAY - sodium fluoride-xylitol chew tab 1.1 (0.5 mg f)-236.79 mg 2 FLUOR-A-DAY - sodium fluoride-xylitol chew tab 2.2 (1 mg f)-236.79 mg 2 FLUORABON - sodium fluoride soln 0.25 mg/0.6ml (from 0.55 mg/0.6ml naf) 3 LURIDE - sodium fluoride chew tab 0.25 3 mg f (from 0.55 mg naf) 3 LURIDE - sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) 3 LURIDE - sodium fluoride chew tab 1 mg f (from 2.2 mg naf) 3 LURIDE - sodium fluoride soln 0.5 mg/ ml f (from 1.1 mg/ml naf) 3 MAGNEBIND 400 - magnesiumcalcium-folic acid tab 400-200-1 mg 1 magnesium chloride inj 200 mg/ml FLURA-DROPS - sodium fluoride soln 0.25 mg/drop f (from 0.55 mg/drop naf) 2 GALZIN - zinc acetate cap 25 mg (elemental zinc) 3 GALZIN - zinc acetate cap 50 mg (elemental zinc) 3 GNP VITAMIN D-400 - calcium carbonate-cholecalciferol tab 90 mg-400 unit 3 IODINE STRONG - iodine solution strong 5% (lugol's) 3 IODOPEN - sodium iodide inj 100 mcg/ ml 3 K-PHOS - potassium phosphate monobasic tab 500 mg 2 VP-ZEL - multiple vitamins w/ minerals tab MINERALS and ELECTROLYTES 132 MAGNESIUM SULFATE - magnesium sulfate inj 4% 3 MAGNESIUM SULFATE - magnesium sulfate inj 8% 3 magnesium sulfate inj 50% 1 MICRO-K - potassium chloride cap cr 8 meq 3 MICRO-K - potassium chloride cap cr 10 3 meq 1 pot bicarbonate & chloride effer tab 25 meq 1 pot phos monobasic w/sod phos di & monobas tab 155-852-130mg (Kphos neutral) SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 potassium bicarbonate effer tab 25 meq 1 sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf) 1 potassium chloride cap cr 10 meq (Micro-k) 1 sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) (Luride) 1 potassium chloride cap cr 8 meq (Micro-k) 1 SSKI - potassium iodide soln 1 gm/ml 2 3 zinc sulfate cap 220 mg (50 mg elemental zn) 1 POTASSIUM CHLORIDE ER potassium chloride tab cr 20 meq (1500 mg) potassium chloride microencapsulated crys cr tab 10 meq 1 potassium chloride microencapsulated crys cr tab 20 meq 1 potassium chloride oral liq 10% (20 meq/15ml) 1 potassium chloride oral liq 20% (40 meq/15ml) 1 TRYPTOPHAN - tryptophan cap 500 mg 3 3 WHEY PROTEIN DRINK MIX - protein oral powder potassium chloride powder packet 20 meq 1 DIETARY PRODUCTS potassium chloride tab cr 10 meq (Ktab) 1 potassium chloride tab cr 8 meq (600 mg) 1 sodium chloride flush iv soln 0.9% 1 sodium chloride inj 0.9% 1 sodium chloride inj 2.5 meq/ml (14.6%) 1 SODIUM FLUORIDE - sodium fluoride tab 0.5 mg f (from 1.1 mg naf) 2 SODIUM FLUORIDE - sodium fluoride tab 1 mg f (from 2.2 mg naf) 2 sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) (Luride) 1 sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) (Luride) 1 sodium fluoride chew tab 1 mg f (from 2.2 mg naf) (Luride) 1 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 NUTRIENTS SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare acetylcysteine cap 600 mg 1 CARDIOVID PLUS - dha-epa-vit b6b12-folic acid cap 240-360-20-0.5-0.8 mg 3 LECITHIN - lecithin granules 3 NUTRESTORE - glutamine powd pack 5 gm 3 nutritional supplement liquid 1 APPTRIM LIFESTYLES OBESIT dietary management product - diet aids caps 3 APPTRIM LIFESTYLES POST-B dietary management product - diet aids caps 3 APPTRIM LIFESTYLES PRE-BA dietary management product - diet aids caps 3 CAMINO PRO 15PE - nutritional supplement liquid 3 CARDIOTEK-RX - folic acid-b12-b6arginine-black pepper tab 3 FALESSA - levomefolate glucosamine tab 1 mg (folate equivalent) 3 FOLBEE AR - folic acid-b12-b6arginine-black pepper tab 3 PKU EASY MICROTABS - nutritional supplement tabs delayed release 3 Products January 2015 133 RENASTART - nutritional supplement pack 3 SACCHARIN SODIUM - sodium saccharin powder 3 SODIUM SACCHARIN DIHYDRAT sodium saccharin powder 3 TYLACTIN RESTORE 10 - nutritional supplement liquid 3 TYLACTIN RTD 15 - nutritional supplement liquid 3 ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln inj 40 mcg/ml 4 ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln inj 40 mcg/0.4ml 4 ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln inj 60 mcg/ml 4 ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln inj 60 mcg/0.3ml 4 fe fum-iron polysacch complex-fab cmplx-c-zn-mn-cu cap (Tandem plus) ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln inj 100 mcg/ml 4 1 4 ferrous fumarate-fa-b complex-c-znmg-mn-cu tab 106-1 mg 1 ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln inj 100 mcg/0.5ml folic acid-vit b6-vit b12-omega 3phytosterols cap 1 mg 1 4 iron combination cap 1 ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln inj 150 mcg/0.75ml iron-docusate-b12-folic acid-c-e-cubiotin tab 150-1 mg (Hematron-af) 1 4 ACTIVE FE - fe carbonyl-fa-b complexa-c-d-e-min tab 75-1.25 mg 3 ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln inj 150 mcg/0.3ml 4 ALBAFORT - ferric ammon cit-vit b12liver inj 67-50 mg-mcg/ml 3 ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln inj 200 mcg/ml ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln inj 200 mcg/0.4ml 4 ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln inj 300 mcg/ml 4 ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln inj 300 mcg/0.6ml 4 ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln inj 500 mcg/ml 4 B-6 FOLIC ACID - cobalamine combination cap 3 HEMATOLOGICAL AGENTS HEMATOPOIETIC AGENTS ANIMI-3 - folic acid-vit b6-vit b12-omega 3 3-phytosterols cap 1 mg ANIMI-3 - folic acid-b6-b12-d-omega 3- 3 phytosterols cap 1 mg ANIMI-3/VITAMIN D - folic acid-b6-b12- 3 d-omega 3-phytosterols cap 1 mg 4 ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln inj 25 mcg/ml 4 ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln inj 25 mcg/0.42ml 134 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 BIFERARX - polysacch fe cmplx-fe heme poly-fa-b12 tab 22-6-1-0.025 mg 3 fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1 mg 1 BP VIT 3 - folic acid-vit b6-vit b12omega 3-phytosterols cap 1 mg FE 90 PLUS - fe carbonyl-fe gluconatefa-vit b12-vit c-dss tab 90-1 mg 3 3 carbonyl iron chew tab 15 mg (elemental iron) FER-IN-SOL - ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe) 3 1 1 FERIVA - fe bisglycin-fe carbonyl-c-fab12-biotin-dss cap 75-1 mg 3 carbonyl iron susp 15 mg/1.25ml (elemental iron) CENFOL - folic acid-vitamin b6-vitamin b12 tab 2.3-24.5-2 mg FERIVA 21/7 - fe asparto gly-b12-fa-cdss-succinic acid-zn tab 75-1 mg 3 3 CENTRATEX - ferrous fumarate-fa-b complex-c-zn-mg-mn-cu cap 106-1 mg 3 CERDELGA - eliglustat tartrate cap 84 mg (base equivalent) 3 CIFEREX - folic acid-cholecalciferol cap 1 mg-3775 unit 3 CORVITE FE - iron combination tab 3 CORVITE 150 - iron combination tab 3 CORVITE 150 - iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg 3 cyanocobalamin inj 1000 mcg/ml 1 DIVISTA - folic acid-vit b6-vit b12omega 3-biotin-cr cap 1 mg 3 DROXIA - hydroxyurea cap 200 mg 3 DROXIA - hydroxyurea cap 300 mg 3 DROXIA - hydroxyurea cap 400 mg 3 ED CYTE F - ferrous fumarate-folic acid-docusate sodium tab 324-1-50 mg 3 EPOGEN - epoetin alfa inj 2000 unit/ml 5 EPOGEN - epoetin alfa inj 3000 unit/ml 5 EPOGEN - epoetin alfa inj 4000 unit/ml 5 3 fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240 mg 1 Quantity Limits Step Therapy FERIVAFA - iron-c-fa-b12-biotin-copper- 3 docusate cap 110-1 mg 3 FERRALET 90 - fe carbonyl-fe gluconate-fa-vit b12-vit c-dss tab 90-1 mg FERRAPLUS 90 - iron-folic acid-vit b12- 3 vit c-docusate sod tab 90-1 mg 3 FERRETTS CHEWABLE IRON carbonyl iron chew tab 18 mg (elemental iron) 3 FERREX 150 FORTE PLUS - fe asp gly-fe polysacch-succ ac-c-threon acb12-fa cap FERREX 28 - fe asparto gly-fe fum-b12- 3 fa-c-succinic ac tab ther pack 3 FERRO-PLEX HEMATINIC - fe fumdss-vit c-vit e-vit b12-if-fa tab 115-1 mg 3 FERROTRIN - iron w/ b12-vit c-fa-ifc cap 36-0.015-75-0.5-240 mg 1 ferrous fumarate-folic acid tab 324-1 mg 3 FERROUS SULFATE - ferrous sulfate syrup 300 mg/5ml (60 mg/5ml elemental fe) 1 ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe) ferrous sulfate soln 75 mg/ml (15 mg/ 1 ml elemental fe) 1 ferrous sulfate-vit c-folic acid tab cr 105-500-0.8 mg EPOGEN - epoetin alfa inj 10000 unit/ml 5 EPOGEN - epoetin alfa inj 20000 unit/ml 5 FA-8 - folic acid cap 0.8 mg Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 135 FOLGARD RX - folic acid-vitamin b6vitamin b12 tab 2.2-25-1 mg 3 ICAR PEDIATRIC - carbonyl iron susp 15 mg/1.25ml (elemental iron) 3 FOLIC ACID - folic acid inj 5 mg/ml 3 3 folic acid tab 1 mg 1 ICAR-C PLUS - iron-vit c-vit b12-folic acid tab 100-250-0.025-1 mg folic acid tab 400 mcg 1 3 folic acid tab 800 mcg 1 INTEGRA F - fe fum-fe poly-fa-c-b3 cap 62.5-62.5-1-40-3mg(125 mg fe) 1 INTEGRA PLUS - fe fum-iron polysacch complex-fa-b complex-c-biotin cap 3 folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg 1 IRON - iron combination tab 3 folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg (Folgard rx) 3 folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg 1 IRON ASP GLY/ POLYSACCH C - fe asp gly-fe polysacch-succ ac-c-threon ac-b12-fa cap 3 iron dextran inj 50 mg/ml (elemental iron) 1 FOLIVANE-F - fe fum-fe poly-fa-c-b3 cap 62.5-62.5-1-40-3mg(125 mg fe) 3 iron polysacch complex-vit b12-fa cap 150-0.025-1 mg 1 FOLIVANE-PLUS - fe fum-iron polysacch complex-fa-b complex-cbiotin cap 1 FOLTRATE - cobalamine combination tab 3 iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg (Corvite 150) 1 FUSION PLUS - fe fum-iron poly cmplxfa-b cmplx-c-biotin-probiotic cap 3 iron-vit c-vit b12-folic acid tab 100-250-0.025-1 mg (Icar-c plus) 3 GRANIX - tbo-filgrastim soln prefilled syringe 300 mcg/0.5ml 4 IROSPAN 24/6 - fe asp gly-fe polyssucc acd-b cmplx-c-ca-fa tab ther pk 3 GRANIX - tbo-filgrastim soln prefilled syringe 480 mcg/0.8ml 4 IS 24/6 - fe asp gly-fe polys-succ acd-b cmplx-c-ca-fa tab ther pk HEMATOGEN FA - fe fumarate-vit c-vit b12-fa cap 200-250-0.01-1 mg 3 HEMATRON-AF - iron-docusate-b12folic acid-c-e-cu-biotin tab 150-1 mg 3 HEMETAB - polysacch fe cmplx-fe heme poly-fa-b12 tab 22-6-1-0.025 mg 3 HEMOCYTE PLUS - ferrous fumaratefa-b complex-c-zn-mg-mn-cu cap 106-1 mg 3 HEMOCYTE-F - iron combination elixir 3 HYDROXOCOBALAMIN hydroxocobalamin inj 1000 mcg/ml 3 ICAR - carbonyl iron chew tab 15 mg (elemental iron) 3 136 LEUKINE - sargramostim inj 500 mcg/ml 5 MAXARON FORTE - fe gly-fe fum-vit c- 3 vit b12-methylfolate tab 3 MAXFE - iron-fa-vit b12-biotin-vit cdocusate-mg-zn tab 160-1 mg 5 MOZOBIL - plerixafor subcutaneous inj 24 mg/1.2ml (20 mg/ml) MULTIGEN - fe asparto gly-succ acd-c- 3 threonic acd-b12-des stom tab 3 MULTIGEN FOLIC - fe asparto glysuccinic acd-vit c-threonic acd-b12-fa tab MULTIGEN PLUS - fe aspart gly-fe fum- 3 succ acd-c-threonic acd-b12-fa tab SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 MV FE ASPARTO GLY/FE FUM/ - fe aspart gly-fe fum-succ acd-c-threonic acd-b12-fa tab 3 MV FE ASPARTO GLY/VIT C/V - fe asparto gly-succ acd-c-threonic acdb12-des stom tab 3 MYKIDZ IRON 10 - iron susp 15 mg/1.5ml PRE-FOLIC - folic acid-vitamin c tab 1-100 mg 3 PROCRIT - epoetin alfa inj 2000 unit/ml 4 PROCRIT - epoetin alfa inj 3000 unit/ml 4 PROCRIT - epoetin alfa inj 4000 unit/ml 4 3 PROCRIT - epoetin alfa inj 10000 unit/ ml 4 NASCOBAL - cyanocobalamin nasal spray 500 mcg/0.1ml 3 PROCRIT - epoetin alfa inj 20000 unit/ ml 4 NATALVIRT FLT - fe carbonyl-fe gluconate-fa-vit b12-vit c-dss tab 90-1 mg 3 PROCRIT - epoetin alfa inj 40000 unit/ ml 4 3 NEPHRON FA - ferrous fumarate w/ fadss-b complex-vit c tab 3 PROFERRIN-FORTE - iron heme polypeptide-folic acid tab 12-1 mg (fe equiv) NEULASTA - pegfilgrastim inj 6 mg/0.6ml 4 PROMACTA - eltrombopag olamine tab 12.5 mg (base equiv) 5 NEUMEGA - oprelvekin for inj 5 mg 4 5 NEUPOGEN - filgrastim inj 300 mcg/ml 5 PROMACTA - eltrombopag olamine tab 25 mg (base equiv) 5 PROMACTA - eltrombopag olamine tab 50 mg (base equiv) 5 NEUPOGEN - filgrastim inj 480 mcg/1.6ml (300 mcg/ml) 5 PROMACTA - eltrombopag olamine tab 75 mg (base equiv) 5 NEUPOGEN - filgrastim inj 300 mcg/0.5ml (600 mcg/ml) 5 PROTECTIRON - iron polysacch-fa-b complex-vit c-e & minerals tab 60-1 mg 3 NEUPOGEN - filgrastim inj 480 mcg/0.8ml (600 mcg/ml) NEURIN-SL - cyanocobalaminmethylcobalamin tab sl 600-600 mcg 3 3 NIRON KOMPLETE - fe bisglycinate-fe fum-vit c-vit b12-vit e-fa tab 30-1 mg 3 PUREFE PLUS - ferrous fumarate-fab complex-c-zn-mg-mn-cu cap 106-1 mg NOVAFERRUM - polysacch iron complex-vit c-fa for soln 100-60-1 mg/5ml TANDEM F - ferrous fum-iron polysacch-fa cap 162-115.2-1 mg (106 mg fe) 3 3 NPLATE - romiplostim for inj 250 mcg TANDEM PLUS - fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu cap 3 5 NPLATE - romiplostim for inj 500 mcg 5 3 OMONTYS - peginesatide acetate soln inj 10 mg/ml 3 TARON FORTE - fe bisglycinate-fe polysacch-vit c-vit b12-fa cap ZAVESCA - miglustat cap 100 mg 5 OMONTYS - peginesatide acetate soln inj 20 mg/2ml 3 ANTICOAGULANTS PHYSICIANS EZ USE B-12 CO cyanocobalamin inj kit 1000 mcg/ml 3 ACD FORMULA A - anticoagulant citrate dextrose solution a SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 3 137 ACD FORMULA B - anticoagulant citrate dextrose solution b 3 enoxaparin sodium inj 120 mg/0.8ml (Lovenox) 1 ACD-A - anticoagulant citrate dextrose solution a 3 enoxaparin sodium inj 150 mg/ml (Lovenox) 1 ACD-A NOCLOT-50 - anticoagulant citrate dextrose solution a 3 enoxaparin sodium inj 30 mg/0.3ml (Lovenox) 1 ANTICOAGULANT CITRATE DEX anticoagulant citrate dextrose solution a 3 enoxaparin sodium inj 300 mg/3ml (Lovenox) 1 ANTICOAGULANT CITRATE PHO anticoagulant citrate phosphate dextrose soln enoxaparin sodium inj 40 mg/0.4ml (Lovenox) 1 3 enoxaparin sodium inj 60 mg/0.6ml (Lovenox) 1 ANTICOAGULANT SODIUM CITR anticoagulant sodium citrate soln 4% 3 enoxaparin sodium inj 80 mg/0.8ml (Lovenox) 1 ARIXTRA - fondaparinux sodium inj 2.5 mg/0.5ml 3 fondaparinux sodium inj 10 mg/0.8ml (Arixtra) 1 ARIXTRA - fondaparinux sodium inj 5 mg/0.4ml 3 fondaparinux sodium inj 2.5 mg/0.5ml (Arixtra) 1 ARIXTRA - fondaparinux sodium inj 7.5 mg/0.6ml 3 fondaparinux sodium inj 5 mg/0.4ml (Arixtra) 1 ARIXTRA - fondaparinux sodium inj 10 mg/0.8ml 3 fondaparinux sodium inj 7.5 mg/0.6ml (Arixtra) 1 COUMADIN - warfarin sodium tab 1 mg 3 COUMADIN - warfarin sodium tab 2 mg FRAGMIN - dalteparin sodium inj 10000 unit/ml 3 3 COUMADIN - warfarin sodium tab 2.5 mg 3 FRAGMIN - dalteparin sodium inj 2500 unit/0.2ml 3 COUMADIN - warfarin sodium tab 3 mg 3 3 COUMADIN - warfarin sodium tab 4 mg 3 FRAGMIN - dalteparin sodium inj 5000 unit/0.2ml COUMADIN - warfarin sodium tab 5 mg 3 3 COUMADIN - warfarin sodium tab 6 mg 3 FRAGMIN - dalteparin sodium inj 7500 unit/0.3ml 3 FRAGMIN - dalteparin sodium inj 12500 unit/0.5ml 3 COUMADIN - warfarin sodium tab 7.5 mg 3 FRAGMIN - dalteparin sodium inj 15000 unit/0.6ml 3 COUMADIN - warfarin sodium tab 10 mg 3 FRAGMIN - dalteparin sodium inj 18000 unit/0.72ml 3 ELIQUIS - apixaban tab 2.5 mg ELIQUIS - apixaban tab 5 mg 3 enoxaparin sodium inj 100 mg/ml (Lovenox) FRAGMIN - dalteparin sodium inj 25000 unit/ml 3 1 HEPARIN SODIUM - heparin sodium (porcine) inj 2500 unit/ml 2 138 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 heparin sodium (porcine) inj 1000 unit/ml 1 heparin sodium (porcine) inj 10000 unit/ml 1 heparin sodium (porcine) inj 20000 unit/ml PRADAXA - dabigatran etexilate mesylate cap 75 mg (etexilate base eq) 3 3 1 PRADAXA - dabigatran etexilate mesylate cap 150 mg (etexilate base eq) heparin sodium (porcine) inj 5000 unit/ml 1 TRICITRASOL - anticoagulant sodium citrate concentrate 46.7% 3 heparin sodium (porcine) pf inj 5000 unit/0.5ml 1 heparin sodium (porcine) 2 unit/ml in sodium chloride 0.9% (Heparin sodium/sodiu) 1 warfarin sodium tab 1 mg (Coumadin) 1 1 warfarin sodium tab 10 mg (Coumadin) warfarin sodium tab 2 mg (Coumadin) 1 HEPARIN SODIUM/NACL 0.45% heparin sodium (porcine) 50 unit/ml in sodium chloride 0.45% 3 HEPARIN SODIUM/NACL 0.45% heparin sodium (porcine) 100 unt/ml in sodium chloride 0.45% 3 HEPARIN SODIUM/SODIUM CHL heparin sodium (porcine) 2 unit/ml in sodium chloride 0.9% 3 IPRIVASK - desirudin for inj 15 mg 3 LOVENOX - enoxaparin sodium inj 30 mg/0.3ml 3 LOVENOX - enoxaparin sodium inj 40 mg/0.4ml 3 LOVENOX - enoxaparin sodium inj 60 mg/0.6ml 3 3 AMICAR - aminocaproic acid tab 500 mg 3 LOVENOX - enoxaparin sodium inj 80 mg/0.8ml 3 AMICAR - aminocaproic acid tab 1000 mg 3 LOVENOX - enoxaparin sodium inj 100 mg/ml LOVENOX - enoxaparin sodium inj 120 mg/0.8ml 3 LOVENOX - enoxaparin sodium inj 150 mg/ml 3 LOVENOX - enoxaparin sodium inj 300 mg/3ml 3 warfarin sodium tab 2.5 mg (Coumadin) Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 1 warfarin sodium tab 3 mg (Coumadin) 1 warfarin sodium tab 4 mg (Coumadin) 1 warfarin sodium tab 5 mg (Coumadin) 1 warfarin sodium tab 6 mg (Coumadin) 1 warfarin sodium tab 7.5 mg (Coumadin) 1 XARELTO - rivaroxaban tab 10 mg 2 XARELTO - rivaroxaban tab 15 mg 2 XARELTO - rivaroxaban tab 20 mg 2 XARELTO STARTER PACK rivaroxaban tab starter therapy pack 15 mg & 20 mg 2 HEMOSTATICS AMICAR - aminocaproic acid syrup 25% 3 AMINOCAPROIC ACID - aminocaproic 3 acid tab 1000 mg 1 aminocaproic acid syrup 25% (Amicar) 1 aminocaproic acid tab 500 mg (Amicar) SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 139 3 TISSEEL - fibrin sealant component kit 2 ml 3 ASTRINGYN - ferric subsulfate soln 259 3 mg/gm EVICEL - fibrin sealant component kit 2 3 ml EVICEL - fibrin sealant component kit 5 3 ml 3 EVITHROM - thrombin (human) topical soln 800-1200 unit/ml LYSTEDA - tranexamic acid tab 650 mg 3 TISSEEL - fibrin sealant component kit 4 ml 3 TISSEEL - fibrin sealant component kit 10 ml 3 tranexamic acid tab 650 mg (Lysteda) 1 ARTISS - fibrin sealant component solution HEMATOLOGICAL AGENTS - MISC. AGGRENOX - aspirin-dipyridamole cap sr 12hr 25-200 mg 3 AGRYLIN - anagrelide hcl cap 0.5 mg 3 anagrelide hcl cap 0.5 mg (Agrylin) 1 anagrelide hcl cap 1 mg 1 BRILINTA - ticagrelor tab 90 mg 3 MONSELS FERRIC SUBSULFATE ferric subsulfate soln 3 RECOTHROM - thrombin (recombinant) for soln 5000 unit 3 RECOTHROM - thrombin (recombinant) for soln 20000 unit 3 CATHFLO ACTIVASE - alteplase for inj 2 mg 3 RECOTHROM SPRAY KIT - thrombin (recombinant) for soln 20000 unit 3 cilostazol tab 100 mg (Pletal) 1 cilostazol tab 50 mg (Pletal) 1 THROMBIN-JMI DILUENT - thrombin for soln 5000 unit 3 clopidogrel bisulfate tab 300 mg (base equiv) (Plavix) 1 THROMBIN-JMI DILUENT - thrombin for soln 20000 unit 3 clopidogrel bisulfate tab 75 mg (base equiv) (Plavix) 1 THROMBIN-JMI EPISTAXIS - thrombin for soln kit 5000 unit 3 dipyridamole tab 25 mg (Persantine) 1 1 3 dipyridamole tab 50 mg (Persantine) THROMBIN-JMI SYRINGE SPRA thrombin for soln kit 5000 unit dipyridamole tab 75 mg (Persantine) 1 3 EFFIENT - prasugrel hcl tab 5 mg (base equiv) 2 THROMBIN-JMI SYRINGE SPRA thrombin for soln kit 20000 unit 3 EFFIENT - prasugrel hcl tab 10 mg (base equiv) 2 THROMBIN-JMI W/DIL SPRAY thrombin for soln kit 20000 unit 3 FIRAZYR - icatibant acetate inj 30 mg/3ml (base equivalent) 4 THROMBOGEN - thrombin for soln 1000 unit • 3 KALBITOR - ecallantide inj 10 mg/ml 5 THROMBOGEN - thrombin for soln 10000 unit • THROMBOGEN - thrombin for soln kit 10000 unit 3 TISSEEL - fibrin sealant component solution 3 140 KINLYTIC - urokinase for inj 250000 unit 3 1 pentoxifylline tab cr 400 mg PERSANTINE - dipyridamole tab 25 mg 3 PERSANTINE - dipyridamole tab 50 mg 3 PERSANTINE - dipyridamole tab 75 mg 3 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 PLAVIX - clopidogrel bisulfate tab 75 mg 3 (base equiv) 3 PLAVIX - clopidogrel bisulfate tab 300 mg (base equiv) 3 PLETAL - cilostazol tab 50 mg ATROPINE SULFATE - atropine sulfate ophth oint 1% 2 atropine sulfate ophth soln 1% (Isopto atropine) 1 AZASITE - azithromycin ophth soln 1% 3 1 3 PLETAL - cilostazol tab 100 mg 3 ticlopidine hcl tab 250 mg 1 azelastine hcl ophth soln 0.05% (Optivar) TRENTAL - pentoxifylline tab cr 400 mg 3 AZOPT - brinzolamide ophth susp 1% ZONTIVITY - vorapaxar sulfate tab 2.08 mg (base equivalent) 3 BACITRACIN - bacitracin ophth oint 500 2 unit/gm 1 bacitracin-polymyxin b ophth oint TOPICAL PRODUCTS OPHTHALMIC AGENTS bacitracin-polymyxin-neomycin-hc ophth oint 1% 1 BEPREVE - bepotastine besilate ophth soln 1.5% 3 BESIVANCE - besifloxacin hcl ophth susp 0.6% (base equiv) 3 BETADINE OPHTHALMIC PREP povidone-iodine ophth soln 5% 3 BETAGAN - levobunolol hcl ophth soln 0.5% 3 betaxolol hcl ophth soln 0.5% 1 BETIMOL - timolol ophth soln 0.25% 3 ophthalmic irrigation solution intraocular (Bss plus) 1 ACULAR - ketorolac tromethamine ophth soln 0.5% 3 ACULAR LS - ketorolac tromethamine ophth soln 0.4% 3 ACUVAIL - ketorolac tromethamine ophth soln 0.45% 3 AKTEN - lidocaine hcl ophth gel 3.5% 3 ALCAINE - proparacaine hcl ophth soln 0.5% 3 ALOCRIL - nedocromil sodium ophth soln 2% 3 BETIMOL - timolol ophth soln 0.5% 3 3 ALOMIDE - lodoxamide tromethamine ophth soln 0.1% 3 BETOPTIC-S - betaxolol hcl ophth susp 0.25% 3 ALPHAGAN P - brimonidine tartrate ophth soln 0.1% 3 BLEPH-10 - sulfacetamide sodium ophth soln 10% 3 ALPHAGAN P - brimonidine tartrate ophth soln 0.15% 3 BLEPHAMIDE - sulfacetamide sodiumprednisolone ophth susp 10-0.2% 3 ALREX - loteprednol etabonate ophth susp 0.2% 2 BLEPHAMIDE S.O.P. - sulfacetamide sodium-prednisolone ophth oint 10-0.2% AMVISC - sodium hyaluronate intraocular inj 12 mg/ml 3 brimonidine tartrate ophth soln 0.15% (Alphagan p) 1 AMVISC PLUS - sodium hyaluronate intraocular inj 16 mg/ml 3 brimonidine tartrate ophth soln 0.2% 1 3 apraclonidine hcl ophth soln 0.5% (base equivalent) (Iopidine) 1 BROMDAY - bromfenac sodium ophth soln 0.09% (base equiv) (once-daily) SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 141 bromfenac sodium ophth soln 0.09% (base equiv) (once-daily) 1 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml (Cosopt) 1 bromfenac sodium ophth soln 0.09% (base equivalent) 1 DUREZOL - difluprednate ophth emulsion 0.05% 3 BSS PLUS - ophthalmic irrigation solution - intraocular 3 ELESTAT - epinastine hcl ophth soln 0.05% 3 carteolol hcl ophth soln 1% 1 3 CILOXAN - ciprofloxacin hcl ophth soln 0.3% 3 EMADINE - emedastine difumarate ophth soln 0.05% (base equiv) 1 CILOXAN - ciprofloxacin hcl ophth oint 0.3% 2 epinastine hcl ophth soln 0.05% (Elestat) erythromycin ophth oint 5 mg/gm 1 ciprofloxacin hcl ophth soln 0.3% (Ciloxan) 1 EYLEA - aflibercept intravitreal inj 2 mg/0.05ml (40 mg/ml) 5 COMBIGAN - brimonidine tartratetimolol maleate ophth soln 0.2-0.5% 3 FLAREX - fluorometholone acetate ophth susp 0.1% 3 COSOPT - dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml 3 fluorometholone ophth susp 0.1% (Fml liquifilm) 1 COSOPT PF - dorzolamide hcl-timolol maleate ophth sol 22.3-6.8 mg/ml pf 3 flurbiprofen sodium ophth soln 0.03% (Ocufen) 1 cromolyn sodium ophth soln 4% 1 FML - fluorometholone ophth oint 0.1% 3 CYCLOGYL - cyclopentolate hcl ophth soln 0.5% 3 FML FORTE - fluorometholone ophth susp 0.25% 3 CYCLOGYL - cyclopentolate hcl ophth soln 1% 3 FML LIQUIFILM - fluorometholone ophth susp 0.1% 3 CYCLOGYL - cyclopentolate hcl ophth soln 2% 3 GARAMYCIN - gentamicin sulfate ophth soln 0.3% 3 CYCLOMYDRIL - cyclopentolate w/ phenylephrine ophth soln 0.2-1% 3 gatifloxacin ophth soln 0.5% (Zymaxid) 1 cyclopentolate hcl ophth soln 1% (Cyclogyl) 1 cyclopentolate hcl ophth soln 2% (Cyclogyl) 1 GELFILM OP - gelatin adsorbable ophth 3 film 1 gentamicin sulfate ophth oint 0.3% CYSTARAN - cysteamine hcl ophth soln 5 0.44% (base equivalent) 1 dexamethasone sodium phosphate ophth soln 0.1% 1 diclofenac sodium ophth soln 0.1% dorzolamide hcl ophth soln 2% (Trusopt) 142 1 gentamicin sulfate ophth soln 0.3% (Garamycin) 1 HEALON - sodium hyaluronate intraocular inj 10 mg/ml 3 HEALON GV - sodium hyaluronate intraocular inj 14 mg/ml 3 HEALON5 - sodium hyaluronate intraocular inj 23 mg/ml 3 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 homatropine hbr ophth soln 5% (Isopto homatropine) 1 levobunolol hcl ophth soln 0.5% (Betagan) 1 ILEVRO - nepafenac ophth susp 0.3% 3 levofloxacin ophth soln 0.5% 1 IOPIDINE - apraclonidine hcl ophth soln 0.5% (base equivalent) 3 LOTEMAX - loteprednol etabonate ophth susp 0.5% 2 IOPIDINE - apraclonidine hcl ophth soln 1% (base equivalent) 3 LOTEMAX - loteprednol etabonate ophth gel 0.5% 2 ISOPTO ATROPINE - atropine sulfate ophth soln 1% 3 LOTEMAX - loteprednol etabonate ophth oint 0.5% 2 ISOPTO CARBACHOL - carbachol ophth soln 1.5% 3 LUCENTIS - ranibizumab intravitreal inj 0.3 mg/0.05ml (6 mg/ml) 5 ISOPTO CARBACHOL - carbachol ophth soln 3% 3 LUCENTIS - ranibizumab intravitreal inj 0.5 mg/0.05ml (10 mg/ml) 5 ISOPTO CARPINE - pilocarpine hcl ophth soln 1% 3 LUMIGAN - bimatoprost ophth soln 0.01% 2 ISOPTO CARPINE - pilocarpine hcl ophth soln 2% 3 LUMIGAN - bimatoprost ophth soln 0.03% 2 ISOPTO CARPINE - pilocarpine hcl ophth soln 4% 3 MACUGEN - pegaptanib sodium intravitreous inj 0.3 mg/90 microliter 5 MAXIDEX - dexamethasone ophth susp 0.1% 3 MAXITROL - neomycin-polymyxindexamethasone ophth susp 0.1% 3 MAXITROL - neomycin-polymyxindexamethasone ophth oint 0.1% 3 METIPRANOLOL - metipranolol ophth soln 0.3% 3 MIOCHOL-E - acetylcholine chloride intraocular for soln 1:100 (20 mg) 3 MIOSTAT - carbachol intraocular inj 0.01% 3 MITOSOL - mitomycin for ophth soln kit 0.2 mg 3 2 ISOPTO HOMATROPINE - homatropine 3 hbr ophth soln 2% ISOPTO HOMATROPINE - homatropine 3 hbr ophth soln 5% ISOPTO HYOSCINE - scopolamine hbr 3 ophth soln 0.25% 3 ISTALOL - timolol maleate ophth soln 0.5% (once-daily) JETREA - ocriplasmin intravitreal inj 0.5 5 mg/0.2ml (2.5 mg/ml) 1 ketorolac tromethamine ophth soln 0.4% (Acular ls) 1 ketorolac tromethamine ophth soln 0.5% (Acular) LACRISERT - artificial tear ophth insert 3 LASTACAFT - alcaftadine ophth soln 0.25% 3 MOXEZA - moxifloxacin hcl ophth soln 0.5% (base eq) (2 times daily) 3 latanoprost ophth soln 0.005% (Xalatan) 1 MYDFRIN - phenylephrine hcl ophth soln 2.5% 3 LEVOBUNOLOL HCL - levobunolol hcl ophth soln 0.25% 2 NAPHAZOLINE HCL - naphazoline hcl ophth soln 0.1% NATACYN - natamycin ophth susp 5% 2 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 143 neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin 1 pilocarpine hcl ophth soln 2% (Isopto carpine) 1 neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml (Neosporin) 1 pilocarpine hcl ophth soln 4% (Isopto carpine) 1 neomycin-polymyxindexamethasone ophth oint 0.1% (Maxitrol) 1 neomycin-polymyxindexamethasone ophth susp 0.1% (Maxitrol) 1 NEOMYCIN/POLYMYXIN/HYDROC neomycin-polymyxin-hc ophth susp 3 NEOSPORIN - neomycin-polymygramicid op sol 1.75-10000-0.025mgunt-mg/ml 3 NEVANAC - nepafenac ophth susp 0.1% 3 OCUFEN - flurbiprofen sodium ophth soln 0.03% 3 OCUFLOX - ofloxacin ophth soln 0.3% 3 ofloxacin ophth soln 0.3% (Ocuflox) 1 OMNIPRED - prednisolone acetate ophth susp 1% 3 OPTIVAR - azelastine hcl ophth soln 0.05% 3 OZURDEX - dexamethasone intravitreal implant 0.7 mg 3 PATADAY - olopatadine hcl ophth soln 0.2% 2 PATANOL - olopatadine hcl ophth soln 0.1% 3 phenylephrine hcl ophth soln 10% 1 phenylephrine hcl ophth soln 2.5% 1 PHOSPHOLINE IODIDE echothiophate iodide ophth for soln 0.125% 3 pilocarpine hcl ophth soln 1% (Isopto carpine) 1 144 PILOPINE HS - pilocarpine hcl ophth gel 3 4% 1 polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% (Polytrim) 3 POLYTRIM - polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% 3 PRED FORTE - prednisolone acetate ophth susp 1% 3 PRED MILD - prednisolone acetate ophth susp 0.12% PRED-G - gentamicin-prednisolone ace 3 ophth susp 0.3-1% 3 PRED-G S.O.P. - gentamicinprednisolone ace ophth oint 0.3-0.6% prednisolone acetate ophth susp 1% 1 (Pred forte) 3 PREDNISOLONE SODIUM PHOSP prednisolone sodium phosphate ophth soln 1% PROLENSA - bromfenac sodium ophth 3 soln 0.07% (base equivalent) 1 proparacaine hcl ophth soln 0.5% (Alcaine) 3 PROVISC - sodium hyaluronate intraocular inj 10 mg/ml 3 RESCULA - unoprostone isopropyl ophth soln 0.15% 3 RESTASIS - cyclosporine (ophth) emulsion 0.05% 3 RETISERT - fluocinolone acetonide intravitreal implant 0.59 mg 3 SHELLGEL - sodium hyaluronate intraocular inj 12 mg/ml SIMBRINZA - brinzolamide-brimonidine 2 tartrate ophth susp 1-0.2% SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 SULFACETAMIDE SODIUM sulfacetamide sodium ophth oint 10% 3 sulfacetamide sodium ophth soln 10% (Bleph-10) 2 1 TRAVATAN Z - travoprost ophth soln 0.004% (benzalkonium free) (bak free) 3 sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)% 1 TRAVOPROST - travoprost ophth soln 0.004% 3 tetracaine hcl ophth soln 0.5% 1 TRIESENCE - triamcinolone acetonide ophth inj 40 mg/ml timolol maleate ophth gel forming soln 0.25% (Timoptic-xe) 1 trifluridine ophth soln 1% (Viroptic) 1 1 timolol maleate ophth gel forming soln 0.5% (Timoptic-xe) 1 tropicamide ophth soln 1% (Mydriacyl) 3 timolol maleate ophth soln 0.25% (Timoptic) 1 TRUSOPT - dorzolamide hcl ophth soln 2% VEXOL - rimexolone ophth susp 1% 3 timolol maleate ophth soln 0.5% (Timoptic) 1 VIGAMOX - moxifloxacin hcl ophth soln 0.5% (base equiv) 2 TIMOPTIC - timolol maleate ophth soln 0.25% 3 VIROPTIC - trifluridine ophth soln 1% 3 3 XALATAN - latanoprost ophth soln 0.005% 3 TIMOPTIC - timolol maleate ophth soln 0.5% TIMOPTIC OCUDOSE - timolol maleate preservative free ophth soln 0.25% ZIOPTAN - tafluprost ophth soln 0.0015% 3 3 ZIRGAN - ganciclovir ophth gel 0.15% 3 TIMOPTIC OCUDOSE - timolol maleate preservative free ophth soln 0.5% 3 ZYLET - loteprednol etabonatetobramycin ophth susp 0.5-0.3% 2 TIMOPTIC-XE - timolol maleate ophth gel forming soln 0.25% 3 ZYMAXID - gatifloxacin ophth soln 0.5% 3 TIMOPTIC-XE - timolol maleate ophth gel forming soln 0.5% 3 TOBRADEX - tobramycindexamethasone ophth susp 0.3-0.1% 3 TOBRADEX - tobramycindexamethasone ophth oint 0.3-0.1% 3 TOBRADEX ST - tobramycindexamethasone ophth susp 0.3-0.05% 3 tobramycin ophth soln 0.3% (Tobrex) 1 tobramycin-dexamethasone ophth susp 0.3-0.1% (Tobradex) 1 TOBREX - tobramycin ophth soln 0.3% 3 TOBREX - tobramycin ophth oint 0.3% 3 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 OTIC AGENTS SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare antipyrine-benzocaine-polycosanol otic sol 5.4-1.4-0.0097% (Treagan otic) 1 acetic acid otic soln 2% 1 ACETIC ACID/ALUMINUM ACET acetic acid 2% in aluminum acetate otic soln 3 antipyrine-benzocaine otic soln 54-14 mg/ml (5.4-1.4%) 1 antipyrine-benzocaine otic soln 55-14 mg/ml (5.5-1.4%) 1 ANTIPYRINE/BENZOCAINE antipyrine-benzocaine otic soln 55-14 mg/ml (5.5-1.4%) 3 Products January 2015 145 AURALGAN - antipyrine-benzocaine otic soln 55-14 mg/ml (5.5-1.4%) 3 OTOZIN - antipyrine-benzocaineglycerin-zinc ace otic liqd 5.4-1-2-1% 3 CETRAXAL - ciprofloxacin hcl otic soln 0.2% (base equivalent) 3 PINNACAINE OTIC - benzocaine otic soln 20% 3 CIPRO HC - ciprofloxacinhydrocortisone otic susp 0.2-1% 3 PRAMOTIC - pramoxine-chloroxylenol otic liquid 1-0.1% 3 CIPRODEX - ciprofloxacindexamethasone otic susp 0.3-0.1% 3 pramoxine-chloroxylenol otic liquid 1-0.1% (Pramotic) 1 CIPROFLOXACIN - ciprofloxacin hcl otic soln 0.2% (base equivalent) 3 1 COLY-MYCIN S - neomycin-colistin-hcthonzonium otic susp 3.3-3-10-0.5 mg/ml 3 pramoxine-hc-chloroxylenol aqueous otic soln 10-10-1 mg/ml (Cortane-b aqueous) pramoxine-hc-chloroxylenol otic soln 10-10-1 mg/ml (Cortane-b-otic) 1 CORTANE-B AQUEOUS - pramoxinehc-chloroxylenol aqueous otic soln 10-10-1 mg/ml 3 TREAGAN OTIC - antipyrinebenzocaine-polycosanol otic sol 5.4-1.4-0.0097% 3 CORTANE-B-OTIC - pramoxine-hcchloroxylenol otic soln 10-10-1 mg/ml 3 VOSOL HC - hydrocortisone w/ acetic acid otic soln 1-2% 3 CORTISPORIN - neomycin-polymyxinhc otic soln 1% 3 MOUTH/THROAT/DENTAL AGENTS CORTISPORIN-TC - neomycin-colistinhc-thonzonium otic susp 3.3-3-10-0.5 mg/ml 3 CRESYLATE - cresyl acetate otic soln 25% 3 DERMOTIC - fluocinolone acetonide (otic) oil 0.01% 3 fluocinolone acetonide (otic) oil 0.01% (Dermotic) mouthwashes - liquid 1 AQUORAL - artificial saliva - aero soln 3 ARESTIN - minocycline hcl subgingival powder cartridge 1 mg 3 benzocaine dental soln 20% 1 CAPHOSOL - artificial saliva - solution 3 cevimeline hcl cap 30 mg (Evoxac) 1 1 chlorhexidine gluconate soln 0.12% (Peridex) 1 hydrocortisone w/ acetic acid otic soln 1-2% (Vosol hc) 1 clotrimazole troche 10 mg 1 MYOXIN - benzocaine-chloroxylenol-hc otic soln 15-1-10 mg/ml 3 neomycin-polymyxin-hc otic soln 1% (Cortisporin) 1 DEBACTEROL - sulfuric acid-sulfonated 3 phenolics soln 30-50% 3 EVOXAC - cevimeline hcl cap 30 mg neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% 1 ofloxacin otic soln 0.3% 1 OTICIN HC NR - pramoxine-hcchloroxylenol otic soln 10-10-1 mg/ml 3 146 FIRST-BXN MOUTHWASH diphenhydramine-lidocaine-nystatin susp 3 FIRST-DUKES MOUTHWASH diphenhydramine-hydrocortisonenystatin susp 3 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 pilocarpine hcl tab 7.5 mg (Salagen) 1 PREVIDENT - sodium fluoride rinse 0.2% 3 PREVIDENT FLUORIDE - sodium fluoride gel 1.1% (0.5% f) 3 PREVIDENT 5000 BOOSTER - sodium fluoride paste 1.1% 3 FIRST-MOUTHWASH BLM diphenhyd-lidocaine-al hydroxide-mg hydroxide-simeth susp 3 FLUORIDEX DAILY DEFENSE S sodium fluoride-potassium nitrate gel 1.1-5% 3 GEL-KAM ORAL CARE RINSE stannous fluoride conc 0.63% 3 PREVIDENT 5000 BOOSTER PL sodium fluoride paste 1.1% 3 GELCLAIR - povidone-sodium hyaluronate-glycyrrhetinic acid gel 3 PREVIDENT 5000 DRY MOUTH sodium fluoride gel 1.1% (0.5% f) 3 GELX - oral wound care products - gel 3 3 lidocaine hcl laryngotracheal soln 4% (Lta 360 kit) 1 PREVIDENT 5000 ENAMEL PRO sodium fluoride-potassium nitrate paste 1.1-5% 1 PREVIDENT 5000 PLUS - sodium fluoride cream 1.1% 3 lidocaine hcl viscous soln 2% LTA 360 KIT - lidocaine hcl laryngotracheal soln 4% 3 Quantity Limits 1 3 Step Therapy pilocarpine hcl tab 5 mg (Salagen) FIRST-MARYS MOUTHWASH diphenhydramine-hydrocortisonenystatin-tetracycline susp Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 PREVIDENT 5000 SENSITIVE - sodium 3 fluoride-potassium nitrate paste 1.1-5% PROTHELIAL - sucralfate-malate paste 3 10% 3 SALAGEN - pilocarpine hcl tab 5 mg MUCOTROL - oral wound care products 3 - wafer 3 NAFRINSE DAILY/ACIDULATED sodium fluoride-phosphoric acid for soln 1 mg/5ml (f equiv) 3 NAFRINSE DAILY/NEUTRAL - sodium fluoride for soln rinse 0.05% 3 NAFRINSE WEEKLY - sodium fluoride for soln rinse 0.2% 3 NEUTRASAL - artificial saliva - packet SALAGEN - pilocarpine hcl tab 7.5 mg 3 SALICEPT - oral wound care products for susp rinse 3 sodium fluoride cream 1.1% (Prevident 5000 plus) 1 sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride) 1 sodium fluoride paste 1.1% (Prevident 5000 boost) 1 NUMOISYN - artificial saliva - solution 3 NUMOISYN - artificial saliva - lozenge 3 nystatin susp 100000 unit/ml 1 ORAFATE - sucralfate-malate paste 10% 3 sodium fluoride rinse 0.2% (Prevident) 1 ORAMAGICRX - oral wound care products - for susp rinse 3 sodium fluoride-potassium nitrate paste 1.1-5% (Prevident 5000 sensi) 1 ORAVIG - miconazole buccal tab 50 mg (mouth-throat) 3 stannous fluoride conc 0.63% (Gelkam oral care ri) 1 stannous fluoride gel 0.4% 1 PERIDEX - chlorhexidine gluconate soln 3 0.12% SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 147 THERA-FLUR-N - sodium fluoride gel 1.1% (0.5% f) 3 hydrocortisone acetate w/ pramoxine rectal cream 1-1% (Analpram-hc) 1 triamcinolone acetonide dental paste 0.1% 1 hydrocortisone acetate w/ pramoxine rectal cream 2.5-1% (Analpram-hc) 1 hydrocortisone enema 100 mg/60ml (Cortenema) 1 hydrocortisone rectal cream 1% (Proctocort) 1 hydrocortisone rectal cream 2.5% (Anusol-hc) 1 LIDOCAINE HCL-HYDROCORTIS lidocaine-hydrocortisone acetate rectal gel 2.8-0.55% 3 lidocaine-hydrocortisone acetate rectal cream kit 2-2% 1 lidocaine-hydrocortisone acetate rectal cream kit 3-0.5% 1 lidocaine-hydrocortisone acetate rectal cream kit 3-1% 1 lidocaine-hydrocortisone acetate rectal cream 3-0.5% 1 lidocaine-hydrocortisone acetate rectal gel kit 3-2.5% 1 PROCORT - hydrocortisone acetate w/ pramoxine rectal cream 1.85-1.15% 3 PROCTOCORT - hydrocortisone rectal cream 1% 3 PROCTOCORT - hydrocortisone acetate suppos 30 mg 3 PROCTOFOAM HC - hydrocortisone acetate w/ pramoxine rectal foam 1-1% 3 RECTIV - nitroglycerin oint 0.4% 3 ANORECTAL AGENTS 1 hc-pramoxine emol cream 2.5-1% & pramoxine wipe 1% kit (Analpram e) 3 ANALPRAM ADVANCED - hcpramoxine cr & diet manage prod tab & cleans wipe kit 3 ANALPRAM E - hc-pramoxine emol cream 2.5-1% & pramoxine wipe 1% kit 3 ANALPRAM-HC - hydrocortisone acetate w/ pramoxine rectal cream 1-1% 3 ANALPRAM-HC - hydrocortisone acetate w/ pramoxine rectal cream 2.5-1% 3 ANALPRAM-HC - hydrocortisone acetate w/ pramoxine rectal lotn 2.5-1% 3 ANALPRAM-HC SINGLES hydrocortisone acetate w/ pramoxine rectal cream 1-1% 3 ANALPRAM-HC SINGLES hydrocortisone acetate w/ pramoxine rectal cream 2.5-1% 3 ANUSOL-HC - hydrocortisone rectal cream 2.5% 3 ANUSOL-HC - hydrocortisone acetate suppos 25 mg 3 CORTENEMA - hydrocortisone enema 100 mg/60ml 2 CORTIFOAM - hydrocortisone acetate rectal foam 90 mg/dose 1 hydrocortisone acetate suppos 25 mg (Anusol-hc) 1 hydrocortisone acetate suppos 30 mg (Proctocort) 148 DERMATOLOGICALS nystatin topical powder 1 salicylic acid cream 6% & cleanser liqd kit (Salex cream) 1 salicylic acid lotion 6% & cleanser liqd kit (Salex lotion) 1 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 sulfacetamide sod-sulfur wash 9-4.5% & skin cleanser kit (Sumadan kit) 1 sulfacetamide sod-sulfur wash 9-4.5% & sunscreen kit (Sumadan xlt) 1 sulfacetamide sodium-sulfur w/ sunscreens cream 10-5% 1 wound dressings - cream 1 A.A.G.C. KIT IN TERODERM amantad-amitript-gaba-cycloben cream 8-4-10-4% (cmpd kit) ACTIVE-TRAMADOL KIT - tramadol hcl cream 8% (compound kit) 3 acyclovir oint 5% (Zovirax) 1 ACZONE - dapsone gel 5% 3 adapalene cream 0.1% (Differin) 1 adapalene gel 0.1% (Differin) 1 adapalene gel 0.3% (Differin) 1 3 3 AIF #2 DRUG PREPARATION flurbiprofen-gabapent-cycloben-lidodexameth cr (cmp kit) 3 ABSORICA - isotretinoin cap 10 mg 3 ABSORICA - isotretinoin cap 20 mg 3 AIF #3 DRUG PREPARATION K flurbiprofen-baclofen-cycloben-lido cream (cmp kit) 3 AKNE-MYCIN - erythromycin oint 2% 3 ABSORICA - isotretinoin cap 25 mg 3 ALA QUIN - clioquinol-hc cream 3-0.5% 3 ABSORICA - isotretinoin cap 30 mg 3 ALA SCALP - hydrocortisone lotion 2% 3 ABSORICA - isotretinoin cap 35 mg 3 alclometasone dipropionate cream 0.05% (Aclovate) 1 ABSORICA - isotretinoin cap 40 mg ACANYA - clindamycin phosphatebenzoyl peroxide gel 1.2-2.5% 3 alclometasone dipropionate oint 0.05% 1 acitretin cap 10 mg (Soriatane) 1 acitretin cap 17.5 mg (Soriatane) acitretin cap 25 mg (Soriatane) 1 ALCORTIN A - iodoquinolhydrocortisone-aloe polysaccharide gel 1-2-1% 3 1 ACLOVATE - alclometasone dipropionate cream 0.05% 3 ALDARA - imiquimod cream 5% 3 3 ACTIVE-KETOPROFEN KIT ketoprofen cream 5% (compound kit) 3 ALEVEER - capsaicin-menthol topical patch 0.0375-5% 3 ACTIVE-PREP KIT I - flurbiprofencyclobenzaprine cream (cmpd kit) 3 ALEVICYN ANTIPRURITIC GEL wound dressings - gel 3 ACTIVE-PREP KIT II - ketoprofenbaclofen-gabapentin cream (cmpd kit) 3 ALEVICYN DERMAL SPRAY - wound dressings - soln 3 ACTIVE-PREP KIT III - ketoprofenlidocaine-gabapentin cream (cmpd kit) 3 ALLEVYN AG ADHESIVE - wound dressings - pads ALLEVYN AG GENTLE BORDER wound dressings - pads 3 ACTIVE-PREP KIT IV - tramadolgabapentin-menthol-camphor cream (cmpd kit) 3 ACTIVE-PREP KIT V - itraconazolephenytoin sodium cream (cmpd kit) 3 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 ALLEVYN AG NON-ADHESIVE - wound 3 dressings - pads 3 ALLEVYN AG SACRUM - wound dressings - pads SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 149 ALLEVYN GENTLE - wound dressings pads 3 AVAR LS CLEANSER - sulfacetamide sodium w/ sulfur cleanser 10-2% 3 ALOQUIN - iodoquinol-aloe polysaccharides gel 1.25-1% 3 AVAR-E LS - sulfacetamide sodium w/ sulfur cream 10-2% 3 ALTABAX - retapamulin oint 1% 3 3 ALUMINUM ACETATE - aluminum acetate soln 3 AVO CREAM - wound dressings emulsion AZELEX - azelaic acid cream 20% 3 aluminum chloride soln 20% (Drysol) 1 BACTROBAN - mupirocin oint 2% 3 ALUVEA - urea cream 39% 3 3 AMCINONIDE - amcinonide cream 0.1% 3 BACTROBAN - mupirocin calcium cream 2% 3 AMCINONIDE - amcinonide lotion 0.1% 3 BENSAL HP - salicylic acid & benzoic acid oint 3-6% AMCINONIDE - amcinonide oint 0.1% 3 3 ANACAINE - benzocaine oint 10% 3 BENZAC AC WASH - benzoyl peroxide liq 5% 3 BENZAC W WASH - benzoyl peroxide liq 5% 3 APEXICON E - diflorasone diacetate emollient base cream 0.05% 3 BENZACLIN - clindamycin phosphatebenzoyl peroxide gel 1-5% 3 APOP - sulfacetamide sodium in bakuchiol vehicle gel 10% 3 BENZACLIN WITH PUMP - clindamycin phosphate-benzoyl peroxide gel 1-5% 3 ARNICA FLOWER - arnica - tincture ARZOL SILVER NITRATE APP - silver nitrate-potassium nitrate applicator 75-25% 3 BENZAMYCIN - benzoyl peroxideerythromycin gel 5-3% 3 3 BENZAMYCINPAK - benzoyl peroxideerythromycin gel pack 5-3% 3 ATOPICLAIR - emollient - cream ATRALIN - tretinoin gel 0.05% 3 3 BENZEFOAM - benzoyl peroxide foam 5.3% 3 ATRAPRO ANTIPRURITIC HYDR wound dressings - gel ATRAPRO CP - wound dressings - kit 3 ATRAPRO DERMAL SPRAY - wound cleansers - liquid 3 BENZEFOAMULTRA - benzoyl peroxide 3 foam 9.8% 3 BENZIQ - benzoyl peroxide gel 5.25 % AURSTAT - emollient cream & wound dressing gel kit BENZIQ LS - benzoyl peroxide gel 2.75% 3 3 3 AURSTAT ANTI-ITCH HYDROGE dermatological products misc - gel 3 BENZOIN COMPOUND TINCTURE benzoin compound tincture BENZOIN TINCTURE - benzoin tincture 3 AURSTAT ANTI-ITCH HYDROGE dermatological products misc - kit 3 benzoyl peroxide cleanser 4.25% 1 3 benzoyl peroxide cloth 3% 1 AVAR - sulfacetamide sodium w/ sulfur cleansing pad 9.5-5% benzoyl peroxide cloth 6% 1 AVAR LS - sulfacetamide sodium w/ sulfur cleansing pad 10-2% 3 benzoyl peroxide cloth 9% 1 150 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 BORIC ACID - boric acid granules 3 BPO - benzoyl peroxide gel 4% 3 BPO - benzoyl peroxide gel 8% 3 BPO CREAMY WASH COMPLETE benzoyl peroxide creamy wash 8% &benzoyl peroxide bar 5% kit 3 BPO 3% FOAMING CLOTHS - benzoyl peroxide cloth 3% 3 BPO 6% FOAMING CLOTHS - benzoyl peroxide cloth 6% 3 BPO 9% FOAMING CLOTHS - benzoyl peroxide cloth 9% 3 1 benzoyl peroxide creamy wash 8% & cleanser lotion kit 1 benzoyl peroxide creamy wash 8% &benzoyl peroxide bar 5% kit (Bpo creamy wash comp) 1 benzoyl peroxide foam 5.3% (Benzefoam) 1 benzoyl peroxide foam 9.8% (Benzefoamultra) 1 benzoyl peroxide gel 10% 1 benzoyl peroxide gel 5% 1 benzoyl peroxide liq 2.5% 1 benzoyl peroxide liq 5.25% 1 calcipotriene cream 0.005% (Dovonex) benzoyl peroxide liq 7% 1 calcipotriene oint 0.005% 1 benzoyl peroxide lotion 6% 1 1 benzoyl peroxide-erythromycin gel 5-3% (Benzamycin) 1 calcipotriene soln 0.005% (50 mcg/ ml) 1 betamethasone dipropionate augmented cream 0.05% (Diprolene af) 1 calcipotriene-betamethasone dipropionate oint 0.005-0.064% (Taclonex) CALCITRIOL - calcitriol oint 3 mcg/gm 3 betamethasone dipropionate augmented gel 0.05% 1 CAPEX - fluocinolone acetonide shampoo 0.01% 3 CARAC - fluorouracil cream 0.5% 2 CARMOL-HC - urea-hc acetate cream 1% 3 CARRASYN HYDROGEL WOUND D wound dressings - gel 3 CEM-UREA - urea soln 45% 3 CENTANY - mupirocin oint 2% 3 CENTANY AT - mupirocin oint kit 2% 3 CETACAINE - butamben-tetracainebenzocaine aerosol spray 2-2-14% 3 CICLODAN CREAM KIT - ciclopirox olamine cream 0.77% (base equiv) & cleanser kit 3 CICLODAN SOLUTION KIT - ciclopirox solution kit 8% 3 1 betamethasone dipropionate augmented lotion 0.05% (Diprolene) 1 betamethasone dipropionate augmented oint 0.05% (Diprolene) 1 betamethasone dipropionate cream 0.05% 1 betamethasone dipropionate lotion 0.05% 1 betamethasone dipropionate oint 0.05% 1 betamethasone valerate aerosol foam 0.12% (Luxiq) 1 betamethasone valerate cream 0.1% betamethasone valerate lotion 0.1% 1 betamethasone valerate oint 0.1% 1 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits 3 1 Step Therapy BIAFINE - wound dressings - emulsion benzoyl peroxide creamy wash 4% & cleanser lotion kit Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 151 1 1 clindamycin phosphate soln 1% (Cleocin-t) 1 ciclopirox olamine susp 0.77% (base equiv) 1 clindamycin phosphate swab 1% (Cleocin-t) 1 ciclopirox shampoo 1% (Loprox shampoo) 1 clindamycin phosphate-benzoyl peroxide gel 1-5% (Benzaclin) 1 ciclopirox solution kit 8% (Ciclodan solution ki) 1 clobetasol propionate cream 0.05% (Temovate) 1 ciclopirox solution 8% (Penlac Nail Lacquer) 1 clobetasol propionate emollient base cream 0.05% (Temovate e) 1 CICLOPIROX TOPICAL SOLUTI ciclopirox solution 8% & vitamin e 5% topical kit 3 clobetasol propionate emulsion foam 0.05% (Olux-e) clobetasol propionate foam 0.05% (Olux) 1 CLARAVIS - isotretinoin cap 30 mg 3 clobetasol propionate gel 0.05% (Temovate) 1 clobetasol propionate lotion 0.05% (Clobex) 1 clobetasol propionate oint 0.05% (Temovate) 1 clobetasol propionate shampoo 0.05% (Clobex) 1 clobetasol propionate soln 0.05% (Temovate) 1 CLOBEX - clobetasol propionate spray 0.05% 3 CLOBEX - clobetasol propionate lotion 0.05% 3 CLOBEX - clobetasol propionate shampoo 0.05% 3 CLOCORTOLONE PIVALATE clocortolone pivalate cream 0.1% 3 CLOCORTOLONE PIVALATE PUM clocortolone pivalate cream 0.1% 3 CLODAN KIT - clobetasol propionate shampoo 0.05% & cleanser kit 3 CLODERM - clocortolone pivalate cream 0.1% 3 CLODERM PUMP - clocortolone pivalate cream 0.1% 3 CLARIFOAM EF - sulfacetamide sodium 3 w/ sulfur foam 10-5% 3 CLEOCIN-T - clindamycin phosphate soln 1% 3 CLEOCIN-T - clindamycin phosphate gel 1% 3 CLEOCIN-T - clindamycin phosphate lotion 1% 3 CLEOCIN-T - clindamycin phosphate swab 1% 3 CLINDACIN ETZ - clindamycin phosphate swab 1% & cleanser kit 3 CLINDACIN PAC - clindamycin phosphate swab 1% & cleanser kit 3 CLINDAGEL - clindamycin phosphate gel 1% 1 clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% (Duac) 1 clindamycin phosphate foam 1% (Evoclin) 1 clindamycin phosphate gel 1% (Cleocin-t) 1 clindamycin phosphate lotion 1% (Cleocin-t) 152 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier ciclopirox olamine cream 0.77% (base equiv) Quantity Limits 1 Step Therapy ciclopirox gel 0.77% Prior Authorization Drug Name Drug Tier 2015 3 1 CUTIVATE - fluticasone propionate oint 0.005% clotrimazole w/ betamethasone cream 1-0.05% (Lotrisone) 1 DENAVIR - penciclovir cream 1% 3 3 clotrimazole w/ betamethasone lotion 1-0.05% 1 DERMA-SMOOTHE/FS BODY fluocinolone acetonide oil 0.01% (body oil) CNL8 NAIL KIT - ciclopirox soln 8% & lacquer removal pads kit 3 3 COAL TAR - coal tar soln 20% 3 DERMA-SMOOTHE/FS BODY OIL fluocinolone acetonide oil 0.01% (body oil) 3 COCAINE HCL - cocaine hcl soln 10% 3 DERMA-SMOOTHE/FS SCALP fluocinolone acetonide oil 0.01% (scalp oil) 3 COCAINE HCL - cocaine hcl soln 4% CONDYLOX - podofilox soln 0.5% 3 3 CONDYLOX - podofilox gel 0.5% 3 CORDRAN - flurandrenolide cream 0.05% 3 DERMA-SMOOTHE/FS SCALP OI fluocinolone acetonide oil 0.01% (scalp oil) 3 CORDRAN - flurandrenolide lotion 0.05% 3 DERMASORB AF - clioquinol-hc cream 3-0.5% & emollient liqd kit 3 CORDRAN - flurandrenolide oint 0.05% 3 DERMASORB HC - hydrocortisone lot 2% & cleanser liq kit CORDRAN TAPE - flurandrenolide tape 4 mcg/sqcm 3 CORTANE-B - hydrocortisonepramoxine-chloroxylenol lot 10-10-1mg/ml 3 CORTISPORIN - neomycin-polymyxinhc cream 0.5% 3 CORTISPORIN - bacitracin-polymyxinneomycin hc oint 1% 3 CURAGEL HYDROGEL ISLAND W hydroactive (sterile) dressing 3 CURAGEL HYDROGEL WOUND DR hydroactive (sterile) dressing 3 CURITY HYPERTONIC SODIUM wound dressings - misc 3 CURITY SODIUM CHLORIDE DR wound dressings - pads 3 CUTIVATE - fluticasone propionate cream 0.05% 3 CUTIVATE - fluticasone propionate lotion 0.05% 3 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier clotrimazole soln 1% Quantity Limits 1 Step Therapy clotrimazole cream 1% Prior Authorization Drug Name Drug Tier 2015 DERMASORB TA - triamcinolone cream 3 0.1% & emollient cream kit DERMASORB XM - urea cream 39% & 3 emollient cream kit 3 DERMATOP - prednicarbate cream 0.1% 3 DERMATOP - prednicarbate oint 0.1% SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare DESONATE - desonide gel 0.05% 3 desonide cream 0.05% (Desowen) 1 desonide lotion 0.05% (Desowen) 1 desonide oint 0.05% (Desowen) 1 DESOWEN - desonide cream 0.05% 3 DESOWEN - desonide lotion 0.05% 3 DESOWEN - desonide oint 0.05% 3 DESOWEN CREAM/CETAPHIL LO - desonide cream 0.05% w/ moisturizing lotion kit 3 DESOWEN LOTION/CETAPHIL C desonide lotion 0.05% w/ moisturizing cream kit 3 Products January 2015 153 ECOZA - econazole nitrate foam 1% 3 EFUDEX - fluorouracil cream 5% 3 ELENZAPATCH - lidocaine-menthol patch 4-1% 3 ELETONE - emollient - cream 3 DESOXIMETASONE - desoximetasone cream 0.05% 2 DESOXIMETASONE - desoximetasone oint 0.05% 3 desoximetasone cream 0.25% (Topicort) 1 ELETONE TWINPACK - emollient cream 3 desoximetasone gel 0.05% (Topicort) 1 ELIDEL - pimecrolimus cream 1% 2 ELIMITE - permethrin cream 5% 3 ELOCON - mometasone furoate solution 0.1% (lotion) 3 ELOCON - mometasone furoate cream 0.1% 3 ELOCON - mometasone furoate oint 0.1% 3 EMLA - lidocaine-prilocaine cream 2.5-2.5% 3 EMULSION SB - dermatological products misc - emulsion 3 ENOVARX-BACLOFEN - baclofen cream 1% (compound kit) 3 desoximetasone oint 0.25% (Topicort) 1 3 DIAB - wound dressings - gel DIAB F.D.G. FREEZE-DRIED - wound dressings - gel 3 diclofenac sodium (actinic keratoses) gel 3% (Solaraze) 1 diclofenac sodium soln 1.5% (Pennsaid) 1 DIFFERIN - adapalene cream 0.1% 3 DIFFERIN - adapalene gel 0.1% 3 DIFFERIN - adapalene gel 0.3% 3 DIFFERIN - adapalene lotion 0.1% 3 DIFLORASONE DIACETATE diflorasone diacetate cream 0.05% 2 ENOVARX-IBUPROFEN - ibuprofen cream 10% (compounding kit) 3 diflorasone diacetate oint 0.05% 1 3 DIPROLENE - betamethasone dipropionate augmented lotion 0.05% 3 ENOVARX-LIDOCAINE HCL - lidocaine hcl cream 5% (compound kit) 3 DIPROLENE - betamethasone dipropionate augmented oint 0.05% 3 ENOVARX-LIDOCAINE HCL - lidocaine hcl cream 10% (compound kit) 3 DIPROLENE AF - betamethasone dipropionate augmented cream 0.05% 3 ENOVARX-NAPROXEN - naproxen cream 10% (compound kit) ENOVARX-TRAMADOL - tramadol hcl cream 5% (compound kit) 3 DOVONEX - calcipotriene cream 0.005% 3 EPICERAM - dermatological products misc - emulsion 3 DRITHO-CREME HP - anthralin cream 1% 3 EPIDUO - adapalene-benzoyl peroxide gel 0.1-2.5% 3 DRYSOL - aluminum chloride soln 20% 3 3 DUAC - clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% 3 EPIFOAM - pramoxine-hc aerosol foam 1-1% 154 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits 1 3 Step Therapy econazole nitrate cream 1% DESOWEN OINTMENT/CETAPHIL desonide ointment 0.05% w/ moisturizing lotion kit Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 ERTACZO - sertaconazole nitrate cream 2% 3 fluocinolone acetonide cream 0.025% (Synalar) 1 ERYGEL - erythromycin gel 2% 3 1 erythromycin gel 2% (Erygel) 1 fluocinolone acetonide oil 0.01% (body oil) (Derma-smoothe/fs bod) erythromycin pads 2% 1 1 erythromycin soln 2% 1 fluocinolone acetonide oil 0.01% (scalp oil) (Derma-smoothe/fs sca) 3 fluocinolone acetonide oint 0.025% (Synalar) 1 ETHYL CHLORIDE - ethyl chloride aerosol spray 3 fluocinolone acetonide soln 0.01% (Synalar) 1 ETHYL CHLORIDE/FINE PINPO - ethyl chloride aerosol spray fluocinonide cream 0.05% 1 fluocinonide cream 0.1% (Vanos) 1 fluocinonide emulsified base cream 0.05% 1 fluocinonide gel 0.05% 1 fluocinonide oint 0.05% 1 fluocinonide soln 0.05% 1 FLUOROPLEX - fluorouracil cream 1% 2 FLUOROURACIL - fluorouracil cream 0.5% 3 fluorouracil cream 5% (Efudex) 1 fluorouracil soln 2% 1 fluorouracil soln 5% 1 fluticasone propionate cream 0.05% (Cutivate) 1 fluticasone propionate lotion 0.05% (Cutivate) 1 fluticasone propionate oint 0.005% (Cutivate) 1 GEBAUERS PAIN EASE pentafluoropropane-tetrafluoroethane aero spray 3 3 ETHYL CHLORIDE/FINE STREA - ethyl 3 chloride aerosol spray 3 ETHYL CHLORIDE/MEDIUM JET ethyl chloride aerosol spray 3 ETHYL CHLORIDE/MEDIUM STR ethyl chloride aerosol spray 3 ETHYL CHLORIDE/MIST - ethyl chloride aerosol spray 3 EUCALYPTUS OIL - eucalyptus (topical) oil 3 EURAX - crotamiton cream 10% EURAX - crotamiton lotion 10% 3 EVOCLIN - clindamycin phosphate foam 3 1% 3 EXELDERM - sulconazole nitrate solution 1% EXELDERM - sulconazole nitrate cream 3 1% 3 EXTINA - ketoconazole foam 2% FABIOR - tazarotene (acne) foam 0.1% 3 FBL KIT - flurbiprofen-baclofen-lidocaine 3 cream 15-4-5% (cmpd kit) 2 FINACEA - azelaic acid gel 15% FIRST-HYDROCORTISONE hydrocortisone gel 10% 3 GEBAUERS SPRAY AND STRETC pentafluoropropane-tetrafluoroethane aero spray FLECTOR - diclofenac epolamine patch 1.3% 3 GENADUR - dermatological products misc - liquid 3 fluocinolone acetonide cream 0.01% 1 GENADUR KIT - dermatological products misc topical/oral - kit 3 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 155 GENTAMICIN SULFATE - gentamicin sulfate cream 0.1% 2 hydrocortisone butyrate cream 0.1% (Locoid) 1 GENTAMICIN SULFATE - gentamicin sulfate oint 0.1% 2 1 GLYCOLIC ACID - glycolic acid soln 70% 3 hydrocortisone butyrate hydrophilic lipo base cream 0.1% (Locoid lipocream) 1 GLYCOLIC ACID 70% HIGH PU glycolic acid soln 70% 3 hydrocortisone butyrate oint 0.1% (Locoid) 1 GORDOFILM - salicylic & lactic acids soln 16.7-16.7% 3 hydrocortisone butyrate soln 0.1% (Locoid) hydrocortisone cream 1% 1 GORDONS UREA - urea ointment 40% 3 hydrocortisone cream 2.5% 1 GRANULEX - trypsin w/ castor oil & peruvian balsam spray 3 hydrocortisone lotion 2.5% 1 hydrocortisone lotion 2% (Ala scalp) 1 GREEN SOAP - green soap tincture 3 hydrocortisone oint 1% 1 halobetasol prop oint 0.05% & ammonium lactate lot 12% kit 1 hydrocortisone oint 2.5% 1 1 hydrocortisone valerate cream 0.2% 1 halobetasol propionate cream 0.05% (Ultravate) 1 halobetasol propionate oint 0.05% (Ultravate) 1 hydrocortisone valerate oint 0.2% (Westcort) 3 HALOG - halcinonide cream 0.1% 3 HYDROFERA BLUE FOAM DRESS wound dressings - pads 3 HYDROFERA BLUE 4"X4" - wound dressings - pads 3 HALOG - halcinonide oint 0.1% HALONATE - halobetasol prop oint 0.05% & ammonium lactate foam 12% kit 3 HYLASE WOUND - hyaluronate sodium gel 3 3 HYLATOPIC - emollient - aerosol foam 3 HALOTIN - haloprogin cream 1% 3 HYLATOPIC PLUS - emollient - cream 3 HPR - emollient - aerosol foam 3 HYLATOPIC PLUS - emollient - aerosol foam 3 HPR PLUS - emollient - cream HPR PLUS - emollient - aerosol foam 3 HPR PLUS/MB HYDROGEL - emollient foam & wound dressing gel kit HYLATOPIC PLUS/AURSTAT emollient foam & wound dressing gel kit 3 3 hyaluronate sodium (emollient) gel 0.2% (Hylira) 1 HYLIRA - hyaluronate sodium (emollient) gel 0.2% 3 HYDRO 35 - urea in lactic acid vehicle foam 35% 3 HYLIRA - hyaluronate sodium (emollient) lotion 0.1% 3 HYDRO 40 FOAM - urea foam 40% 3 imiquimod cream 5% (Aldara) 1 hydrocortisone acetate-aloe vera gel 2% (Nuzon) 1 INOVA - benzoyl peroxide pad 4% & vitamin e topical 5% kit 3 156 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 INOVA - benzoyl peroxide pad 8% & vitamin e topical 5% kit 3 KETODAN KIT - ketoconazole foam 2% & cleanser kit 3 INOVA 4/1 ACNE CONTROL TH benzoyl perox pad 4% & salicylic ac pad 1% & vit e 5% kit 3 KETOROLAC 2% GEL - ketorolac tromethamine gel 2% (cmpd kit) (base equiv) 3 INOVA 8/2 ACNE CONTROL TH benzoyl perox pad 8% & salicylic ac pad 2% & vit e 5% kit 3 KLARON - sulfacetamide sodium lotion 10% (acne) 3 1 LAC-HYDRIN - lactic acid (ammonium lactate) cream 12% 3 iodoquinol-hc cream 1% isotretinoin cap 10 mg 1 3 isotretinoin cap 20 mg 1 LAC-HYDRIN - lactic acid (ammonium lactate) lotion 12% isotretinoin cap 40 mg 1 1 JUBLIA - efinaconazole soln 10% 3 lactic acid (ammonium lactate) cream 12% (Lac-hydrin) 3 lactic acid (ammonium lactate) lotion 10% 1 K.B.G.L. IN TERODERM CREA ketoprofen-baclofen-gabapent-lido crm 15-4-10-2% (cmp kit) 1 KENALOG - triamcinolone acetonide aerosol soln 3 lactic acid (ammonium lactate) lotion 12% (Lac-hydrin) 1 KENDALL AMORPHOUS HYDROGE wound dressings - gel 3 lactic acid w/ vitamin e cream 10%-3500 unit/30gm 3 KENDALL HYDROGEL IMPREGNA hydroactive (sterile) dressing 3 LAMISIL SPRAY - terbinafine hcl soln 1% KENDALL HYDROGEL WOUND DR hydroactive (sterile) dressing 3 KENDALL ZINC CALCIUM ALGI wound dressings - pads 3 KENDALL ZINC CALCIUM ALGI wound dressings - misc 3 KERAFOAM - urea foam 30% 3 KERAFOAM 42 - urea foam 42% 3 KERALAC - urea cream 47% 3 KERALYT - salicylic acid gel 6% 3 KERALYT SCALP - salicylic acid shampoo 6% & salicylic acid gel 6% kit 3 KERYDIN - tavaborole soln 5% 3 ketoconazole cream 2% 1 ketoconazole foam 2% (Extina) 1 ketoconazole shampoo 2% (Nizoral) 1 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 LATRIX XM - urea in zinc undecylenate- 3 lactic acid vehicle emulsion 45% 3 LAVARE WOUND WASH - wound cleansers - gel 3 LAVOCLEN-4 CREAMY WASH benzoyl peroxide liq 4% 3 LAVOCLEN-8 CREAMY WASH benzoyl peroxide liq 8% LEVULAN KERASTICK - aminolevulinic 3 acid hcl for soln 20% (stick applicator) 3 LIDOCAINE HCL - lidocaine hcl lotion 3% 1 lidocaine hcl cream 3% SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare lidocaine hcl gel 2% 1 lidocaine hcl soln 4% (Xylocaine) 1 lidocaine oint 5% 1 lidocaine patch 5% (Lidoderm) 1 lidocaine-prilocaine cream 2.5-2.5% (Emla) 1 Products January 2015 157 LIDOCAINE/PRILOCAINE - lidocaineprilocaine kit 2.5-2.5% 2 MB HYDROGEL - emollient cream & wound dressing gel kit 3 LIDODERM - lidocaine patch 5% 3 3 LIDODEXTRAPINE - lidocaine-menthol patch 4-1% 3 MEDI-DERM-RX - capsaicin-mentholmethyl salicylate cream 0.035-5-20% 3 LIDOPROFEN - ketoprofen-ketaminelidocaine cream 5-5-2% (compound kit) 3 MEDI-DERM/L-RX - lidocainecapsaicin-menthol-methyl sal cream 2-0.035-5-20% 3 LIDORX - lidocaine hcl gel 3% 3 LIDOVIR - acyclovir-lidocaine hcl oint 4-4% (compounding kit) 3 MEDI-PATCH RX - lidocainecapsaicin-menthol-methyl sal patch 0.5-0.035-5-20% 3 lindane lotion 1% 1 MEDIHONEY CALCIUM ALGINAT wound dressings - pads 1 MEDROX-RX - capsaicin-mentholmethyl salicylate oint 0.05-7-20% 3 lindane shampoo 1% LOCOID - hydrocortisone butyrate soln 0.1% 3 MENTAX - butenafine hcl cream 1% 3 3 methoxsalen rapid cap 10 mg (Oxsoralen ultra) 1 LOCOID - hydrocortisone butyrate cream 0.1% METHYL SALICYLATE - methyl salicylate liquid 3 METROCREAM - metronidazole cream 0.75% 3 METROGEL - metronidazole gel 1% 3 METROLOTION - metronidazole lotion 0.75% 3 metronidazole cream 0.75% (Metrocream) 1 metronidazole gel 0.75% 1 LOCOID - hydrocortisone butyrate lotion 3 0.1% 3 LOCOID - hydrocortisone butyrate oint 0.1% LOCOID LIPOCREAM - hydrocortisone 3 butyrate hydrophilic lipo base cream 0.1% 3 LOPROX - ciclopirox gel 0.77% LOPROX SHAMPOO - ciclopirox shampoo 1% 3 LOTRISONE - clotrimazole w/ betamethasone cream 1-0.05% 3 metronidazole gel 1% (Metrogel) 1 1 LOUTREX - antiseborrheic products misc - cream 3 metronidazole lotion 0.75% (Metrolotion) 3 LUXIQ - betamethasone valerate aerosol foam 0.12% 3 METVIXIA - methyl aminolevulinate hcl cream 16.8% (base equiv) MIMYX - emollient - cream 3 LUZU - luliconazole cream 1% 3 3 LYCELLE - nit remover - gel 3 MIRVASO - brimonidine tartrate gel 0.33% (base equivalent) mafenide acetate packet for topical soln 5% (50 gm) (Sulfamylon) 1 mometasone furoate cream 0.1% (Elocon) 1 malathion lotion 0.5% (Ovide) 1 mometasone furoate oint 0.1% (Elocon) 1 158 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 mometasone furoate solution 0.1% (lotion) (Elocon) 1 NUVAIL - dermatological products misc - solution 3 mupirocin calcium cream 2% (Bactroban) 1 NUZON - hydrocortisone acetate-aloe vera gel 2% 3 mupirocin oint 2% (Bactroban) 1 nystatin cream 100000 unit/gm 1 NAFTIN - naftifine hcl cream 1% 3 nystatin oint 100000 unit/gm 1 NAFTIN - naftifine hcl cream 2% 3 1 NAFTIN - naftifine hcl gel 1% 3 nystatin-triamcinolone cream 100000-0.1 unit/gm-% NAFTIN - naftifine hcl gel 2% 3 1 NAPRO 15% COMPOUNDING KIT naproxen cream 15% 3 nystatin-triamcinolone oint 100000-0.1 unit/gm-% 3 NAPRODERM COMPOUNDING KIT naproxen cream 15% 3 OLUX - clobetasol propionate foam 0.05% 3 NATROBA - spinosad susp 0.9% 3 OLUX-E - clobetasol propionate emulsion foam 0.05% 3 OPTASE - trypsin w/ castor oil & peruvian balsam gel 3 NEO-SYNALAR - neomycinfluocinolone cream 0.35-0.025% 3 OVACE PLUS - sulfacetamide sodium cream 10% 3 NEO-SYNALAR KIT - neomycinfluocinolone cream 0.35-0.025% & emollient cr kit 3 NEOSALUS - emollient - cream 3 OVACE PLUS - sulfacetamide sodium lotion 9.8% 3 OVACE PLUS - sulfacetamide sodium shampoo 10% 3 NEOSALUS - emollient - aerosol foam NEOSALUS - emollient - lotion 3 3 NEOSALUS CP - emollient - cream 3 OVACE PLUS WASH - sulfacetamide sodium liquid 10% NEUAC KIT - clindamycin-benzoyl perox gel 1.2-5% & moisturizer cr kit 3 OVACE PLUS WASH - sulfacetamide sodium cleansing gel 10% 3 NIVATOPIC PLUS - dermatological products misc - cream 3 OVACE WASH - sulfacetamide sodium liquid 10% 3 NIZORAL - ketoconazole shampoo 2% 3 OVIDE - malathion lotion 0.5% 3 NORITATE - metronidazole cream 1% 3 3 NOVACORT - hydrocortisone acepramoxine-aloe polysacch gel 2-1-1% 3 OXISTAT - oxiconazole nitrate cream 1% NP #2 DRUG PREPARATION KI tramadol-flurbip-amitrip-gabaclonidine-lido crm (cmp kit) 3 OXISTAT - oxiconazole nitrate lotion 1% 3 3 OXSORALEN - methoxsalen lotion 1% NUCORT - hydrocortisone acetate lotion 3 2% 3 NUOX - benzoyl peroxide-sulfur gel 6-3% SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare OXSORALEN ULTRA - methoxsalen rapid cap 10 mg 3 PANDEL - hydrocortisone probutate cream 0.1% 3 PANRETIN - alitretinoin gel 0.1% 3 Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 159 PEDIADERM AF COMPLETE KIT nystatin cream 100000 unit/gm & diaper rash cream kit 3 PEDIADERM HC - hydrocortisone lot 2% & emollient cream kit 3 PEDIADERM TA - triamcinolone cream 0.1% & emollient cream kit 3 PEDIPIROX-4 NAIL - ciclopirox soln 8% & lacquer removal pads & foot powd kit 3 PENLAC NAIL LACQUER - ciclopirox solution 8% 3 PENNSAID - diclofenac sodium soln 1.5% 3 PENNSAID - diclofenac sodium soln 2% 3 1 permethrin cream 5% (Elimite) PICATO - ingenol mebutate gel 0.015% 2 PICATO - ingenol mebutate gel 0.05% 2 PICO SINGLE USE NEGATIVE - wound 3 dressings - kit 3 PLEXION - sulfacetamide sodium w/ sulfur cream 9.8-4.8% 3 PLEXION - sulfacetamide sodium w/ sulfur lotion 9.8-4.8% 3 PLEXION CLEANSER - sulfacetamide sodium w/ sulfur cleanser 9.8-4.8% 3 PLEXION CLEANSING CLOTHS sulfacetamide sodium w/ sulfur cleansing cloth 9.8-4.8% 3 PLIAGLIS - lidocaine-tetracaine cream 7-7% 3 PODOCON 25 IN BENZOIN TIN podophyllum resin soln 25% 1 podofilox soln 0.5% (Condylox) PR CREAM - dermatological products misc - kit 3 PRAMOSONE - pramoxine-hc cream 1-1% 3 PRAMOSONE - pramoxine-hc cream 1-2.5% 3 160 PRAMOSONE - pramoxine-hc lotion 1-1% 3 PRAMOSONE - pramoxine-hc lotion 1-2.5% 3 PRAMOSONE - pramoxine-hc oint 1-1% 3 3 PRAMOSONE - pramoxine-hc oint 1-2.5% 3 PRAMOSONE E - pramoxine-hc emollient base cream 1-2.5% 1 pramoxine hcl gel 1% pramoxine-hc cream 1-2.5% (Pramosone) 1 prednicarbate cream 0.1% (Dermatop) 1 prednicarbate oint 0.1% (Dermatop) 1 PRESERA - emollient - aerosol foam 3 PROMISEB - antiseborrheic products misc - cream 3 PROMISEB COMPLETE antiseborrheic products misc - kit 3 PROTOPIC - tacrolimus oint 0.03% 2 PROTOPIC - tacrolimus oint 0.1% 2 PRUCLAIR - emollient - cream 3 PRUDOXIN - doxepin hcl cream 5% 3 PRUMYX - emollient - cream 3 PRUTECT - wound dressings emulsion 3 PYROGALLIC ACID - pyrogallolchlorobutanol oint 25-2% 3 QROXIN - capsaicin-menthol topical patch 0.0375-5% 3 QUTENZA - capsaicin patch 8% & cleansing gel kit 3 RADIAGEL - wound dressings - gel 3 RADIAPLEXRX - wound dressings - gel 3 RADIGEL - dermatological products misc - gel 3 RECIPHEXAMINE - lidocaine-menthol patch 4-1% 3 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 REGENECARE - lidocaine hcl-collagenaloe vera gel 2% 3 RTD WOUND CARE DRESSING wound dressings - pads 3 REGRANEX - becaplermin gel 0.01% 3 SALEX - salicylic acid shampoo 6% 3 RELYYKS - lidocaine-menthol patch 4-5% 3 SALEX CREAM - salicylic acid cream 6% & cleanser liqd kit 3 RENOVO - capsaicin-menthol topical patch 0.0375-5% 3 SALEX LOTION - salicylic acid lotion 6% & cleanser liqd kit 3 RESTORE SILVER DRESSING 2 wound dressings - pads 3 SALICYLIC ACID - salicylic acid soln 26% 3 RESTORE SILVER DRESSING 4 wound dressings - pads 3 salicylic acid cream 6% 1 RESTORE SILVER DRESSING 6 wound dressings - pads salicylic acid film forming liquid 27.5% (Virasal) 1 3 salicylic acid foam 6% (Salvax) 1 RETIN-A - tretinoin cream 0.025% 3 salicylic acid gel 6% (Keralyt) 1 RETIN-A - tretinoin cream 0.05% 3 3 RETIN-A - tretinoin gel 0.01% 3 SALICYLIC ACID IN AMMONIU salicylic acid in ammonium lactate vehicle foam 6% 3 RETIN-A - tretinoin cream 0.1% RETIN-A - tretinoin gel 0.025% 3 salicylic acid lotion 6% 1 salicylic acid shampoo 6% (Salex) 1 SALKERA - salicylic acid in ammonium lactate vehicle foam 6% 3 SALVAX - salicylic acid foam 6% 3 SALVAX DUO PLUS - salicylic acid foam 6% & urea in lactic acid foam 35% kit 3 SANARE SCAR THERAPY - scar treatment products - cream 3 SANTYL - collagenase oint 250 unit/gm 3 SCALACORT DK - hc lot 2% & sal acidsulfur shampoo 2-2% & shampoo kit 3 SE BPO 7-5.5 WASH KIT - benzoyl peroxide wash 7% & benzoyl peroxide cream 5.5% kit 3 SEB-PREV - sulfacetamide sodium lotion 10% 3 SELENIUM SULFIDE - selenium sulfide-pyrithione zinc in urea shampoo 2.25% 3 selenium sulfide lotion 2.5% 1 RETIN-A MICRO - tretinoin microsphere 3 gel 0.04% RETIN-A MICRO - tretinoin microsphere 3 gel 0.1% 3 RETIN-A MICRO PUMP - tretinoin microsphere gel 0.04% 3 RETIN-A MICRO PUMP - tretinoin microsphere gel 0.08% 3 RETIN-A MICRO PUMP - tretinoin microsphere gel 0.1% 3 REXAPHENAC - diclofenac sodium cream 1% 3 RIAX - benzoyl peroxide foam 5.5% RIAX - benzoyl peroxide foam 9.5% 3 ROSADAN KIT - metronidazole gel 0.75% w/ cleanser kit 3 ROSADAN KIT - metronidazole cream 0.75% w/ cleanser kit 3 ROSANIL - sulfacetamide sod-sulfur emul 10-5% & skin cleanser kit 3 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 161 selenium sulfide-pyrithione zinc in urea shampoo 2.25% 1 SELRX - selenium sulfide-pyrithione zinc in urea shampoo 2.3% Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 3 3 SODIUM SULFACETAMIDE/SULF sulfacetamide sodium-sulfur in urea gel 10-5% 3 SELSUN SHAMPOO - selenium sulfide lotion 2.5% 3 SODIUM SULFACETAMIDE/UREA sulfacetamide sodium-urea pad 10% 1 SILVADENE - silver sulfadiazine cream 1% 3 sodium thiosulfate-salicylic acid lotion 25-1% 3 SILVASORB - wound dressings - gel 3 SOLAICE - capsaicin-menthol topical patch 0.05-5% SILVER NITRATE - silver nitrate soln 0.5% 3 SOLARAZE - diclofenac sodium (actinic keratoses) gel 3% 3 SILVER NITRATE - silver nitrate soln 10% 3 SONAFINE - wound dressings emulsion 3 SILVER NITRATE - silver nitrate soln 25% 3 SORIATANE - acitretin cap 10 mg 3 SORIATANE - acitretin cap 17.5 mg 3 SILVER NITRATE - silver nitrate soln 50% 3 SORIATANE - acitretin cap 25 mg 3 SORILUX - calcipotriene foam 0.005% 3 SILVER NITRATE - silver nitrate oint 10% 3 SPECTRAGEL - wound dressings - gel 3 1 SPINOSAD - spinosad susp 0.9% 3 silver nitrate-potassium nitrate applicator 75-25% (Arzol silver nitrate) SSS 10-4 - sulfacetamide sodium w/ sulfur foam 10-4% 3 silver sulfadiazine cream 1% (Silvadene) 1 STELARA - ustekinumab soln prefilled syringe 45 mg/0.5ml 5 • • SILVERSEAL HYDROGEL DRESS silver - pad 2"x3" 3 STELARA - ustekinumab soln prefilled syringe 90 mg/ml 5 • • SILVERSEAL HYDROGEL DRESS silver - pad 4"x5" 3 sulfacetamide sodium cleansing gel 10% (Ovace plus wash) 1 SILVRSTAT WOUND DRESSING silver - gel 3 sulfacetamide sodium liquid 10% (Ovace wash) 1 SKLICE - ivermectin lotion 0.5% 3 1 SODIUM SULFACETAMIDE WASH sulfacetamide sodium in bakuchiol vehicle wash 10% 3 sulfacetamide sodium lotion 10% (acne) (Klaron) sulfacetamide sodium shampoo 10% (Ovace plus) 1 SODIUM SULFACETAMIDE/SULF sulfacetamide sodium w/ sulfur susp 10-5% 2 sulfacetamide sodium w/ sulfur cleanser 10-2% (Avar ls cleanser) 1 1 SODIUM SULFACETAMIDE/SULF sulfacetamide sodium-sulfur in urea emulsion 10-5% 3 sulfacetamide sodium w/ sulfur cleansing cloth 10-5% sulfacetamide sodium w/ sulfur cleansing pad 10-4% (Sumaxin) 1 162 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 sulfacetamide sodium w/ sulfur cream 10-2% (Avar-e ls) 1 SUMAXIN WASH - sulfacetamide sodium w/ sulfur wash 9-4% 3 sulfacetamide sodium w/ sulfur cream 10-5% 1 SYNALAR - fluocinolone acetonide soln 0.01% 3 sulfacetamide sodium w/ sulfur emulsion 10-1% 1 SYNALAR - fluocinolone acetonide cream 0.025% 3 sulfacetamide sodium w/ sulfur emulsion 10-5% 1 SYNALAR - fluocinolone acetonide oint 0.025% 3 sulfacetamide sodium w/ sulfur foam 10-5% (Clarifoam ef) 1 SYNALAR CREAM KIT - fluocinolone cream 0.025%-emollient cream kit 3 sulfacetamide sodium w/ sulfur lotion 10-5% 1 3 sulfacetamide sodium w/ sulfur susp 8-4% (Sumaxin ts) 1 SYNALAR OINTMENT KIT fluocinolone oint 0.025%-emollient cream kit 3 sulfacetamide sodium w/ sulfur wash 9-4.5% (Sumadan wash) 1 SYNALAR TS - fluocinolone acetonide soln 0.01% & cleanser kit 3 sulfacetamide sodium w/ sulfur wash 9-4% (Sumaxin wash) 1 SYNERA - lidocaine-tetracaine topical patch 70-70 mg 3 sulfacetamide sodium-sulfur in urea emulsion 10-4% 1 TACLONEX - calcipotrienebetamethasone dipropionate susp 0.005-0.064% SULFAMYLON - mafenide acetate packet for topical soln 5% (50 gm) 3 3 SULFAMYLON - mafenide acetate cream 85 mg/gm 3 TACLONEX - calcipotrienebetamethasone dipropionate oint 0.005-0.064% TARGRETIN - bexarotene gel 1% 5 SULFOAM - sulfur shampoo 2% 3 TAZORAC - tazarotene cream 0.05% 2 SULFURATED LIME - sulfurated lime solution 3 TAZORAC - tazarotene cream 0.1% 2 TAZORAC - tazarotene gel 0.05% 2 SUMADAN KIT - sulfacetamide sodsulfur wash 9-4.5% & skin cleanser kit 3 TAZORAC - tazarotene gel 0.1% 2 TEGADERM AG MESH DRESSING wound dressings - pads 3 SUMADAN WASH - sulfacetamide sodium w/ sulfur wash 9-4.5% 3 TEMOVATE - clobetasol propionate soln 0.05% 3 SUMADAN XLT - sulfacetamide sodsulfur wash 9-4.5% & sunscreen kit 3 TEMOVATE - clobetasol propionate cream 0.05% 3 SUMAXIN - sulfacetamide sodium w/ sulfur cleansing pad 10-4% 3 TEMOVATE - clobetasol propionate gel 0.05% 3 SUMAXIN CP KIT - sulfacetamide sodsulfur pad 10-4% & skin cleanser kit 3 TEMOVATE - clobetasol propionate oint 0.05% 3 TEMOVATE E - clobetasol propionate emollient base cream 0.05% 3 SUMAXIN TS - sulfacetamide sodium w/ 3 sulfur susp 8-4% SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 163 TERSI FOAM - selenium sulfide foam 2.25% 3 tretinoin microsphere gel 0.04% (Retin-a micro) 1 TETRIX - dermatological products misc - kit 3 tretinoin microsphere gel 0.1% (Retin-a micro) 1 TEXACORT - hydrocortisone soln 2.5% 3 3 THERAHONEY - wound dressings - gel 3 TRI-CHLOR - trichloroacetic acid liqd 80% TL TRISEB - antiseborrheic products misc - cream 3 TRIAMCINOLONE ACETONIDE triamcinolone acetonide oint 0.5% 2 TL-CERMIDE - dermatological products misc - emulsion 3 triamcinolone acetonide cream 0.025% 1 TOPICORT - desoximetasone spray 0.25% 3 triamcinolone acetonide cream 0.1% 1 triamcinolone acetonide cream 0.5% 1 TOPICORT - desoximetasone cream 0.05% 3 triamcinolone acetonide lotion 0.025% 1 TOPICORT - desoximetasone cream 0.25% 3 triamcinolone acetonide lotion 0.1% 1 triamcinolone acetonide oint 0.025% 1 TOPICORT - desoximetasone gel 0.05% 3 triamcinolone acetonide oint 0.1% 1 3 TRIANEX - triamcinolone acetonide oint 0.05% 3 TOPICORT - desoximetasone oint 0.05% 3 TROPAZONE - emollient - lotion 3 TOPICORT - desoximetasone oint 0.25% 1 TRETIN-X - tretinoin cream 0.0375% 3 trypsin w/ castor oil & peruvian balsam oint (Xenaderm) 3 trypsin w/ castor oil & peruvian balsam spray (Granulex) 1 TRETIN-X - tretinoin cream 0.075% TRETIN-X - tretinoin gel 0.01% w/ cleanser & moisturizer kit 3 TURPENTINE SPIRITS - turpentine spirit 3 TRETIN-X - tretinoin gel 0.025% w/ cleanser & moisturizer kit 3 U-CORT - urea-hc acetate cream 1% 3 3 ULESFIA - benzyl alcohol lotion 5% 3 TRETIN-X - tretinoin cream 0.025% w/ cleanser & moisturizer kit 3 TRETIN-X - tretinoin cream 0.05% w/ cleanser & moisturizer kit 3 ULTRASAL-ER - salicylic acid filmforming soln 28.5% 3 TRETIN-X - tretinoin cream 0.1% w/ cleanser & moisturizer kit 3 ULTRAVATE - halobetasol propionate cream 0.05% 3 tretinoin cream 0.025% (Retin-a) 1 ULTRAVATE - halobetasol propionate oint 0.05% 1 tretinoin cream 0.1% (Retin-a) 1 ULTRAVATE PAC - halobetasol prop cream 0.05% & ammonium lactate lot 12% kit 3 tretinoin cream 0.05% (Retin-a) tretinoin gel 0.01% (Retin-a) 1 tretinoin gel 0.025% (Retin-a) 1 164 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 3 ULTRAVATE X - halobetasol prop cream 0.05% & lactic acid cream 10% kit 3 ULTRAVATE X - halobetasol prop oint 0.05% & lactic acid cream 10% kit 3 UMECTA - urea emulsion 40% 3 UMECTA - urea suspension 40% 3 UMECTA NAIL FILM - urea suspension 40% 3 3 URAMAXIN - urea lotion 45% 3 URAMAXIN - urea in ammonium lactate vehicle foam 20% 3 URAMAXIN GT - urea gel 45% 3 URAMAXIN GT KIT - urea gel 45% & emollient cream kit 3 urea cream 39% (Aluvea) 1 urea cream 40% 1 urea cream 45% (Uramaxin) 1 urea cream 50% 1 urea foam 40% (Hydro 40 foam) 1 urea gel 40% 1 urea gel 45% (Uramaxin) 1 urea in lactic acid vehicle foam 35% (Hydro 35) 1 urea in lactic acid-salicylic acid vehicle susp 50% 1 urea in zinc undecylenate-lactic acid vehicle emulsion 50% 1 urea lotion 40% 1 Quantity Limits Step Therapy 1 Prior Authorization Quantity Limits Step Therapy urea lotion 45% (Uramaxin) UREA NAIL - urea in zinc undecylenate- 3 lactic acid vehicle stick 50% 3 UREA NAIL KIT - urea susp 40% & hyaluronate sodium gel 0.2% kit 1 urea suspension 40% (Umecta) UMECTA PD - urea-hyaluronate sodium 3 emulsion 40-0.3% UMECTA PD - urea-hyaluronate sodium 3 susp 40-0.3% 3 URAMAXIN - urea cream 45% URAMAXIN - urea gel 45% Drug Name Drug Tier ULTRAVATE PAC - halobetasol prop oint 0.05% & ammonium lactate lot 12% kit Prior Authorization Drug Name Drug Tier 2015 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare UTOPIC - urea cream 41% 3 VALCHLOR - mechlorethamine hcl gel 0.016% (base equivalent) 4 VANOS - fluocinonide cream 0.1% 3 VANOXIDE-HC - benzoyl peroxide-hc lotion 5-0.5% 3 VASCUDERM HYDROGEL WOUND wound dressings - gel 3 VASCUDERM STASIS KIT - wound dressings - kit 3 VECTICAL - calcitriol oint 3 mcg/gm 3 VELTIN - clindamycin phosphatetretinoin gel 1.2-0.025% 3 VENELEX - balsam peru-castor oil oint 3 VERDESO - desonide foam 0.05% 3 VEREGEN - sinecatechins oint 15% 3 VEXA - allantoin-lidocaine-petrolatum patch 2-4-30% 3 VIRASAL - salicylic acid film forming liquid 27.5% 3 VOLTAREN - diclofenac sodium gel 1% 2 VOPAC - ketoprofen-lidocaine hcl cream 10-2% (compound kit) 3 VOPAC GB - ketoprofen-lidocainegabapentin cream 5-2-5% (cmpd kit) 3 VOPAC KT - ketoprofen-ketaminelidocaine cream 5-5-2% (compound kit) 3 VUSION - miconazole-zinc oxide-white petrolatum oint 0.25-15-81.35% 3 VYTONE - iodoquinol-hydrocortisone in aloe vehicle cream 1-1.9% 3 Products January 2015 165 WESTCORT - hydrocortisone valerate oint 0.2% 3 WITCH HAZEL - witch hazel (hamamelis virginiana) liqd (hamamelis water) 3 3 ZACARE 4% KIT - benzoyl peroxide lotion 4% & hyaluronate sodium gel 0.2% kit 3 XCLAIR - dermatological products misc - cream 3 ZACARE 8% KIT - benzoyl peroxide lotion 8% & hyaluronate sodium gel 0.2% kit 3 XENADERM - trypsin w/ castor oil & peruvian balsam oint 3 ZACLIR CLEANSING - benzoyl peroxide lotion 8% XERAC AC - aluminum chloride in alcohol solution 6.25% 2 ZIANA - clindamycin phosphate-tretinoin 3 gel 1.2-0.025% 3 ZITHRANOL - anthralin shampoo 1% XERESE - acyclovir-hydrocortisone cream 5-1% 3 ZITHRANOL-RR - anthralin cream 1.2% 3 ZONALON - doxepin hcl cream 5% 3 XEROFORM NON-OCCLUSIVE OI bismuth tribromophenate-petrolatum dressing pads 3 ZOVIRAX - acyclovir cream 5% 3 ZOVIRAX - acyclovir oint 5% 3 XEROFORM NON-OCCLUSIVE OI bismuth tribromophenate-petrolatum dressing - misc 3 ZYCLARA - imiquimod cream 3.75% 2 ZYCLARA PUMP - imiquimod cream 2.5% 2 XEROFORM OCCLUSIVE PETROL bismuth tribromophenate-petrolatum dressing pads 3 ZYCLARA PUMP - imiquimod cream 3.75% 2 8-MOP - methoxsalen cap 10 mg 3 XEROFORM OCCLUSIVE PETROL bismuth tribromophenate-petrolatum dressing - misc 3 XEROFORM PETROLATUM DRESS bismuth tribromophenate-petrolatum dressing pads 3 XEROFORM PETROLATUM DRESS bismuth tribromophenate-petrolatum dressing - misc 3 XOLEGEL - ketoconazole gel 2% 3 XOLEGEL COREPAK - ketoconazole gel 2% & hydrocortisone gel 1% kit MISCELLANEOUS PRODUCTS ANTISEPTICS & DISINFECTANTS BENZALKONIUM CHLORIDE benzalkonium chloride soln 3 BENZALKONIUM CHLORIDE benzalkonium chloride soln 17% 3 BENZALKONIUM CHLORIDE benzalkonium chloride soln 50% 3 3 3 BUCALSEP - antiseptic products misc liquid 3 XOLEGEL DUO/HEAD & SHOULD ketoconazole gel 2% & pyrithione zinc shampoo 1% kit 3 BUCALSEP - antiseptic products misc solution CHLORHEXIDINE DIGLUCONATE chlorhexidine gluconate soln 20% 3 XOLEGEL DUO/XOLEX - ketoconazole gel 2% & pyrithione zinc shampoo 1% kit 3 CHLORHEXIDINE GLUCONATE chlorhexidine gluconate soln 20% 3 XYLOCAINE - lidocaine hcl soln 4% FORMA-RAY - formaldehyde solution 20% 3 3 166 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 FORMALDEHYDE - formaldehyde solution 37% 3 CYANIDE ANTIDOTE PKG - cyanide antidote kit 3 formaldehyde solution 10% 1 1 GLUTARALDEHYDE - glutaral soln 25% 3 deferoxamine mesylate for inj 2 gm (Desferal) 1 HYDROGEN PEROXIDE - hydrogen peroxide soln 30% 3 deferoxamine mesylate for inj 500 mg (Desferal) HYDROGEN PEROXIDE - hydrogen peroxide soln 35% 3 IODINE TINCTURE - iodine tincture 3 IODINE TINCTURE MILD - iodine tincture 3 IODINE TINCTURE STRONG - iodine tincture strong 3 IODINE TINCTURE STRONG DE iodine tincture strong 3 IV PREP WIPES - antiseptic products misc - pads 3 KERR TRIPLE DYE - triple dye swabs 3 LUGOLS STRONG IODINE - iodine solution 3 MICROCLENS WIPES - antiseptic products misc - pads 3 PHISOHEX - hexachlorophene liq 3% 1 naloxone hcl inj 0.4 mg/ml 1 3 naloxone hcl inj 1 mg/ml 1 TRIPLE DYE - triple dye solution 3 naltrexone hcl tab 50 mg (Revia) 1 UNI-SOLVE - antiseptic products misc pads 3 3 UNI-SOLVE WIPES - antiseptic products misc - pads 3 PENTETATE CALCIUM TRISODI pentetate calcium trisodium iv or inhalation soln 200 mg/ml PENTETATE ZINC TRISODIUM pentetate zinc trisodium iv or inhalation soln 200 mg/ml 3 PHYSOSTIGMINE SALICYLATE physostigmine salicylate inj 1 mg/ml 3 PRALIDOXIME CHLORIDE pralidoxime chloride im soln autoinjector 600 mg/2ml 3 RADIOGARDASE - prussian blue insoluble cap 0.5 gm 3 REVIA - naltrexone hcl tab 50 mg 3 ANTIDOTES 3 CALCIUM DISODIUM VERSENAT edetate calcium disodium inj 500 mg/2.5ml (200 mg/ml) 3 CALCIUM DISODIUM VERSENAT edetate calcium disodium inj 1 gm/5ml (200 mg/ml) 3 CHEMET - succimer cap 100 mg 2 Quantity Limits Step Therapy DESFERAL - deferoxamine mesylate for 3 inj 500 mg DESFERAL - deferoxamine mesylate for 3 inj 2 gm 3 DUODOTE - atropine 2.1 mg/0.7mlpralidoxime cl 600 mg/2ml im auto-inj 3 EVZIO - naloxone hcl solution autoinjector 0.4 mg/0.4ml 5 EXJADE - deferasirox tab for oral susp 125 mg 5 EXJADE - deferasirox tab for oral susp 250 mg 5 EXJADE - deferasirox tab for oral susp 500 mg 5 FERRIPROX - deferiprone tab 500 mg methylene blue inj 1% BAL IN OIL - dimercaprol inj 100 mg/ml Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 167 VIVITROL - naltrexone for im extended release susp 380 mg 5 DIAGNOSTIC PRODUCTS LIQUIHEP BD 3ML PREFILLED arterial blood gas kit 3 3 ACCU-CHEK ACTIVE STRIPS glucose blood test strip 2 LIQUIHEP II BD 3ML LL SYR - arterial blood gas kit 3 ACCU-CHEK AVIVA - glucose blood test strip 2 LIQUIHEP II BD 3ML PREFIL - arterial blood gas kit 3 ACCU-CHEK AVIVA PLUS - glucose blood test strip 2 PRESET 1ML LS SYR/PREFILL arterial blood gas kit 3 ACCU-CHEK COMFORT CURVE T glucose blood test strip 2 PRESET 3ML LL SYR/PREFILL arterial blood gas kit 3 ACCU-CHEK COMPACT PLUS glucose blood test strip 2 PRESET 3ML SYR/PREFILL LY arterial blood gas kit 3 ACCU-CHEK COMPACT TEST DR glucose blood test strip 2 PRESET 3ML SYR/PREFILLED arterial blood gas kit 3 ACCU-CHEK SMARTVIEW STRIP glucose blood test strip 2 3ML GLASS SYR KIT/1ML NA - arterial blood gas kit 3 ACCUTREND GLUCOSE - glucose blood test strip 2 5ML GLASS SYR KIT/1ML NA - arterial blood gas kit ASCENSIA AUTODISC TEST ST glucose blood test disk 2 ISCAR MALI - european mistletoe (viscum album) inj 5 mg/ml BAYER BREEZE 2 TEST DISC glucose blood test disk 2 BAYER CONTOUR BLOOD GLUCO glucose blood test strip 2 BAYER CONTOUR NEXT BLOOD glucose blood test strip 2 QUINZYME - coenzyme q10 tab disp 90 3 mg 3 RELAMINE - glucosamine-chondroitinpaba-vit e-alpha lipoic acid tab 3 VALERIAN ROOT - valerian (valeriana officinalis) fl extract BD 3ML LL SYR/PREFILL LIT - arterial blood gas kit 3 CHEMICALS DRIHEP ARTERIAL LINE SAMP arterial blood gas kit DENATURED ALCOHOL - alcohol, rubbing 95% 3 3 DRIHEP PLUS 3ML LL PREFIL arterial blood gas kit ENOVARX-AMITRIPTYLINE amitriptyline hcl cream 2% kit (compounding kit) 3 3 DRIHEP PLUS 3ML PREFILLED arterial blood gas kit 3 GLUCOSE BLOOD TEST STRIPS – VARIOUS 3 ALTERNATIVE MEDICINES LIQUIHEP BD 3ML PREFIL SY - arterial 3 blood gas kit 168 • 3 ISOPROPANOL - isopropyl alcohol 70% 3 3 ISOPROPYL ALCOHOL - isopropyl alcohol 70% 1 isopropyl alcohol, rubbing 70% POTASSIUM HYDROXIDE - potassium hydroxide solution 5% SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare 3 Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 MEDICAL DEVICES ALCOH-GLOVE CONTOURED WIP alcohol swabs 3 ALCOH-WIPE 12" X 12" - alcohol swabs 3 2 BLOOD GLUCOSE CALIBRATION LIQUID – VARIOUS 3 ERECAID CLASSIC - impotence aid device - kit 3 ERECAID ESTEEM - impotence aid device - kit 3 EROS-CTD - clitoral vacuum device MI PASTE PLUS - dentifrices - paste 3 OMNIFLEX DIAPHRAGM - diaphragms 3 ORTHO DIAPHRAGM ALL-FLEX/ diaphragm arc-spring 65 mm 3 ORTHO DIAPHRAGM ALL-FLEX/ diaphragm arc-spring 70 mm 3 ORTHO DIAPHRAGM ALL-FLEX/ diaphragm arc-spring 75 mm 3 ORTHO DIAPHRAGM ALL-FLEX/ diaphragm arc-spring 80 mm 3 ORTHO DIAPHRAGM COIL SPRI diaphragm coil spring kit 50 mm 3 FC FEMALE CONDOM - condoms female 3 ORTHO DIAPHRAGM COIL SPRI diaphragm coil spring kit 100 mm 3 FC2 FEMALE CONDOM - condoms female 3 ORTHO DIAPHRAGM COIL SPRI diaphragm coil spring kit 105 mm 3 FEMCAP - cervical cap 22 mm 3 3 FEMCAP - cervical cap 26 mm 3 ORTHO DIAPHRAGM FLAT SPRI diaphragm flat spring kit 55 mm FEMCAP - cervical cap 30 mm 3 3 GLUCOCARD EXPRESSION AUDI blood glucose monitoring kit w/ device 3 ORTHO DIAPHRAGM FLAT SPRI diaphragm flat spring kit 60 mm ORTHO DIAPHRAGM FLAT SPRI diaphragm flat spring kit 65 mm 3 GLUCOCARD VITAL BLOOD GLU blood glucose monitoring kit w/ device 3 ORTHO DIAPHRAGM FLAT SPRI diaphragm flat spring kit 70 mm 3 3 GLUCOCARD X-METER - blood glucose monitoring kit w/ device 3 ORTHO DIAPHRAGM FLAT SPRI diaphragm flat spring kit 75 mm 3 GLUCOCARD 01 BLOOD GLUCOS blood glucose monitoring kit w/ device 3 ORTHO DIAPHRAGM FLAT SPRI diaphragm flat spring kit 80 mm ORTHO DIAPHRAGM FLAT SPRI diaphragm flat spring kit 85 mm 3 GLUCOCARD 01-MINI BLOOD G blood glucose monitoring kit w/ device 3 ORTHO DIAPHRAGM FLAT SPRI diaphragm flat spring kit 90 mm 3 3 ORTHO DIAPHRAGM FLAT SPRI diaphragm flat spring kit 95 mm 3 GMATE SMART STARTER KIT - blood glucose monitoring kit w/ device 2 PRENTIF CAVITY-RIM CERVIC cervical cap 22 mm 3 INSULIN PEN NEEDLES – VARIOUS INSULIN SYRINGES – VARIOUS 2 3 LANCETS – VARIOUS 2 PRENTIF CAVITY-RIM CERVIC cervical cap 25 mm SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits 3 Step Therapy MI PASTE - dentifrices - paste Prior Authorization Quantity Limits Step Therapy 3 Drug Name Drug Tier SODIUM HYDROXIDE - sodium hydroxide solution 10% Prior Authorization Drug Name Drug Tier 2015 169 PRENTIF CAVITY-RIM CERVIC cervical cap 28 mm 3 PRENTIF CAVITY-RIM CERVIC cervical cap 31 mm 3 PRENTIF FITTING SET - cervical caps 3 Q-CARE Q2 ORAL CLEANSING/ - oral hygiene products - kit ASSORTED CLASSES irrigation solution, physiological 1 peritoneal dialysis solutions 346 mosm/l 1 1 3 sodium polystyrene sulfonate powder (Kayexalate) 3 alprostadil inj 500 mcg/ml (Prostin vr pediatric) 1 Q-CARE Q4 ORAL CLEANSING/ - oral hygiene products - kit RAPPORT RING LOADING SYST impotence aid device - kit AMMONIA AROMATIC INHALANT ammonia aromatic spirit 3 3 RAPPORT VACUUM THERAPY DE impotence aid device - kit 3 REMESENSE - dental desensitizing product - misc 3 SIDEKICK BLOOD GLUCOSE SY blood glucose meter disposable device with test strips 3 SURE-T INFUSION SET 18" subcutaneous infusion set 3 SURE-T INFUSION SET 23" subcutaneous infusion set 3 SURE-T INFUSION SET 32" subcutaneous infusion set 3 WIDE-SEAL SILICONE DIAPHR diaphragm wide seal 60 mm 3 WIDE-SEAL SILICONE DIAPHR diaphragm wide seal 65 mm 3 WIDE-SEAL SILICONE DIAPHR diaphragm wide seal 70 mm 3 WIDE-SEAL SILICONE DIAPHR diaphragm wide seal 75 mm 3 WIDE-SEAL SILICONE DIAPHR diaphragm wide seal 80 mm 3 cyclosporine cap 100 mg (Sandimmune) 1 WIDE-SEAL SILICONE DIAPHR diaphragm wide seal 85 mm 3 cyclosporine cap 25 mg (Sandimmune) 1 WIDE-SEAL SILICONE DIAPHR diaphragm wide seal 90 mm 3 CYCLOSPORINE MODIFIED cyclosporine modified cap 50 mg 2 WIDE-SEAL SILICONE DIAPHR diaphragm wide seal 95 mm 3 cyclosporine modified cap 100 mg (Neoral) 1 170 • AMPHADASE - hyaluronidase bovine inj 3 150 unit/ml ASTAGRAF XL - tacrolimus cap sr 24hr 3 0.5 mg ASTAGRAF XL - tacrolimus cap sr 24hr 3 1 mg ASTAGRAF XL - tacrolimus cap sr 24hr 3 5 mg 3 AURUM - misc natural products liqd AZASAN - azathioprine tab 75 mg 3 AZASAN - azathioprine tab 100 mg 3 azathioprine tab 50 mg (Imuran) 1 CELLCEPT - mycophenolate mofetil cap 3 250 mg CELLCEPT - mycophenolate mofetil tab 3 500 mg CELLCEPT - mycophenolate mofetil for 2 oral susp 200 mg/ml 3 CHELIDONIUM COMPOUND - misc natural products liqd CUPRIMINE - penicillamine cap 250 mg 4 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier Quantity Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 cyclosporine modified cap 25 mg (Neoral) 1 cyclosporine modified oral soln 100 mg/ml (Neoral) 3 1 DIANEAL PD-2/4.25% DEXTRO peritoneal dialysis solutions 485 mosm/l 3 DELFLEX-LC/2.5% DEXTROSE peritoneal dialysis solutions 3 ERYSIDORON #2 - misc natural products tab 3 DELFLEX-LC/4.25% DEXTROSE peritoneal dialysis solutions 483 mosm/l 3 EXTRANEAL - peritoneal dialysis solutions HYLENEX - hyaluronidase human inj 150 unit/ml 3 DELFLEX-LM/2.5% DEXTROSE peritoneal dialysis solutions 396 mosm/l 3 IMURAN - azathioprine tab 50 mg 3 KAYEXALATE - sodium polystyrene sulfonate powder 3 DELFLEX-LM/4.25% DEXTROSE peritoneal dialysis solutions 485 mosm/l 3 lactated ringer's for irrigation 1 1 DELFLEX-SM/1.5% DEXTROSE peritoneal dialysis solutions 347 mosm/l 3 mycophenolate mofetil cap 250 mg (Cellcept) mycophenolate mofetil tab 500 mg (Cellcept) 1 DELFLEX-SM/2.5% DEXTROSE peritoneal dialysis solutions 398 mosm/l 3 mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) (Myfortic) 1 DELFLEX-SM/4.25% DEXTROSE peritoneal dialysis solutions 486 mosm/l 3 mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) (Myfortic) 1 DEPEN TITRATABS - penicillamine tab 250 mg 5 3 DIANEAL LOW CALCIUM/1.5% peritoneal dialysis solutions 344 mosm/l 3 MYFORTIC - mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) 3 DIANEAL LOW CALCIUM/2.5% peritoneal dialysis solutions 395 mosm/l 3 MYFORTIC - mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) DIANEAL LOW CALCIUM/4.25% peritoneal dialysis solutions 483 mosm/l 3 DIANEAL PD-2/1.5% DEXTROS peritoneal dialysis solutions 346 mosm/l 3 DIANEAL PD-2/2.5% DEXTROS peritoneal dialysis solutions 396 mosm/l 3 Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 NEORAL - cyclosporine modified cap 25 3 mg 3 NEORAL - cyclosporine modified cap 100 mg 3 NEORAL - cyclosporine modified oral soln 100 mg/ml 3 NEXAVIR - liver derivative complex inj 25.5 mg/ml 3 PHYSIOSOL IRRIGATION PH 7 irrigation solution, physiological 3 PROGRAF - tacrolimus cap 0.5 mg SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 171 M PROGRAF - tacrolimus cap 5 mg 3 THALOMID - thalidomide cap 150 mg M PROSTIN VR PEDIATRIC - alprostadil inj 500 mcg/ml 3 THALOMID - thalidomide cap 200 mg M RAPAMUNE - sirolimus tab 0.5 mg ULTRABAG/DIANEAL LOW CALC peritoneal dialysis solutions 3 3 RAPAMUNE - sirolimus tab 1 mg 2 3 RAPAMUNE - sirolimus tab 2 mg 2 RAPAMUNE - sirolimus oral soln 1 mg/ ml 2 ULTRABAG/DIANEAL LOW CALC peritoneal dialysis solutions 395 mosm/l 3 REVLIMID - lenalidomide caps 2.5 mg M ULTRABAG/DIANEAL PD-2/1.5 peritoneal dialysis solutions 346 mosm/l REVLIMID - lenalidomide cap 5 mg M REVLIMID - lenalidomide cap 10 mg REVLIMID - lenalidomide cap 15 mg M ULTRABAG/DIANEAL PD-2/2.5 peritoneal dialysis solutions 396 mosm/l 3 M REVLIMID - lenalidomide cap 20 mg M 3 REVLIMID - lenalidomide cap 25 mg M ULTRABAG/DIANEAL PD-2/4.2 peritoneal dialysis solutions 485 mosm/l ringer's solution for irrigation 1 VIASPAN - organ preservation solution 3 SANDIMMUNE - cyclosporine cap 25 mg 3 VITRASE - hyaluronidase ovine inj 200 unit/ml 3 SANDIMMUNE - cyclosporine cap 100 mg 3 water for irrigation, sterile irrigation soln 1 SANDIMMUNE - cyclosporine oral soln 100 mg/ml 3 XIAFLEX - collagenase clostridium histolyticum for inj 0.9 mg 5 SARAPIN - misc natural products inj 3 ZORTRESS - everolimus tab 0.25 mg 2 sirolimus tab 0.5 mg (Rapamune) 1 ZORTRESS - everolimus tab 0.5 mg 2 sirolimus tab 1 mg (Rapamune) 1 ZORTRESS - everolimus tab 0.75 mg 2 sirolimus tab 2 mg (Rapamune) 1 sodium polystyrene sulfonate oral susp 15 gm/60ml (Sps) 1 sodium polystyrene sulfonate rectal susp 30 gm/120ml 1 SPS - sodium polystyrene sulfonate oral susp 15 gm/60ml 3 SYPRINE - trientine hcl cap 250 mg 5 tacrolimus cap 0.5 mg (Prograf) 1 tacrolimus cap 1 mg (Prograf) 1 tacrolimus cap 5 mg (Prograf) 1 THALOMID - thalidomide cap 50 mg M 172 • • • • • • • • • • SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 Quantity Limits THALOMID - thalidomide cap 100 mg Step Therapy 3 Prior Authorization Drug Name Drug Tier Quantity Limits Step Therapy PROGRAF - tacrolimus cap 1 mg Prior Authorization Drug Name Drug Tier 2015 2015 ACCOLATE -zafirlukast tab 10 mg....................................67 ACCOLATE -zafirlukast tab 20 mg....................................67 ACCU-CHEK ACTIVE STRIPS -glucose blood test strip.................................................................................168 ACCU-CHEK AVIVA -glucose blood test strip.................168 ACCU-CHEK AVIVA PLUS -glucose blood test strip.......168 ACCU-CHEK COMFORT CURVE T -glucose blood test strip.................................................................................168 ACCU-CHEK COMPACT PLUS -glucose blood test strip.................................................................................168 ACCU-CHEK COMPACT TEST DR -glucose blood test strip.................................................................................168 ACCU-CHEK SMARTVIEW STRIP -glucose blood test strip.................................................................................168 ACCUNEB -albuterol sulfate soln nebu 0.63 mg/3ml (base equiv)................................................................................67 ACCUNEB -albuterol sulfate soln nebu 1.25 mg/3ml (base equiv)................................................................................67 ACCUPRIL -quinapril hcl tab 10 mg..................................49 ACCUPRIL -quinapril hcl tab 20 mg..................................49 ACCUPRIL -quinapril hcl tab 40 mg..................................49 ACCUPRIL -quinapril hcl tab 5 mg....................................49 ACCURETIC -quinapril-hydrochlorothiazide tab 10-12.5 mg.................................................................................... 49 ACCURETIC -quinapril-hydrochlorothiazide tab 20-12.5 mg.................................................................................... 49 ACCURETIC -quinapril-hydrochlorothiazide tab 20-25 mg.................................................................................... 49 ACCUTREND GLUCOSE -glucose blood test strip.........168 ACD-A - anticoagulant citrate dextrose solution a .......... 138 ACD-A NOCLOT-50 - anticoagulant citrate dextrose solution a ...................................................................... 138 ACD FORMULA A - anticoagulant citrate dextrose solution a .................................................................................... 137 ACD FORMULA B - anticoagulant citrate dextrose solution b .................................................................................... 138 acebutolol hcl cap 200 mg (Sectral).............................. 44 acebutolol hcl cap 400 mg (Sectral).............................. 44 ACEON -perindopril erbumine tab 4 mg............................50 ACEON -perindopril erbumine tab 8 mg............................50 ACETAMINOPHEN/CAFFEINE/DI -acetaminophencaffeine-dihydrocodeine tab 712.8-60-32 mg.................102 acetaminophen-isometheptene-caffeine tab 325-65-20 mg (Prodrin)................................................................. 114 acetaminophen-isometheptene-dichloral cap 325-65-100 mg.............................................................. 114 acetaminophen-salicylamide-phenyltoloxamine cap 300-200-20mg................................................................100 acetaminophen w/ codeine soln 120-12 mg/5ml......... 102 acetaminophen w/ codeine tab 300-15 mg (Tylenol/ codeine).........................................................................102 acetaminophen w/ codeine tab 300-30 mg (Tylenol/ codeine #3)................................................................... 102 acetaminophen w/ codeine tab 300-60 mg (Tylenol/ codeine #4)................................................................... 102 INDEX 3ML GLASS SYR KIT/1ML NA - arterial blood gas kit ....................................................................................... 168 5ML GLASS SYR KIT/1ML NA - arterial blood gas kit ....................................................................................... 168 8-MOP -methoxsalen cap 10 mg.....................................166 A A.A.G.C. KIT IN TERODERM - amantad-amitript-gabacycloben cream 8-4-10-4% (cmpd kit) .......................... 149 abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg (Trizivir)................................................. 8 abacavir sulfate tab 300 mg (base equiv) (Ziagen)......... 8 ABILIFY -aripiprazole im inj 9.75 mg/1.3ml (7.5 mg/ml).....87 ABILIFY -aripiprazole oral solution 1 mg/ml...................... 87 ABILIFY -aripiprazole tab 10 mg....................................... 87 ABILIFY -aripiprazole tab 15 mg....................................... 87 ABILIFY -aripiprazole tab 20 mg....................................... 87 ABILIFY -aripiprazole tab 2 mg......................................... 87 ABILIFY -aripiprazole tab 30 mg....................................... 87 ABILIFY -aripiprazole tab 5 mg......................................... 87 ABILIFY DISCMELT -aripiprazole orally disintegrating tab 10 mg............................................................................... 88 ABILIFY DISCMELT -aripiprazole orally disintegrating tab 15 mg............................................................................... 88 ABILIFY MAINTENA -aripiprazole im for extended release susp 300 mg.................................................................... 88 ABILIFY MAINTENA -aripiprazole im for extended release susp 400 mg.................................................................... 88 ABSORICA -isotretinoin cap 10 mg.................................149 ABSORICA -isotretinoin cap 20 mg.................................149 ABSORICA -isotretinoin cap 25 mg.................................149 ABSORICA -isotretinoin cap 30 mg.................................149 ABSORICA -isotretinoin cap 35 mg.................................149 ABSORICA -isotretinoin cap 40 mg.................................149 ABSTRAL -fentanyl citrate sl tab 100 mcg (base equiv)..............................................................................102 ABSTRAL -fentanyl citrate sl tab 200 mcg (base equiv)..............................................................................102 ABSTRAL -fentanyl citrate sl tab 300 mcg (base equiv)..............................................................................102 ABSTRAL -fentanyl citrate sl tab 400 mcg (base equiv)..............................................................................102 ABSTRAL -fentanyl citrate sl tab 600 mcg (base equiv)..............................................................................102 ABSTRAL -fentanyl citrate sl tab 800 mcg (base equiv)..............................................................................102 acamprosate calcium tab delayed release 333 mg (Campral).........................................................................96 ACANYA -clindamycin phosphate-benzoyl peroxide gel 1.2-2.5%......................................................................... 149 acarbose tab 100 mg (Precose)..................................... 31 acarbose tab 25 mg (Precose)....................................... 31 acarbose tab 50 mg (Precose)....................................... 31 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 173 2015 ACETAZOLAMIDE -acetazolamide tab 125 mg................ 57 acetazolamide cap sr 12hr 500 mg (Diamox)................ 57 acetazolamide sodium for inj 500 mg............................57 acetazolamide tab 250 mg.............................................. 57 ACETIC ACID/ALUMINUM ACET -acetic acid 2% in aluminum acetate otic soln............................................ 145 acetic acid irrigation soln 0.25%....................................80 acetic acid otic soln 2%................................................145 acetylcysteine cap 600 mg........................................... 133 acetylcysteine inhal soln 10%........................................ 64 acetylcysteine inhal soln 20%........................................ 64 acitretin cap 10 mg (Soriatane).................................... 149 acitretin cap 17.5 mg (Soriatane)................................. 149 acitretin cap 25 mg (Soriatane).................................... 149 ACLOVATE -alclometasone dipropionate cream 0.05%............................................................................. 149 ACTEMRA -tocilizumab subcutaneous soln prefilled syringe 162 mg/0.9ml.................................................... 111 ACTHAR HP -corticotropin inj gel 80 unit/ml..................... 39 ACTHIB -haemophilus b polysaccharide conjugate vaccine for inj................................................................................ 13 ACTIGALL -ursodiol cap 300 mg...................................... 75 ACTIMMUNE -interferon gamma-1b inj 100 mcg/0.5ml (2000000 unit/0.5ml)........................................................ 18 ACTIQ -fentanyl citrate lollipop 1200 mcg....................... 102 ACTIQ -fentanyl citrate lollipop 1600 mcg....................... 102 ACTIQ -fentanyl citrate lollipop 200 mcg......................... 102 ACTIQ -fentanyl citrate lollipop 400 mcg......................... 102 ACTIQ -fentanyl citrate lollipop 600 mcg......................... 102 ACTIQ -fentanyl citrate lollipop 800 mcg......................... 102 ACTIVE-CYCLOBENZAPRINE KI - cyclobenzaprine hcl td cream 5% (compound kit) ............................................ 126 ACTIVE FE - fe carbonyl-fa-b complex-a-c-d-e-min tab 75-1.25 mg ................................................................... 134 ACTIVE-KETOPROFEN KIT - ketoprofen cream 5% (compound kit) .............................................................. 149 ACTIVELLA -estradiol & norethindrone acetate tab 0.5-0.1 mg.................................................................................... 26 ACTIVELLA -estradiol & norethindrone acetate tab 1-0.5 mg.................................................................................... 26 ACTIVE-PAC/GABAPENTIN -gabapentin oral cap 300 mg & lidocaine-menthol gel ther pk....................................... 96 ACTIVE-PREP KIT I - flurbiprofen-cyclobenzaprine cream (cmpd kit) ......................................................................149 ACTIVE-PREP KIT III - ketoprofen-lidocaine-gabapentin cream (cmpd kit) ...........................................................149 ACTIVE-PREP KIT II - ketoprofen-baclofen-gabapentin cream (cmpd kit) ...........................................................149 ACTIVE-PREP KIT IV - tramadol-gabapentin-mentholcamphor cream (cmpd kit) ............................................149 ACTIVE-PREP KIT V - itraconazole-phenytoin sodium cream (cmpd kit) ...........................................................149 ACTIVE-TRAMADOL KIT - tramadol hcl cream 8% (compound kit) .............................................................. 149 ACTONEL -risedronate sodium tab 150 mg......................39 174 ACTONEL -risedronate sodium tab 30 mg........................39 ACTONEL -risedronate sodium tab 35 mg........................39 ACTONEL -risedronate sodium tab 5 mg..........................39 ACTOPLUS MET -pioglitazone hcl-metformin hcl tab 15-500 mg........................................................................31 ACTOPLUS MET -pioglitazone hcl-metformin hcl tab 15-850 mg........................................................................31 ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab sr 24hr 15-1000 mg............................................................. 31 ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab sr 24hr 30-1000 mg............................................................. 31 ACTOS -pioglitazone hcl tab 15 mg (base equiv)..............31 ACTOS -pioglitazone hcl tab 30 mg (base equiv)..............31 ACTOS -pioglitazone hcl tab 45 mg (base equiv)..............31 ACULAR -ketorolac tromethamine ophth soln 0.5%........141 ACULAR LS -ketorolac tromethamine ophth soln 0.4%............................................................................... 141 ACUVAIL -ketorolac tromethamine ophth soln 0.45%..... 141 acyclovir cap 200 mg (Zovirax)........................................ 8 acyclovir oint 5% (Zovirax)........................................... 149 acyclovir susp 200 mg/5ml (Zovirax)...............................8 acyclovir tab 400 mg (Zovirax).........................................8 acyclovir tab 800 mg (Zovirax).........................................8 ACZONE -dapsone gel 5%............................................. 149 ADACEL -tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lfmcg/0.5ml.........................................................................16 ADAGEN -pegademase bovine inj 250 unit/ml..................18 ADALAT CC -nifedipine tab sr 24hr 30 mg....................... 46 ADALAT CC -nifedipine tab sr 24hr 60 mg....................... 46 ADALAT CC -nifedipine tab sr 24hr 90 mg....................... 46 adapalene cream 0.1% (Differin).................................. 149 adapalene gel 0.1% (Differin)........................................149 adapalene gel 0.3% (Differin)........................................149 ADASUVE -loxapine aerosol powder breath activated 10 mg.................................................................................... 88 ADCIRCA -tadalafil tab 20 mg (pah)................................. 61 ADDERALL -amphetamine-dextroamphetamine tab 10 mg.................................................................................... 93 ADDERALL -amphetamine-dextroamphetamine tab 12.5 mg.................................................................................... 93 ADDERALL -amphetamine-dextroamphetamine tab 15 mg.................................................................................... 93 ADDERALL -amphetamine-dextroamphetamine tab 20 mg.................................................................................... 93 ADDERALL -amphetamine-dextroamphetamine tab 30 mg.................................................................................... 93 ADDERALL -amphetamine-dextroamphetamine tab 5 mg.................................................................................... 93 ADDERALL -amphetamine-dextroamphetamine tab 7.5 mg.................................................................................... 93 ADDERALL XR -amphetamine-dextroamphetamine cap sr 24hr 10 mg...................................................................... 93 ADDERALL XR -amphetamine-dextroamphetamine cap sr 24hr 15 mg...................................................................... 93 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 AFLURIA 2012-2013 -influenza virus vaccine split inj....... 14 AFLURIA 2013-2014 -influenza virus vaccine split inj....... 14 AFLURIA 2014-2015 -influenza virus vaccine split inj....... 14 AFLURIA PF 2012-2013 -influenza virus vaccine split preservative free inj......................................................... 13 AFLURIA PF 2013-2014 -influenza virus vaccine split preservative free inj......................................................... 14 AFLURIA PF 2014-2015 -influenza virus vaccine split preservative free inj......................................................... 14 AGGRENOX -aspirin-dipyridamole cap sr 12hr 25-200 mg.................................................................................. 140 AGRYLIN -anagrelide hcl cap 0.5 mg............................. 140 A-HYDROCORT -hydrocortisone sodium succinate for inj 100 mg............................................................................. 22 AIF #2 DRUG PREPARATION - flurbiprofen-gabapentcycloben-lido-dexameth cr (cmp kit) ............................. 149 AIF #3 DRUG PREPARATION K - flurbiprofen-baclofencycloben-lido cream (cmp kit) .......................................149 AKNE-MYCIN -erythromycin oint 2%.............................. 149 AKTEN -lidocaine hcl ophth gel 3.5%............................. 141 AKYNZEO -netupitant-palonosetron cap 300-0.5 mg........ 74 ALAGESIC LQ -butalbital-acetaminophen-caffeine soln 50-325-40 mg/15ml........................................................ 100 ALAHIST AC -phenylephrine w/ codeine liqd 7.5-10 mg/5ml..............................................................................64 ALAHIST DHC -phenylephrine-dihydrocodeine liqd 7.5-3 mg/5ml..............................................................................64 ALA QUIN -clioquinol-hc cream 3-0.5%.......................... 149 ALA SCALP -hydrocortisone lotion 2%........................... 149 ALBAFORT - b-complex w/ iron inj ................................ 129 ALBAFORT -ferric ammon cit-vit b12-liver inj 67-50 mgmcg/ml............................................................................134 ALBATUSSIN NN - phenyleph-dm-pyril-pot guai-sod cit-cit acid liquid ........................................................................64 ALBATUSSIN -phenylephrine-carbetapentane-gg cap 10-25-400 mg...................................................................64 ALBENZA -albendazole tab 200 mg................................. 12 albuterol sulfate soln nebu 0.083% (2.5 mg/3ml).......... 67 albuterol sulfate soln nebu 0.5% (5 mg/ml)...................67 albuterol sulfate soln nebu 0.63 mg/3ml (base equiv)...............................................................................67 albuterol sulfate soln nebu 1.25 mg/3ml (base equiv)...............................................................................67 albuterol sulfate syrup 2 mg/5ml................................... 67 albuterol sulfate tab 2 mg...............................................67 albuterol sulfate tab 4 mg...............................................67 albuterol sulfate tab sr 12hr 4 mg (Vospire er)............. 67 albuterol sulfate tab sr 12hr 8 mg (Vospire er)............. 67 ALCAINE -proparacaine hcl ophth soln 0.5%..................141 alclometasone dipropionate cream 0.05% (Aclovate)...................................................................... 149 alclometasone dipropionate oint 0.05%...................... 149 ALCOH-GLOVE CONTOURED WIP - alcohol swabs ....................................................................................... 169 ALCOH-WIPE 12" X 12" - alcohol swabs .......................169 ADDERALL XR -amphetamine-dextroamphetamine cap sr 24hr 20 mg...................................................................... 93 ADDERALL XR -amphetamine-dextroamphetamine cap sr 24hr 25 mg...................................................................... 93 ADDERALL XR -amphetamine-dextroamphetamine cap sr 24hr 30 mg...................................................................... 93 ADDERALL XR -amphetamine-dextroamphetamine cap sr 24hr 5 mg........................................................................ 93 adefovir dipivoxil tab 10 mg (Hepsera)........................... 8 ADEMPAS -riociguat tab 0.5 mg....................................... 61 ADEMPAS -riociguat tab 1.5 mg....................................... 61 ADEMPAS -riociguat tab 1 mg.......................................... 61 ADEMPAS -riociguat tab 2.5 mg....................................... 61 ADEMPAS -riociguat tab 2 mg.......................................... 61 ADRENACLICK -epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000).......................................................... 58 ADRENACLICK -epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)............................................................58 ADRENAL C FORMULA - bioflavonoid products tab ......129 ADRENALIN -epinephrine hcl inj 1 mg/ml......................... 67 ADRENALIN -epinephrine hcl nasal soln 0.1%................. 63 ADRENALIN -epinephrine inj 1 mg/ml (1:1000)................ 58 ADRENALIN -epinephrine inj 30 mg/30ml (1 mg/ml) (1:1000)............................................................................ 58 ADULT ASPIRIN LOW STRENGT -aspirin dispersible tab 81 mg............................................................................. 100 ADVAIR DISKUS -fluticasone-salmeterol aer powder ba 100-50 mcg/dose............................................................. 67 ADVAIR DISKUS -fluticasone-salmeterol aer powder ba 250-50 mcg/dose............................................................. 67 ADVAIR DISKUS -fluticasone-salmeterol aer powder ba 500-50 mcg/dose............................................................. 67 ADVAIR HFA -fluticasone-salmeterol inhal aerosol 115-21 mcg/act.............................................................................67 ADVAIR HFA -fluticasone-salmeterol inhal aerosol 230-21 mcg/act.............................................................................67 ADVAIR HFA -fluticasone-salmeterol inhal aerosol 45-21 mcg/act.............................................................................67 ADVANCED AM/PM - multiple vitamins w/ calcium therapy pack .............................................................................. 129 ADVICOR -niacin-lovastatin tab sr 24hr 1000-20 mg........ 59 ADVICOR -niacin-lovastatin tab sr 24hr 1000-40 mg........ 59 ADVICOR -niacin-lovastatin tab sr 24hr 500-20 mg.......... 59 ADVICOR -niacin-lovastatin tab sr 24hr 750-20 mg.......... 59 AEROSPAN -flunisolide hfa inhal aerosol 80 mcg/act....... 67 AFINITOR DISPERZ -everolimus tab for oral susp 2 mg.................................................................................... 18 AFINITOR DISPERZ -everolimus tab for oral susp 3 mg.................................................................................... 18 AFINITOR DISPERZ -everolimus tab for oral susp 5 mg.................................................................................... 18 AFINITOR -everolimus tab 10 mg..................................... 18 AFINITOR -everolimus tab 2.5 mg.................................... 18 AFINITOR -everolimus tab 5 mg....................................... 18 AFINITOR -everolimus tab 7.5 mg.................................... 18 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 175 2015 ALCORTIN A - iodoquinol-hydrocortisone-aloe polysaccharide gel 1-2-1% ........................................... 149 ALDACTAZIDE -spironolactone & hydrochlorothiazide tab 25-25 mg..........................................................................57 ALDACTAZIDE -spironolactone & hydrochlorothiazide tab 50-50 mg..........................................................................57 ALDACTONE -spironolactone tab 100 mg........................ 57 ALDACTONE -spironolactone tab 25 mg.......................... 57 ALDACTONE -spironolactone tab 50 mg.......................... 57 ALDARA -imiquimod cream 5%...................................... 149 ALENDRONATE SODIUM -alendronate sodium oral soln 70 mg/75ml...................................................................... 39 ALENDRONATE SODIUM -alendronate sodium tab 40 mg.................................................................................... 39 alendronate sodium tab 10 mg...................................... 39 alendronate sodium tab 35 mg...................................... 39 alendronate sodium tab 5 mg........................................ 39 alendronate sodium tab 70 mg (Fosamax)....................39 ALEVEER -capsaicin-menthol topical patch 0.0375-5%...................................................................... 149 ALEVICYN ANTIPRURITIC GEL - wound dressings - gel ....................................................................................... 149 ALEVICYN DERMAL SPRAY - wound dressings - soln ....................................................................................... 149 ALFENTA -alfentanil inj 500 mcg/ml................................102 alfentanil inj 500 mcg/ml (Alfenta)............................... 102 ALFERON N -interferon alfa-n3 inj 5000000 unit/ml..........18 alfuzosin hcl tab sr 24hr 10 mg (Uroxatral)...................80 ALINIA -nitazoxanide for susp 100 mg/5ml....................... 12 ALINIA -nitazoxanide tab 500 mg......................................12 ALKERAN -melphalan tab 2 mg........................................18 ALLEVYN AG ADHESIVE - wound dressings - pads ..... 149 ALLEVYN AG GENTLE BORDER - wound dressings pads .............................................................................. 149 ALLEVYN AG NON-ADHESIVE - wound dressings - pads ....................................................................................... 149 ALLEVYN AG SACRUM - wound dressings - pads ........149 ALLEVYN GENTLE - wound dressings - pads ............... 150 ALLFEN CD -guaifenesin-codeine tab 400-10 mg.............64 ALLFEN CDX -guaifenesin-codeine liquid 200-20 mg/5ml..............................................................................64 ALLFEN CDX -guaifenesin-codeine tab 400-20 mg.......... 64 allopurinol tab 100 mg (Zyloprim)................................116 allopurinol tab 300 mg (Zyloprim)................................116 ALOCRIL -nedocromil sodium ophth soln 2%................. 141 ALOMIDE -lodoxamide tromethamine ophth soln 0.1%............................................................................... 141 ALOQUIN - iodoquinol-aloe polysaccharides gel 1.25-1% ....................................................................................... 150 ALORA -estradiol td patch biweekly 0.025 mg/24hr.......... 26 ALORA -estradiol td patch biweekly 0.05 mg/24hr............ 26 ALORA -estradiol td patch biweekly 0.075 mg/24hr.......... 26 ALORA -estradiol td patch biweekly 0.1 mg/24hr.............. 26 ALPAIN -phenyltoloxamine-acetaminophen tab 60-500 mg.................................................................................. 100 176 ALPHAGAN P -brimonidine tartrate ophth soln 0.1%...... 141 ALPHAGAN P -brimonidine tartrate ophth soln 0.15%............................................................................. 141 ALPRAZOLAM INTENSOL -alprazolam conc 1 mg/ml......81 alprazolam orally disintegrating tab 0.25 mg (Niravam).........................................................................81 alprazolam orally disintegrating tab 0.5 mg..................81 alprazolam orally disintegrating tab 1 mg.....................81 alprazolam orally disintegrating tab 2 mg.....................81 alprazolam tab 0.25 mg (Xanax).....................................81 alprazolam tab 0.5 mg (Xanax).......................................81 alprazolam tab 1 mg (Xanax)..........................................81 alprazolam tab 2 mg (Xanax)..........................................81 alprazolam tab sr 24hr 0.5 mg (Xanax xr)..................... 81 alprazolam tab sr 24hr 1 mg (Xanax xr)........................ 81 alprazolam tab sr 24hr 2 mg (Xanax xr)........................ 81 alprazolam tab sr 24hr 3 mg (Xanax xr)........................ 81 alprostadil inj 500 mcg/ml (Prostin vr pediatric).........170 ALREX -loteprednol etabonate ophth susp 0.2%............ 141 ALSUMA -sumatriptan succinate solution auto-injector 6 mg/0.5ml.........................................................................115 ALTABAX -retapamulin oint 1%...................................... 150 ALTACE -ramipril cap 1.25 mg......................................... 50 ALTACE -ramipril cap 10 mg............................................ 50 ALTACE -ramipril cap 2.5 mg........................................... 50 ALTACE -ramipril cap 5 mg.............................................. 50 ALTOPREV -lovastatin tab sr 24hr 20 mg.........................59 ALTOPREV -lovastatin tab sr 24hr 40 mg.........................59 ALTOPREV -lovastatin tab sr 24hr 60 mg.........................59 ALUMINUM ACETATE -aluminum acetate soln.............. 150 aluminum chloride soln 20% (Drysol)......................... 150 ALUVEA -urea cream 39%..............................................150 ALVESCO -ciclesonide inhal aerosol 160 mcg/act............ 67 ALVESCO -ciclesonide inhal aerosol 80 mcg/act.............. 67 AMANTADINE HCL -amantadine hcl tab 100 mg............124 amantadine hcl cap 100 mg......................................... 124 amantadine hcl syrup 50 mg/5ml................................. 124 AMARYL -glimepiride tab 1 mg......................................... 31 AMARYL -glimepiride tab 2 mg......................................... 31 AMARYL -glimepiride tab 4 mg......................................... 31 AMBIEN CR -zolpidem tartrate tab cr 12.5 mg..................91 AMBIEN CR -zolpidem tartrate tab cr 6.25 mg..................91 AMBIEN -zolpidem tartrate tab 10 mg...............................91 AMBIEN -zolpidem tartrate tab 5 mg.................................91 AMBIFED CD -pseudoephedrine w/ cod-gg tab 30-10-400 mg.................................................................................... 64 AMBIFED CDX -pseudoephedrine w/ cod-gg tab 30-20-400 mg...................................................................64 AMBIFED-G CD -pseudoephedrine w/ cod-gg tab 20-10-400 mg...................................................................64 AMBIFED-G CDX -pseudoephedrine w/ cod-gg tab 20-20-400 mg...................................................................64 AMCINONIDE -amcinonide cream 0.1%......................... 150 AMCINONIDE -amcinonide lotion 0.1%.......................... 150 AMCINONIDE -amcinonide oint 0.1%............................. 150 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 amlodipine besylate-benazepril hcl cap 2.5-10 mg (Lotrel)............................................................................. 50 amlodipine besylate-benazepril hcl cap 5-10 mg (Lotrel)............................................................................. 50 amlodipine besylate-benazepril hcl cap 5-20 mg (Lotrel)............................................................................. 50 amlodipine besylate-benazepril hcl cap 5-40 mg (Lotrel)............................................................................. 50 amlodipine besylate tab 10 mg (Norvasc)..................... 46 amlodipine besylate tab 2.5 mg (Norvasc).................... 46 amlodipine besylate tab 5 mg (Norvasc).......................46 amlodipine besylate-valsartan tab 10-160 mg (Exforge)..........................................................................50 amlodipine besylate-valsartan tab 10-320 mg (Exforge)..........................................................................50 amlodipine besylate-valsartan tab 5-160 mg (Exforge)..........................................................................50 amlodipine besylate-valsartan tab 5-320 mg (Exforge)..........................................................................50 AMMONIA AROMATIC INHALANT -ammonia aromatic spirit................................................................................170 AMOXAPINE -amoxapine tab 100 mg.............................. 82 AMOXAPINE -amoxapine tab 150 mg.............................. 82 AMOXAPINE -amoxapine tab 25 mg................................ 82 AMOXAPINE -amoxapine tab 50 mg................................ 82 amoxicillin (trihydrate) cap 250 mg................................. 1 amoxicillin (trihydrate) cap 500 mg................................. 1 amoxicillin (trihydrate) for susp 125 mg/5ml.................. 1 amoxicillin (trihydrate) for susp 200 mg/5ml.................. 1 amoxicillin (trihydrate) for susp 250 mg/5ml.................. 1 amoxicillin (trihydrate) for susp 400 mg/5ml.................. 1 amoxicillin (trihydrate) tab 500 mg.................................. 1 amoxicillin (trihydrate) tab 875 mg.................................. 1 amoxicillin & k clavulanate chew tab 200-28.5 mg......... 1 amoxicillin & k clavulanate chew tab 400-57 mg............ 1 amoxicillin & k clavulanate for susp 200-28.5 mg/5ml...............................................................................1 amoxicillin & k clavulanate for susp 250-62.5 mg/5ml (Augmentin)...................................................................... 1 amoxicillin & k clavulanate for susp 400-57 mg/5ml...... 1 amoxicillin & k clavulanate for susp 600-42.9 mg/5ml (Augmentin es-600)..........................................................1 amoxicillin & k clavulanate tab 250-125 mg....................1 amoxicillin & k clavulanate tab 500-125 mg (Augmentin)...................................................................... 1 amoxicillin & k clavulanate tab 875-125 mg (Augmentin)...................................................................... 1 amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg (Augmentin xr)................................................................. 1 AMOXICILLIN -amoxicillin (trihydrate) chew tab 125 mg.....1 AMOXICILLIN -amoxicillin (trihydrate) chew tab 250 mg.....1 amoxicillin cap-clarithro tab-lansopraz cap dr therapy pack (Prevpac)............................................................... 71 AMOXICILLIN ER -amoxicillin (trihydrate) tab sr 24hr 775 mg...................................................................................... 1 AMERGE -naratriptan hcl tab 1 mg (base equiv)............ 115 AMERGE -naratriptan hcl tab 2.5 mg (base equiv)..........115 AMETHYST -levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg..................................................................28 AMICAR -aminocaproic acid syrup 25%......................... 139 AMICAR -aminocaproic acid tab 1000 mg...................... 139 AMICAR -aminocaproic acid tab 500 mg........................ 139 amikacin sulfate inj 1 gm/4ml (250 mg/ml)......................6 amikacin sulfate inj 500 mg/2ml (250 mg/ml).................. 6 amiloride & hydrochlorothiazide tab 5-50 mg............... 57 amiloride hcl tab 5 mg.................................................... 57 AMINOBENZOATE POTASSIUM -potassium aminobenzoate packet 2 gm..........................................128 AMINOCAPROIC ACID -aminocaproic acid tab 1000 mg.................................................................................. 139 aminocaproic acid syrup 25% (Amicar).......................139 aminocaproic acid tab 500 mg (Amicar)......................139 amiodarone hcl tab 100 mg............................................48 amiodarone hcl tab 200 mg (Cordarone).......................48 amiodarone hcl tab 400 mg............................................48 AMITIZA -lubiprostone cap 24 mcg...................................75 AMITIZA -lubiprostone cap 8 mcg.....................................75 amitriptyline hcl tab 100 mg...........................................82 amitriptyline hcl tab 10 mg.............................................82 amitriptyline hcl tab 150 mg...........................................82 amitriptyline hcl tab 25 mg.............................................82 amitriptyline hcl tab 50 mg.............................................82 amitriptyline hcl tab 75 mg.............................................82 amlodipine besylate-atorvastatin calcium tab 10-10 mg (Caduet)...........................................................................61 amlodipine besylate-atorvastatin calcium tab 10-20 mg (Caduet)...........................................................................61 amlodipine besylate-atorvastatin calcium tab 10-40 mg (Caduet)...........................................................................61 amlodipine besylate-atorvastatin calcium tab 10-80 mg (Caduet)...........................................................................62 amlodipine besylate-atorvastatin calcium tab 2.5-10 mg (Caduet).................................................................... 62 amlodipine besylate-atorvastatin calcium tab 2.5-20 mg (Caduet).................................................................... 62 amlodipine besylate-atorvastatin calcium tab 2.5-40 mg (Caduet).................................................................... 62 amlodipine besylate-atorvastatin calcium tab 5-10 mg (Caduet)...........................................................................62 amlodipine besylate-atorvastatin calcium tab 5-20 mg (Caduet)...........................................................................62 amlodipine besylate-atorvastatin calcium tab 5-40 mg (Caduet)...........................................................................62 amlodipine besylate-atorvastatin calcium tab 5-80 mg (Caduet)...........................................................................62 amlodipine besylate-benazepril hcl cap 10-20 mg (Lotrel)............................................................................. 50 amlodipine besylate-benazepril hcl cap 10-40 mg (Lotrel)............................................................................. 50 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 177 2015 AMPHADASE -hyaluronidase bovine inj 150 unit/ml....... 170 amphetamine-dextroamphetamine cap sr 24hr 10 mg (Adderall xr)....................................................................93 amphetamine-dextroamphetamine cap sr 24hr 15 mg (Adderall xr)....................................................................93 amphetamine-dextroamphetamine cap sr 24hr 20 mg (Adderall xr)....................................................................93 amphetamine-dextroamphetamine cap sr 24hr 25 mg (Adderall xr)....................................................................93 amphetamine-dextroamphetamine cap sr 24hr 30 mg (Adderall xr)....................................................................93 amphetamine-dextroamphetamine cap sr 24hr 5 mg (Adderall xr)....................................................................93 amphetamine-dextroamphetamine tab 10 mg (Adderall).........................................................................93 amphetamine-dextroamphetamine tab 12.5 mg (Adderall).........................................................................93 amphetamine-dextroamphetamine tab 15 mg (Adderall).........................................................................93 amphetamine-dextroamphetamine tab 20 mg (Adderall).........................................................................93 amphetamine-dextroamphetamine tab 30 mg (Adderall).........................................................................93 amphetamine-dextroamphetamine tab 5 mg (Adderall).........................................................................93 amphetamine-dextroamphetamine tab 7.5 mg (Adderall).........................................................................93 AMPHOTERICIN B -amphotericin b for inj 50 mg............... 7 AMPICILLIN -ampicillin for susp 125 mg/5ml...................... 1 AMPICILLIN -ampicillin for susp 250 mg/5ml...................... 1 ampicillin cap 250 mg....................................................... 1 ampicillin cap 500 mg....................................................... 1 AMPYRA -dalfampridine tab sr 12hr 10 mg...................... 96 AMRIX -cyclobenzaprine hcl cap sr 24hr 15 mg..............126 AMRIX -cyclobenzaprine hcl cap sr 24hr 30 mg..............126 AMTURNIDE -aliskiren-amlodipine-hydrochlorothiazide tab 150-5-12.5 mg..................................................................50 AMTURNIDE -aliskiren-amlodipine-hydrochlorothiazide tab 300-10-12.5 mg................................................................50 AMTURNIDE -aliskiren-amlodipine-hydrochlorothiazide tab 300-10-25 mg...................................................................50 AMTURNIDE -aliskiren-amlodipine-hydrochlorothiazide tab 300-5-12.5 mg..................................................................50 AMTURNIDE -aliskiren-amlodipine-hydrochlorothiazide tab 300-5-25 mg.....................................................................50 AMVISC PLUS -sodium hyaluronate intraocular inj 16 mg/ ml....................................................................................141 AMVISC -sodium hyaluronate intraocular inj 12 mg/ ml....................................................................................141 AMYTAL SODIUM -amobarbital sodium for inj 500 mg..... 92 ANACAINE -benzocaine oint 10%...................................150 ANADROL-50 -oxymetholone tab 50 mg.......................... 25 ANAFRANIL -clomipramine hcl cap 25 mg....................... 82 ANAFRANIL -clomipramine hcl cap 50 mg....................... 82 ANAFRANIL -clomipramine hcl cap 75 mg....................... 82 178 anagrelide hcl cap 0.5 mg (Agrylin).............................140 anagrelide hcl cap 1 mg............................................... 140 ANALPRAM ADVANCED -hc-pramoxine cr & diet manage prod tab & cleans wipe kit............................................. 148 ANALPRAM E -hc-pramoxine emol cream 2.5-1% & pramoxine wipe 1% kit...................................................148 ANALPRAM-HC -hydrocortisone acetate w/ pramoxine rectal cream 1-1%..........................................................148 ANALPRAM-HC -hydrocortisone acetate w/ pramoxine rectal cream 2.5-1%.......................................................148 ANALPRAM-HC -hydrocortisone acetate w/ pramoxine rectal lotn 2.5-1%...........................................................148 ANALPRAM-HC SINGLES -hydrocortisone acetate w/ pramoxine rectal cream 1-1%........................................148 ANALPRAM-HC SINGLES -hydrocortisone acetate w/ pramoxine rectal cream 2.5-1%.....................................148 ANAPROX DS -naproxen sodium tab 550 mg................ 111 ANAPROX -naproxen sodium tab 275 mg...................... 111 ANASPAZ -hyoscyamine sulfate tab disp 0.125 mg..........71 anastrozole tab 1 mg (Arimidex)....................................18 ANCOBON -flucytosine cap 250 mg................................... 7 ANCOBON -flucytosine cap 500 mg................................... 7 ANDRODERM -testosterone td patch 24hr 2 mg/24hr...... 25 ANDRODERM -testosterone td patch 24hr 4 mg/24hr...... 25 ANDROGEL PUMP -testosterone td gel 12.5 mg/act (1%)..................................................................................25 ANDROGEL PUMP -testosterone td gel 20.25 mg/act (1.62%).............................................................................25 ANDROGEL -testosterone td gel 20.25 mg/1.25gm (1.62%).............................................................................25 ANDROGEL -testosterone td gel 25 mg/2.5gm (1%)........ 25 ANDROGEL -testosterone td gel 40.5 mg/2.5gm (1.62%).............................................................................25 ANDROGEL -testosterone td gel 50 mg/5gm (1%)........... 25 ANDROID -methyltestosterone cap 10 mg........................25 ANDROXY -fluoxymesterone tab 10 mg........................... 25 ANECTINE -succinylcholine chloride inj 20 mg/ml.......... 126 ANGELIQ -drospirenone-estradiol tab 0.25-0.5 mg...........26 ANGELIQ -drospirenone-estradiol tab 0.5-1 mg................26 ANIMI-3/VITAMIN D - folic acid-b6-b12-d-omega 3phytosterols cap 1 mg .................................................. 134 ANIMI-3 - folic acid-b6-b12-d-omega 3-phytosterols cap 1 mg ................................................................................. 134 ANIMI-3 - folic acid-vit b6-vit b12-omega 3-phytosterols cap 1 mg ...................................................................... 134 ANORO ELLIPTA -umeclidinium-vilanterol aero powd ba 62.5-25 mcg/inh............................................................... 67 ANTABUSE -disulfiram tab 250 mg.................................. 96 ANTABUSE -disulfiram tab 500 mg.................................. 96 ANTARA -fenofibrate micronized cap 130 mg...................59 ANTARA -fenofibrate micronized cap 30 mg.....................59 ANTARA -fenofibrate micronized cap 43 mg.....................59 ANTARA -fenofibrate micronized cap 90 mg.....................59 ANTICOAGULANT CITRATE DEX - anticoagulant citrate dextrose solution a ....................................................... 138 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 AQUORAL - artificial saliva - aero soln .......................... 146 ARALEN -chloroquine phosphate tab 500 mg...................12 ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate 80 soln inj 100 mcg/0.5ml..............................................134 ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate 80 soln inj 100 mcg/ml...................................................134 ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate 80 soln inj 150 mcg/0.3ml..............................................134 ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate 80 soln inj 150 mcg/0.75ml............................................134 ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate 80 soln inj 200 mcg/0.4ml..............................................134 ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate 80 soln inj 200 mcg/ml...................................................134 ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate 80 soln inj 25 mcg/0.42ml..............................................134 ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate 80 soln inj 25 mcg/ml.................................................... 134 ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate 80 soln inj 300 mcg/0.6ml..............................................134 ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate 80 soln inj 300 mcg/ml...................................................134 ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate 80 soln inj 40 mcg/0.4ml................................................134 ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate 80 soln inj 40 mcg/ml.................................................... 134 ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate 80 soln inj 500 mcg/ml...................................................134 ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate 80 soln inj 60 mcg/0.3ml................................................134 ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate 80 soln inj 60 mcg/ml.................................................... 134 ARAVA -leflunomide tab 10 mg.......................................111 ARAVA -leflunomide tab 20 mg.......................................111 ARCALYST -rilonacept for inj 220 mg.............................111 ARCAPTA NEOHALER -indacaterol maleate inhal powder cap 75 mcg (base equiv)................................................. 67 ARESTIN -minocycline hcl subgingival powder cartridge 1 mg.................................................................................. 146 ARICEPT -donepezil hydrochloride tab 10 mg.................. 96 ARICEPT -donepezil hydrochloride tab 23 mg.................. 96 ARICEPT -donepezil hydrochloride tab 5 mg.................... 96 ARICEPT ODT -donepezil hydrochloride orally disintegrating tab 10 mg.................................................. 97 ARICEPT ODT -donepezil hydrochloride orally disintegrating tab 5 mg.................................................... 97 ARIMIDEX -anastrozole tab 1 mg..................................... 18 ARISTOSPAN INTRA-ARTICULA -triamcinolone hexacetonide inj susp 20 mg/ml...................................... 22 ARISTOSPAN INTRALESIONAL -triamcinolone hexacetonide inj susp 5 mg/ml........................................ 22 ARIXTRA -fondaparinux sodium inj 10 mg/0.8ml............ 138 ARIXTRA -fondaparinux sodium inj 2.5 mg/0.5ml........... 138 ARIXTRA -fondaparinux sodium inj 5 mg/0.4ml.............. 138 ARIXTRA -fondaparinux sodium inj 7.5 mg/0.6ml........... 138 ANTICOAGULANT CITRATE PHO - anticoagulant citrate phosphate dextrose soln .............................................. 138 ANTICOAGULANT SODIUM CITR -anticoagulant sodium citrate soln 4%............................................................... 138 ANTIPYRINE/BENZOCAINE -antipyrine-benzocaine otic soln 55-14 mg/ml (5.5-1.4%)......................................... 145 antipyrine-benzocaine otic soln 54-14 mg/ml (5.4-1.4%).......................................................................145 antipyrine-benzocaine otic soln 55-14 mg/ml (5.5-1.4%).......................................................................145 antipyrine-benzocaine-polycosanol otic sol 5.4-1.4-0.0097% (Treagan otic)....................................145 ANTIVENIN LATRODECTUS MAC -antivenin latrodectus mactans inj kit.................................................................. 16 ANUSOL-HC -hydrocortisone acetate suppos 25 mg......148 ANUSOL-HC -hydrocortisone rectal cream 2.5%............ 148 ANZEMET -dolasetron mesylate tab 100 mg.................... 74 ANZEMET -dolasetron mesylate tab 50 mg...................... 74 APEXICON E -diflorasone diacetate emollient base cream 0.05%............................................................................. 150 APIDRA -insulin glulisine inj 100 unit/ml........................... 35 APIDRA SOLOSTAR -insulin glulisine soln pen-injector inj 100 unit/ml....................................................................... 35 APLENZIN -bupropion hbr tab sr 24hr 174 mg................. 83 APLENZIN -bupropion hbr tab sr 24hr 348 mg................. 83 APLENZIN -bupropion hbr tab sr 24hr 522 mg................. 83 APOKYN -apomorphine hydrochloride inj 10 mg/ml........124 APOP -sulfacetamide sodium in bakuchiol vehicle gel 10%................................................................................ 150 APPBUTAMONE -bupropion hcl tab 75 mg & dietary management cap pack.................................................... 83 APPBUTAMONE-D -bupropion hcl tab 75 mg & dietary management cap pack.................................................... 83 APPFORMIN-D -metformin hcl tab 500 mg & dietary management cap pack.................................................... 32 APPFORMIN -metformin hcl tab 500 mg & dietary management cap pack.................................................... 32 APPTRIM LIFESTYLES OBESIT - dietary management product - diet aids caps ................................................ 133 APPTRIM LIFESTYLES POST-B - dietary management product - diet aids caps ................................................ 133 APPTRIM LIFESTYLES PRE-BA - dietary management product - diet aids caps ................................................ 133 apraclonidine hcl ophth soln 0.5% (base equivalent) (Iopidine)....................................................................... 141 APRISO -mesalamine cap sr 24hr 0.375 gm.................... 75 APTIOM -eslicarbazepine acetate tab 200 mg................ 119 APTIOM -eslicarbazepine acetate tab 400 mg................ 119 APTIOM -eslicarbazepine acetate tab 600 mg................ 119 APTIOM -eslicarbazepine acetate tab 800 mg................ 119 APTIVUS -tipranavir cap 250 mg........................................ 8 APTIVUS -tipranavir oral soln 100 mg/ml............................8 AP-ZEL - multiple vitamins w/ minerals tab .................... 129 AQUASOL A PARENTERAL -vitamin a inj 50000 unit/ ml....................................................................................128 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 179 2015 ARMOUR THYROID -thyroid tab 120 mg (2 grain)........... 36 ARMOUR THYROID -thyroid tab 15 mg (1/4 grain).......... 36 ARMOUR THYROID -thyroid tab 180 mg (3 grain)........... 36 ARMOUR THYROID -thyroid tab 240 mg (4 grain)........... 36 ARMOUR THYROID -thyroid tab 300 mg (5 grain)........... 36 ARMOUR THYROID -thyroid tab 30 mg (1/2 grain).......... 36 ARMOUR THYROID -thyroid tab 60 mg (1 grain)............. 36 ARMOUR THYROID -thyroid tab 90 mg (1 1/2 grain)....... 36 ARNICA FLOWER - arnica - tincture ............................. 150 AROMASIN -exemestane tab 25 mg.................................18 ARTHROTEC 50 -diclofenac w/ misoprostol tab delayed release 50-0.2 mg..........................................................111 ARTHROTEC 75 -diclofenac w/ misoprostol tab delayed release 75-0.2 mg..........................................................111 ARTICADENT DENTAL -articaine-epinephrine inj 4%-1:100000.................................................................. 117 ARTICADENT DENTAL -articaine-epinephrine inj 4%-1:200000.................................................................. 117 ARTISS - fibrin sealant component solution ...................140 ARZOL SILVER NITRATE APP -silver nitrate-potassium nitrate applicator 75-25%............................................... 150 ASACOL HD -mesalamine tab delayed release 800 mg.................................................................................... 75 ASACOL -mesalamine tab delayed release 400 mg......... 75 ASCENSIA AUTODISC TEST ST -glucose blood test disk................................................................................. 168 ASCORBIC ACID -ascorbic acid oral granules............... 128 ascorbic acid inj 500 mg/ml......................................... 128 ASMANEX TWISTHALER 120 ME -mometasone furoate inhal powd 220 mcg/inh (breath activated)...................... 67 ASMANEX TWISTHALER 14 MET -mometasone furoate inhal powd 220 mcg/inh (breath activated)...................... 67 ASMANEX TWISTHALER 30 ME -mometasone furoate inhal powd 220 mcg/inh (breath activated)...................... 67 ASMANEX TWISTHALER 30 MET -mometasone furoate inhal powd 110 mcg/inh (breath activated)...................... 68 ASMANEX TWISTHALER 60 MET -mometasone furoate inhal powd 220 mcg/inh (breath activated)...................... 68 ASMANEX TWISTHALER 7 METE -mometasone furoate inhal powd 110 mcg/inh (breath activated)...................... 68 aspirin buffered (ca carb-mg carb-mg ox) tab 325 mg.................................................................................. 100 ASPIRIN-CAFFEINE-DIHYDROC -aspirin-caffeinedihydrocodeine cap 356.4-30-16 mg............................. 102 aspirin chew tab 81 mg.................................................100 ASPIRIN LOW DOSE -aspirin tab 81 mg........................ 100 aspirin tab 325 mg.........................................................100 aspirin tab 81 mg...........................................................100 aspirin tab delayed release 325 mg............................. 100 aspirin tab delayed release 81 mg............................... 100 ASTAGRAF XL -tacrolimus cap sr 24hr 0.5 mg.............. 170 ASTAGRAF XL -tacrolimus cap sr 24hr 1 mg................. 170 ASTAGRAF XL -tacrolimus cap sr 24hr 5 mg................. 170 ASTELIN -azelastine hcl nasal spray 137 mcg/spray (1 mg/ml).............................................................................. 63 180 ASTEPRO -azelastine hcl nasal spray 0.15% (205.5 mcg/ spray)............................................................................... 63 ASTRINGYN -ferric subsulfate soln 259 mg/gm..............140 ATACAND -candesartan cilexetil tab 16 mg......................50 ATACAND -candesartan cilexetil tab 32 mg......................50 ATACAND -candesartan cilexetil tab 4 mg........................50 ATACAND -candesartan cilexetil tab 8 mg........................50 ATACAND HCT -candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg................................................................ 50 ATACAND HCT -candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg................................................................ 50 ATACAND HCT -candesartan cilexetil-hydrochlorothiazide tab 32-25 mg................................................................... 50 ATELVIA -risedronate sodium tab delayed release 35 mg.................................................................................... 39 atenolol & chlorthalidone tab 100-25 mg (Tenoretic 100).................................................................................. 50 atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50).................................................................................... 50 atenolol tab 100 mg (Tenormin)..................................... 44 atenolol tab 25 mg (Tenormin)....................................... 44 atenolol tab 50 mg (Tenormin)....................................... 44 ATIVAN -lorazepam inj 2 mg/ml........................................ 81 ATIVAN -lorazepam inj 4 mg/ml........................................ 81 ATIVAN -lorazepam tab 0.5 mg........................................ 81 ATIVAN -lorazepam tab 1 mg........................................... 81 ATIVAN -lorazepam tab 2 mg........................................... 81 ATOPICLAIR - emollient - cream ................................... 150 atorvastatin calcium tab 10 mg (base equivalent) (Lipitor)............................................................................59 atorvastatin calcium tab 20 mg (base equivalent) (Lipitor)............................................................................59 atorvastatin calcium tab 40 mg (base equivalent) (Lipitor)............................................................................59 atorvastatin calcium tab 80 mg (base equivalent) (Lipitor)............................................................................59 atovaquone-proguanil hcl tab 250-100 mg (Malarone)....................................................................... 12 atovaquone-proguanil hcl tab 62.5-25 mg (Malarone)....................................................................... 12 atovaquone susp 750 mg/5ml (Mepron)........................ 12 ATRALIN -tretinoin gel 0.05%......................................... 150 ATRAPRO ANTIPRURITIC HYDR - wound dressings - gel ....................................................................................... 150 ATRAPRO CP - wound dressings - kit ...........................150 ATRAPRO DERMAL SPRAY - wound cleansers - liquid ....................................................................................... 150 ATRIPLA -efavirenz-emtricitabine-tenofovir df tab 600-200-300 mg.................................................................8 ATROPEN -atropine sulfate im inj device 0.25 mg/0.3ml...........................................................................71 ATROPEN -atropine sulfate im inj device 0.5 mg/0.7ml...........................................................................71 ATROPEN -atropine sulfate im inj device 1 mg/0.7ml....... 71 ATROPEN -atropine sulfate im inj device 2 mg/0.7ml....... 71 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 AVANDARYL -rosiglitazone maleate-glimepiride tab 4-2 mg.................................................................................... 32 AVANDARYL -rosiglitazone maleate-glimepiride tab 4-4 mg.................................................................................... 32 AVANDARYL -rosiglitazone maleate-glimepiride tab 8-2 mg.................................................................................... 32 AVANDARYL -rosiglitazone maleate-glimepiride tab 8-4 mg.................................................................................... 32 AVANDIA -rosiglitazone maleate tab 2 mg (base equiv)................................................................................32 AVANDIA -rosiglitazone maleate tab 4 mg (base equiv)................................................................................32 AVANDIA -rosiglitazone maleate tab 8 mg (base equiv)................................................................................32 AVAPRO -irbesartan tab 150 mg...................................... 50 AVAPRO -irbesartan tab 300 mg...................................... 50 AVAPRO -irbesartan tab 75 mg........................................ 50 AVAR-E LS -sulfacetamide sodium w/ sulfur cream 10-2%............................................................................. 150 AVAR LS CLEANSER -sulfacetamide sodium w/ sulfur cleanser 10-2%.............................................................. 150 AVAR LS -sulfacetamide sodium w/ sulfur cleansing pad 10-2%............................................................................. 150 AVAR -sulfacetamide sodium w/ sulfur cleansing pad 9.5-5%............................................................................ 150 AVC -sulfanilamide vaginal cream 15%............................ 79 AVEED -testosterone undecanoate im inj in oil 750 mg/3ml (250mg/ml)....................................................................... 25 AVELOX ABC PACK -moxifloxacin hcl tab 400 mg (base equiv)..................................................................................5 AVELOX -moxifloxacin hcl tab 400 mg (base equiv)........... 5 AVINZA -morphine sulfate beads cap sr 24hr 120 mg.....102 AVINZA -morphine sulfate beads cap sr 24hr 30 mg...... 102 AVINZA -morphine sulfate beads cap sr 24hr 45 mg...... 102 AVINZA -morphine sulfate beads cap sr 24hr 60 mg...... 102 AVINZA -morphine sulfate beads cap sr 24hr 75 mg...... 102 AVINZA -morphine sulfate beads cap sr 24hr 90 mg...... 102 AVO CREAM - wound dressings - emulsion .................. 150 AVODART -dutasteride cap 0.5 mg.................................. 80 AVONEX -interferon beta-1a for im inj kit 30mcg (33mcg(6.6 mu)/vial)........................................................ 97 AVONEX -interferon beta-1a im inj kit 30 mcg/0.5ml.........97 AVONEX PEN -interferon beta-1a im inj kit 30 mcg/0.5ml.........................................................................97 AXERT -almotriptan malate tab 12.5 mg.........................115 AXERT -almotriptan malate tab 6.25 mg.........................115 AXID -nizatidine cap 300 mg.............................................71 AXID -nizatidine oral soln 15 mg/ml.................................. 71 AXIRON -testosterone td soln 30 mg/act.......................... 25 AYGESTIN -norethindrone acetate tab 5 mg.................... 31 azacitidine for inj 100 mg (Vidaza).................................18 AZACTAM -aztreonam for inj 1 gm................................... 12 AZACTAM -aztreonam for inj 2 gm................................... 12 AZASAN -azathioprine tab 100 mg................................. 170 AZASAN -azathioprine tab 75 mg................................... 170 ATROPINE SULFATE -atropine sulfate inj 0.05 mg/ml..... 71 ATROPINE SULFATE -atropine sulfate inj 0.8 mg/ml....... 71 ATROPINE SULFATE -atropine sulfate ophth oint 1%.................................................................................. 141 atropine sulfate inj 0.1 mg/ml.........................................71 atropine sulfate inj 0.4 mg/ml.........................................71 atropine sulfate inj 1 mg/ml............................................71 atropine sulfate ophth soln 1% (Isopto atropine)....... 141 ATROVENT HFA -ipratropium bromide hfa inhal aerosol 17 mcg/act....................................................................... 68 ATROVENT -ipratropium bromide nasal soln 0.03% (21 mcg/spray)........................................................................63 ATROVENT -ipratropium bromide nasal soln 0.06% (42 mcg/spray)........................................................................64 AUBAGIO -teriflunomide tab 14 mg.................................. 97 AUBAGIO -teriflunomide tab 7 mg.................................... 97 AUGMENTIN -amoxicillin & k clavulanate for susp 125-31.25 mg/5ml.............................................................. 1 AUGMENTIN -amoxicillin & k clavulanate for susp 250-62.5 mg/5ml................................................................ 1 AUGMENTIN -amoxicillin & k clavulanate tab 500-125 mg...................................................................................... 1 AUGMENTIN -amoxicillin & k clavulanate tab 875-125 mg...................................................................................... 1 AUGMENTIN ES-600 -amoxicillin & k clavulanate for susp 600-42.9 mg/5ml................................................................ 1 AUGMENTIN XR -amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg.....................................................................1 AURALGAN -antipyrine-benzocaine otic soln 55-14 mg/ml (5.5-1.4%).......................................................................146 AURSTAT ANTI-ITCH HYDROGE - dermatological products misc - gel ....................................................... 150 AURSTAT ANTI-ITCH HYDROGE - dermatological products misc - kit ........................................................ 150 AURSTAT -emollient cream & wound dressing gel kit.....150 AURUM - misc natural products liqd .............................. 170 AUVI-Q -epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000)............................................................................ 58 AUVI-Q -epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)............................................................................ 58 AVALIDE -irbesartan-hydrochlorothiazide tab 150-12.5 mg.................................................................................... 50 AVALIDE -irbesartan-hydrochlorothiazide tab 300-12.5 mg.................................................................................... 50 AVANDAMET -rosiglitazone maleate-metformin hcl tab 2-1000 mg........................................................................32 AVANDAMET -rosiglitazone maleate-metformin hcl tab 2-500 mg..........................................................................32 AVANDAMET -rosiglitazone maleate-metformin hcl tab 4-1000 mg........................................................................32 AVANDAMET -rosiglitazone maleate-metformin hcl tab 4-500 mg..........................................................................32 AVANDARYL -rosiglitazone maleate-glimepiride tab 4-1 mg.................................................................................... 32 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 181 2015 AZASITE -azithromycin ophth soln 1%........................... 141 azathioprine tab 50 mg (Imuran).................................. 170 azelastine hcl nasal spray 0.15% (205.5 mcg/spray) (Astepro)......................................................................... 64 azelastine hcl nasal spray 137 mcg/spray (1 mg/ ml).................................................................................... 64 azelastine hcl ophth soln 0.05% (Optivar)...................141 AZELEX -azelaic acid cream 20%.................................. 150 AZILECT -rasagiline mesylate tab 0.5 mg (base equiv)..............................................................................124 AZILECT -rasagiline mesylate tab 1 mg (base equiv)......124 AZITHROMYCIN -azithromycin powd pack for susp 1 gm...................................................................................... 4 azithromycin for susp 100 mg/5ml (Zithromax).............. 4 azithromycin for susp 200 mg/5ml (Zithromax).............. 4 azithromycin tab 250 mg (Zithromax)..............................4 azithromycin tab 500 mg (Zithromax)..............................4 azithromycin tab 600 mg (Zithromax)..............................4 AZOPT -brinzolamide ophth susp 1%............................. 141 AZOR -amlodipine besylate-olmesartan medoxomil tab 10-20 mg..........................................................................50 AZOR -amlodipine besylate-olmesartan medoxomil tab 10-40 mg..........................................................................50 AZOR -amlodipine besylate-olmesartan medoxomil tab 5-20 mg............................................................................50 AZOR -amlodipine besylate-olmesartan medoxomil tab 5-40 mg............................................................................50 aztreonam for inj 1 gm (Azactam)..................................12 aztreonam for inj 2 gm (Azactam)..................................12 AZULFIDINE EN-TABS -sulfasalazine tab delayed release 500 mg............................................................................. 75 AZULFIDINE -sulfasalazine tab 500 mg............................75 B B-6 FOLIC ACID - cobalamine combination cap ............ 134 BABY DDROPS -cholecalciferol drops 400 unit/0.03ml (per drop)....................................................................... 128 BACITRACIN -bacitracin intramuscular for soln 50000 unit....................................................................................12 BACITRACIN -bacitracin ophth oint 500 unit/gm............. 141 bacitracin intramuscular for soln 50000 unit (Bacitracin)......................................................................12 bacitracin-polymyxin b ophth oint............................... 141 bacitracin-polymyxin-neomycin-hc ophth oint 1%..... 141 baclofen tab 10 mg........................................................126 baclofen tab 20 mg........................................................127 BACMIN - multiple vitamins w/ minerals tab ...................129 BACTRIM DS -sulfamethoxazole-trimethoprim tab 800-160 mg.................................................................................... 12 BACTRIM -sulfamethoxazole-trimethoprim tab 400-80 mg.................................................................................... 12 BACTROBAN -mupirocin calcium cream 2%.................. 150 BACTROBAN -mupirocin oint 2%................................... 150 BACTROBAN NASAL -mupirocin calcium nasal oint 2%.................................................................................... 64 BAL IN OIL -dimercaprol inj 100 mg/ml...........................167 182 balsalazide disodium cap 750 mg (Colazal).................. 76 BANZEL -rufinamide susp 40 mg/ml............................... 119 BANZEL -rufinamide tab 200 mg.................................... 119 BANZEL -rufinamide tab 400 mg.................................... 119 BARACLUDE -entecavir oral soln 0.05 mg/ml.................... 8 BARACLUDE -entecavir tab 0.5 mg....................................8 BARACLUDE -entecavir tab 1 mg.......................................8 BAYER BREEZE 2 TEST DISC -glucose blood test disk................................................................................. 168 BAYER CONTOUR BLOOD GLUCO -glucose blood test strip.................................................................................168 BAYER CONTOUR NEXT BLOOD -glucose blood test strip.................................................................................168 b-complex vitamin inj ...................................................129 b-complex w/ c & folic acid cap 1 mg (Nephrocaps)................................................................ 129 b-complex w/ c & folic acid tab....................................129 b-complex w/ c & folic acid tab 1 mg (Nephro-vite rx)...................................................................................129 b-complex w/ c & folic acid tab 5 mg.......................... 129 b-complex w/ c-biotin-minerals & folic acid tab 5 mg (Diatx zn).......................................................................129 BD 3ML LL SYR/PREFILL LIT - arterial blood gas kit .....168 BD PUDENDAL/LOCAL BLOCK -lidocaine hcl local inj kit 1%.................................................................................. 117 BELLADONNA & OPIUM -belladonna alkaloids & opium suppos 16.2-30 mg.......................................................... 71 BELLADONNA ALKALOIDS & OP -belladonna alkaloids & opium suppos 16.2-60 mg............................................... 72 benazepril & hydrochlorothiazide tab 10-12.5 mg (Lotensin hct)................................................................. 50 benazepril & hydrochlorothiazide tab 20-12.5 mg (Lotensin hct)................................................................. 50 benazepril & hydrochlorothiazide tab 20-25 mg (Lotensin hct)................................................................. 50 benazepril & hydrochlorothiazide tab 5-6.25 mg.......... 51 benazepril hcl tab 10 mg (Lotensin).............................. 51 benazepril hcl tab 20 mg (Lotensin).............................. 51 benazepril hcl tab 40 mg (Lotensin).............................. 51 benazepril hcl tab 5 mg.................................................. 51 BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 20-12.5 mg................................ 51 BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 40-12.5 mg................................ 51 BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 40-25 mg................................... 51 BENICAR -olmesartan medoxomil tab 20 mg................... 51 BENICAR -olmesartan medoxomil tab 40 mg................... 51 BENICAR -olmesartan medoxomil tab 5 mg..................... 51 BENSAL HP -salicylic acid & benzoic acid oint 3-6%...... 150 BENTYL -dicyclomine hcl cap 10 mg................................ 72 BENTYL -dicyclomine hcl inj 10 mg/ml............................. 72 BENTYL -dicyclomine hcl oral soln 10 mg/5ml..................72 BENTYL -dicyclomine hcl tab 20 mg.................................72 BENZAC AC WASH -benzoyl peroxide liq 5%................ 150 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 BETALIDO -betamethasone sod phos & ace inj 6 mg/ml & lido inj 1% kit................................................................... 22 betamethasone dipropionate augmented cream 0.05% (Diprolene af)................................................................151 betamethasone dipropionate augmented gel 0.05%............................................................................. 151 betamethasone dipropionate augmented lotion 0.05% (Diprolene).................................................................... 151 betamethasone dipropionate augmented oint 0.05% (Diprolene).................................................................... 151 betamethasone dipropionate cream 0.05%................. 151 betamethasone dipropionate lotion 0.05%..................151 betamethasone dipropionate oint 0.05%..................... 151 betamethasone sod phosphate & acetate inj susp 6 (3-3) mg/ml (Celestone-soluspan)................................ 22 betamethasone valerate aerosol foam 0.12% (Luxiq)........................................................................... 151 betamethasone valerate cream 0.1%........................... 151 betamethasone valerate lotion 0.1%............................151 betamethasone valerate oint 0.1%............................... 151 BETAPACE AF -sotalol hcl (afib/afl) tab 120 mg...............44 BETAPACE AF -sotalol hcl (afib/afl) tab 160 mg...............44 BETAPACE AF -sotalol hcl (afib/afl) tab 80 mg.................44 BETAPACE -sotalol hcl tab 120 mg.................................. 44 BETAPACE -sotalol hcl tab 160 mg.................................. 44 BETAPACE -sotalol hcl tab 80 mg....................................44 BETASERON -interferon beta-1b for inj kit 0.3 mg............97 betaxolol hcl ophth soln 0.5%......................................141 betaxolol hcl tab 10 mg (Kerlone)..................................44 betaxolol hcl tab 20 mg (Kerlone)..................................44 bethanechol chloride tab 10 mg (Urecholine)............... 78 bethanechol chloride tab 25 mg (Urecholine)............... 78 bethanechol chloride tab 50 mg (Urecholine)............... 78 bethanechol chloride tab 5 mg (Urecholine).................78 BETHKIS -tobramycin nebu soln 300 mg/4ml..................... 6 BETIMOL -timolol ophth soln 0.25%............................... 141 BETIMOL -timolol ophth soln 0.5%................................. 141 BETOPTIC-S -betaxolol hcl ophth susp 0.25%............... 141 BEYAZ -drospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg...............................................................28 BIAFINE - wound dressings - emulsion ..........................151 BIAXIN -clarithromycin for susp 250 mg/5ml.......................4 BIAXIN -clarithromycin tab 250 mg..................................... 4 BIAXIN -clarithromycin tab 500 mg..................................... 4 BIAXIN XL -clarithromycin tab sr 24hr 500 mg....................4 BIAXIN XL PAC -clarithromycin tab sr 24hr 500 mg............4 bicalutamide tab 50 mg (Casodex)................................ 18 BICILLIN C-R -penicillin g benzathine & procaine inj 900000-300000 unt/2ml..................................................... 1 BICILLIN C-R -penicillin g benzathine & procaine inj susp 1200000 unit/2ml............................................................... 1 BICILLIN L-A -penicillin g benzathine intramuscular susp 1200000 unit/2ml............................................................... 1 BICILLIN L-A -penicillin g benzathine intramuscular susp 2400000 unit/4ml............................................................... 1 BENZACLIN -clindamycin phosphate-benzoyl peroxide gel 1-5%............................................................................... 150 BENZACLIN WITH PUMP -clindamycin phosphatebenzoyl peroxide gel 1-5%............................................ 150 BENZAC W WASH -benzoyl peroxide liq 5%..................150 BENZALKONIUM CHLORIDE -benzalkonium chloride soln.................................................................................166 BENZALKONIUM CHLORIDE -benzalkonium chloride soln 17%................................................................................ 166 BENZALKONIUM CHLORIDE -benzalkonium chloride soln 50%................................................................................ 166 BENZAMYCIN -benzoyl peroxide-erythromycin gel 5-3%............................................................................... 150 BENZAMYCINPAK -benzoyl peroxide-erythromycin gel pack 5-3%...................................................................... 150 BENZEFOAM -benzoyl peroxide foam 5.3%...................150 BENZEFOAMULTRA -benzoyl peroxide foam 9.8%....... 150 BENZIQ -benzoyl peroxide gel 5.25 %............................150 BENZIQ LS -benzoyl peroxide gel 2.75%....................... 150 benzocaine dental soln 20%.........................................146 BENZOIN COMPOUND TINCTURE -benzoin compound tincture............................................................................150 BENZOIN TINCTURE -benzoin tincture.......................... 150 benzonatate cap 100 mg (Tessalon perles)...................64 benzonatate cap 200 mg.................................................64 benzoyl peroxide cleanser 4.25%................................ 150 benzoyl peroxide cloth 3%........................................... 150 benzoyl peroxide cloth 6%........................................... 150 benzoyl peroxide cloth 9%........................................... 150 benzoyl peroxide creamy wash 4% & cleanser lotion kit................................................................................... 151 benzoyl peroxide creamy wash 8% &benzoyl peroxide bar 5% kit (Bpo creamy wash comp)......................... 151 benzoyl peroxide creamy wash 8% & cleanser lotion kit................................................................................... 151 benzoyl peroxide-erythromycin gel 5-3% (Benzamycin)................................................................ 151 benzoyl peroxide foam 5.3% (Benzefoam).................. 151 benzoyl peroxide foam 9.8% (Benzefoamultra).......... 151 benzoyl peroxide gel 10%.............................................151 benzoyl peroxide gel 5%...............................................151 benzoyl peroxide liq 2.5%.............................................151 benzoyl peroxide liq 5.25%...........................................151 benzoyl peroxide liq 7%................................................151 benzoyl peroxide lotion 6%.......................................... 151 benztropine mesylate inj 1 mg/ml (Cogentin)............. 124 benztropine mesylate tab 0.5 mg................................. 124 benztropine mesylate tab 1 mg....................................124 benztropine mesylate tab 2 mg....................................124 BEPREVE -bepotastine besilate ophth soln 1.5%........... 141 BESIVANCE -besifloxacin hcl ophth susp 0.6% (base equiv)..............................................................................141 BETADINE OPHTHALMIC PREP -povidone-iodine ophth soln 5%.......................................................................... 141 BETAGAN -levobunolol hcl ophth soln 0.5%...................141 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 183 2015 BICILLIN L-A -penicillin g benzathine intramuscular susp 600000 unit/ml................................................................... 1 BIDIL -isosorbide dinitrate-hydralazine hcl tab 20-37.5 mg.................................................................................... 62 BIFERARX -polysacch fe cmplx-fe heme poly-fa-b12 tab 22-6-1-0.025 mg............................................................ 135 BILTRICIDE -praziquantel tab 600 mg.............................. 12 BINOSTO -alendronate sodium effervescent tab 70 mg.................................................................................... 39 BIOREGESIC -phenyltoloxamine-acetaminophen tab 50-650 mg......................................................................100 BIO-STATIN -nystatin cap 1000000 unit............................. 7 BIO-STATIN -nystatin cap 500000 unit............................... 7 bisoprolol & hydrochlorothiazide tab 10-6.25 mg (Ziac)................................................................................51 bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg (Ziac)................................................................................51 bisoprolol & hydrochlorothiazide tab 5-6.25 mg (Ziac)................................................................................51 bisoprolol fumarate tab 10 mg (Zebeta)........................ 44 bisoprolol fumarate tab 5 mg (Zebeta).......................... 44 bleomycin sulfate for inj 15 unit.................................... 18 bleomycin sulfate for inj 30 unit.................................... 18 BLEPH-10 -sulfacetamide sodium ophth soln 10%......... 141 BLEPHAMIDE S.O.P. -sulfacetamide sodium-prednisolone ophth oint 10-0.2%.........................................................141 BLEPHAMIDE -sulfacetamide sodium-prednisolone ophth susp 10-0.2%................................................................. 141 BLOOD GLUCOSE CALIBRATION LIQUID – VARIOUS....................................................................... 169 BONIVA -ibandronate sodium tab 150 mg (base equivalent)........................................................................39 BOOSTRIX -tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lflf-mcg/0.5ml......................................................................16 BORIC ACID -boric acid granules................................... 151 BOSULIF -bosutinib tab 100 mg....................................... 18 BOSULIF -bosutinib tab 500 mg....................................... 18 BOTOX -onabotulinumtoxina for inj 100 unit................... 126 BOTOX -onabotulinumtoxina for inj 200 unit................... 126 BPO 3% FOAMING CLOTHS -benzoyl peroxide cloth 3%.................................................................................. 151 BPO 6% FOAMING CLOTHS -benzoyl peroxide cloth 6%.................................................................................. 151 BPO 9% FOAMING CLOTHS -benzoyl peroxide cloth 9%.................................................................................. 151 BPO -benzoyl peroxide gel 4%....................................... 151 BPO -benzoyl peroxide gel 8%....................................... 151 BPO CREAMY WASH COMPLETE -benzoyl peroxide creamy wash 8% &benzoyl peroxide bar 5% kit............ 151 BP VIT 3 - folic acid-vit b6-vit b12-omega 3-phytosterols cap 1 mg ...................................................................... 135 BREO ELLIPTA -fluticasone furoate-vilanterol aero powd ba 100-25 mcg/inh........................................................... 68 BREVICON-28 -norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg....................................................................... 28 184 BRILINTA -ticagrelor tab 90 mg...................................... 140 brimonidine tartrate ophth soln 0.15% (Alphagan p).................................................................................... 141 brimonidine tartrate ophth soln 0.2%.......................... 141 BRINTELLIX -vortioxetine hbr tab 10 mg (base equiv)...... 83 BRINTELLIX -vortioxetine hbr tab 20 mg (base equiv)...... 83 BRINTELLIX -vortioxetine hbr tab 5 mg (base equiv)........83 BRISDELLE -paroxetine mesylate cap 7.5 mg (base equiv)................................................................................97 BROMDAY -bromfenac sodium ophth soln 0.09% (base equiv) (once-daily)......................................................... 141 bromfenac sodium ophth soln 0.09% (base equiv) (once-daily)................................................................... 142 bromfenac sodium ophth soln 0.09% (base equivalent).................................................................... 142 bromocriptine mesylate cap 5 mg (Parlodel).............. 124 bromocriptine mesylate tab 2.5 mg............................. 124 brompheniramine & pseudoephedrine tab sr 12hr 6-45 mg.................................................................................... 64 brompheniramine maleate tab sr 12hr 6 mg................. 63 BROMPHENIRAMINE TANNATE -brompheniramine tannate chew tab 12 mg.................................................. 63 BRONCOMAR-1 -theophylline-pse-gg elixir 150-30-150 mg/15ml............................................................................68 BRONCOPECTOL -phenyleph-chlorphen w/ dm-gg syrup 5-2-5-75 mg/5ml...............................................................64 BRONDIL -dyphylline-guaifenesin liqd 100-100 mg/15ml............................................................................68 BROVANA -arformoterol tartrate soln nebu 15 mcg/2ml (base equiv)..................................................................... 68 BSS PLUS - ophthalmic irrigation solution - intraocular ....................................................................................... 142 BUCALSEP - antiseptic products misc - liquid ............... 166 BUCALSEP - antiseptic products misc - solution ........... 166 budesonide cap sr 24hr 3 mg (Entocort ec)..................22 budesonide inhalation susp 0.25 mg/2ml (Pulmicort)...................................................................... 68 budesonide inhalation susp 0.5 mg/2ml (Pulmicort)...................................................................... 68 budesonide nasal susp 32 mcg/act (Rhinocort aqua)................................................................................64 BUFFERIN -aspirin buffered (ca carb-mg carb-mg ox) tab 325 mg........................................................................... 100 BUFFERIN LOW DOSE -aspirin buffered (ca carb-mg carb-mg ox) tab 81 mg.................................................. 100 bumetanide inj 0.25 mg/ml............................................. 57 bumetanide tab 0.5 mg................................................... 57 bumetanide tab 1 mg...................................................... 57 bumetanide tab 2 mg...................................................... 57 BUNAVAIL -buprenorphine-naloxone buccal film 2.1-0.3 mg (base equiv)............................................................. 102 BUNAVAIL -buprenorphine-naloxone buccal film 4.2-0.7 mg (base equiv)............................................................. 102 BUNAVAIL -buprenorphine-naloxone buccal film 6.3-1 mg (base equiv)................................................................... 102 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 butalbital-acetaminophen-caffeine cap 50-500-40 mg.................................................................................. 100 butalbital-acetaminophen-caffeine tab 50-325-40 mg (Esgic)........................................................................... 100 butalbital-acetaminophen-caffeine tab 50-500-40 mg.................................................................................. 100 butalbital-acetaminophen-caff w/ cod cap 50-300-40-30 mg (Fioricet/codeine)...................................................102 butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg.................................................................................. 102 butalbital-acetaminophen tab 50-325 mg.................... 100 butalbital-acetaminophen tab 50-650 mg.................... 100 butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal)........................................................................ 101 butalbital-aspirin-caffeine tab 50-325-40 mg............... 101 butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg (Fiorinal/codeine #3).................................................... 102 BUTISOL SODIUM -butabarbital sodium elixir 30 mg/5ml..............................................................................92 BUTISOL SODIUM -butabarbital sodium tab 30 mg..........92 BUTISOL SODIUM -butabarbital sodium tab 50 mg..........92 butorphanol tartrate inj 1 mg/ml.................................. 102 butorphanol tartrate inj 2 mg/ml.................................. 102 butorphanol tartrate nasal soln 10 mg/ml................... 103 BUTRANS -buprenorphine td patch weekly 10 mcg/ hr.................................................................................... 103 BUTRANS -buprenorphine td patch weekly 15 mcg/ hr.................................................................................... 103 BUTRANS -buprenorphine td patch weekly 20 mcg/ hr.................................................................................... 103 BUTRANS -buprenorphine td patch weekly 5 mcg/hr......103 BUTRANS -buprenorphine td patch weekly 7.5 mcg/ hr.................................................................................... 103 BYDUREON -exenatide extended release for inj susp 2 mg.................................................................................... 32 BYDUREON -exenatide extended release for susp peninjector 2 mg.................................................................... 32 BYETTA -exenatide soln pen-injector 10 mcg/0.04ml....... 32 BYETTA -exenatide soln pen-injector 5 mcg/0.02ml......... 32 BYSTOLIC -nebivolol hcl tab 10 mg (base equivalent)......44 BYSTOLIC -nebivolol hcl tab 2.5 mg (base equivalent).....44 BYSTOLIC -nebivolol hcl tab 20 mg (base equivalent)......44 BYSTOLIC -nebivolol hcl tab 5 mg (base equivalent)........44 BUPAP -butalbital-acetaminophen tab 50-300 mg.......... 100 BUPAP -butalbital-acetaminophen tab 50-650 mg.......... 100 BUPHENYL -sodium phenylbutyrate oral powder 3 gm/ teaspoonful.......................................................................39 BUPHENYL -sodium phenylbutyrate tab 500 mg.............. 39 bupivacaine 0.75% in dextrose inj 8.25% (Marcaine spinal)............................................................................117 bupivacaine hcl inj 0.25% (Marcaine).......................... 117 bupivacaine hcl inj 0.5% (Marcaine)............................ 117 bupivacaine hcl preservative free (pf) inj 0.25% (Marcaine)..................................................................... 117 bupivacaine hcl preservative free (pf) inj 0.5% (Marcaine)..................................................................... 117 bupivacaine hcl preservative free (pf) inj 0.75% (Marcaine w/o epi)........................................................117 bupivacaine inj 0.25% w/ epinephrine (Marcaine/ epinephrine)..................................................................117 bupivacaine inj 0.25% w/ epinephrine preservative free (pf) (Marcaine/epinephrine)......................................... 117 bupivacaine inj 0.5% w/ epinephrine (Marcaine/ epinephrine)..................................................................117 bupivacaine inj 0.5% w/ epinephrine preservative free (pf) (Marcaine/epinephrine)......................................... 117 BUPIVILOG KIT -triamcinolone inj 40 mg/ml & bupivacaine hcl inj 0.5% kit................................................................. 22 BUPRENEX -buprenorphine hcl inj 0.3 mg/ml (base equiv)..............................................................................102 buprenorphine hcl inj 0.3 mg/ml (base equiv) (Buprenex).................................................................... 102 buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv).............................................................................102 buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv).............................................................................102 buprenorphine hcl sl tab 2 mg (base equiv)............... 102 buprenorphine hcl sl tab 8 mg (base equiv)............... 102 bupropion hcl (smoking deterrent) tab sr 12hr 150 mg (Zyban)............................................................................ 97 bupropion hcl tab 100 mg (Wellbutrin)..........................83 bupropion hcl tab 75 mg (Wellbutrin)............................83 bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr).........83 bupropion hcl tab sr 12hr 150 mg (Wellbutrin sr).........83 bupropion hcl tab sr 12hr 200 mg (Wellbutrin sr).........83 bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl)......... 83 bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl)......... 83 buspirone hcl tab 10 mg.................................................81 buspirone hcl tab 15 mg.................................................81 buspirone hcl tab 30 mg.................................................81 buspirone hcl tab 5 mg...................................................81 buspirone hcl tab 7.5 mg................................................81 BUTALBITAL/ASPIRIN/CAFFEI -butalbital-aspirin-caffeine tab 50-325-40 mg.......................................................... 101 butalbital-acetaminophen-caffeine cap 50-300-40 mg (Fioricet)........................................................................ 100 butalbital-acetaminophen-caffeine cap 50-325-40 mg.................................................................................. 100 C cabergoline tab 0.5 mg................................................... 39 CADUET -amlodipine besylate-atorvastatin calcium tab 10-10 mg..........................................................................62 CADUET -amlodipine besylate-atorvastatin calcium tab 10-20 mg..........................................................................62 CADUET -amlodipine besylate-atorvastatin calcium tab 10-40 mg..........................................................................62 CADUET -amlodipine besylate-atorvastatin calcium tab 10-80 mg..........................................................................62 CADUET -amlodipine besylate-atorvastatin calcium tab 2.5-10 mg.........................................................................62 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 185 2015 CADUET -amlodipine besylate-atorvastatin calcium tab 2.5-20 mg.........................................................................62 CADUET -amlodipine besylate-atorvastatin calcium tab 2.5-40 mg.........................................................................62 CADUET -amlodipine besylate-atorvastatin calcium tab 5-10 mg............................................................................62 CADUET -amlodipine besylate-atorvastatin calcium tab 5-20 mg............................................................................62 CADUET -amlodipine besylate-atorvastatin calcium tab 5-40 mg............................................................................62 CADUET -amlodipine besylate-atorvastatin calcium tab 5-80 mg............................................................................62 CAFCIT -caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv)...................................................................... 93 CAFERGOT -ergotamine w/ caffeine tab 1-100 mg........ 115 CAFFEINE/SODIUM BENZOATE -caffeine & sodium benzoate inj 125-125 mg/ml (500 mg/2ml)...................... 94 caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv) (Cafcit)................................................................. 94 CALAN SR -verapamil hcl tab cr 120 mg.......................... 46 CALAN SR -verapamil hcl tab cr 180 mg.......................... 46 CALAN SR -verapamil hcl tab cr 240 mg.......................... 46 CALAN -verapamil hcl tab 120 mg....................................46 CALAN -verapamil hcl tab 80 mg......................................46 CALCIFOL -ca carb-folic acid-vit d-b6-b12-boron-mag wafer 1342-1.6 mg.........................................................132 calcipotriene-betamethasone dipropionate oint 0.005-0.064% (Taclonex)..............................................151 calcipotriene cream 0.005% (Dovonex)....................... 151 calcipotriene oint 0.005%..............................................151 calcipotriene soln 0.005% (50 mcg/ml)........................ 151 calcitonin (salmon) nasal soln 200 unit/act (Miacalcin).......................................................................39 CALCITRIOL -calcitriol oint 3 mcg/gm.............................151 calcitriol cap 0.25 mcg (Rocaltrol)................................. 39 calcitriol cap 0.5 mcg (Rocaltrol)................................... 39 calcitriol oral soln 1 mcg/ml (Rocaltrol)........................ 39 calcium acetate (phosphate binder) cap 667 mg (169 mg ca) (Phoslo)..............................................................76 calcium acetate (phosphate binder) tab 667 mg (Eliphos).......................................................................... 76 CALCIUM DISODIUM VERSENAT -edetate calcium disodium inj 1 gm/5ml (200 mg/ml)................................167 CALCIUM DISODIUM VERSENAT -edetate calcium disodium inj 500 mg/2.5ml (200 mg/ml).........................167 CALCIUM-FOLIC ACID PLUS D -ca carb-folic acid-vit db6-b12-boron-mag wafer 1342-1 mg............................. 132 CALCIUM FOLINATE -leucovorin calcium inj 100 mg/10ml (10 mg/ml)........................................................................18 CALCIUM FOLINATE -leucovorin calcium inj 300 mg/30ml (10 mg/ml)........................................................................18 CAMBIA -diclofenac potassium packet 50 mg.................115 CAMINO PRO 15PE - nutritional supplement liquid ....... 133 CAMPRAL -acamprosate calcium tab delayed release 333 mg.................................................................................... 97 186 CANASA -mesalamine suppos 1000 mg...........................76 candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg (Atacand hct)........................................................... 51 candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg (Atacand hct)........................................................... 51 candesartan cilexetil-hydrochlorothiazide tab 32-25 mg (Atacand hct)........................................................... 51 candesartan cilexetil tab 16 mg (Atacand).................... 51 candesartan cilexetil tab 32 mg (Atacand).................... 51 candesartan cilexetil tab 4 mg (Atacand)......................51 candesartan cilexetil tab 8 mg (Atacand)......................51 CANTIL -mepenzolate bromide tab 25 mg........................ 72 CAPASTAT SULFATE -capreomycin sulfate for inj 1 gm...................................................................................... 6 capecitabine tab 150 mg (Xeloda)..................................18 capecitabine tab 500 mg (Xeloda)..................................18 CAPEX -fluocinolone acetonide shampoo 0.01%............151 CAPHOSOL - artificial saliva - solution .......................... 146 CAPITAL/CODEINE -acetaminophen w/ codeine susp 120-12 mg/5ml............................................................... 103 CAPRELSA -vandetanib tab 100 mg................................ 18 CAPRELSA -vandetanib tab 300 mg................................ 18 CAPTOPRIL/HYDROCHLOROTHIA -captopril & hydrochlorothiazide tab 25-15 mg................................... 51 CAPTOPRIL/HYDROCHLOROTHIA -captopril & hydrochlorothiazide tab 25-25 mg................................... 51 CAPTOPRIL/HYDROCHLOROTHIA -captopril & hydrochlorothiazide tab 50-15 mg................................... 51 CAPTOPRIL/HYDROCHLOROTHIA -captopril & hydrochlorothiazide tab 50-25 mg................................... 51 captopril tab 100 mg....................................................... 51 captopril tab 12.5 mg...................................................... 51 captopril tab 25 mg......................................................... 51 captopril tab 50 mg......................................................... 51 CARAC -fluorouracil cream 0.5%.................................... 151 CARAFATE -sucralfate susp 1 gm/10ml........................... 72 CARAFATE -sucralfate tab 1 gm...................................... 72 CARBAGLU -carglumic acid tab 200 mg...........................39 carbamazepine cap sr 12hr 100 mg (Carbatrol).......... 119 carbamazepine cap sr 12hr 200 mg (Carbatrol).......... 119 carbamazepine cap sr 12hr 300 mg (Carbatrol).......... 119 carbamazepine chew tab 100 mg.................................119 carbamazepine susp 100 mg/5ml (Tegretol)............... 119 carbamazepine tab 200 mg (Tegretol)......................... 119 carbamazepine tab sr 12hr 200 mg (Tegretol-xr)........ 119 carbamazepine tab sr 12hr 400 mg (Tegretol-xr)........ 119 CARBAPHEN 12 PED -phenyleph-chlorphencarbetapentane susp 2.5-1.25-7.5 mg/ml........................ 64 CARBAPHEN 12 -phenyleph-chlorphen-carbetapentane liqd 10-4-27.5 mg/5ml...................................................... 64 CARBATROL -carbamazepine cap sr 12hr 100 mg........ 119 CARBATROL -carbamazepine cap sr 12hr 200 mg........ 119 CARBATROL -carbamazepine cap sr 12hr 300 mg........ 119 CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 12.5-50-200 mg.................................. 124 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 CARDIZEM LA -diltiazem hcl coated beads tab sr 24hr 120 mg............................................................................. 46 CARDIZEM LA -diltiazem hcl coated beads tab sr 24hr 180 mg............................................................................. 46 CARDIZEM LA -diltiazem hcl coated beads tab sr 24hr 240 mg............................................................................. 46 CARDIZEM LA -diltiazem hcl coated beads tab sr 24hr 300 mg............................................................................. 46 CARDIZEM LA -diltiazem hcl coated beads tab sr 24hr 360 mg............................................................................. 46 CARDIZEM LA -diltiazem hcl coated beads tab sr 24hr 420 mg............................................................................. 46 CARDURA -doxazosin mesylate tab 1 mg........................ 51 CARDURA -doxazosin mesylate tab 2 mg........................ 51 CARDURA -doxazosin mesylate tab 4 mg........................ 51 CARDURA -doxazosin mesylate tab 8 mg........................ 51 CARDURA XL -doxazosin mesylate tab sr 24 hr 4 mg (base equiv)..................................................................... 80 CARDURA XL -doxazosin mesylate tab sr 24 hr 8 mg (base equiv)..................................................................... 80 CARISOPRODOL -carisoprodol tab 250 mg................... 127 carisoprodol tab 350 mg (Soma)..................................127 carisoprodol w/ aspirin & codeine tab 200-325-16 mg.................................................................................. 127 carisoprodol w/ aspirin tab 200-325 mg...................... 127 CARMOL-HC -urea-hc acetate cream 1%.......................151 CARNITOR -levocarnitine oral soln 1 gm/10ml (10%)....... 39 CARNITOR -levocarnitine tab 330 mg.............................. 39 CARNITOR SF -levocarnitine oral soln 1 gm/10ml (10%)................................................................................39 CARRASYN HYDROGEL WOUND D - wound dressings gel ................................................................................. 151 carteolol hcl ophth soln 1%......................................... 142 CARTICEL - autologous cultured chondrocytes for implantation ...................................................................127 carvedilol tab 12.5 mg (Coreg)....................................... 44 carvedilol tab 25 mg (Coreg).......................................... 44 carvedilol tab 3.125 mg (Coreg)..................................... 44 carvedilol tab 6.25 mg (Coreg)....................................... 44 CASCARA SAGRADA -cascara sagrada fl ext 1 gm/ ml......................................................................................70 CASODEX -bicalutamide tab 50 mg................................. 18 CATAFLAM -diclofenac potassium tab 50 mg.................111 CATAPRES -clonidine hcl tab 0.1 mg............................... 51 CATAPRES -clonidine hcl tab 0.2 mg............................... 51 CATAPRES -clonidine hcl tab 0.3 mg............................... 51 CATAPRES-TTS-1 -clonidine hcl td patch weekly 0.1 mg/24hr............................................................................ 51 CATAPRES-TTS-2 -clonidine hcl td patch weekly 0.2 mg/24hr............................................................................ 51 CATAPRES-TTS-3 -clonidine hcl td patch weekly 0.3 mg/24hr............................................................................ 51 CATHFLO ACTIVASE -alteplase for inj 2 mg..................140 CAYSTON -aztreonam lysine for inhal soln 75 mg (base equivalent)........................................................................12 CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 18.75-75-200 mg................................ 124 CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 25-100-200 mg...................................124 CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 31.25-125-200 mg.............................. 124 CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 37.5-150-200 mg................................ 124 CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 50-200-200 mg...................................124 carbidopa & levodopa orally disintegrating tab 10-100 mg.................................................................................. 124 carbidopa & levodopa orally disintegrating tab 25-100 mg.................................................................................. 124 carbidopa & levodopa orally disintegrating tab 25-250 mg.................................................................................. 124 carbidopa & levodopa tab 10-100 mg (Sinemet)......... 124 carbidopa & levodopa tab 25-100 mg (Sinemet)......... 124 carbidopa & levodopa tab 25-250 mg (Sinemet)......... 124 carbidopa & levodopa tab cr 25-100 mg (Sinemet cr)...................................................................................124 carbidopa & levodopa tab cr 50-200 mg (Sinemet cr)...................................................................................124 carbidopa tab 25 mg (Lodosyn)................................... 124 carbinoxamine maleate soln 4 mg/5ml..........................63 carbinoxamine maleate tab 4 mg...................................63 CARBOCAINE -mepivacaine hcl inj 1.5%....................... 117 CARBOCAINE -mepivacaine hcl inj 1%.......................... 117 CARBOCAINE -mepivacaine hcl inj 2%.......................... 117 CARBOCAINE -mepivacaine hcl preservative free (pf) inj 1%.................................................................................. 117 CARBOCAINE -mepivacaine hcl preservative free (pf) inj 2%.................................................................................. 117 carbonyl iron chew tab 15 mg (elemental iron)...........135 carbonyl iron susp 15 mg/1.25ml (elemental iron)......135 CARDENE SR -nicardipine hcl cap sr 12hr 30 mg............ 46 CARDENE SR -nicardipine hcl cap sr 12hr 60 mg............ 46 CARDIOTEK-RX - folic acid-b12-b6-arginine-black pepper tab ................................................................................. 133 CARDIOVID PLUS -dha-epa-vit b6-b12-folic acid cap 240-360-20-0.5-0.8 mg.................................................. 133 CARDIZEM CD -diltiazem hcl coated beads cap sr 24hr 120 mg............................................................................. 46 CARDIZEM CD -diltiazem hcl coated beads cap sr 24hr 180 mg............................................................................. 46 CARDIZEM CD -diltiazem hcl coated beads cap sr 24hr 240 mg............................................................................. 46 CARDIZEM CD -diltiazem hcl coated beads cap sr 24hr 300 mg............................................................................. 46 CARDIZEM CD -diltiazem hcl coated beads cap sr 24hr 360 mg............................................................................. 46 CARDIZEM -diltiazem hcl tab 120 mg...............................46 CARDIZEM -diltiazem hcl tab 30 mg.................................46 CARDIZEM -diltiazem hcl tab 60 mg.................................46 CARDIZEM -diltiazem hcl tab 90 mg.................................46 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 187 2015 CEDAX -ceftibuten cap 400 mg.......................................... 2 CEDAX -ceftibuten for susp 180 mg/5ml.............................2 CEDAX -ceftibuten for susp 90 mg/5ml...............................2 CEENU -lomustine cap 100 mg........................................ 18 CEENU -lomustine cap 10 mg.......................................... 18 CEENU -lomustine cap 40 mg.......................................... 18 cefaclor cap 250 mg..........................................................2 cefaclor cap 500 mg..........................................................2 CEFACLOR -cefaclor for susp 125 mg/5ml.........................2 CEFACLOR -cefaclor for susp 250 mg/5ml.........................2 CEFACLOR -cefaclor for susp 375 mg/5ml.........................2 CEFACLOR ER -cefaclor monohydrate tab sr 12hr 500 mg...................................................................................... 2 cefadroxil cap 500 mg.......................................................2 cefadroxil for susp 250 mg/5ml........................................2 cefadroxil for susp 500 mg/5ml........................................2 cefadroxil tab 1 gm........................................................... 2 CEFAZOLIN SODIUM -cefazolin sodium (bulk) for inj 100 gm...................................................................................... 2 CEFAZOLIN SODIUM -cefazolin sodium (bulk) for inj 300 gm...................................................................................... 2 cefazolin sodium for inj 10 gm.........................................2 cefazolin sodium for inj 1 gm.......................................... 2 cefazolin sodium for inj 20 gm.........................................2 cefazolin sodium for inj 500 mg.......................................2 cefdinir cap 300 mg...........................................................2 cefdinir for susp 125 mg/5ml........................................... 2 cefdinir for susp 250 mg/5ml........................................... 2 CEFDITOREN PIVOXIL -cefditoren pivoxil tab 200 mg (base equivalent)............................................................... 2 CEFDITOREN PIVOXIL -cefditoren pivoxil tab 400 mg (base equivalent)............................................................... 2 cefepime hcl for inj 1 gm (Maxipime).............................. 2 cefepime hcl for inj 2 gm (Maxipime).............................. 2 cefotaxime sodium for inj 10 gm (Claforan)....................2 cefotaxime sodium for inj 1 gm (Claforan)......................2 cefotaxime sodium for inj 2 gm (Claforan)......................2 cefotaxime sodium for inj 500 mg (Claforan)..................2 CEFOTETAN -cefotetan disodium for inj 10 gm..................2 CEFOTETAN -cefotetan disodium for inj 1 gm....................2 CEFOTETAN -cefotetan disodium for inj 2 gm....................2 cefoxitin sodium for inj 10 gm......................................... 2 cefpodoxime proxetil for susp 100 mg/5ml.....................2 cefpodoxime proxetil for susp 50 mg/5ml.......................2 cefpodoxime proxetil tab 100 mg.................................... 2 cefpodoxime proxetil tab 200 mg.................................... 3 cefprozil for susp 125 mg/5ml..........................................3 cefprozil for susp 250 mg/5ml..........................................3 cefprozil tab 250 mg..........................................................3 cefprozil tab 500 mg..........................................................3 CEFTIBUTEN -ceftibuten cap 400 mg................................ 3 CEFTIBUTEN -ceftibuten for susp 180 mg/5ml...................3 CEFTIN -cefuroxime axetil for susp 125 mg/5ml................. 3 CEFTIN -cefuroxime axetil for susp 250 mg/5ml................. 3 CEFTIN -cefuroxime axetil tab 250 mg............................... 3 188 CEFTIN -cefuroxime axetil tab 500 mg............................... 3 ceftriaxone sodium for inj 1 gm (Rocephin)................... 3 ceftriaxone sodium for inj 250 mg................................... 3 ceftriaxone sodium for inj 2 gm.......................................3 ceftriaxone sodium for inj 500 mg (Rocephin)................3 cefuroxime axetil for susp 125 mg/5ml (Ceftin).............. 3 cefuroxime axetil tab 250 mg (Ceftin)..............................3 cefuroxime axetil tab 500 mg (Ceftin)..............................3 CEFUROXIME SODIUM -cefuroxime sodium (bulk) for inj 225 gm............................................................................... 3 CEFUROXIME SODIUM -cefuroxime sodium (bulk) for inj 75 gm................................................................................. 3 cefuroxime sodium for inj 1.5 gm (Zinacef).................... 3 cefuroxime sodium for inj 7.5 gm (Zinacef).................... 3 cefuroxime sodium for inj 750 mg (Zinacef)................... 3 CELEBREX -celecoxib cap 100 mg................................ 111 CELEBREX -celecoxib cap 200 mg................................ 111 CELEBREX -celecoxib cap 400 mg................................ 111 CELEBREX -celecoxib cap 50 mg.................................. 111 CELESTONE -betamethasone soln 0.6 mg/5ml................22 CELESTONE-SOLUSPAN -betamethasone sod phosphate & acetate inj susp 6 (3-3) mg/ml.................... 22 CELEXA -citalopram hydrobromide tab 10 mg (base equiv)................................................................................83 CELEXA -citalopram hydrobromide tab 20 mg (base equiv)................................................................................83 CELEXA -citalopram hydrobromide tab 40 mg (base equiv)................................................................................83 CELLCEPT -mycophenolate mofetil cap 250 mg............ 170 CELLCEPT -mycophenolate mofetil for oral susp 200 mg/ ml....................................................................................170 CELLCEPT -mycophenolate mofetil tab 500 mg............. 170 CELONTIN -methsuximide cap 300 mg.......................... 119 CEM-UREA -urea soln 45%............................................ 151 CENESTIN -estrogens, conjugated synthetic a tab 0.3 mg.................................................................................... 26 CENESTIN -estrogens, conjugated synthetic a tab 0.45 mg.................................................................................... 26 CENESTIN -estrogens, conjugated synthetic a tab 0.625 mg.................................................................................... 26 CENESTIN -estrogens, conjugated synthetic a tab 0.9 mg.................................................................................... 26 CENESTIN -estrogens, conjugated synthetic a tab 1.25 mg.................................................................................... 26 CENFOL -folic acid-vitamin b6-vitamin b12 tab 2.3-24.5-2 mg.................................................................................. 135 CENTANY AT -mupirocin oint kit 2%.............................. 151 CENTANY -mupirocin oint 2%.........................................151 CENTRATEX - ferrous fumarate-fa-b complex-c-zn-mgmn-cu cap 106-1 mg .................................................... 135 cephalexin cap 250 mg (Keflex)....................................... 3 cephalexin cap 500 mg (Keflex)....................................... 3 cephalexin cap 750 mg (Keflex)....................................... 3 CEPHALEXIN -cephalexin tab 250 mg............................... 3 CEPHALEXIN -cephalexin tab 500 mg............................... 3 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 CHLORTHALIDONE -chlorthalidone tab 100 mg.............. 57 CHLORTHALIDONE -chlorthalidone tab 25 mg................ 57 CHLORTHALIDONE -chlorthalidone tab 50 mg................ 57 chlorzoxazone tab 500 mg (Parafon forte dsc)........... 127 cholecalciferol chew tab 400 unit................................ 128 cholecalciferol drops 400 unit/0.03ml (per drop)........ 128 cholecalciferol oral liquid 400 unit/ml......................... 128 cholecalciferol tab 400 unit.......................................... 128 cholestyramine light powder 4 gm/dose (Questran light).................................................................................59 cholestyramine light powder packets 4 gm.................. 59 cholestyramine powder 4 gm/dose (Questran).............59 cholestyramine powder packets 4 gm (Questran)........59 choline & magnesium salicylates liq 500 mg/5ml....... 101 choline & magnesium salicylates tab 1000 mg...........101 choline fenofibrate cap dr 135 mg (fenofibric acid equiv) (Trilipix)............................................................... 59 choline fenofibrate cap dr 45 mg (fenofibric acid equiv) (Trilipix)........................................................................... 59 chorionic gonadotropin for inj 10000 unit.....................39 CIALIS -tadalafil tab 2.5 mg.............................................. 62 CIALIS -tadalafil tab 2.5 mg.............................................. 63 CIALIS -tadalafil tab 5 mg................................................. 62 CIALIS -tadalafil tab 5 mg................................................. 63 CICLODAN CREAM KIT -ciclopirox olamine cream 0.77% (base equiv) & cleanser kit............................................ 151 CICLODAN SOLUTION KIT -ciclopirox solution kit 8%.................................................................................. 151 ciclopirox gel 0.77%...................................................... 152 ciclopirox olamine cream 0.77% (base equiv).............152 ciclopirox olamine susp 0.77% (base equiv)...............152 ciclopirox shampoo 1% (Loprox shampoo)................ 152 ciclopirox solution 8% (Penlac Nail Lacquer)............. 152 ciclopirox solution kit 8% (Ciclodan solution ki)........ 152 CICLOPIROX TOPICAL SOLUTI -ciclopirox solution 8% & vitamin e 5% topical kit..................................................152 CIFEREX -folic acid-cholecalciferol cap 1 mg-3775 unit..................................................................................135 cilostazol tab 100 mg (Pletal)....................................... 140 cilostazol tab 50 mg (Pletal)......................................... 140 CILOXAN -ciprofloxacin hcl ophth oint 0.3%................... 142 CILOXAN -ciprofloxacin hcl ophth soln 0.3%.................. 142 cimetidine hcl soln 300 mg/5ml..................................... 72 cimetidine tab 200 mg.....................................................72 cimetidine tab 300 mg.....................................................72 cimetidine tab 400 mg.....................................................72 cimetidine tab 800 mg.....................................................72 CIMZIA -certolizumab pegol for inj kit 2 x 200 mg............. 76 CIMZIA -certolizumab pegol inj kit 2 x 200 mg/ml............. 76 CIMZIA STARTER KIT -certolizumab pegol inj kit 6 x 200 mg/ml................................................................................76 CIPRO -ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml).......................................................................... 5 CIPRO -ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml).......................................................................... 5 cephalexin for susp 125 mg/5ml...................................... 3 cephalexin for susp 250 mg/5ml...................................... 3 CERDELGA -eliglustat tartrate cap 84 mg (base equivalent)......................................................................135 CEREBYX -fosphenytoin sodium inj 100 mg/2ml (phenytoin equiv)........................................................... 119 CEREBYX -fosphenytoin sodium inj 500 mg/10ml (phenytoin equiv)........................................................... 119 CERVARIX -human papillomavirus (hpv) bival (type 16, 18) recmb vac inj............................................................. 14 CERVIDIL -dinoprostone vaginal inserts 10 mg................ 38 CESAMET -nabilone cap 1 mg......................................... 74 CETACAINE -butamben-tetracaine-benzocaine aerosol spray 2-2-14%................................................................151 CETRAXAL -ciprofloxacin hcl otic soln 0.2% (base equivalent)......................................................................146 cevimeline hcl cap 30 mg (Evoxac)............................. 146 CHANTIX CONTINUING MONTH -varenicline tartrate tab 1 mg (base equiv)............................................................97 CHANTIX STARTING MONTH PA -varenicline tartrate tab 0.5 mg x 11 & tab 1 mg x 42 pack.................................. 97 CHANTIX -varenicline tartrate tab 0.5 mg (base equiv).....97 CHANTIX -varenicline tartrate tab 1 mg (base equiv)........97 CHELIDONIUM COMPOUND - misc natural products liqd ....................................................................................... 170 CHEMET -succimer cap 100 mg.....................................167 CHENODAL -chenodiol tab 250 mg.................................. 76 CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxideamitriptyline tab 10-25 mg............................................... 97 CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxideamitriptyline tab 5-12.5 mg.............................................. 97 chlordiazepoxide hcl cap 10 mg.................................... 81 chlordiazepoxide hcl cap 25 mg.................................... 81 chlordiazepoxide hcl cap 5 mg...................................... 81 CHLORHEXIDINE DIGLUCONATE -chlorhexidine gluconate soln 20%....................................................... 166 CHLORHEXIDINE GLUCONATE -chlorhexidine gluconate soln 20%........................................................................ 166 chlorhexidine gluconate soln 0.12% (Peridex)............146 chloroprocaine hcl inj 2% (Nesacaine-mpf)................ 117 chloroprocaine hcl inj 3% (Nesacaine-mpf)................ 117 chloroquine phosphate tab 250 mg............................... 12 chloroquine phosphate tab 500 mg (Aralen).................12 CHLOROTHIAZIDE -chlorothiazide tab 250 mg................57 chlorothiazide tab 250 mg.............................................. 57 chlorothiazide tab 500 mg.............................................. 57 CHLORPROMAZINE HCL -chlorpromazine hcl inj 25 mg/ ml......................................................................................88 chlorpromazine hcl tab 100 mg......................................88 chlorpromazine hcl tab 10 mg........................................88 chlorpromazine hcl tab 200 mg......................................88 chlorpromazine hcl tab 25 mg........................................88 chlorpromazine hcl tab 50 mg........................................88 CHLORPROPAMIDE -chlorpropamide tab 100 mg...........32 CHLORPROPAMIDE -chlorpropamide tab 250 mg...........32 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 189 2015 CIPRO -ciprofloxacin hcl tab 250 mg (base equiv)..............5 CIPRO -ciprofloxacin hcl tab 500 mg (base equiv)..............5 CIPRODEX -ciprofloxacin-dexamethasone otic susp 0.3-0.1%......................................................................... 146 CIPROFLOXACIN -ciprofloxacin hcl otic soln 0.2% (base equivalent)......................................................................146 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq) (Cipro xr).................................................... 5 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq) (Cipro xr)......................................................... 5 ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) (Cipro)............................................................ 5 ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) (Cipro)............................................................ 5 ciprofloxacin hcl ophth soln 0.3% (Ciloxan)............... 142 ciprofloxacin hcl tab 100 mg (base equiv)...................... 5 ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)..........5 ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)..........5 ciprofloxacin hcl tab 750 mg (base equiv)...................... 5 CIPRO HC -ciprofloxacin-hydrocortisone otic susp 0.2-1%............................................................................ 146 CIPRO XR -ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq).......................................................................5 CIPRO XR -ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq)..................................................................... 5 citalopram hydrobromide oral soln 10 mg/5ml............. 83 citalopram hydrobromide tab 10 mg (base equiv) (Celexa)........................................................................... 83 citalopram hydrobromide tab 20 mg (base equiv) (Celexa)........................................................................... 83 citalopram hydrobromide tab 40 mg (base equiv) (Celexa)........................................................................... 83 CITANEST FORTE DENTAL -prilocaine 4% w/ epinephrine inj................................................................117 CITANEST PLAIN DENTAL -prilocaine hcl inj 4%...........117 CITROLITH -potassium & sodium citrates tab 50-950 mg.................................................................................... 80 CLAFORAN -cefotaxime sodium for inj 10 gm.................... 3 CLAFORAN -cefotaxime sodium for inj 1 gm...................... 3 CLAFORAN -cefotaxime sodium for inj 2 gm...................... 3 CLAFORAN -cefotaxime sodium for inj 500 mg.................. 3 CLARAVIS -isotretinoin cap 30 mg................................. 152 CLARIFOAM EF -sulfacetamide sodium w/ sulfur foam 10-5%............................................................................. 152 clarithromycin for susp 125 mg/5ml................................ 4 clarithromycin for susp 250 mg/5ml (Biaxin).................. 4 clarithromycin tab 250 mg (Biaxin)..................................4 clarithromycin tab 500 mg (Biaxin)..................................4 clarithromycin tab sr 24hr 500 mg (Biaxin xl pac).......... 4 CLEMASTINE FUMARATE -clemastine fumarate syrup 0.67 mg/5ml (0.5 mg/5ml base eq)..................................63 clemastine fumarate tab 2.68 mg...................................63 CLEOCIN -clindamycin hcl cap 150 mg............................ 12 CLEOCIN -clindamycin hcl cap 300 mg............................ 12 CLEOCIN -clindamycin hcl cap 75 mg.............................. 12 190 CLEOCIN -clindamycin phosphate vaginal cream 2%.......79 CLEOCIN -clindamycin phosphate vaginal suppos 100 mg.................................................................................... 79 CLEOCIN PEDIATRIC GRANULE -clindamycin palmitate hcl for soln 75 mg/5ml (base equiv)................................ 12 CLEOCIN PHOSPHATE -clindamycin phosphate inj 300 mg/2ml..............................................................................12 CLEOCIN PHOSPHATE -clindamycin phosphate inj 600 mg/4ml..............................................................................12 CLEOCIN PHOSPHATE -clindamycin phosphate inj 900 mg/6ml..............................................................................12 CLEOCIN PHOSPHATE -clindamycin phosphate inj 9 gm/60ml............................................................................12 CLEOCIN-T -clindamycin phosphate gel 1%...................152 CLEOCIN-T -clindamycin phosphate lotion 1%............... 152 CLEOCIN-T -clindamycin phosphate soln 1%................. 152 CLEOCIN-T -clindamycin phosphate swab 1%............... 152 clidinium & chlordiazepoxide cap 2.5-5 mg (Librax)............................................................................ 72 CLIMARA -estradiol td patch weekly 0.025 mg/24hr......... 26 CLIMARA -estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr)......................................................................... 26 CLIMARA -estradiol td patch weekly 0.05 mg/24hr........... 26 CLIMARA -estradiol td patch weekly 0.06 mg/24hr........... 26 CLIMARA -estradiol td patch weekly 0.075 mg/24hr......... 26 CLIMARA -estradiol td patch weekly 0.1 mg/24hr............. 27 CLIMARA PRO -estradiol-levonorgestrel td patch weekly 0.045-0.015 mg/day......................................................... 27 CLINDACIN ETZ -clindamycin phosphate swab 1% & cleanser kit.....................................................................152 CLINDACIN PAC -clindamycin phosphate swab 1% & cleanser kit.....................................................................152 CLINDAGEL -clindamycin phosphate gel 1%..................152 clindamycin hcl cap 150 mg (Cleocin)...........................12 clindamycin hcl cap 300 mg (Cleocin)...........................12 clindamycin hcl cap 75 mg (Cleocin)............................ 12 clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) (Cleocin pediatric gr)......................................... 12 clindamycin phosphate-benzoyl peroxide gel 1-5% (Benzaclin).................................................................... 152 clindamycin phosphate foam 1% (Evoclin)................. 152 clindamycin phosphate gel 1% (Cleocin-t)..................152 clindamycin phosphate inj 300 mg/2ml (Cleocin phosphate)...................................................................... 13 clindamycin phosphate inj 600 mg/4ml (Cleocin phosphate)...................................................................... 13 clindamycin phosphate inj 900 mg/6ml (Cleocin phosphate)...................................................................... 13 clindamycin phosphate inj 9 gm/60ml (Cleocin phosphate)...................................................................... 13 clindamycin phosphate lotion 1% (Cleocin-t)............. 152 clindamycin phosphate soln 1% (Cleocin-t)................152 clindamycin phosphate swab 1% (Cleocin-t).............. 152 clindamycin phosphate vaginal cream 2% (Cleocin).......................................................................... 79 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 clorazepate dipotassium tab 15 mg (Tranxene t)..........81 clorazepate dipotassium tab 3.75 mg (Tranxene t).......81 clorazepate dipotassium tab 7.5 mg (Tranxene t).........81 CLORPRES -clonidine & chlorthalidone tab 0.1-15 mg..... 52 CLORPRES -clonidine & chlorthalidone tab 0.2-15 mg..... 52 CLORPRES -clonidine & chlorthalidone tab 0.3-15 mg..... 52 clotrimazole cream 1%..................................................153 clotrimazole soln 1%..................................................... 153 clotrimazole troche 10 mg............................................ 146 clotrimazole w/ betamethasone cream 1-0.05% (Lotrisone).....................................................................153 clotrimazole w/ betamethasone lotion 1-0.05%...........153 CLOZAPINE ODT -clozapine orally disintegrating tab 100 mg.................................................................................... 88 CLOZAPINE ODT -clozapine orally disintegrating tab 12.5 mg.................................................................................... 88 CLOZAPINE ODT -clozapine orally disintegrating tab 25 mg.................................................................................... 88 clozapine tab 100 mg (Clozaril)......................................88 clozapine tab 200 mg...................................................... 88 clozapine tab 25 mg (Clozaril)........................................88 clozapine tab 50 mg........................................................ 88 CLOZARIL -clozapine tab 100 mg.................................... 88 CLOZARIL -clozapine tab 25 mg...................................... 88 CNL8 NAIL KIT -ciclopirox soln 8% & lacquer removal pads kit...........................................................................153 COAL TAR -coal tar soln 20%........................................ 153 COARTEM -artemether-lumefantrine tab 20-120 mg........ 12 COCA COLA SYURP -phosphorated carbohydrate w/ caffeine syrup...................................................................74 COCAINE HCL -cocaine hcl soln 10%............................ 153 COCAINE HCL -cocaine hcl soln 4%..............................153 CODEINE SULFATE -codeine sulfate oral soln 30 mg/5ml............................................................................103 CODEINE SULFATE -codeine sulfate tab 15 mg............ 103 codeine sulfate tab 30 mg............................................ 103 codeine sulfate tab 60 mg............................................ 103 COD LIVER OIL - cod liver oil ....................................... 129 COGENTIN -benztropine mesylate inj 1 mg/ml............... 124 COLAZAL -balsalazide disodium cap 750 mg................... 76 colchicine w/ probenecid tab 0.5-500 mg.................... 116 COLCRYS -colchicine tab 0.6 mg................................... 116 COLESTID -colestipol hcl granule packets 5 gm...............59 COLESTID -colestipol hcl granules 5 gm.......................... 59 COLESTID -colestipol hcl tab 1 gm.................................. 59 COLESTID FLAVORED -colestipol hcl granule packets 5 gm.................................................................................... 59 COLESTID FLAVORED -colestipol hcl granules 5 gm...... 59 colestipol hcl granule packets 5 gm (Colestid flavored).......................................................................... 59 colestipol hcl granules 5 gm (Colestid flavored).......... 59 colestipol hcl tab 1 gm (Colestid).................................. 59 colistimethate sodium for inj 150 mg (Coly-Mycin M)..................................................................................... 13 COLY-MYCIN M -colistimethate sodium for inj 150 mg..... 13 clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% (Duac)................................................................ 152 CLINDESSE -clindamycin phosphate (one dose) vaginal cream 2%.........................................................................79 clobetasol propionate cream 0.05% (Temovate).........152 clobetasol propionate emollient base cream 0.05% (Temovate e).................................................................152 clobetasol propionate emulsion foam 0.05% (Oluxe).................................................................................... 152 clobetasol propionate foam 0.05% (Olux)................... 152 clobetasol propionate gel 0.05% (Temovate).............. 152 clobetasol propionate lotion 0.05% (Clobex).............. 152 clobetasol propionate oint 0.05% (Temovate).............152 clobetasol propionate shampoo 0.05% (Clobex)........ 152 clobetasol propionate soln 0.05% (Temovate)............152 CLOBEX -clobetasol propionate lotion 0.05%................. 152 CLOBEX -clobetasol propionate shampoo 0.05%........... 152 CLOBEX -clobetasol propionate spray 0.05%.................152 CLOCORTOLONE PIVALATE -clocortolone pivalate cream 0.1%....................................................................152 CLOCORTOLONE PIVALATE PUM -clocortolone pivalate cream 0.1%....................................................................152 CLODAN KIT -clobetasol propionate shampoo 0.05% & cleanser kit.....................................................................152 CLODERM -clocortolone pivalate cream 0.1%................152 CLODERM PUMP -clocortolone pivalate cream 0.1%.....152 clomipramine hcl cap 25 mg (Anafranil)....................... 83 clomipramine hcl cap 50 mg (Anafranil)....................... 83 clomipramine hcl cap 75 mg (Anafranil)....................... 83 clonazepam orally disintegrating tab 0.125 mg.......... 119 clonazepam orally disintegrating tab 0.25 mg............ 119 clonazepam orally disintegrating tab 0.5 mg.............. 119 clonazepam orally disintegrating tab 1 mg................. 119 clonazepam orally disintegrating tab 2 mg................. 119 clonazepam tab 0.5 mg (Klonopin).............................. 119 clonazepam tab 1 mg (Klonopin)................................. 119 clonazepam tab 2 mg (Klonopin)................................. 119 clonidine hcl inj (for epidural infusion) 100 mcg/ml (Duraclon)..................................................................... 101 clonidine hcl inj (for epidural infusion) 500 mcg/ml (Duraclon)..................................................................... 101 clonidine hcl tab 0.1 mg (Catapres)...............................51 clonidine hcl tab 0.2 mg (Catapres)...............................52 clonidine hcl tab 0.3 mg (Catapres)...............................52 clonidine hcl tab sr 12hr 0.1 mg (Kapvay).....................94 clonidine hcl td patch weekly 0.1 mg/24hr (Cataprestts-1).................................................................................52 clonidine hcl td patch weekly 0.2 mg/24hr (Cataprestts-2).................................................................................52 clonidine hcl td patch weekly 0.3 mg/24hr (Cataprestts-3).................................................................................52 clopidogrel bisulfate tab 300 mg (base equiv) (Plavix)...........................................................................140 clopidogrel bisulfate tab 75 mg (base equiv) (Plavix)...........................................................................140 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 191 2015 COLY-MYCIN S -neomycin-colistin-hc-thonzonium otic susp 3.3-3-10-0.5 mg/ml................................................ 146 COLYTE-FLAVOR PACKS -peg 3350-kcl-na bicarb-naclna sulfate for soln 227.1 gm............................................70 COLYTE-FLAVOR PACKS -peg 3350-kcl-na bicarb-naclna sulfate for soln 240 gm...............................................70 COMBIGAN -brimonidine tartrate-timolol maleate ophth soln 0.2-0.5%................................................................. 142 COMBIPATCH -estradiol-norethindrone ace td pttw 0.05-0.14 mg/day............................................................. 27 COMBIPATCH -estradiol-norethindrone ace td pttw 0.05-0.25 mg/day............................................................. 27 COMBIVENT -ipratropium-albuterol aerosol 18-103 mcg/ act (20-120mcg/act)......................................................... 68 COMBIVENT RESPIMAT -ipratropium-albuterol inhal aerosol soln 20-100 mcg/act............................................68 COMBIVIR -lamivudine-zidovudine tab 150-300 mg........... 8 COMETRIQ -cabozantinib s-malate cap 3 x 20 mg (60 mg dose) kit........................................................................... 18 COMETRIQ -cabozantinib s-mal cap 1 x 80 mg & 1 x 20 mg (100 dose) kit.............................................................18 COMETRIQ -cabozantinib s-mal cap 1 x 80 mg & 3 x 20 mg (140 dose) kit.............................................................18 COMMIT -nicotine polacrilex lozenge 2 mg.......................97 COMMIT -nicotine polacrilex lozenge 4 mg.......................97 COMPAZINE -prochlorperazine maleate tab 10 mg..........88 COMPAZINE -prochlorperazine maleate tab 5 mg............88 COMPLERA -emtricitabine-rilpivirine-tenofovir df tab 200-25-300 mg...................................................................8 COMTAN -entacapone tab 200 mg................................. 124 COMVAX -haemophilus b polysac conj-hepatitis b (recomb) vac im susp...................................................... 14 CONCERTA -methylphenidate hcl tab sa osm 18 mg....... 94 CONCERTA -methylphenidate hcl tab sa osm 27 mg....... 94 CONCERTA -methylphenidate hcl tab sa osm 36 mg....... 94 CONCERTA -methylphenidate hcl tab sa osm 54 mg....... 94 CONDYLOX -podofilox gel 0.5%.....................................153 CONDYLOX -podofilox soln 0.5%................................... 153 CONZIP -tramadol hcl cap sr 24hr biphasic release 100 mg.................................................................................. 103 CONZIP -tramadol hcl cap sr 24hr biphasic release 200 mg.................................................................................. 103 CONZIP -tramadol hcl cap sr 24hr biphasic release 300 mg.................................................................................. 103 COPAXONE -glatiramer acetate inj kit 20 mg/ml.............. 97 COPAXONE -glatiramer acetate soln prefilled syringe 40 mg/ml................................................................................97 COPEGUS -ribavirin tab 200 mg.........................................8 CORDARONE -amiodarone hcl tab 200 mg..................... 48 CORDRAN -flurandrenolide cream 0.05%...................... 153 CORDRAN -flurandrenolide lotion 0.05%........................153 CORDRAN -flurandrenolide oint 0.05%...........................153 CORDRAN TAPE -flurandrenolide tape 4 mcg/sqcm...... 153 COREG -carvedilol tab 12.5 mg........................................44 COREG -carvedilol tab 25 mg...........................................44 192 COREG -carvedilol tab 3.125 mg......................................44 COREG -carvedilol tab 6.25 mg........................................44 COREG CR -carvedilol phosphate cap sr 24hr 10 mg...... 44 COREG CR -carvedilol phosphate cap sr 24hr 20 mg...... 44 COREG CR -carvedilol phosphate cap sr 24hr 40 mg...... 44 COREG CR -carvedilol phosphate cap sr 24hr 80 mg...... 44 CORGARD -nadolol tab 20 mg......................................... 44 CORGARD -nadolol tab 40 mg......................................... 44 CORGARD -nadolol tab 80 mg......................................... 44 CORTANE-B AQUEOUS -pramoxine-hc-chloroxylenol aqueous otic soln 10-10-1 mg/ml.................................. 146 CORTANE-B -hydrocortisone-pramoxine-chloroxylenol lot 10-10-1mg/ml................................................................. 153 CORTANE-B-OTIC -pramoxine-hc-chloroxylenol otic soln 10-10-1 mg/ml................................................................146 CORTEF -hydrocortisone tab 10 mg................................. 22 CORTEF -hydrocortisone tab 20 mg................................. 22 CORTEF -hydrocortisone tab 5 mg...................................22 CORTENEMA -hydrocortisone enema 100 mg/60ml.......148 CORTIFOAM -hydrocortisone acetate rectal foam 90 mg/ dose................................................................................148 CORTISONE ACETATE -cortisone acetate tab 25 mg......23 CORTISPORIN -bacitracin-polymyxin-neomycin hc oint 1%.................................................................................. 153 CORTISPORIN -neomycin-polymyxin-hc cream 0.5%............................................................................... 153 CORTISPORIN -neomycin-polymyxin-hc otic soln 1%.................................................................................. 146 CORTISPORIN-TC -neomycin-colistin-hc-thonzonium otic susp 3.3-3-10-0.5 mg/ml................................................ 146 CORVITE 150 - iron combination tab .............................135 CORVITE 150 -iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg...................................................................135 CORVITE FE - iron combination tab .............................. 135 CORVITE -multiple vitamins w/ minerals & fa tab 1.25 mg.................................................................................. 129 CORZIDE -nadolol & bendroflumethiazide tab 40-5 mg.................................................................................... 52 CORZIDE -nadolol & bendroflumethiazide tab 80-5 mg.................................................................................... 52 COSOPT -dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml............................................................... 142 COSOPT PF -dorzolamide hcl-timolol maleate ophth sol 22.3-6.8 mg/ml pf...........................................................142 COTAB A -chlorpheniramine w/ codeine tab 4-10 mg....... 64 COTAB AX -chlorpheniramine w/ codeine tab 4-20 mg.....64 COTABFLU -codeine-chlorpheniramine-acetaminophen tab 20-4-500 mg.............................................................. 64 COUMADIN -warfarin sodium tab 10 mg........................ 138 COUMADIN -warfarin sodium tab 1 mg.......................... 138 COUMADIN -warfarin sodium tab 2.5 mg....................... 138 COUMADIN -warfarin sodium tab 2 mg.......................... 138 COUMADIN -warfarin sodium tab 3 mg.......................... 138 COUMADIN -warfarin sodium tab 4 mg.......................... 138 COUMADIN -warfarin sodium tab 5 mg.......................... 138 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 CYCLOGYL -cyclopentolate hcl ophth soln 0.5%............142 CYCLOGYL -cyclopentolate hcl ophth soln 1%...............142 CYCLOGYL -cyclopentolate hcl ophth soln 2%...............142 CYCLOMYDRIL -cyclopentolate w/ phenylephrine ophth soln 0.2-1%.................................................................... 142 cyclopentolate hcl ophth soln 1% (Cyclogyl)..............142 cyclopentolate hcl ophth soln 2% (Cyclogyl)..............142 CYCLOPHOSPHAMIDE -cyclophosphamide cap 25 mg.................................................................................... 18 CYCLOPHOSPHAMIDE -cyclophosphamide cap 50 mg.................................................................................... 18 CYCLOPHOSPHAMIDE -cyclophosphamide tab 25 mg.................................................................................... 18 CYCLOPHOSPHAMIDE -cyclophosphamide tab 50 mg.................................................................................... 18 cyclophosphamide for inj 1 gm..................................... 18 cyclophosphamide for inj 2 gm..................................... 19 cyclophosphamide for inj 500 mg................................. 19 CYCLOSERINE -cycloserine cap 250 mg...........................6 CYCLOSET -bromocriptine mesylate tab 0.8 mg (base equivalent)........................................................................32 cyclosporine cap 100 mg (Sandimmune).................... 170 cyclosporine cap 25 mg (Sandimmune)...................... 170 cyclosporine modified cap 100 mg (Neoral)............... 170 cyclosporine modified cap 25 mg (Neoral)................. 171 CYCLOSPORINE MODIFIED -cyclosporine modified cap 50 mg............................................................................. 170 cyclosporine modified oral soln 100 mg/ml (Neoral)..........................................................................171 CYMBALTA -duloxetine hcl enteric coated pellets cap 20 mg.................................................................................... 83 CYMBALTA -duloxetine hcl enteric coated pellets cap 30 mg.................................................................................... 83 CYMBALTA -duloxetine hcl enteric coated pellets cap 60 mg.................................................................................... 83 cyproheptadine hcl syrup 2 mg/5ml.............................. 63 cyproheptadine hcl tab 4 mg......................................... 63 CYSTADANE - betaine powder for oral solution .............. 39 CYSTAGON -cysteamine bitartrate cap 150 mg............... 80 CYSTAGON -cysteamine bitartrate cap 50 mg................. 80 CYSTARAN -cysteamine hcl ophth soln 0.44% (base equivalent)......................................................................142 CYTARABINE -cytarabine for inj 100 mg.......................... 19 CYTARABINE -cytarabine for inj 1 gm..............................19 cytarabine for inj 1 gm....................................................19 cytarabine for inj 500 mg................................................19 cytarabine inj 20 mg/ml...................................................19 cytarabine inj pf 100 mg/ml............................................ 19 cytarabine inj pf 20 mg/ml.............................................. 19 CYTOMEL -liothyronine sodium tab 25 mcg..................... 37 CYTOMEL -liothyronine sodium tab 50 mcg..................... 37 CYTOMEL -liothyronine sodium tab 5 mcg....................... 37 CYTOTEC -misoprostol tab 100 mcg................................ 72 CYTOTEC -misoprostol tab 200 mcg................................ 72 COUMADIN -warfarin sodium tab 6 mg.......................... 138 COUMADIN -warfarin sodium tab 7.5 mg....................... 138 COZAAR -losartan potassium tab 100 mg........................ 52 COZAAR -losartan potassium tab 25 mg.......................... 52 COZAAR -losartan potassium tab 50 mg.......................... 52 CPB WC -pseudoephedrine-bromphen-codeine liq 10-1.3-6.3 mg/5ml............................................................64 CREON -pancrelipase (lip-prot-amyl) dr cap 12000-38000-60000 unit.................................................. 75 CREON -pancrelipase (lip-prot-amyl) dr cap 24000-76000-120000 unit................................................ 75 CREON -pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000 unit...................................................... 75 CREON -pancrelipase (lip-prot-amyl) dr cap 36000-114000-180000 unit.............................................. 75 CREON -pancrelipase (lip-prot-amyl) dr cap 6000-19000-30000 unit.................................................... 75 CRESTOR -rosuvastatin calcium tab 10 mg..................... 59 CRESTOR -rosuvastatin calcium tab 20 mg..................... 60 CRESTOR -rosuvastatin calcium tab 40 mg..................... 60 CRESTOR -rosuvastatin calcium tab 5 mg....................... 59 CRESYLATE -cresyl acetate otic soln 25%.................... 146 CRINONE -progesterone vaginal gel 4%.......................... 79 CRINONE -progesterone vaginal gel 8%.......................... 79 CRIXIVAN -indinavir sulfate cap 200 mg............................ 8 CRIXIVAN -indinavir sulfate cap 400 mg............................ 8 cromolyn sodium ophth soln 4%................................. 142 cromolyn sodium oral conc 100 mg/5ml (Gastrocrom)...................................................................76 cromolyn sodium soln nebu 20 mg/2ml........................ 68 CUPRIMINE -penicillamine cap 250 mg..........................170 CURAGEL HYDROGEL ISLAND W - hydroactive (sterile) dressing ........................................................................ 153 CURAGEL HYDROGEL WOUND DR - hydroactive (sterile) dressing ........................................................... 153 CURITY HYPERTONIC SODIUM - wound dressings misc ...............................................................................153 CURITY SODIUM CHLORIDE DR - wound dressings pads .............................................................................. 153 CUROSURF -poractant alfa intratracheal susp 80 mg/ ml......................................................................................70 CUTIVATE -fluticasone propionate cream 0.05%............153 CUTIVATE -fluticasone propionate lotion 0.05%............. 153 CUTIVATE -fluticasone propionate oint 0.005%..............153 CUVPOSA -glycopyrrolate oral soln 1 mg/5ml.................. 72 CVS VITAMIN D3 -cholecalciferol cap 400 unit...............128 CYANIDE ANTIDOTE PKG -cyanide antidote kit............ 167 cyanocobalamin inj 1000 mcg/ml.................................135 CYCLESSA -desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg-mg.........................28 CYCLOBENZAPRINE COMFORT P -cyclobenzaprine hcl tab 10 mg & liniment topical gel kit................................127 cyclobenzaprine hcl tab 10 mg.................................... 127 cyclobenzaprine hcl tab 5 mg...................................... 127 cyclobenzaprine hcl tab 7.5 mg (Fexmid)....................127 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 193 2015 CYTRA-3 -pot & sod citrates w/ cit ac syrup 550-500-334 mg/5ml..............................................................................80 D D.H.E. 45 -dihydroergotamine mesylate inj 1 mg/ml........115 D3 -cholecalciferol cap 400 unit...................................... 128 DALIRESP -roflumilast tab 500 mcg................................. 68 danazol cap 100 mg........................................................ 25 danazol cap 200 mg........................................................ 25 danazol cap 50 mg.......................................................... 26 DANTRIUM -dantrolene sodium cap 100 mg.................. 127 DANTRIUM -dantrolene sodium cap 25 mg.................... 127 DANTRIUM -dantrolene sodium cap 50 mg.................... 127 dantrolene sodium cap 25 mg (Dantrium)...................127 dantrolene sodium cap 50 mg (Dantrium)...................127 DANTROLENE SODIUM -dantrolene sodium cap 100 mg.................................................................................. 127 DAPSONE -dapsone tab 100 mg......................................13 DAPSONE -dapsone tab 25 mg........................................13 DAPTACEL -diph, acellular pert & tet tox inj 15 lf-10 mcg-5 lf/0.5ml..............................................................................16 DARAPRIM -pyrimethamine tab 25 mg.............................12 DAYPRO -oxaprozin tab 600 mg.................................... 111 DAYTRANA -methylphenidate td patch 10 mg/9hr............94 DAYTRANA -methylphenidate td patch 15 mg/9hr............94 DAYTRANA -methylphenidate td patch 20 mg/9hr............94 DAYTRANA -methylphenidate td patch 30 mg/9hr............94 DDAVP -desmopressin acetate inj 4 mcg/ml.....................39 DDAVP -desmopressin acetate nasal soln 0.01% (refrigerated).....................................................................39 DDAVP -desmopressin acetate nasal spray soln 0.01%............................................................................... 39 DDAVP -desmopressin acetate tab 0.1 mg.......................39 DDAVP -desmopressin acetate tab 0.2 mg.......................39 DEBACTEROL -sulfuric acid-sulfonated phenolics soln 30-50%........................................................................... 146 DECARA -cholecalciferol cap 25000 unit........................ 128 DECON-A -brompheniramine & phenylephrine elixir 2-5 mg/5ml..............................................................................65 DECON-G -phenylephrine-brompheniramine-guaifenesin liqd 2-1-40 mg/ml............................................................. 65 deferoxamine mesylate for inj 2 gm (Desferal)........... 167 deferoxamine mesylate for inj 500 mg (Desferal)....... 167 DELESTROGEN -estradiol valerate im in oil 10 mg/ml..... 27 DELESTROGEN -estradiol valerate im in oil 20 mg/ml..... 27 DELESTROGEN -estradiol valerate im in oil 40 mg/ml..... 27 DELFLEX-LC/2.5% DEXTROSE - peritoneal dialysis solutions ........................................................................171 DELFLEX-LC/4.25% DEXTROSE - peritoneal dialysis solutions 483 mosm/l ....................................................171 DELFLEX-LM/2.5% DEXTROSE - peritoneal dialysis solutions 396 mosm/l ....................................................171 DELFLEX-LM/4.25% DEXTROSE - peritoneal dialysis solutions 485 mosm/l ....................................................171 DELFLEX-SM/1.5% DEXTROSE - peritoneal dialysis solutions 347 mosm/l ....................................................171 194 DELFLEX-SM/2.5% DEXTROSE - peritoneal dialysis solutions 398 mosm/l ....................................................171 DELFLEX-SM/4.25% DEXTROSE - peritoneal dialysis solutions 486 mosm/l ....................................................171 DELZICOL -mesalamine cap dr 400 mg........................... 76 DEMADEX -torsemide tab 100 mg....................................57 DEMADEX -torsemide tab 10 mg......................................57 DEMADEX -torsemide tab 20 mg......................................57 DEMADEX -torsemide tab 5 mg........................................57 demeclocycline hcl tab 150 mg........................................4 demeclocycline hcl tab 300 mg........................................4 DEMEROL -meperidine hcl inj 100 mg/2ml (50 mg/ ml).................................................................................. 103 DEMEROL -meperidine hcl inj 100 mg/ml.......................103 DEMEROL -meperidine hcl inj 25 mg/0.5ml (50 mg/ ml).................................................................................. 103 DEMEROL -meperidine hcl inj 25 mg/ml.........................103 DEMEROL -meperidine hcl inj 50 mg/ml.........................103 DEMEROL -meperidine hcl inj 75 mg/1.5ml (50 mg/ ml).................................................................................. 103 DEMEROL -meperidine hcl inj 75 mg/ml.........................103 DEMEROL -meperidine hcl tab 100 mg.......................... 103 DEMEROL -meperidine hcl tab 50 mg............................ 103 DEMSER -metyrosine cap 250 mg................................... 52 DENATURED ALCOHOL -alcohol, rubbing 95%.............168 DENAVIR -penciclovir cream 1%.................................... 153 DEPAKENE -valproate sodium syrup 250 mg/5ml (base equiv)..............................................................................119 DEPAKENE -valproic acid cap 250 mg........................... 119 DEPAKOTE -divalproex sodium tab delayed release 125 mg.................................................................................. 119 DEPAKOTE -divalproex sodium tab delayed release 250 mg.................................................................................. 119 DEPAKOTE -divalproex sodium tab delayed release 500 mg.................................................................................. 119 DEPAKOTE ER -divalproex sodium tab sr 24 hr 250 mg.................................................................................. 119 DEPAKOTE ER -divalproex sodium tab sr 24 hr 500 mg.................................................................................. 120 DEPAKOTE SPRINKLES -divalproex sodium cap sprinkle 125 mg........................................................................... 120 DEPEN TITRATABS -penicillamine tab 250 mg..............171 DEPOCYT -cytarabine liposome inj 50 mg/5ml.................19 DEPODUR -morphine sulfate ext-release liposome epidural inj 10 mg/ml..................................................... 103 DEPODUR -morphine sulfate ext-rel liposome epidural inj 15 mg/1.5ml................................................................... 103 DEPO-ESTRADIOL -estradiol cypionate im in oil 5 mg/ ml......................................................................................27 DEPO-MEDROL -methylprednisolone acetate inj susp 20 mg/ml................................................................................23 DEPO-MEDROL -methylprednisolone acetate inj susp 40 mg/ml................................................................................23 DEPO-MEDROL -methylprednisolone acetate inj susp 80 mg/ml................................................................................23 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5) (Mircette)......................................................... 29 desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg-mg (Cyclessa).....29 desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg (Desogen)........................................................................29 DESONATE -desonide gel 0.05%................................... 153 desonide cream 0.05% (Desowen)............................... 153 desonide lotion 0.05% (Desowen)................................153 desonide oint 0.05% (Desowen)...................................153 DESOWEN CREAM/CETAPHIL LO -desonide cream 0.05% w/ moisturizing lotion kit..................................... 153 DESOWEN -desonide cream 0.05%............................... 153 DESOWEN -desonide lotion 0.05%................................ 153 DESOWEN -desonide oint 0.05%................................... 153 DESOWEN LOTION/CETAPHIL C -desonide lotion 0.05% w/ moisturizing cream kit............................................... 153 DESOWEN OINTMENT/CETAPHIL -desonide ointment 0.05% w/ moisturizing lotion kit..................................... 154 desoximetasone cream 0.25% (Topicort).................... 154 DESOXIMETASONE -desoximetasone cream 0.05%.....154 DESOXIMETASONE -desoximetasone oint 0.05%......... 154 desoximetasone gel 0.05% (Topicort)......................... 154 desoximetasone oint 0.25% (Topicort)........................ 154 DESOXYN -methamphetamine hcl tab 5 mg.................... 94 DESVENLAFAXINE ER -desvenlafaxine fumarate tab sr 24hr 100 mg (base equiv)............................................... 83 DESVENLAFAXINE ER -desvenlafaxine fumarate tab sr 24hr 50 mg (base equiv)................................................. 83 DESVENLAFAXINE ER -desvenlafaxine tab sr 24hr 100 mg.................................................................................... 83 DESVENLAFAXINE ER -desvenlafaxine tab sr 24hr 50 mg.................................................................................... 83 DETROL LA -tolterodine tartrate cap sr 24hr 2 mg........... 78 DETROL LA -tolterodine tartrate cap sr 24hr 4 mg........... 78 DETROL -tolterodine tartrate tab 1 mg............................. 78 DETROL -tolterodine tartrate tab 2 mg............................. 78 DEXAMETHASONE -dexamethasone soln 0.5 mg/5ml..............................................................................23 DEXAMETHASONE -dexamethasone tab 1 mg............... 23 DEXAMETHASONE -dexamethasone tab 2 mg............... 23 dexamethasone elixir 0.5 mg/5ml.................................. 23 DEXAMETHASONE INTENSOL -dexamethasone conc 1 mg/ml................................................................................23 DEXAMETHASONE SODIUM PHOS -dexamethasone sodium phosphate inj 10 mg/ml.......................................23 DEXAMETHASONE SODIUM PHOS -dexamethasone sod phosphate preservative free inj 10 mg/ml........................23 dexamethasone sodium phosphate inj 100 mg/10ml...........................................................................23 dexamethasone sodium phosphate inj 120 mg/30ml...........................................................................23 dexamethasone sodium phosphate inj 20 mg/5ml....... 23 dexamethasone sodium phosphate inj 4 mg/ml........... 23 DEPO-PROVERA CONTRACEPTIV medroxyprogesterone acetate im susp 150 mg/ml.......... 28 DEPO-PROVERA -medroxyprogesterone acetate im susp 400 mg/ml........................................................................ 19 DEPO-SUBQ PROVERA 104 -medroxyprogesterone acetate subcutaneous susp 104 mg/0.65ml.................... 28 DEPO-TESTOSTERONE -testosterone cypionate im inj in oil 100 mg/ml................................................................... 26 DEPO-TESTOSTERONE -testosterone cypionate im inj in oil 200 mg/ml................................................................... 26 DEPRIZINE FUSEPAQ - ranitidine hcl for oral susp 22.4 mg/ml (compound kit) ..................................................... 72 DERMA-SMOOTHE/FS BODY -fluocinolone acetonide oil 0.01% (body oil).............................................................153 DERMA-SMOOTHE/FS BODY OIL -fluocinolone acetonide oil 0.01% (body oil)....................................... 153 DERMA-SMOOTHE/FS SCALP -fluocinolone acetonide oil 0.01% (scalp oil)............................................................ 153 DERMA-SMOOTHE/FS SCALP OI -fluocinolone acetonide oil 0.01% (scalp oil)....................................................... 153 DERMASORB AF -clioquinol-hc cream 3-0.5% & emollient liqd kit.............................................................................153 DERMASORB HC -hydrocortisone lot 2% & cleanser liq kit....................................................................................153 DERMASORB TA -triamcinolone cream 0.1% & emollient cream kit........................................................................ 153 DERMASORB XM -urea cream 39% & emollient cream kit....................................................................................153 DERMATOP -prednicarbate cream 0.1%........................ 153 DERMATOP -prednicarbate oint 0.1%............................ 153 DERMOTIC -fluocinolone acetonide (otic) oil 0.01%....... 146 DESFERAL -deferoxamine mesylate for inj 2 gm............167 DESFERAL -deferoxamine mesylate for inj 500 mg........167 desipramine hcl tab 100 mg (Norpramin)......................83 desipramine hcl tab 10 mg (Norpramin)........................83 desipramine hcl tab 150 mg (Norpramin)......................83 desipramine hcl tab 25 mg (Norpramin)........................83 desipramine hcl tab 50 mg (Norpramin)........................83 desipramine hcl tab 75 mg (Norpramin)........................83 desloratadine tab 5 mg (Clarinex)..................................63 desloratadine tab orally disintegrating 2.5 mg (Clarinex reditabs)......................................................... 63 desloratadine tab orally disintegrating 5 mg (Clarinex reditabs).......................................................................... 63 desmopressin acetate inj 4 mcg/ml (Ddavp).................39 desmopressin acetate nasal soln 0.01% (refrigerated) (Ddavp)............................................................................ 39 desmopressin acetate nasal spray soln 0.01% (Ddavp)............................................................................ 39 desmopressin acetate nasal spray soln 0.01% (refrigerated)................................................................... 39 desmopressin acetate tab 0.1 mg (Ddavp)....................40 desmopressin acetate tab 0.2 mg (Ddavp)....................40 DESOGEN -desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg...................................................................................29 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 195 2015 dexamethasone sodium phosphate ophth soln 0.1%............................................................................... 142 dexamethasone tab 0.5 mg............................................ 23 dexamethasone tab 0.75 mg.......................................... 23 dexamethasone tab 1.5 mg............................................ 23 dexamethasone tab 4 mg............................................... 23 dexamethasone tab 6 mg............................................... 23 DEXCHLORPHENIRAMINE MALEA -dexchlorpheniramine maleate syrup 2 mg/5ml.................................................. 63 DEXEDRINE -dextroamphetamine sulfate cap sr 24hr 10 mg.................................................................................... 94 DEXEDRINE -dextroamphetamine sulfate cap sr 24hr 15 mg.................................................................................... 94 DEXEDRINE -dextroamphetamine sulfate cap sr 24hr 5 mg.................................................................................... 94 DEXLIDO -dexamethasone sod phos pf inj 10 mg/ml & lidocaine 1% kit................................................................23 DEXLIDO-M -dexamethasone pf inj 10 mg/ml & bupiv 0.25% & lido 1% kit......................................................... 23 dexmethylphenidate hcl cap sr 24 hr 15 mg (Focalin xr).....................................................................................94 dexmethylphenidate hcl cap sr 24 hr 30 mg (Focalin xr).....................................................................................94 dexmethylphenidate hcl cap sr 24 hr 40 mg (Focalin xr).....................................................................................94 dexmethylphenidate hcl tab 10 mg (Focalin)................ 94 dexmethylphenidate hcl tab 2.5 mg (Focalin)............... 94 dexmethylphenidate hcl tab 5 mg (Focalin).................. 94 DEXPAK 10 DAY -dexamethasone tab 1.5 mg taper pack..................................................................................23 DEXPAK 13 DAY -dexamethasone tab 1.5 mg taper pack..................................................................................23 DEXPAK 6 DAY -dexamethasone tab 1.5 mg taper pack..................................................................................23 DEXPANTHENOL -dexpanthenol inj 250 mg/ml............... 76 dextroamphetamine sulfate cap sr 24hr 10 mg (Dexedrine)......................................................................94 dextroamphetamine sulfate cap sr 24hr 15 mg (Dexedrine)......................................................................94 dextroamphetamine sulfate cap sr 24hr 5 mg (Dexedrine)......................................................................94 dextroamphetamine sulfate oral solution 5 mg/5ml (Procentra)...................................................................... 94 dextroamphetamine sulfate tab 10 mg.......................... 94 dextroamphetamine sulfate tab 5 mg............................ 94 DEXTROMETHORPHAN HBR/CHLO -phenylephrinechlorphen-dm liquid 1.75-0.75-2.75 mg/ml...................... 65 DIABETA -glyburide tab 1.25 mg...................................... 32 DIABETA -glyburide tab 2.5 mg........................................ 32 DIABETA -glyburide tab 5 mg........................................... 32 DIAB F.D.G. FREEZE-DRIED - wound dressings - gel ....................................................................................... 154 DIAB - wound dressings - gel ........................................ 154 DIALYVITE/ZINC -b-complex w/ c-zn & folic acid tab 1 mg.................................................................................. 129 196 DIALYVITE 3000 -b-complex w/ c-biotin-e-minerals & folic acid tab 3 mg.................................................................129 DIALYVITE 5000 -b-complex w/ c-biotin-e-minerals & folic acid tab 5 mg.................................................................129 DIALYVITE SUPREME D -multiple vitamins w/ minerals & fa tab 3 mg.................................................................... 129 DIAMOX -acetazolamide cap sr 12hr 500 mg................... 57 DIANEAL LOW CALCIUM/1.5% - peritoneal dialysis solutions 344 mosm/l ....................................................171 DIANEAL LOW CALCIUM/2.5% - peritoneal dialysis solutions 395 mosm/l ....................................................171 DIANEAL LOW CALCIUM/4.25% - peritoneal dialysis solutions 483 mosm/l ....................................................171 DIANEAL PD-2/1.5% DEXTROS - peritoneal dialysis solutions 346 mosm/l ....................................................171 DIANEAL PD-2/2.5% DEXTROS - peritoneal dialysis solutions 396 mosm/l ....................................................171 DIANEAL PD-2/4.25% DEXTRO - peritoneal dialysis solutions 485 mosm/l ....................................................171 DIASTAT ACUDIAL -diazepam rectal gel delivery system 10 mg............................................................................. 120 DIASTAT ACUDIAL -diazepam rectal gel delivery system 20 mg............................................................................. 120 DIASTAT PEDIATRIC -diazepam rectal gel delivery system 2.5 mg............................................................... 120 DIATX ZN -b-complex w/ c-biotin-minerals & folic acid tab 5 mg............................................................................... 129 DIAZEPAM -diazepam im inj device 10 mg/2ml................ 81 DIAZEPAM -diazepam inj 5 mg/ml....................................81 DIAZEPAM -diazepam rectal gel delivery system 10 mg.................................................................................. 120 DIAZEPAM -diazepam rectal gel delivery system 2.5 mg.................................................................................. 120 DIAZEPAM -diazepam rectal gel delivery system 20 mg.................................................................................. 120 DIAZEPAM -diazepam soln 1 mg/ml................................. 81 DIAZEPAM INTENSOL -diazepam conc 5 mg/ml............. 81 diazepam tab 10 mg (Valium)......................................... 81 diazepam tab 2 mg (Valium)...........................................81 diazepam tab 5 mg (Valium)...........................................81 DIBENZYLINE -phenoxybenzamine hcl cap 10 mg...........52 DICLEGIS -doxylamine-pyridoxine tab delayed release 10-10 mg..........................................................................74 diclofenac potassium tab 50 mg (Cataflam)................111 diclofenac sodium (actinic keratoses) gel 3% (Solaraze)...................................................................... 154 diclofenac sodium ophth soln 0.1%............................ 142 diclofenac sodium soln 1.5% (Pennsaid).................... 154 diclofenac sodium tab delayed release 25 mg............111 diclofenac sodium tab delayed release 50 mg............111 diclofenac sodium tab delayed release 75 mg............111 diclofenac sodium tab sr 24hr 100 mg (Voltarenxr)...................................................................................111 diclofenac w/ misoprostol tab delayed release 50-0.2 mg (Arthrotec 50).........................................................111 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 DILAUDID -hydromorphone hcl preservative free (pf) inj 1 mg/ml..............................................................................103 DILAUDID -hydromorphone hcl preservative free (pf) inj 2 mg/ml..............................................................................103 DILAUDID -hydromorphone hcl preservative free (pf) inj 4 mg/ml..............................................................................103 DILAUDID -hydromorphone hcl tab 2 mg........................103 DILAUDID -hydromorphone hcl tab 4 mg........................103 DILAUDID -hydromorphone hcl tab 8 mg........................103 diltiazem hcl cap sr 12hr 120 mg................................... 46 diltiazem hcl cap sr 12hr 60 mg.....................................46 diltiazem hcl cap sr 12hr 90 mg.....................................46 diltiazem hcl cap sr 24hr 120 mg................................... 47 diltiazem hcl cap sr 24hr 180 mg................................... 47 diltiazem hcl cap sr 24hr 240 mg................................... 47 diltiazem hcl coated beads cap sr 24hr 120 mg (Cardizem cd)................................................................. 47 diltiazem hcl coated beads cap sr 24hr 180 mg (Cardizem cd)................................................................. 47 diltiazem hcl coated beads cap sr 24hr 240 mg (Cardizem cd)................................................................. 47 diltiazem hcl coated beads cap sr 24hr 300 mg (Cardizem cd)................................................................. 47 diltiazem hcl coated beads cap sr 24hr 360 mg (Cardizem cd)................................................................. 47 diltiazem hcl coated beads tab sr 24hr 180 mg (Cardizem la).................................................................. 47 diltiazem hcl coated beads tab sr 24hr 240 mg (Cardizem la).................................................................. 47 diltiazem hcl coated beads tab sr 24hr 300 mg (Cardizem la).................................................................. 47 diltiazem hcl coated beads tab sr 24hr 360 mg (Cardizem la).................................................................. 47 diltiazem hcl coated beads tab sr 24hr 420 mg (Cardizem la).................................................................. 47 diltiazem hcl extended release beads cap sr 24hr 120 mg (Tiazac)..................................................................... 47 diltiazem hcl extended release beads cap sr 24hr 180 mg (Tiazac)..................................................................... 47 diltiazem hcl extended release beads cap sr 24hr 240 mg (Tiazac)..................................................................... 47 diltiazem hcl extended release beads cap sr 24hr 300 mg (Tiazac)..................................................................... 47 diltiazem hcl extended release beads cap sr 24hr 360 mg (Tiazac)..................................................................... 47 diltiazem hcl extended release beads cap sr 24hr 420 mg (Tiazac)..................................................................... 47 diltiazem hcl tab 120 mg (Cardizem)............................. 47 diltiazem hcl tab 30 mg (Cardizem)............................... 47 diltiazem hcl tab 60 mg (Cardizem)............................... 47 diltiazem hcl tab 90 mg...................................................47 DIMENHYDRINATE -dimenhydrinate inj 50 mg/ml........... 74 DIOVAN HCT -valsartan-hydrochlorothiazide tab 160-12.5 mg.................................................................................... 52 diclofenac w/ misoprostol tab delayed release 75-0.2 mg (Arthrotec 75).........................................................111 dicloxacillin sodium cap 250 mg..................................... 1 dicloxacillin sodium cap 500 mg..................................... 1 DICOPANOL FUSEPAQ - diphenhydramine hcl for oral susp 5 mg/ml (compound kit) ......................................... 63 dicyclomine hcl cap 10 mg (Bentyl).............................. 72 DICYCLOMINE HCL -dicyclomine hcl oral soln 10 mg/5ml..............................................................................72 dicyclomine hcl tab 20 mg (Bentyl)............................... 72 didanosine delayed release capsule 125 mg (Videx ec)...................................................................................... 8 didanosine delayed release capsule 200 mg (Videx ec)...................................................................................... 8 didanosine delayed release capsule 250 mg (Videx ec)...................................................................................... 8 didanosine delayed release capsule 400 mg (Videx ec)...................................................................................... 8 DIDRONEL -etidronate disodium tab 400 mg....................40 DIFFERIN -adapalene cream 0.1%.................................154 DIFFERIN -adapalene gel 0.1%...................................... 154 DIFFERIN -adapalene gel 0.3%...................................... 154 DIFFERIN -adapalene lotion 0.1%.................................. 154 DIFICID -fidaxomicin tab 200 mg........................................ 4 DIFLORASONE DIACETATE -diflorasone diacetate cream 0.05%............................................................................. 154 diflorasone diacetate oint 0.05%..................................154 DIFLUCAN -fluconazole for susp 10 mg/ml.........................7 DIFLUCAN -fluconazole for susp 40 mg/ml.........................7 DIFLUCAN -fluconazole tab 100 mg................................... 7 DIFLUCAN -fluconazole tab 150 mg................................... 7 DIFLUCAN -fluconazole tab 200 mg................................... 7 DIFLUCAN -fluconazole tab 50 mg..................................... 7 diflunisal tab 500 mg.....................................................101 DIGEX NF -hyoscyamine-phenyltoloxamine cap 0.0625-15 mg.................................................................................... 72 DIGOXIN -digoxin oral soln 0.05 mg/ml............................ 43 digoxin inj 0.25 mg/ml (Lanoxin)....................................43 digoxin tab 125 mcg (0.125 mg) (Lanoxin).................... 43 digoxin tab 250 mcg (0.25 mg) (Lanoxin)...................... 43 DIHYDROERGOTAMINE MESYLAT -dihydroergotamine mesylate nasal spray 4 mg/ml....................................... 115 dihydroergotamine mesylate inj 1 mg/ml (D.h.e. 45).................................................................................. 115 DILACOR XR -diltiazem hcl cap sr 24hr 240 mg...............46 DILANTIN INFATABS -phenytoin chew tab 50 mg..........120 DILANTIN -phenytoin sodium extended cap 100 mg.......120 DILANTIN -phenytoin sodium extended cap 30 mg.........120 DILANTIN -phenytoin susp 125 mg/5ml.......................... 120 DILATRATE SR -isosorbide dinitrate cap cr 40 mg........... 43 DILAUDID-HP -hydromorphone hcl for inj 250 mg.......... 103 DILAUDID-HP -hydromorphone hcl preservative free (pf) inj 10 mg/ml................................................................... 103 DILAUDID -hydromorphone hcl liqd 1 mg/ml...................103 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 197 2015 DIOVAN HCT -valsartan-hydrochlorothiazide tab 160-25 mg.................................................................................... 52 DIOVAN HCT -valsartan-hydrochlorothiazide tab 320-12.5 mg.................................................................................... 52 DIOVAN HCT -valsartan-hydrochlorothiazide tab 320-25 mg.................................................................................... 52 DIOVAN HCT -valsartan-hydrochlorothiazide tab 80-12.5 mg.................................................................................... 52 DIOVAN -valsartan tab 160 mg.........................................52 DIOVAN -valsartan tab 320 mg.........................................52 DIOVAN -valsartan tab 40 mg...........................................52 DIOVAN -valsartan tab 80 mg...........................................52 DIPENTUM -olsalazine sodium cap 250 mg..................... 76 diphenhydramine hcl cap 50 mg....................................63 diphenhydramine hcl elixir 12.5 mg/5ml........................63 diphenhydramine hcl inj 50 mg/ml.................................63 DIPHENOXYLATE/ATROPINE -diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml........................................................ 71 diphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil).......................................................................... 71 DIPHTHERIA/TETANUS TOXOID -diphtheria-tetanus tox adsorbed (dt) im inj 25-5 unit/0.5ml................................. 16 DIPROLENE AF -betamethasone dipropionate augmented cream 0.05%..................................................................154 DIPROLENE -betamethasone dipropionate augmented lotion 0.05%................................................................... 154 DIPROLENE -betamethasone dipropionate augmented oint 0.05%...................................................................... 154 dipyridamole tab 25 mg (Persantine)...........................140 dipyridamole tab 50 mg (Persantine)...........................140 dipyridamole tab 75 mg (Persantine)...........................140 DISALCID -salsalate tab 500 mg.................................... 101 DISALCID -salsalate tab 750 mg.................................... 101 disopyramide phosphate cap 100 mg (Norpace).......... 49 disopyramide phosphate cap 150 mg (Norpace).......... 49 disulfiram tab 250 mg (Antabuse)..................................97 disulfiram tab 500 mg (Antabuse)..................................97 DITROPAN XL -oxybutynin chloride tab sr 24hr 10 mg..... 78 DITROPAN XL -oxybutynin chloride tab sr 24hr 15 mg..... 78 DITROPAN XL -oxybutynin chloride tab sr 24hr 5 mg.......78 DIURIL -chlorothiazide susp 250 mg/5ml.......................... 57 divalproex sodium cap sprinkle 125 mg (Depakote sprinkles)...................................................................... 120 divalproex sodium tab delayed release 125 mg (Depakote).....................................................................120 divalproex sodium tab delayed release 250 mg (Depakote).....................................................................120 divalproex sodium tab delayed release 500 mg (Depakote).....................................................................120 divalproex sodium tab sr 24 hr 250 mg (Depakote er)...................................................................................120 divalproex sodium tab sr 24 hr 500 mg (Depakote er)...................................................................................120 DIVIGEL -estradiol td gel 0.25 mg/0.25gm (0.1%)............ 27 DIVIGEL -estradiol td gel 0.5 mg/0.5gm (0.1%)................ 27 198 DIVIGEL -estradiol td gel 1 mg/gm (0.1%)........................ 27 DIVISTA - folic acid-vit b6-vit b12-omega 3-biotin-cr cap 1 mg ................................................................................. 135 DOLGIC PLUS -butalbital-acetaminophen-caffeine tab 50-750-40 mg.................................................................101 DOLOGESIC -phenyltoloxamine-acetaminophen liquid 30-500 mg/15ml............................................................. 101 DOLOPHINE HCL -methadone hcl tab 5 mg.................. 103 DOLOPHINE -methadone hcl tab 10 mg.........................103 DONATUSS DC -phenylephrine-dihydrocodeine-gg syrup 7.5-7.5-50 mg/5ml............................................................65 donepezil hydrochloride orally disintegrating tab 10 mg (Aricept odt)............................................................. 97 donepezil hydrochloride orally disintegrating tab 5 mg.................................................................................... 97 donepezil hydrochloride tab 10 mg (Aricept)................97 donepezil hydrochloride tab 23 mg (Aricept)................97 donepezil hydrochloride tab 5 mg (Aricept)..................97 DONNATAL EXTENTABS -pb-hyoscy-atrop-scopol tab cr 48.6-0.3111-0.0582-0.0195 mg........................................72 DONNATAL -pb-hyoscy-atrop-scopol elix 16.2-0.1037-0.0194-0.0065 mg/5ml.................................72 DONNATAL -pb-hyoscy-atrop-scopol tab 16.2-0.1037-0.0194-0.0065 mg........................................72 DORAL -quazepam tab 15 mg.......................................... 92 dorzolamide hcl ophth soln 2% (Trusopt)................... 142 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml (Cosopt).............................................................142 DOUBLEDEX - dexamethasone sodium phosphate pf inj 10 mg/ml kit .................................................................... 23 DOVONEX -calcipotriene cream 0.005%........................ 154 doxazosin mesylate tab 1 mg (Cardura)........................52 doxazosin mesylate tab 2 mg (Cardura)........................52 doxazosin mesylate tab 4 mg (Cardura)........................52 doxazosin mesylate tab 8 mg (Cardura)........................52 doxepin hcl cap 100 mg..................................................84 doxepin hcl cap 10 mg................................................... 83 doxepin hcl cap 150 mg..................................................84 doxepin hcl cap 25 mg................................................... 84 doxepin hcl cap 50 mg................................................... 84 doxepin hcl conc 10 mg/ml............................................ 84 DOXEPIN HCL -doxepin hcl cap 75 mg............................83 doxercalciferol cap 0.5 mcg (Hectorol)......................... 40 doxercalciferol cap 1 mcg (Hectorol)............................ 40 doxercalciferol cap 2.5 mcg (Hectorol)......................... 40 doxycycline hyclate cap 100 mg (Vibramycin)............... 4 doxycycline hyclate cap 50 mg........................................5 doxycycline hyclate tab 100 mg.......................................5 doxycycline hyclate tab 20 mg.........................................5 doxycycline hyclate tab delayed release 150 mg (Doryx)...............................................................................5 doxycycline monohydrate cap 100 mg (Monodox).........5 doxycycline monohydrate cap 150 mg (Adoxa)............. 5 doxycycline monohydrate cap 50 mg..............................5 doxycycline monohydrate cap 75 mg (Monodox)...........5 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 DURAGESIC -fentanyl td patch 72hr 25 mcg/hr..............103 DURAGESIC -fentanyl td patch 72hr 50 mcg/hr..............103 DURAGESIC -fentanyl td patch 72hr 75 mcg/hr..............103 DURASAFE SPINAL/EPIDURAL -lidocaine hcl local inj kit 1%.................................................................................. 117 DUREZOL -difluprednate ophth emulsion 0.05%............ 142 DUTOPROL -metoprolol & hydrochlorothiazide tab sr 24hr 100-12.5 mg.....................................................................52 DUTOPROL -metoprolol & hydrochlorothiazide tab sr 24hr 25-12.5 mg.......................................................................52 DUTOPROL -metoprolol & hydrochlorothiazide tab sr 24hr 50-12.5 mg.......................................................................52 D-VI-SOL -cholecalciferol oral liquid 400 unit/ml............. 128 DYAZIDE -triamterene & hydrochlorothiazide cap 37.5-25 mg.................................................................................... 57 DYMISTA -azelastine hcl-fluticasone prop nasal spray 137-50 mcg/act................................................................ 64 dyphylline-guaifenesin liqd 100-100 mg/5ml.................68 DYRENIUM -triamterene cap 100 mg............................... 57 DYRENIUM -triamterene cap 50 mg................................. 57 DYSPORT -abobotulinumtoxina for inj 300 unit.............. 126 DYSPORT -abobotulinumtoxina for inj 500 unit.............. 126 DYURAL-40 -methylprednisolone inj 40 mg/ml & bupiv 0.25% &lido 1% kit.......................................................... 23 DYURAL-80 -methylprednisolone inj 80 mg/ml & bupiv 0.25% &lido 1% kit.......................................................... 23 DYURAL-L -methylprednisolone inj 40 mg/ml & lidocaine inj 1% kit.......................................................................... 23 DYURAL-LM -methylprednisolone inj 40 mg/ml & bupiv 0.25% &lido 1% kit.......................................................... 23 doxycycline monohydrate tab 100 mg (Adoxa pak 1/100)................................................................................. 5 doxycycline monohydrate tab 150 mg (Adoxa pak 1/150)................................................................................. 5 doxycycline monohydrate tab 50 mg (Adoxa)................ 5 doxycycline monohydrate tab 75 mg (Adoxa)................ 5 DOXYTEX -doxylamine succinate liquid 2.5 mg/2.5ml...... 63 DRIHEP ARTERIAL LINE SAMP - arterial blood gas kit ....................................................................................... 168 DRIHEP PLUS 3ML LL PREFIL - arterial blood gas kit ....................................................................................... 168 DRIHEP PLUS 3ML PREFILLED - arterial blood gas kit ....................................................................................... 168 DRISDOL -ergocalciferol cap 50000 unit........................ 128 DRITHO-CREME HP -anthralin cream 1%......................154 dronabinol cap 10 mg (Marinol)..................................... 74 dronabinol cap 2.5 mg (Marinol).................................... 74 dronabinol cap 5 mg (Marinol)....................................... 74 droperidol inj 2.5 mg/ml..................................................81 drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz)......29 drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin 28).................................................................................... 29 DROXIA -hydroxyurea cap 200 mg................................. 135 DROXIA -hydroxyurea cap 300 mg................................. 135 DROXIA -hydroxyurea cap 400 mg................................. 135 DRYSOL -aluminum chloride soln 20%...........................154 DUAC -clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5%...................................................................... 154 DUAVEE -conjugated estrogens-bazedoxifene tab 0.45-20 mg.................................................................................... 27 DUETACT -pioglitazone hcl-glimepiride tab 30-2 mg........ 32 DUETACT -pioglitazone hcl-glimepiride tab 30-4 mg........ 32 DUEXIS -ibuprofen-famotidine tab 800-26.6 mg............. 111 DULERA -mometasone furoate-formoterol fumarate aerosol 100-5 mcg/act..................................................... 68 DULERA -mometasone furoate-formoterol fumarate aerosol 200-5 mcg/act..................................................... 68 duloxetine hcl enteric coated pellets cap 20 mg (Cymbalta).......................................................................84 duloxetine hcl enteric coated pellets cap 30 mg (Cymbalta).......................................................................84 duloxetine hcl enteric coated pellets cap 60 mg (Cymbalta).......................................................................84 DUOCAINE -lidocaine hcl-bupivacaine hcl inj 1-0.375%........................................................................ 117 DUODOTE -atropine 2.1 mg/0.7ml-pralidoxime cl 600 mg/2ml im auto-inj......................................................... 167 DUONEB -ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml..............................................................................68 DURACLON -clonidine hcl inj (for epidural infusion) 100 mcg/ml............................................................................101 DURACLON -clonidine hcl inj (for epidural infusion) 500 mcg/ml............................................................................101 DURAGESIC -fentanyl td patch 72hr 100 mcg/hr............103 DURAGESIC -fentanyl td patch 72hr 12 mcg/hr..............103 E E.E.S. 400 -erythromycin ethylsuccinate tab 400 mg.......... 4 E.E.S. GRANULES -erythromycin ethylsuccinate for susp 200 mg/5ml........................................................................ 4 EC-NAPROSYN -naproxen tab ec 375 mg..................... 112 EC-NAPROSYN -naproxen tab ec 500 mg..................... 112 econazole nitrate cream 1%......................................... 154 ECOTRIN REGULAR STRENGTH -aspirin tab delayed release 325 mg.............................................................. 101 ECOZA -econazole nitrate foam 1%............................... 154 EDARBI -azilsartan medoxomil tab 40 mg........................ 52 EDARBI -azilsartan medoxomil tab 80 mg........................ 52 EDARBYCLOR -azilsartan medoxomil-chlorthalidone tab 40-12.5 mg.......................................................................52 EDARBYCLOR -azilsartan medoxomil-chlorthalidone tab 40-25 mg..........................................................................52 ED CYTE F -ferrous fumarate-folic acid-docusate sodium tab 324-1-50 mg............................................................ 135 EDECRIN -ethacrynic acid tab 25 mg............................... 57 EDLUAR -zolpidem tartrate sl tab 10 mg.......................... 92 EDLUAR -zolpidem tartrate sl tab 5 mg............................ 92 EDURANT -rilpivirine hcl tab 25 mg (base equivalent)........ 8 EFFER-K -potassium bicarbonate-citric acid effer tab 10 meq................................................................................ 132 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 199 2015 EFFER-K -potassium bicarbonate-citric acid effer tab 20 meq................................................................................ 132 EFFEXOR XR -venlafaxine hcl cap sr 24hr 150 mg (base equivalent)........................................................................84 EFFEXOR XR -venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent)........................................................................84 EFFEXOR XR -venlafaxine hcl cap sr 24hr 75 mg (base equivalent)........................................................................84 EFFIENT -prasugrel hcl tab 10 mg (base equiv)............. 140 EFFIENT -prasugrel hcl tab 5 mg (base equiv)............... 140 EFUDEX -fluorouracil cream 5%..................................... 154 EGRIFTA -tesamorelin acetate for inj 1 mg (base equiv)................................................................................40 EGRIFTA -tesamorelin acetate for inj 2 mg (base equiv)................................................................................40 ELDEPRYL -selegiline hcl cap 5 mg............................... 124 ELENZAPATCH -lidocaine-menthol patch 4-1%............. 154 ELESTAT -epinastine hcl ophth soln 0.05%....................142 ELESTRIN -estradiol gel 0.06% (0.52 mg/0.87 gm metered-dose pump)........................................................27 ELETONE - emollient - cream ........................................154 ELETONE TWINPACK - emollient - cream .................... 154 ELIDEL -pimecrolimus cream 1%....................................154 ELIGARD -leuprolide acetate (3 month) for subcutaneous inj kit 22.5mg................................................................... 19 ELIGARD -leuprolide acetate (4 month) for subcutaneous inj kit 30 mg..................................................................... 19 ELIGARD -leuprolide acetate (6 month) for subcutaneous inj kit 45 mg..................................................................... 19 ELIGARD -leuprolide acetate for subcutaneous inj kit 7.5 mg.................................................................................... 19 ELIMITE -permethrin cream 5%...................................... 154 ELIPHOS -calcium acetate (phosphate binder) tab 667 mg.................................................................................... 76 ELIQUIS -apixaban tab 2.5 mg....................................... 138 ELIQUIS -apixaban tab 5 mg.......................................... 138 ELIXOPHYLLIN -theophylline elixir 80 mg/15ml................68 ELLA -ulipristal acetate tab 30 mg.................................... 29 ELLIOTTS B - intrathecal electrolytes w/ dextrose ......... 132 ELMIRON -pentosan polysulfate sodium caps 100 mg..... 80 ELOCON -mometasone furoate cream 0.1%.................. 154 ELOCON -mometasone furoate oint 0.1%...................... 154 ELOCON -mometasone furoate solution 0.1% (lotion)............................................................................ 154 ELSPAR -asparaginase for inj 10000 unit......................... 19 EMADINE -emedastine difumarate ophth soln 0.05% (base equiv)................................................................... 142 EMCYT -estramustine phosphate sodium cap 140 mg......19 EMEND -aprepitant capsule 125 mg................................. 74 EMEND -aprepitant capsule 40 mg...................................74 EMEND -aprepitant capsule 80 mg...................................74 EMEND -aprepitant capsule therapy pack 80 & 125 mg.................................................................................... 74 EMLA -lidocaine-prilocaine cream 2.5-2.5%....................154 EMSAM -selegiline td patch 24hr 12 mg/24hr................... 84 200 EMSAM -selegiline td patch 24hr 6 mg/24hr..................... 84 EMSAM -selegiline td patch 24hr 9 mg/24hr..................... 84 EMTRIVA -emtricitabine caps 200 mg................................ 8 EMTRIVA -emtricitabine soln 10 mg/ml...............................8 EMULSION SB - dermatological products misc - emulsion ....................................................................................... 154 ENABLEX -darifenacin hydrobromide tab sr 24hr 15 mg (base equiv)..................................................................... 78 ENABLEX -darifenacin hydrobromide tab sr 24hr 7.5 mg (base equiv)..................................................................... 78 enalapril maleate & hydrochlorothiazide tab 10-25 mg (Vaseretic)....................................................................... 52 enalapril maleate & hydrochlorothiazide tab 5-12.5 mg.................................................................................... 52 enalapril maleate tab 10 mg (Vasotec).......................... 52 enalapril maleate tab 2.5 mg (Vasotec)......................... 52 enalapril maleate tab 20 mg (Vasotec).......................... 52 enalapril maleate tab 5 mg (Vasotec)............................ 52 ENBREL -etanercept for subcutaneous inj kit 25 mg.......112 ENBREL -etanercept subcutaneous soln prefilled syringe 25 mg/0.5ml................................................................... 112 ENBREL -etanercept subcutaneous soln prefilled syringe 50 mg/ml........................................................................ 112 ENBREL SURECLICK -etanercept subcutaneous solution auto-injector 50 mg/ml................................................... 112 ENCARE -nonoxynol-9 vaginal suppos 100 mg................ 79 ENDOMETRIN -progesterone vaginal insert 100 mg........ 79 ENGERIX-B -hepatitis b vaccine (recombinant) 10 mcg/0.5ml.........................................................................14 ENGERIX-B -hepatitis b vaccine (recombinant) 20 mcg/ ml......................................................................................14 ENGERIX-B -hepatitis b vaccine (recombinant) susp 10 mcg/0.5ml.........................................................................14 ENGERIX-B -hepatitis b vaccine (recombinant) susp 20 mcg/ml..............................................................................14 ENJUVIA -estrogens, conjugated synthetic b tab 0.3 mg.................................................................................... 27 ENJUVIA -estrogens, conjugated synthetic b tab 0.45 mg.................................................................................... 27 ENJUVIA -estrogens, conjugated synthetic b tab 0.625 mg.................................................................................... 27 ENJUVIA -estrogens, conjugated synthetic b tab 0.9 mg.................................................................................... 27 ENJUVIA -estrogens, conjugated synthetic b tab 1.25 mg.................................................................................... 27 ENLON -edrophonium chloride inj 10 mg/ml................... 128 ENOVARX-AMITRIPTYLINE -amitriptyline hcl cream 2% kit (compounding kit)......................................................168 ENOVARX-BACLOFEN - baclofen cream 1% (compound kit) ................................................................................. 154 ENOVARX-CYCLOBENZAPRINE H - cyclobenzaprine hcl td cream 20 mg/gm (compound kit) ..............................127 ENOVARX-IBUPROFEN - ibuprofen cream 10% (compounding kit) ......................................................... 154 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 EQUETRO -carbamazepine (antipsychotic) cap sr 12hr 200 mg............................................................................. 88 EQUETRO -carbamazepine (antipsychotic) cap sr 12hr 300 mg............................................................................. 88 ERECAID CLASSIC - impotence aid device - kit ............169 ERECAID ESTEEM - impotence aid device - kit ............ 169 ergocalciferol cap 50000 unit (Drisdol)........................128 ergoloid mesylates tab 1 mg.......................................... 97 ERGOMAR -ergotamine tartrate sl tab 2 mg...................115 ERIVEDGE -vismodegib cap 150 mg................................19 EROS-CTD - clitoral vacuum device .............................. 169 ERTACZO -sertaconazole nitrate cream 2%...................155 ERWINAZE -asparaginase erwinia chrysanthemi for im inj 10000 unit........................................................................ 19 ERYGEL -erythromycin gel 2%....................................... 155 ERYPED 200 -erythromycin ethylsuccinate for susp 200 mg/5ml................................................................................4 ERYPED 400 -erythromycin ethylsuccinate for susp 400 mg/5ml................................................................................4 ERYSIDORON #2 - misc natural products tab ............... 171 ERY-TAB -erythromycin tab delayed release 250 mg......... 4 ERY-TAB -erythromycin tab delayed release 333 mg......... 4 ERY-TAB -erythromycin tab delayed release 500 mg......... 4 ERYTHROCIN STEARATE -erythromycin stearate tab 250 mg...................................................................................... 4 ERYTHROMYCIN BASE -erythromycin tab 250 mg........... 4 ERYTHROMYCIN BASE -erythromycin tab 500 mg........... 4 ERYTHROMYCIN ETHYLSUCCINA -erythromycin ethylsuccinate tab 400 mg.................................................4 erythromycin gel 2% (Erygel)....................................... 155 erythromycin ophth oint 5 mg/gm............................... 142 erythromycin pads 2%.................................................. 155 erythromycin soln 2%................................................... 155 erythromycin-sulfisoxazole for susp 200-600 mg/5ml.............................................................................13 erythromycin w/ delayed release particles cap 250 mg...................................................................................... 4 ESBRIET -pirfenidone cap 267 mg................................... 70 ESCAVITE D - pediatric multiple vitamins w/ fl-fe chew tab 0.25-6 mg ..................................................................... 130 ESCAVITE - pediatric multiple vitamins w/ fl-fe chew tab 0.25-7.5 mg .................................................................. 129 escitalopram oxalate soln 5 mg/5ml (base equiv) (Lexapro)......................................................................... 84 escitalopram oxalate tab 10 mg (base equiv) (Lexapro)......................................................................... 84 escitalopram oxalate tab 20 mg (base equiv) (Lexapro)......................................................................... 84 escitalopram oxalate tab 5 mg (base equiv) (Lexapro)......................................................................... 84 ESGIC -butalbital-acetaminophen-caffeine cap 50-325-40 mg.................................................................................. 101 ESGIC -butalbital-acetaminophen-caffeine tab 50-325-40 mg.................................................................................. 101 ENOVARX-LIDOCAINE HCL - lidocaine hcl cream 10% (compound kit) .............................................................. 154 ENOVARX-LIDOCAINE HCL - lidocaine hcl cream 5% (compound kit) .............................................................. 154 ENOVARX-NAPROXEN - naproxen cream 10% (compound kit) .............................................................. 154 ENOVARX-TRAMADOL - tramadol hcl cream 5% (compound kit) .............................................................. 154 enoxaparin sodium inj 100 mg/ml (Lovenox).............. 138 enoxaparin sodium inj 120 mg/0.8ml (Lovenox)......... 138 enoxaparin sodium inj 150 mg/ml (Lovenox).............. 138 enoxaparin sodium inj 300 mg/3ml (Lovenox)............ 138 enoxaparin sodium inj 30 mg/0.3ml (Lovenox)........... 138 enoxaparin sodium inj 40 mg/0.4ml (Lovenox)........... 138 enoxaparin sodium inj 60 mg/0.6ml (Lovenox)........... 138 enoxaparin sodium inj 80 mg/0.8ml (Lovenox)........... 138 entacapone tab 200 mg (Comtan)................................ 124 entecavir tab 0.5 mg (Baraclude)..................................... 8 entecavir tab 1 mg (Baraclude)........................................ 8 ENTEREG -alvimopan cap 12 mg.....................................76 ENTOCORT EC -budesonide cap sr 24hr 3 mg................23 EPANED -enalapril maleate for oral soln 1 mg/ml.............52 ephedrine sulfate inj 50 mg/ml.......................................58 EPICERAM - dermatological products misc - emulsion ....................................................................................... 154 EPIDUO -adapalene-benzoyl peroxide gel 0.1-2.5%.......154 EPIFOAM -pramoxine-hc aerosol foam 1-1%................. 154 epinastine hcl ophth soln 0.05% (Elestat)................... 142 EPINEPHRINE -epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000).......................................................... 58 EPINEPHRINE -epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)............................................................58 epinephrine hcl inj 1 mg/ml............................................68 epinephrine hcl soln prefilled syringe 0.1 mg/ml..........68 EPIPEN 2-PAK -epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)............................................................58 EPIPEN-JR 2-PAK -epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000)............................................................59 EPIVIR HBV -lamivudine oral soln 5 mg/ml........................ 8 EPIVIR HBV -lamivudine tab 100 mg..................................8 EPIVIR -lamivudine oral soln 10 mg/ml...............................8 EPIVIR -lamivudine tab 150 mg.......................................... 8 EPIVIR -lamivudine tab 300 mg.......................................... 8 eplerenone tab 25 mg (Inspra)....................................... 52 eplerenone tab 50 mg (Inspra)....................................... 53 EPOGEN -epoetin alfa inj 10000 unit/ml......................... 135 EPOGEN -epoetin alfa inj 20000 unit/ml......................... 135 EPOGEN -epoetin alfa inj 2000 unit/ml........................... 135 EPOGEN -epoetin alfa inj 3000 unit/ml........................... 135 EPOGEN -epoetin alfa inj 4000 unit/ml........................... 135 eprosartan mesylate tab 600 mg (Teveten)................... 53 EPZICOM -abacavir sulfate-lamivudine tab 600-300 mg.....8 EQUAGESIC -meprobamate-aspirin tab 200-325 mg..... 101 EQUETRO -carbamazepine (antipsychotic) cap sr 12hr 100 mg............................................................................. 88 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 201 2015 ESGIC-PLUS -butalbital-acetaminophen-caffeine cap 50-500-40 mg.................................................................101 ESGIC-PLUS -butalbital-acetaminophen-caffeine tab 50-500-40 mg.................................................................101 estazolam tab 1 mg......................................................... 92 estazolam tab 2 mg......................................................... 92 esterified estrogens & methyltestosterone tab 0.625-1.25 mg................................................................. 27 esterified estrogens & methyltestosterone tab 1.25-2.5 mg.................................................................................... 27 ESTRACE -estradiol tab 0.5 mg........................................27 ESTRACE -estradiol tab 1 mg.......................................... 27 ESTRACE -estradiol tab 2 mg.......................................... 27 ESTRACE -estradiol vaginal cream 0.1 mg/gm.................79 estradiol & norethindrone acetate tab 0.5-0.1 mg (Activella)........................................................................ 27 estradiol & norethindrone acetate tab 1-0.5 mg (Activella)........................................................................ 27 estradiol tab 0.5 mg (Estrace)........................................ 27 estradiol tab 1 mg (Estrace)........................................... 27 estradiol tab 2 mg (Estrace)........................................... 27 estradiol td patch weekly 0.025 mg/24hr (Climara).......27 estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) (Climara)....................................................... 27 estradiol td patch weekly 0.05 mg/24hr (Climara).........27 estradiol td patch weekly 0.06 mg/24hr (Climara).........27 estradiol td patch weekly 0.075 mg/24hr (Climara).......27 estradiol td patch weekly 0.1 mg/24hr (Climara)...........27 estradiol valerate im in oil 10 mg/ml............................. 27 estradiol valerate im in oil 20 mg/ml (Delestrogen)...... 27 estradiol valerate im in oil 40 mg/ml (Delestrogen)...... 27 ESTRASORB -estradiol transdermal emulsion 4.35 mg/1.74gm....................................................................... 27 ESTRING -estradiol vaginal ring 2 mg (7.5 mcg/24hrs).....79 ESTROGEL -estradiol gel 0.06% (0.75 mg/1.25 gm metered-dose pump)........................................................27 ESTROPIPATE -estropipate tab 3 mg.............................. 27 estropipate tab 0.75 mg.................................................. 27 estropipate tab 1.5 mg.................................................... 27 ESTROSTEP FE -norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg....................................................29 eszopiclone tab 1 mg (Lunesta).....................................92 eszopiclone tab 2 mg (Lunesta).....................................92 eszopiclone tab 3 mg (Lunesta).....................................92 ethambutol hcl tab 100 mg (Myambutol).........................6 ethambutol hcl tab 400 mg (Myambutol).........................6 ethosuximide cap 250 mg (Zarontin)........................... 120 ethosuximide soln 250 mg/5ml (Zarontin)...................120 ETHYL CHLORIDE/FINE PINPO -ethyl chloride aerosol spray...............................................................................155 ETHYL CHLORIDE/FINE STREA -ethyl chloride aerosol spray...............................................................................155 ETHYL CHLORIDE/MEDIUM JET -ethyl chloride aerosol spray...............................................................................155 202 ETHYL CHLORIDE/MEDIUM STR -ethyl chloride aerosol spray...............................................................................155 ETHYL CHLORIDE/MIST -ethyl chloride aerosol spray...............................................................................155 ETHYL CHLORIDE -ethyl chloride aerosol spray............155 ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg.................................................................................. 29 ETIDRONATE DISODIUM -etidronate disodium tab 200 mg.................................................................................... 40 ETIDRONATE DISODIUM -etidronate disodium tab 400 mg.................................................................................... 40 etodolac cap 200 mg..................................................... 112 etodolac cap 300 mg..................................................... 112 etodolac tab 400 mg......................................................112 etodolac tab 500 mg......................................................112 etodolac tab sr 24hr 400 mg.........................................112 etodolac tab sr 24hr 500 mg.........................................112 etodolac tab sr 24hr 600 mg.........................................112 ETOPOSIDE -etoposide cap 50 mg..................................19 EUCALYPTUS OIL -eucalyptus (topical) oil.................... 155 EURAX -crotamiton cream 10%...................................... 155 EURAX -crotamiton lotion 10%....................................... 155 EVAMIST -estradiol transdermal spray 1.53 mg/spray...... 27 EVICEL - fibrin sealant component kit 2 ml ....................140 EVICEL - fibrin sealant component kit 5 ml ....................140 EVISTA -raloxifene hcl tab 60 mg..................................... 40 EVITHROM -thrombin (human) topical soln 800-1200 unit/ ml....................................................................................140 EVOCLIN -clindamycin phosphate foam 1%................... 155 EVOXAC -cevimeline hcl cap 30 mg...............................146 EVZIO -naloxone hcl solution auto-injector 0.4 mg/0.4ml.........................................................................167 EXACTUSS -phenylephrine w/ dm-gg liqd 10-28-388 mg/5ml..............................................................................65 EXALGO -hydromorphone hcl tab er 24hr deter 12 mg.................................................................................. 104 EXALGO -hydromorphone hcl tab er 24hr deter 16 mg.................................................................................. 104 EXALGO -hydromorphone hcl tab er 24hr deter 32 mg.................................................................................. 104 EXALGO -hydromorphone hcl tab er 24hr deter 8 mg.....104 EXELDERM -sulconazole nitrate cream 1%....................155 EXELDERM -sulconazole nitrate solution 1%................. 155 EXELON -rivastigmine tartrate cap 1.5 mg....................... 97 EXELON -rivastigmine tartrate cap 3 mg.......................... 97 EXELON -rivastigmine tartrate cap 4.5 mg....................... 97 EXELON -rivastigmine tartrate cap 6 mg.......................... 97 EXELON -rivastigmine tartrate soln 2 mg/ml..................... 97 EXELON -rivastigmine td patch 24hr 13.3 mg/24hr...........97 EXELON -rivastigmine td patch 24hr 4.6 mg/24hr.............97 EXELON -rivastigmine td patch 24hr 9.5 mg/24hr.............97 exemestane tab 25 mg (Aromasin)................................ 19 EXFORGE -amlodipine besylate-valsartan tab 10-160 mg.................................................................................... 53 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 FARXIGA -dapagliflozin propanediol tab 10 mg (base equivalent)........................................................................32 FARXIGA -dapagliflozin propanediol tab 5 mg (base equivalent)........................................................................32 FASLODEX -fulvestrant inj 250 mg/5ml............................ 19 FAZACLO -clozapine orally disintegrating tab 100 mg...... 88 FAZACLO -clozapine orally disintegrating tab 12.5 mg..... 88 FAZACLO -clozapine orally disintegrating tab 150 mg...... 88 FAZACLO -clozapine orally disintegrating tab 200 mg...... 88 FAZACLO -clozapine orally disintegrating tab 25 mg........ 88 FBL KIT - flurbiprofen-baclofen-lidocaine cream 15-4-5% (cmpd kit) ......................................................................155 FC2 FEMALE CONDOM - condoms - female ................ 169 FC FEMALE CONDOM - condoms - female .................. 169 FE 90 PLUS - fe carbonyl-fe gluconate-fa-vit b12-vit c-dss tab 90-1 mg .................................................................. 135 fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1 mg.................................................................................. 135 fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240 mg.................................................................................. 135 fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu cap (Tandem plus)....................................................... 134 felbamate susp 600 mg/5ml (Felbatol).........................120 felbamate tab 400 mg (Felbatol)...................................120 felbamate tab 600 mg (Felbatol)...................................120 FELBATOL -felbamate susp 600 mg/5ml........................ 120 FELBATOL -felbamate tab 400 mg................................. 120 FELBATOL -felbamate tab 600 mg................................. 120 FELDENE -piroxicam cap 10 mg.................................... 112 FELDENE -piroxicam cap 20 mg.................................... 112 felodipine tab sr 24hr 10 mg.......................................... 47 felodipine tab sr 24hr 2.5 mg......................................... 47 felodipine tab sr 24hr 5 mg............................................ 47 FEMARA -letrozole tab 2.5 mg......................................... 19 FEMCAP -cervical cap 22 mm........................................ 169 FEMCAP -cervical cap 26 mm........................................ 169 FEMCAP -cervical cap 30 mm........................................ 169 FEMCON FE -norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg.......................................................... 29 FEMHRT 1/5 -norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg......................................................................... 28 FEMHRT LOW DOSE -norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg........................................... 28 FEM PH -acetic acid-oxyquinoline vaginal gel 0.9-0.025%....................................................................... 79 FEMRING -estradiol acetate vaginal ring 0.05 mg/24hr............................................................................ 79 FEMRING -estradiol acetate vaginal ring 0.1 mg/24hr...... 79 FENOFIBRATE -fenofibrate cap 150 mg.......................... 60 FENOFIBRATE -fenofibrate cap 50 mg............................ 60 fenofibrate micronized cap 130 mg............................... 60 fenofibrate micronized cap 134 mg (Lofibra)................ 60 fenofibrate micronized cap 200 mg (Lofibra)................ 60 fenofibrate micronized cap 43 mg................................. 60 fenofibrate micronized cap 67 mg (Lofibra).................. 60 EXFORGE -amlodipine besylate-valsartan tab 10-320 mg.................................................................................... 53 EXFORGE -amlodipine besylate-valsartan tab 5-160 mg.................................................................................... 53 EXFORGE -amlodipine besylate-valsartan tab 5-320 mg.................................................................................... 53 EXFORGE HCT -amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5 mg......................................................... 53 EXFORGE HCT -amlodipine-valsartan-hydrochlorothiazide tab 10-160-25 mg............................................................ 53 EXFORGE HCT -amlodipine-valsartan-hydrochlorothiazide tab 10-320-25 mg............................................................ 53 EXFORGE HCT -amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg........................................................... 53 EXFORGE HCT -amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg.............................................................. 53 EXJADE -deferasirox tab for oral susp 125 mg............... 167 EXJADE -deferasirox tab for oral susp 250 mg............... 167 EXJADE -deferasirox tab for oral susp 500 mg............... 167 EXPAREL -bupivacaine liposome inj 1.3% (13.3 mg/ ml).................................................................................. 117 EXTAVIA -interferon beta-1b for inj kit 0.3 mg.................. 97 EXTINA -ketoconazole foam 2%..................................... 155 EXTRANEAL - peritoneal dialysis solutions ................... 171 EYLEA -aflibercept intravitreal inj 2 mg/0.05ml (40 mg/ ml).................................................................................. 142 F FA-8 -folic acid cap 0.8 mg............................................. 135 FABIOR -tazarotene (acne) foam 0.1%...........................155 FACTIVE -gemifloxacin mesylate tab 320 mg (base equiv)..................................................................................5 FALESSA -levomefolate glucosamine tab 1 mg (folate equivalent)......................................................................133 FALESSA -levonorgest-eth estrad tab 0.1 mg-20 mcg & fa tab 1 mg kit......................................................................29 famciclovir tab 125 mg (Famvir)...................................... 8 famciclovir tab 250 mg (Famvir)...................................... 8 famciclovir tab 500 mg (Famvir)...................................... 8 famotidine for susp 40 mg/5ml (Pepcid)....................... 72 famotidine tab 20 mg (Pepcid)....................................... 72 famotidine tab 40 mg (Pepcid)....................................... 72 FAMVIR -famciclovir tab 125 mg.........................................8 FAMVIR -famciclovir tab 250 mg.........................................8 FAMVIR -famciclovir tab 500 mg.........................................8 FANAPT -iloperidone tab 10 mg....................................... 88 FANAPT -iloperidone tab 12 mg....................................... 88 FANAPT -iloperidone tab 1 mg......................................... 88 FANAPT -iloperidone tab 2 mg......................................... 88 FANAPT -iloperidone tab 4 mg......................................... 88 FANAPT -iloperidone tab 6 mg......................................... 88 FANAPT -iloperidone tab 8 mg......................................... 88 FANAPT TITRATION PACK -iloperidone tab 1 mg & 2 mg & 4 mg & 6 mg titration pak............................................ 88 FARESTON -toremifene citrate tab 60 mg (base equivalent)........................................................................19 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 203 2015 fenofibrate tab 145 mg (Tricor)...................................... 60 fenofibrate tab 160 mg (Lofibra).................................... 60 fenofibrate tab 48 mg (Tricor)........................................ 60 fenofibrate tab 54 mg (Lofibra)...................................... 60 FENOFIBRIC ACID -fenofibric acid tab 105 mg................ 60 FENOFIBRIC ACID -fenofibric acid tab 35 mg.................. 60 FENOGLIDE -fenofibrate tab 120 mg................................60 FENOGLIDE -fenofibrate tab 40 mg................................. 60 FENOPROFEN CALCIUM -fenoprofen calcium cap 400 mg.................................................................................. 112 FENOPROFEN CALCIUM -fenoprofen calcium tab 600 mg.................................................................................. 112 fentanyl citrate lollipop 1200 mcg (Actiq)....................104 fentanyl citrate lollipop 1600 mcg (Actiq)....................104 fentanyl citrate lollipop 200 mcg (Actiq)..................... 104 fentanyl citrate lollipop 400 mcg (Actiq)..................... 104 fentanyl citrate lollipop 600 mcg (Actiq)..................... 104 fentanyl citrate lollipop 800 mcg (Actiq)..................... 104 fentanyl td patch 72hr 100 mcg/hr (Duragesic)...........104 fentanyl td patch 72hr 12 mcg/hr (Duragesic).............104 fentanyl td patch 72hr 25 mcg/hr (Duragesic).............104 fentanyl td patch 72hr 50 mcg/hr (Duragesic).............104 fentanyl td patch 72hr 75 mcg/hr (Duragesic).............104 FENTORA -fentanyl citrate buccal tab 100 mcg (base equiv)..............................................................................104 FENTORA -fentanyl citrate buccal tab 200 mcg (base equiv)..............................................................................104 FENTORA -fentanyl citrate buccal tab 400 mcg (base equiv)..............................................................................104 FENTORA -fentanyl citrate buccal tab 600 mcg (base equiv)..............................................................................104 FENTORA -fentanyl citrate buccal tab 800 mcg (base equiv)..............................................................................104 FER-IN-SOL -ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe).................................................................. 135 FERIVA 21/7 - fe asparto gly-b12-fa-c-dss-succinic acid-zn tab 75-1 mg .................................................................. 135 FERIVAFA - iron-c-fa-b12-biotin-copper-docusate cap 110-1 mg ...................................................................... 135 FERIVA - fe bisglycin-fe carbonyl-c-fa-b12-biotin-dss cap 75-1 mg ........................................................................ 135 FERRALET 90 - fe carbonyl-fe gluconate-fa-vit b12-vit cdss tab 90-1 mg ........................................................... 135 FERRAPLUS 90 - iron-folic acid-vit b12-vit c-docusate sod tab 90-1 mg .................................................................. 135 FERRETTS CHEWABLE IRON -carbonyl iron chew tab 18 mg (elemental iron)........................................................135 FERREX 150 FORTE PLUS - fe asp gly-fe polysacch-succ ac-c-threon ac-b12-fa cap ............................................ 135 FERREX 28 - fe asparto gly-fe fum-b12-fa-c-succinic ac tab ther pack .................................................................135 FERRIC CITRATE -ferric citrate tab 1 gm (210 mg ferric iron).................................................................................. 76 FERRIPROX -deferiprone tab 500 mg............................ 167 204 FERRO-PLEX HEMATINIC - fe fum-dss-vit c-vit e-vit b12if-fa tab 115-1 mg ......................................................... 135 FERROTRIN -iron w/ b12-vit c-fa-ifc cap 36-0.015-75-0.5-240 mg................................................ 135 ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1 mg ...................................................................... 134 ferrous fumarate-folic acid tab 324-1 mg.................... 135 ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe)................................................................................... 135 FERROUS SULFATE -ferrous sulfate syrup 300 mg/5ml (60 mg/5ml elemental fe)...............................................135 ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe)................................................................................... 135 ferrous sulfate-vit c-folic acid tab cr 105-500-0.8 mg.................................................................................. 135 FETZIMA -levomilnacipran hcl cap sr 24hr 120 mg (base equivalent)........................................................................84 FETZIMA -levomilnacipran hcl cap sr 24hr 20 mg (base equivalent)........................................................................84 FETZIMA -levomilnacipran hcl cap sr 24hr 40 mg (base equivalent)........................................................................84 FETZIMA -levomilnacipran hcl cap sr 24hr 80 mg (base equivalent)........................................................................84 FETZIMA TITRATION PACK -levomilnacipran hcl cap sr 24hr 20 & 40 mg therapy pack........................................ 84 FEXMID -cyclobenzaprine hcl tab 7.5 mg....................... 127 FIBRICOR -fenofibric acid tab 105 mg..............................60 FIBRICOR -fenofibric acid tab 35 mg................................60 FINACEA -azelaic acid gel 15%......................................155 finasteride tab 5 mg (Proscar)........................................80 FIORICET/CODEINE -butalbital-acetaminophen-caff w/ cod cap 50-300-40-30 mg............................................. 104 FIORICET/CODEINE -butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg............................................. 104 FIORICET -butalbital-acetaminophen-caffeine cap 50-300-40 mg.................................................................101 FIORICET -butalbital-acetaminophen-caffeine tab 50-325-40 mg.................................................................101 FIORINAL/CODEINE #3 -butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg.................................................... 104 FIORINAL -butalbital-aspirin-caffeine cap 50-325-40 mg.................................................................................. 101 FIRAZYR -icatibant acetate inj 30 mg/3ml (base equivalent)......................................................................140 FIRMAGON -degarelix acetate for inj 120 mg (base equiv)................................................................................19 FIRMAGON -degarelix acetate for inj 80 mg (base equiv)................................................................................19 FIRST-BXN MOUTHWASH - diphenhydramine-lidocainenystatin susp .................................................................146 FIRST-DUKES MOUTHWASH - diphenhydraminehydrocortisone-nystatin susp ........................................ 146 FIRST-HYDROCORTISONE -hydrocortisone gel 10%................................................................................ 155 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 floxuridine for inj 0.5 gm................................................ 19 FLUARIX 2012-2013 -influenza virus vaccine split preservative free inj......................................................... 14 FLUARIX 2013-2014 -influenza virus vaccine split preservative free inj......................................................... 14 FLUARIX 2014-2015 -influenza virus vaccine split preservative free inj......................................................... 14 FLUARIX QUADRIVALENT 2013 -influenza virus vaccine split quadrivalent inj 0.5 ml.............................................. 14 FLUARIX QUADRIVALENT 2014 -influenza virus vaccine split quadrivalent inj 0.5 ml.............................................. 14 FLUBLOK 2013-2014 -influenza virus vac recombinant hemagglutinin (ha) inj...................................................... 14 FLUBLOK 2014-2015 -influenza virus vac recombinant hemagglutinin (ha) inj...................................................... 14 FLUCELVAX 2012-2013 -influenza virus vaccine tissuecultured subunit inj...........................................................14 FLUCELVAX 2013-2014 -influenza virus vaccine tissuecultured subunit inj...........................................................14 FLUCELVAX 2014-2015 -influenza virus vaccine tissuecultured subunit inj...........................................................14 fluconazole for susp 10 mg/ml (Diflucan)....................... 7 fluconazole for susp 40 mg/ml (Diflucan)....................... 7 fluconazole tab 100 mg (Diflucan)................................... 7 fluconazole tab 150 mg (Diflucan)................................... 7 fluconazole tab 200 mg (Diflucan)................................... 7 fluconazole tab 50 mg (Diflucan)..................................... 7 flucytosine cap 250 mg (Ancobon).................................. 7 flucytosine cap 500 mg (Ancobon).................................. 7 fludrocortisone acetate tab 0.1 mg................................ 23 FLULAVAL 2012-2013 -influenza virus vaccine split inj.....14 FLULAVAL 2013-2014 -influenza virus vaccine split inj.....14 FLULAVAL 2014-2015 -influenza virus vaccine split inj.....14 FLULAVAL QUADRIVALENT 201 -influenza virus vaccine split quadrivalent im inj.................................................... 14 FLULAVAL QUADRIVALENT 201 -influenza virus vaccine split quadrivalent inj 0.5 ml.............................................. 14 FLUMADINE -rimantadine hydrochloride tab 100 mg..........8 FLUMIST NASAL VACCINE 201 -influenza virus vaccine live intranasal liquid......................................................... 14 FLUMIST QUADRIVALENT -influenza virus vaccine live quadrivalent intranasal susp............................................ 14 flunisolide nasal soln 25 mcg/act (0.025%) (Flunisolide).................................................................... 64 fluocinolone acetonide (otic) oil 0.01% (Dermotic).....146 fluocinolone acetonide cream 0.01%...........................155 fluocinolone acetonide cream 0.025% (Synalar).........155 fluocinolone acetonide oil 0.01% (body oil) (Dermasmoothe/fs bod)........................................................... 155 fluocinolone acetonide oil 0.01% (scalp oil) (Dermasmoothe/fs sca)............................................................155 fluocinolone acetonide oint 0.025% (Synalar).............155 fluocinolone acetonide soln 0.01% (Synalar)..............155 fluocinonide cream 0.05%............................................ 155 fluocinonide cream 0.1% (Vanos)................................ 155 FIRST-MARYS MOUTHWASH - diphenhydraminehydrocortisone-nystatin-tetracycline susp ..................... 147 FIRST-MOUTHWASH BLM - diphenhyd-lidocaine-al hydroxide-mg hydroxide-simeth susp ........................... 147 FIRST-PROGESTERONE VGS 10 -progesterone vaginal suppository 100 mg......................................................... 79 FIRST-PROGESTERONE VGS 20 -progesterone vaginal suppository 200 mg......................................................... 79 FIRST-PROGESTERONE VGS 25 -progesterone vaginal suppository 25 mg........................................................... 79 FIRST-PROGESTERONE VGS 40 -progesterone vaginal suppository 400 mg......................................................... 79 FIRST-PROGESTERONE VGS 50 -progesterone vaginal suppository 50 mg........................................................... 79 FIRST-TESTOSTERONE MC COM -testosterone propionate td cream 2%.................................................. 26 FIRST-TESTOSTERONE -testosterone propionate td ointment 2%..................................................................... 26 FIRST-VANCOMYCIN 25 - vancomycin hcl oral soln 25 mg/ml (compound kit) ..................................................... 13 FIRST-VANCOMYCIN 50 - vancomycin hcl oral soln 50 mg/ml (compound kit) ..................................................... 13 FLAGYL ER -metronidazole tab sr 24hr 750 mg............... 13 FLAGYL -metronidazole cap 375 mg................................ 13 FLAGYL -metronidazole tab 250 mg................................. 13 FLAGYL -metronidazole tab 500 mg................................. 13 FLAREX -fluorometholone acetate ophth susp 0.1%...... 142 flavoxate hcl tab 100 mg.................................................78 flecainide acetate tab 100 mg.........................................49 flecainide acetate tab 150 mg.........................................49 flecainide acetate tab 50 mg.......................................... 49 FLECTOR -diclofenac epolamine patch 1.3%................. 155 FLEXERIL -cyclobenzaprine hcl tab 10 mg..................... 127 FLEXERIL -cyclobenzaprine hcl tab 5 mg.......................127 FLOMAX -tamsulosin hcl cap 0.4 mg................................80 FLO-PRED -prednisolone acetate oral susp 16.7 mg/5ml (15 mg/5ml base).............................................................23 FLORIVA -ped multiple vitamins & minerals w/ fl chew tab 0.5 mg............................................................................ 130 FLORIVA -ped multiple vitamins & minerals w/ fl chew tab 1 mg............................................................................... 130 FLORIVA -sodium fluoride-vitamin d liqd drops 0.25 mg/ ml-400 unit/ml................................................................ 132 FLOVENT DISKUS -fluticasone propionate aer pow ba 100 mcg/blister.................................................................68 FLOVENT DISKUS -fluticasone propionate aer pow ba 250 mcg/blister.................................................................68 FLOVENT DISKUS -fluticasone propionate aer pow ba 50 mcg/blister........................................................................ 68 FLOVENT HFA -fluticasone propionate hfa inhal aer 110 mcg/act (125/valve)..........................................................68 FLOVENT HFA -fluticasone propionate hfa inhal aer 220 mcg/act (250/valve)..........................................................68 FLOVENT HFA -fluticasone propionate hfa inhal aero 44 mcg/act (50/valve)............................................................68 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 205 2015 fluocinonide emulsified base cream 0.05%.................155 fluocinonide gel 0.05%..................................................155 fluocinonide oint 0.05%................................................ 155 fluocinonide soln 0.05%................................................155 FLUORABON -sodium fluoride soln 0.25 mg/0.6ml (from 0.55 mg/0.6ml naf).........................................................132 FLUOR-A-DAY -sodium fluoride-xylitol chew tab 0.55 (0.25 mg f)-236.79 mg............................................................ 132 FLUOR-A-DAY -sodium fluoride-xylitol chew tab 1.1 (0.5 mg f)-236.79 mg............................................................ 132 FLUOR-A-DAY -sodium fluoride-xylitol chew tab 2.2 (1 mg f)-236.79 mg...................................................................132 FLUORIDEX DAILY DEFENSE S -sodium fluoridepotassium nitrate gel 1.1-5%......................................... 147 fluorometholone ophth susp 0.1% (Fml liquifilm).......142 FLUOROPLEX -fluorouracil cream 1%............................155 fluorouracil cream 5% (Efudex)....................................155 FLUOROURACIL -fluorouracil cream 0.5%.....................155 fluorouracil soln 2%...................................................... 155 fluorouracil soln 5%...................................................... 155 fluoxetine hcl (pmdd) cap 10 mg................................... 97 fluoxetine hcl (pmdd) cap 20 mg................................... 97 fluoxetine hcl cap 10 mg (Prozac)................................. 84 fluoxetine hcl cap 20 mg (Prozac)................................. 84 fluoxetine hcl cap 40 mg (Prozac)................................. 84 fluoxetine hcl cap delayed release 90 mg (Prozac weekly)............................................................................ 84 FLUOXETINE HCL -fluoxetine hcl tab 60 mg....................84 fluoxetine hcl solution 20 mg/5ml..................................84 fluoxetine hcl tab 10 mg................................................. 84 fluoxetine hcl tab 20 mg................................................. 84 fluphenazine decanoate inj 25 mg/ml............................ 88 FLUPHENAZINE HCL -fluphenazine hcl elixir 2.5 mg/5ml..............................................................................88 FLUPHENAZINE HCL -fluphenazine hcl inj 2.5 mg/ml...... 88 FLUPHENAZINE HCL -fluphenazine hcl oral conc 5 mg/ ml......................................................................................88 fluphenazine hcl tab 10 mg............................................ 88 fluphenazine hcl tab 1 mg.............................................. 88 fluphenazine hcl tab 2.5 mg........................................... 88 fluphenazine hcl tab 5 mg.............................................. 88 FLURA-DROPS -sodium fluoride soln 0.25 mg/drop f (from 0.55 mg/drop naf).......................................................... 132 flurazepam hcl cap 15 mg.............................................. 92 flurazepam hcl cap 30 mg.............................................. 92 FLURAZEPAM HCL -flurazepam hcl cap 15 mg............... 92 FLURAZEPAM HCL -flurazepam hcl cap 30 mg............... 92 flurbiprofen sodium ophth soln 0.03% (Ocufen).........142 flurbiprofen tab 100 mg................................................ 112 flurbiprofen tab 50 mg.................................................. 112 flutamide cap 125 mg......................................................19 fluticasone propionate cream 0.05% (Cutivate).......... 155 fluticasone propionate lotion 0.05% (Cutivate)...........155 fluticasone propionate nasal susp 50 mcg/act (Flonase)......................................................................... 64 206 fluticasone propionate oint 0.005% (Cutivate)............ 155 fluvastatin sodium cap 20 mg (Lescol)......................... 60 fluvastatin sodium cap 40 mg (Lescol)......................... 60 FLUVIRIN 2012-2013 -influenza virus vaccine types a & b surface antigen inj............................................................14 FLUVIRIN 2013-2014 -influenza virus vaccine types a & b surface antigen inj............................................................15 FLUVIRIN 2014-2015 -influenza virus vaccine types a & b surface antigen inj............................................................15 FLUVIRIN PF 2012-2013 -influenza virus vaccine types a & b preservative free inj...................................................14 FLUVIRIN PF 2013-2014 -influenza virus vaccine types a & b preservative free inj...................................................14 FLUVIRIN PF 2014-2015 -influenza virus vaccine types a & b preservative free inj...................................................14 fluvoxamine maleate cap sr 24hr 100 mg (Luvox cr).....................................................................................84 fluvoxamine maleate cap sr 24hr 150 mg (Luvox cr).....................................................................................84 fluvoxamine maleate tab 100 mg................................... 84 fluvoxamine maleate tab 25 mg..................................... 84 fluvoxamine maleate tab 50 mg..................................... 84 FLUZONE HIGH-DOSE PF 2012 -influenza virus vac split high-dose preservative free inj.........................................15 FLUZONE HIGH-DOSE PF 2013 -influenza virus vac split high-dose preservative free inj.........................................15 FLUZONE HIGH-DOSE PF 2014 -influenza virus vac split high-dose preservative free inj.........................................15 FLUZONE INTRADERMAL -influenza virus vaccine split intradermal inj 9 mcg/strain............................................. 15 FLUZONE PEDIATRIC PF 2012 -influenza virus vaccine split preservative free inj..................................................15 FLUZONE PEDIATRIC PF 2013 -influenza virus vaccine split preservative free inj..................................................15 FLUZONE PF 2012-2013 -influenza virus vaccine split preservative free inj......................................................... 15 FLUZONE PF 2013-2014 -influenza virus vaccine split preservative free inj......................................................... 15 FLUZONE PF 2014-2015 -influenza virus vaccine split preservative free inj......................................................... 15 FLUZONE QUADRIVALENT 2013 -influenza virus vaccine split quadrivalent inj 0.25 ml............................................ 15 FLUZONE QUADRIVALENT 2013 -influenza virus vaccine split quadrivalent inj 0.5 ml.............................................. 15 FLUZONE QUADRIVALENT 2014 -influenza virus vaccine split quadrivalent im inj.................................................... 15 FLUZONE QUADRIVALENT 2014 -influenza virus vaccine split quadrivalent inj 0.25 ml............................................ 15 FLUZONE QUADRIVALENT 2014 -influenza virus vaccine split quadrivalent inj 0.5 ml.............................................. 15 FLUZONE SPLIT 2012-2013 -influenza virus vaccine split inj......................................................................................15 FLUZONE SPLIT 2013-2014 -influenza virus vaccine split inj......................................................................................15 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 FORMA-RAY -formaldehyde solution 20%......................166 FORTAMET -metformin hcl tab sr 24hr osmotic 1000 mg.................................................................................... 32 FORTAMET -metformin hcl tab sr 24hr osmotic 500 mg.................................................................................... 32 FORTAVIT - multiple vitamins w/ minerals cap .............. 130 FORTEO -teriparatide (recombinant) inj 600 mcg/2.4ml.........................................................................40 FORTESTA -testosterone td gel 10mg/act (2%)............... 26 FORTICAL -calcitonin (salmon) nasal soln 200 unit/ act.....................................................................................40 FOSAMAX -alendronate sodium tab 70 mg...................... 40 FOSAMAX PLUS D -alendronate sodium-cholecalciferol tab 70-2800 mg-unit.........................................................40 FOSAMAX PLUS D -alendronate sodium-cholecalciferol tab 70-5600 mg-unit.........................................................40 fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg.................................................................................... 53 fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg.................................................................................... 53 fosinopril sodium tab 10 mg.......................................... 53 fosinopril sodium tab 20 mg.......................................... 53 fosinopril sodium tab 40 mg.......................................... 53 fosphenytoin sodium inj 100 mg/2ml (phenytoin equiv) (Cerebyx).......................................................................120 fosphenytoin sodium inj 500 mg/10ml (phenytoin equiv) (Cerebyx)...........................................................120 FOSRENOL -lanthanum carbonate chew tab 1000 mg..... 76 FOSRENOL -lanthanum carbonate chew tab 500 mg....... 76 FOSRENOL -lanthanum carbonate chew tab 750 mg....... 76 FRAGMIN -dalteparin sodium inj 10000 unit/ml.............. 138 FRAGMIN -dalteparin sodium inj 12500 unit/0.5ml..........138 FRAGMIN -dalteparin sodium inj 15000 unit/0.6ml..........138 FRAGMIN -dalteparin sodium inj 18000 unit/0.72ml........138 FRAGMIN -dalteparin sodium inj 25000 unit/ml.............. 138 FRAGMIN -dalteparin sodium inj 2500 unit/0.2ml............138 FRAGMIN -dalteparin sodium inj 5000 unit/0.2ml............138 FRAGMIN -dalteparin sodium inj 7500 unit/0.3ml............138 FROVA -frovatriptan succinate tab 2.5 mg (base equivalent)......................................................................115 FULYZAQ -crofelemer tab delayed release 125 mg..........71 FURADANTIN -nitrofurantoin susp 25 mg/5ml.................. 77 FUROSEMIDE -furosemide oral soln 8 mg/ml.................. 57 furosemide inj 10 mg/ml................................................. 57 furosemide oral soln 10 mg/ml...................................... 57 furosemide tab 20 mg (Lasix).........................................58 furosemide tab 40 mg (Lasix).........................................58 furosemide tab 80 mg (Lasix).........................................58 FUSION PLUS - fe fum-iron poly cmplx-fa-b cmplx-cbiotin-probiotic cap ........................................................136 FUZEON -enfuvirtide for inj 90 mg......................................8 FYCOMPA -perampanel tab 10 mg.................................120 FYCOMPA -perampanel tab 12 mg.................................120 FYCOMPA -perampanel tab 2 mg.................................. 120 FYCOMPA -perampanel tab 4 mg.................................. 120 FLUZONE SPLIT 2014-2015 -influenza virus vaccine split inj......................................................................................15 FML -fluorometholone ophth oint 0.1%........................... 142 FML FORTE -fluorometholone ophth susp 0.25%...........142 FML LIQUIFILM -fluorometholone ophth susp 0.1%....... 142 FOCALIN -dexmethylphenidate hcl tab 10 mg.................. 94 FOCALIN -dexmethylphenidate hcl tab 2.5 mg................. 94 FOCALIN -dexmethylphenidate hcl tab 5 mg.................... 94 FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 10 mg.................................................................................... 94 FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 15 mg.................................................................................... 94 FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 20 mg.................................................................................... 94 FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 25 mg.................................................................................... 94 FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 30 mg.................................................................................... 94 FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 35 mg.................................................................................... 94 FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 40 mg.................................................................................... 94 FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 5 mg.................................................................................... 94 FOLBEE AR - folic acid-b12-b6-arginine-black pepper tab ....................................................................................... 133 FOLGARD OS -multiple vit w/ min & calcium-folic acid tab 500-1.1 mg.....................................................................130 FOLGARD RX -folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg....................................................................136 FOLIC ACID -folic acid inj 5 mg/ml................................. 136 folic acid tab 1 mg.........................................................136 folic acid tab 400 mcg...................................................136 folic acid tab 800 mcg...................................................136 folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg.................................................................................. 136 folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg (Folgard rx)................................................................... 136 folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg...... 136 folic acid-vit b6-vit b12-omega 3-phytosterols cap 1 mg .................................................................................134 FOLIVANE-F - fe fum-fe poly-fa-c-b3 cap 62.5-62.5-1-40-3mg(125 mg fe) ....................................136 FOLIVANE-PLUS - fe fum-iron polysacch complex-fa-b complex-c-biotin cap .....................................................136 FOLTRATE - cobalamine combination tab ..................... 136 fondaparinux sodium inj 10 mg/0.8ml (Arixtra)...........138 fondaparinux sodium inj 2.5 mg/0.5ml (Arixtra)..........138 fondaparinux sodium inj 5 mg/0.4ml (Arixtra).............138 fondaparinux sodium inj 7.5 mg/0.6ml (Arixtra)..........138 FORADIL AEROLIZER -formoterol fumarate inhal cap 12 mcg...................................................................................68 FORFIVO XL -bupropion hcl tab sr 24hr 450 mg.............. 84 FORMALDEHYDE -formaldehyde solution 37%............. 167 formaldehyde solution 10%.......................................... 167 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 207 2015 FYCOMPA -perampanel tab 6 mg.................................. 120 FYCOMPA -perampanel tab 8 mg.................................. 120 G gabapentin cap 100 mg (Neurontin)............................ 120 gabapentin cap 300 mg (Neurontin)............................ 120 gabapentin cap 400 mg (Neurontin)............................ 120 gabapentin oral soln 250 mg/5ml (Neurontin).............120 gabapentin tab 600 mg (Neurontin)............................. 120 gabapentin tab 800 mg (Neurontin)............................. 120 GABAVALE-5 -diazepam tab 5 mg & dietary management cap pack...........................................................................81 GABAZOLAMINE-0.5 -alprazolam tab 0.5 mg & dietary management cap pack.................................................... 81 GABAZOLAMINE -alprazolam tab 0.25 mg & dietary management cap pack.................................................... 81 GABAZOLPIDEM-5 -zolpidem tab 5 mg & dietary management cap pack.................................................... 92 GABITIDINE -ranitidine hcl tab 150 mg & dietary management cap pack.................................................... 72 GABITRIL -tiagabine hcl tab 12 mg.................................120 GABITRIL -tiagabine hcl tab 16 mg.................................120 GABITRIL -tiagabine hcl tab 2 mg.................................. 120 GABITRIL -tiagabine hcl tab 4 mg.................................. 120 GABLOFEN -baclofen intrathecal inj 10000 mcg/20ml (500 mcg/ml)...........................................................................127 GABLOFEN -baclofen intrathecal inj 20000 mcg/20ml (1000 mcg/ml)................................................................ 127 GABLOFEN -baclofen intrathecal inj 40000 mcg/20ml (2000 mcg/ml)................................................................ 127 GABLOFEN -baclofen intrathecal inj 50 mcg/ml..............127 GABOXETINE -fluoxetine hcl cap 10 mg & dietary management cap pack.................................................... 84 galantamine hydrobromide cap sr 24hr 16 mg (Razadyne er)................................................................. 98 galantamine hydrobromide cap sr 24hr 24 mg (Razadyne er)................................................................. 98 galantamine hydrobromide cap sr 24hr 8 mg (Razadyne er)................................................................. 98 galantamine hydrobromide oral soln 4 mg/ml (Razadyne)...................................................................... 98 galantamine hydrobromide tab 12 mg (Razadyne)....... 98 galantamine hydrobromide tab 4 mg (Razadyne).........98 galantamine hydrobromide tab 8 mg (Razadyne).........98 GALZIN -zinc acetate cap 25 mg (elemental zinc).......... 132 GALZIN -zinc acetate cap 50 mg (elemental zinc).......... 132 GAMASTAN S/D -immune globulin (human) inj................ 16 GAMMAGARD LIQUID -immune globulin (human) iv or subcutaneous soln 10 gm/100ml..................................... 16 GAMMAGARD LIQUID -immune globulin (human) iv or subcutaneous soln 1 gm/10ml......................................... 16 GAMMAGARD LIQUID -immune globulin (human) iv or subcutaneous soln 2.5 gm/25ml...................................... 16 GAMMAGARD LIQUID -immune globulin (human) iv or subcutaneous soln 20 gm/200ml..................................... 16 208 GAMMAGARD LIQUID -immune globulin (human) iv or subcutaneous soln 30 gm/300ml..................................... 17 GAMMAGARD LIQUID -immune globulin (human) iv or subcutaneous soln 5 gm/50ml......................................... 16 GAMMAKED -immune globulin (human) iv or subcutaneous soln 10 gm/100ml..................................... 17 GAMMAKED -immune globulin (human) iv or subcutaneous soln 1 gm/10ml......................................... 17 GAMMAKED -immune globulin (human) iv or subcutaneous soln 2.5 gm/25ml...................................... 17 GAMMAKED -immune globulin (human) iv or subcutaneous soln 20 gm/200ml..................................... 17 GAMMAKED -immune globulin (human) iv or subcutaneous soln 5 gm/50ml......................................... 17 GAMUNEX-C -immune globulin (human) iv or subcutaneous soln 10 gm/100ml..................................... 17 GAMUNEX-C -immune globulin (human) iv or subcutaneous soln 1 gm/10ml......................................... 17 GAMUNEX-C -immune globulin (human) iv or subcutaneous soln 2.5 gm/25ml...................................... 17 GAMUNEX-C -immune globulin (human) iv or subcutaneous soln 20 gm/200ml..................................... 17 GAMUNEX-C -immune globulin (human) iv or subcutaneous soln 40 gm/400ml..................................... 17 GAMUNEX-C -immune globulin (human) iv or subcutaneous soln 5 gm/50ml......................................... 17 GARAMYCIN -gentamicin sulfate ophth soln 0.3%......... 142 GARDASIL -human papillomavirus (hpv) quadrivalent recombinant vac inj..........................................................15 GASTRINEX NF -hyoscyamine-phenyltoloxamine cap 0.0625-15 mg...................................................................72 GASTROCROM -cromolyn sodium oral conc 100 mg/5ml..............................................................................76 gatifloxacin ophth soln 0.5% (Zymaxid)...................... 142 GATTEX -teduglutide (rdna) for inj kit 5 mg...................... 76 GEBAUERS PAIN EASE -pentafluoropropanetetrafluoroethane aero spray..........................................155 GEBAUERS SPRAY AND STRETC -pentafluoropropanetetrafluoroethane aero spray..........................................155 GELCLAIR - povidone-sodium hyaluronate-glycyrrhetinic acid gel ......................................................................... 147 GELFILM OP -gelatin adsorbable ophth film................... 142 GEL-KAM ORAL CARE RINSE -stannous fluoride conc 0.63%............................................................................. 147 GELNIQUE -oxybutynin chloride td gel 10%..................... 78 GELNIQUE -oxybutynin td gel 3% (28 mg/act metereddose pump)...................................................................... 78 GELX - oral wound care products - gel .......................... 147 gemfibrozil tab 600 mg (Lopid)...................................... 60 GENADUR - dermatological products misc - liquid .........155 GENADUR KIT - dermatological products misc topical/oral - kit ................................................................................155 GENERESS FE -norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg.......................................................... 29 GENOTROPIN MINIQUICK -somatropin for inj 0.2 mg..... 40 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 glipizide-metformin hcl tab 2.5-250 mg......................... 32 glipizide-metformin hcl tab 2.5-500 mg......................... 32 glipizide-metformin hcl tab 5-500 mg............................ 32 glipizide tab 10 mg (Glucotrol).......................................32 glipizide tab 5 mg (Glucotrol).........................................32 glipizide tab sr 24hr 10 mg (Glucotrol xl)......................32 glipizide tab sr 24hr 2.5 mg (Glucotrol xl)..................... 32 glipizide tab sr 24hr 5 mg (Glucotrol xl)........................32 GLUCAGEN -glucagon hcl (rdna) for inj 1 mg (base equiv)................................................................................32 GLUCAGEN HYPOKIT -glucagon hcl (rdna) for inj 1 mg (base equiv)..................................................................... 32 GLUCAGON EMERGENCY KIT -glucagon (rdna) for inj kit 1 mg................................................................................. 32 GLUCOCARD 01 BLOOD GLUCOS - blood glucose monitoring kit w/ device ................................................ 169 GLUCOCARD 01-MINI BLOOD G - blood glucose monitoring kit w/ device ................................................ 169 GLUCOCARD EXPRESSION AUDI - blood glucose monitoring kit w/ device ................................................ 169 GLUCOCARD VITAL BLOOD GLU - blood glucose monitoring kit w/ device ................................................ 169 GLUCOCARD X-METER - blood glucose monitoring kit w/ device ............................................................................169 GLUCOPHAGE -metformin hcl tab 1000 mg.................... 33 GLUCOPHAGE -metformin hcl tab 500 mg...................... 33 GLUCOPHAGE -metformin hcl tab 850 mg...................... 33 GLUCOPHAGE XR -metformin hcl tab sr 24hr 500 mg.....33 GLUCOPHAGE XR -metformin hcl tab sr 24hr 750 mg.....33 GLUCOSE BLOOD TEST STRIPS – VARIOUS............. 168 GLUCOTROL -glipizide tab 10 mg....................................33 GLUCOTROL -glipizide tab 5 mg......................................33 GLUCOTROL XL -glipizide tab sr 24hr 10 mg.................. 33 GLUCOTROL XL -glipizide tab sr 24hr 2.5 mg................. 33 GLUCOTROL XL -glipizide tab sr 24hr 5 mg.................... 33 GLUCOVANCE -glyburide-metformin tab 1.25-250 mg.....33 GLUCOVANCE -glyburide-metformin tab 2.5-500 mg.......33 GLUCOVANCE -glyburide-metformin tab 5-500 mg..........33 GLUMETZA -metformin hcl tab sr 24hr modified release 1000 mg........................................................................... 33 GLUMETZA -metformin hcl tab sr 24hr modified release 500 mg............................................................................. 33 GLUTARALDEHYDE -glutaral soln 25%......................... 167 GLYBURIDE -glyburide tab 1.25 mg................................. 33 GLYBURIDE -glyburide tab 2.5 mg...................................33 GLYBURIDE -glyburide tab 5 mg......................................33 glyburide-metformin tab 1.25-250 mg (Glucovance)...................................................................33 glyburide-metformin tab 2.5-500 mg (Glucovance)...... 33 glyburide-metformin tab 5-500 mg (Glucovance)......... 33 glyburide micronized tab 1.5 mg (Glynase).................. 33 glyburide micronized tab 3 mg (Glynase)..................... 33 glyburide micronized tab 6 mg (Glynase)..................... 33 glyburide tab 1.25 mg..................................................... 33 glyburide tab 2.5 mg....................................................... 33 GENOTROPIN MINIQUICK -somatropin for inj 0.4 mg..... 40 GENOTROPIN MINIQUICK -somatropin for inj 0.6 mg..... 40 GENOTROPIN MINIQUICK -somatropin for inj 0.8 mg..... 40 GENOTROPIN MINIQUICK -somatropin for inj 1.2 mg..... 40 GENOTROPIN MINIQUICK -somatropin for inj 1.4 mg..... 40 GENOTROPIN MINIQUICK -somatropin for inj 1.6 mg..... 40 GENOTROPIN MINIQUICK -somatropin for inj 1.8 mg..... 40 GENOTROPIN MINIQUICK -somatropin for inj 1 mg........ 40 GENOTROPIN MINIQUICK -somatropin for inj 2 mg........ 40 GENOTROPIN -somatropin for inj 12 mg (13.8 mg overfill)..............................................................................40 GENOTROPIN -somatropin for subcutaneous inj 5 mg.....40 GENTAMICIN SULFATE -gentamicin sulfate cream 0.1%............................................................................... 156 GENTAMICIN SULFATE -gentamicin sulfate oint 0.1%............................................................................... 156 gentamicin sulfate inj 10 mg/ml....................................... 6 gentamicin sulfate inj 40 mg/ml....................................... 6 gentamicin sulfate ophth oint 0.3%............................. 142 gentamicin sulfate ophth soln 0.3% (Garamycin)....... 142 GEODON -ziprasidone hcl cap 20 mg.............................. 88 GEODON -ziprasidone hcl cap 40 mg.............................. 88 GEODON -ziprasidone hcl cap 60 mg.............................. 88 GEODON -ziprasidone hcl cap 80 mg.............................. 88 GEODON -ziprasidone mesylate for inj 20 mg (base equivalent)........................................................................88 GIAZO -balsalazide disodium tab 1.1 gm..........................76 GILENYA -fingolimod hcl cap 0.5 mg (base equiv)........... 98 GILOTRIF -afatinib dimaleate tab 20 mg (base equivalent)........................................................................19 GILOTRIF -afatinib dimaleate tab 30 mg (base equivalent)........................................................................19 GILOTRIF -afatinib dimaleate tab 40 mg (base equivalent)........................................................................19 GILPHEX TR -phenylephrine-guaifenesin tab 10-388 mg.................................................................................... 65 GILTUSS PED-C -phenylephrine w/ codeine-gg liquid 2.5-3-50 mg/ml.................................................................65 GILTUSS -phenylephrine w/ dm-gg liqd 10-28-388 mg/5ml..............................................................................65 GILTUSS TR -phenylephrine w/ dm-gg cap 7-14-288 mg.................................................................................... 65 GILTUSS TR -phenylephrine w/ dm-gg tab 10-28-388 mg.................................................................................... 65 GILTUSS TR -phenylephrine w/ dm-gg tab sr 12hr 20-30-600 mg...................................................................65 GLEEVEC -imatinib mesylate tab 100 mg (base equivalent)........................................................................19 GLEEVEC -imatinib mesylate tab 400 mg (base equivalent)........................................................................19 GLIADEL WAFER -carmustine in polifeprosan intracranial implant wafer 7.7 mg....................................................... 19 glimepiride tab 1 mg (Amaryl)........................................32 glimepiride tab 2 mg (Amaryl)........................................32 glimepiride tab 4 mg (Amaryl)........................................32 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 209 2015 glyburide tab 5 mg.......................................................... 33 GLYCATE -glycopyrrolate tab 1.5 mg............................... 72 glycine irrigation soln 1.5%............................................ 80 GLYCOLIC ACID 70% HIGH PU -glycolic acid soln 70%................................................................................ 156 GLYCOLIC ACID -glycolic acid soln 70%....................... 156 glycopyrrolate inj 0.2 mg/ml (Robinul).......................... 72 glycopyrrolate inj 0.4 mg/2ml (0.2 mg/ml) (Robinul).....72 glycopyrrolate inj 1 mg/5ml (0.2 mg/ml) (Robinul)........72 glycopyrrolate inj 4 mg/20ml (0.2 mg/ml) (Robinul)......72 glycopyrrolate tab 1 mg (Robinul)................................. 72 glycopyrrolate tab 2 mg (Robinul forte)........................ 72 GLYNASE -glyburide micronized tab 1.5 mg.................... 33 GLYNASE -glyburide micronized tab 3 mg....................... 33 GLYNASE -glyburide micronized tab 6 mg....................... 33 GLYSET -miglitol tab 100 mg............................................33 GLYSET -miglitol tab 25 mg..............................................33 GLYSET -miglitol tab 50 mg..............................................33 GMATE SMART STARTER KIT - blood glucose monitoring kit w/ device ................................................ 169 GNP VITAMIN D-400 -calcium carbonate-cholecalciferol tab 90 mg-400 unit........................................................ 132 GOLYTELY -peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm..................................................................... 70 GOLYTELY -peg 3350-kcl-na bicarb-nacl-na sulfate packet 227.1 gm.............................................................. 70 GORDOFILM -salicylic & lactic acids soln 16.7-16.7%..................................................................... 156 GORDONS UREA -urea ointment 40%...........................156 GRALISE -gabapentin (phn) tab 300 mg...........................98 GRALISE -gabapentin (phn) tab 600 mg...........................98 GRALISE STARTER -gabapentin (phn) tab starter pack 300 mg (9) & 600 mg (69)...............................................98 granisetron hcl tab 1 mg................................................ 74 GRANISOL -granisetron hcl oral soln 2 mg/10ml (base equivalent)........................................................................74 GRANIX -tbo-filgrastim soln prefilled syringe 300 mcg/0.5ml.......................................................................136 GRANIX -tbo-filgrastim soln prefilled syringe 480 mcg/0.8ml.......................................................................136 GRANULEX -trypsin w/ castor oil & peruvian balsam spray...............................................................................156 GRASTEK -timothy grass pollen allergen ext tab sl 2800 bau................................................................................... 18 GREEN SOAP -green soap tincture................................156 GRIFULVIN V -griseofulvin microsize tab 500 mg...............7 griseofulvin microsize susp 125 mg/5ml.........................7 griseofulvin microsize tab 500 mg (Grifulvin v)..............7 griseofulvin ultramicrosize tab 125 mg (Gris-peg)......... 7 griseofulvin ultramicrosize tab 250 mg (Gris-peg)......... 7 GRIS-PEG -griseofulvin ultramicrosize tab 125 mg.............7 GRIS-PEG -griseofulvin ultramicrosize tab 250 mg.............7 guaifenesin-codeine soln 100-10 mg/5ml......................65 guanfacine hcl tab 1 mg (Tenex)................................... 53 guanfacine hcl tab 2 mg (Tenex)................................... 53 210 GUANIDINE HCL -guanidine hcl tab 125 mg.................. 128 GYNAZOLE-1 -butoconazole nitrate (one dose) vaginal cream 2%.........................................................................79 H H.P. ACTHAR -corticotropin inj gel 80 unit/ml................... 40 HALCION -triazolam tab 0.25 mg......................................92 HALDOL DECANOATE 100 -haloperidol decanoate im soln 100 mg/ml................................................................ 89 HALDOL DECANOATE 50 -haloperidol decanoate im soln 50 mg/ml.......................................................................... 89 HALDOL -haloperidol lactate inj 5 mg/ml.......................... 89 HALFLYTELY BOWEL PREP/FLA -bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for soln kit................................ 70 halobetasol propionate cream 0.05% (Ultravate)........ 156 halobetasol propionate oint 0.05% (Ultravate)............156 halobetasol prop oint 0.05% & ammonium lactate lot 12% kit...........................................................................156 HALOG -halcinonide cream 0.1%................................... 156 HALOG -halcinonide oint 0.1%........................................156 HALONATE -halobetasol prop oint 0.05% & ammonium lactate foam 12% kit...................................................... 156 haloperidol decanoate im soln 100 mg/ml (Haldol decanoate 100)............................................................... 89 haloperidol decanoate im soln 50 mg/ml (Haldol decanoate 50)................................................................. 89 haloperidol lactate inj 5 mg/ml (Haldol).........................89 haloperidol lactate oral conc 2 mg/ml........................... 89 haloperidol tab 0.5 mg.................................................... 89 haloperidol tab 10 mg..................................................... 89 haloperidol tab 1 mg....................................................... 89 haloperidol tab 20 mg..................................................... 89 haloperidol tab 2 mg....................................................... 89 haloperidol tab 5 mg....................................................... 89 HALOTIN -haloprogin cream 1%.....................................156 HARVONI -ledipasvir-sofosbuvir tab 90-400 mg................. 8 HAVRIX -hepatitis a vaccine inj susp 1440 el unit/ml........ 15 HAVRIX -hepatitis a vaccine inj susp 720 el unit/0.5ml..... 15 hc-pramoxine emol cream 2.5-1% & pramoxine wipe 1% kit (Analpram e)..................................................... 148 HEALON5 -sodium hyaluronate intraocular inj 23 mg/ ml....................................................................................142 HEALON GV -sodium hyaluronate intraocular inj 14 mg/ ml....................................................................................142 HEALON -sodium hyaluronate intraocular inj 10 mg/ ml....................................................................................142 HECTOROL -doxercalciferol cap 0.5 mcg.........................40 HECTOROL -doxercalciferol cap 1 mcg............................40 HECTOROL -doxercalciferol cap 2.5 mcg.........................40 HELIDAC -metronidaz tab-tetracyc cap-bis subsal chew tab therapy pack.............................................................. 72 HEMABATE -carboprost tromethamine im soln 250 mcg/ ml......................................................................................39 HEMANGEOL -propranolol hcl oral soln 4.28 mg/ml.........44 HEMATOGEN FA -fe fumarate-vit c-vit b12-fa cap 200-250-0.01-1 mg........................................................ 136 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 HUMALOG MIX 50/50 KWIKPEN -insulin lispro prot & lispro sus pen-inj 100 unit/ml (50-50).............................. 36 HUMALOG MIX 75/25 -insulin lispro prot & lispro (human) inj 100 unit/ml (75-25)......................................................36 HUMALOG MIX 75/25 KWIKPEN -insulin lispro prot & lispro sus pen-inj 100 unit/ml (75-25).............................. 36 HUMATROPE COMBO PACK -somatropin for inj 5 mg.................................................................................... 40 HUMATROPE -somatropin for inj 12 mg (36 unit).............40 HUMATROPE -somatropin for inj 24 mg...........................40 HUMATROPE -somatropin for inj 5 mg.............................40 HUMATROPE -somatropin for inj 6 mg (18 unit)...............40 HUMIRA -adalimumab inj kit 20 mg/0.4ml.......................112 HUMIRA -adalimumab inj kit 40 mg/0.8ml (50 mg/ml)..... 112 HUMIRA -adalimumab prefilled syringe kit 10 mg/0.2ml.........................................................................112 HUMIRA PEDIATRIC CROHNS D -adalimumab inj kit 40 mg/0.8ml (50 mg/ml)......................................................112 HUMIRA PEN -adalimumab inj kit 40 mg/0.8ml (50 mg/ ml).................................................................................. 112 HUMIRA PEN-CROHNS DISEASE -adalimumab inj kit 40 mg/0.8ml (50 mg/ml)......................................................112 HUMIRA PEN-PSORIASIS STAR -adalimumab inj kit 40 mg/0.8ml (50 mg/ml)......................................................112 HUMULIN 70/30 -insulin isophane & regular (human) inj 100 unit/ml (70-30)...........................................................36 HUMULIN 70/30 KWIKPEN -insulin isophane & regular susp pen-inj 100 unit/ml (70-30)...................................... 36 HUMULIN 70/30 PEN -insulin isophane & regular susp pen-inj 100 unit/ml (70-30)...............................................36 HUMULIN N -insulin isophane (human) inj 100 unit/ml......36 HUMULIN N KWIKPEN -insulin isophane (human) susp pen-injector 100 unit/ml................................................... 36 HUMULIN N U-100 PEN -insulin isophane (human) susp pen-injector 100 unit/ml................................................... 36 HUMULIN R -insulin regular (human) inj 100 unit/ml.........35 HUMULIN R U-500 (CONCENTR -insulin regular (human) inj 500 unit/ml.................................................................. 35 hyaluronate sodium (emollient) gel 0.2% (Hylira)....... 156 HYCAMTIN -topotecan hcl cap 0.25 mg (base equiv)....... 19 HYCAMTIN -topotecan hcl cap 1 mg (base equiv)............19 HYCET -hydrocodone-acetaminophen soln 7.5-325 mg/15ml..........................................................................104 hydralazine hcl inj 20 mg/ml.......................................... 53 hydralazine hcl tab 100 mg............................................ 53 hydralazine hcl tab 10 mg.............................................. 53 hydralazine hcl tab 25 mg.............................................. 53 hydralazine hcl tab 50 mg.............................................. 53 HYDREA -hydroxyurea cap 500 mg..................................19 HYDRO 35 -urea in lactic acid vehicle foam 35%........... 156 HYDRO 40 FOAM -urea foam 40%................................ 156 hydrochlorothiazide cap 12.5 mg (Microzide)............... 58 hydrochlorothiazide tab 12.5 mg................................... 58 hydrochlorothiazide tab 25 mg...................................... 58 hydrochlorothiazide tab 50 mg...................................... 58 HEMATRON-AF - iron-docusate-b12-folic acid-c-e-cubiotin tab 150-1 mg ...................................................... 136 HEMETAB -polysacch fe cmplx-fe heme poly-fa-b12 tab 22-6-1-0.025 mg............................................................ 136 HEMOCYTE-F - iron combination elixir ..........................136 HEMOCYTE PLUS - ferrous fumarate-fa-b complex-c-znmg-mn-cu cap 106-1 mg .............................................. 136 HEPAGAM B -hepatitis b immune globulin (human) inj soln...................................................................................17 HEPARIN SODIUM/NACL 0.45% -heparin sodium (porcine) 100 unt/ml in sodium chloride 0.45%.............. 139 HEPARIN SODIUM/NACL 0.45% -heparin sodium (porcine) 50 unit/ml in sodium chloride 0.45%............... 139 HEPARIN SODIUM/SODIUM CHL -heparin sodium (porcine) 2 unit/ml in sodium chloride 0.9%................... 139 heparin sodium (porcine) 2 unit/ml in sodium chloride 0.9% (Heparin sodium/sodiu)......................................139 heparin sodium (porcine) inj 10000 unit/ml.................139 heparin sodium (porcine) inj 1000 unit/ml...................139 heparin sodium (porcine) inj 20000 unit/ml.................139 heparin sodium (porcine) inj 5000 unit/ml...................139 heparin sodium (porcine) pf inj 5000 unit/0.5ml......... 139 HEPARIN SODIUM -heparin sodium (porcine) inj 2500 unit/ml.............................................................................138 HEPSERA -adefovir dipivoxil tab 10 mg............................. 8 HETLIOZ -tasimelteon capsule 20 mg.............................. 92 HEXALEN -altretamine cap 50 mg....................................19 HIBERIX -haemophilus b polysaccharide conjugate vac for inj 10 mcg........................................................................ 15 HIPREX -methenamine hippurate tab 1 gm...................... 77 HIZENTRA -immune globulin (human) subcutaneous inj 10 gm/50ml............................................................................17 HIZENTRA -immune globulin (human) subcutaneous inj 1 gm/5ml..............................................................................17 HIZENTRA -immune globulin (human) subcutaneous inj 2 gm/10ml............................................................................17 HIZENTRA -immune globulin (human) subcutaneous inj 4 gm/20ml............................................................................17 homatropine hbr ophth soln 5% (Isopto homatropine)................................................................ 143 HORIZANT -gabapentin enacarbil tab cr 300 mg..............98 HORIZANT -gabapentin enacarbil tab cr 600 mg..............98 HPR - emollient - aerosol foam ......................................156 HPR PLUS/MB HYDROGEL -emollient foam & wound dressing gel kit...............................................................156 HPR PLUS - emollient - aerosol foam ............................156 HPR PLUS - emollient - cream ...................................... 156 HUMALOG -insulin lispro (human) inj 100 unit/ml............. 35 HUMALOG -insulin lispro (human) soln cartridge 100 unit/ ml......................................................................................35 HUMALOG KWIKPEN -insulin lispro (human) soln peninjector 100 unit/ml...........................................................35 HUMALOG MIX 50/50 -insulin lispro prot & lispro (human) inj 100 unit/ml (50-50)......................................................36 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 211 2015 HYDROCODONE/ACETAMINOPHEN -hydrocodoneacetaminophen soln 10-325 mg/15ml............................105 HYDROCODONE/ACETAMINOPHEN -hydrocodoneacetaminophen tab 7.5-500 mg..................................... 105 HYDROCODONE/ACETAMINOPHEN -hydrocodoneacetaminophen tab 7.5-650 mg..................................... 105 HYDROCODONE/ACETAMINOPHEN -hydrocodoneacetaminophen tab 7.5-750 mg..................................... 105 hydrocodone-acetaminophen cap 5-500 mg...............104 hydrocodone-acetaminophen soln 10-325 mg/15ml.........................................................................104 hydrocodone-acetaminophen soln 7.5-325 mg/15ml (Hycet)........................................................................... 104 hydrocodone-acetaminophen soln 7.5-500 mg/15ml.........................................................................104 hydrocodone-acetaminophen tab 10-300 mg (Xodol)........................................................................... 104 hydrocodone-acetaminophen tab 10-325 mg (Norco)...........................................................................104 hydrocodone-acetaminophen tab 10-500 mg..............104 hydrocodone-acetaminophen tab 10-650 mg..............104 hydrocodone-acetaminophen tab 10-660 mg..............104 hydrocodone-acetaminophen tab 10-750 mg..............104 hydrocodone-acetaminophen tab 2.5-325 mg.............104 hydrocodone-acetaminophen tab 2.5-500 mg.............104 hydrocodone-acetaminophen tab 5-300 mg (Xodol)........................................................................... 104 hydrocodone-acetaminophen tab 5-325 mg (Norco)...........................................................................104 hydrocodone-acetaminophen tab 5-500 mg................104 hydrocodone-acetaminophen tab 7.5-300 mg (Xodol)........................................................................... 105 hydrocodone-acetaminophen tab 7.5-325 mg (Norco)...........................................................................105 hydrocodone-acetaminophen tab 7.5-500 mg.............105 hydrocodone-acetaminophen tab 7.5-650 mg.............105 hydrocodone-acetaminophen tab 7.5-750 mg.............105 hydrocodone-ibuprofen tab 10-200 mg (Ibudone)...... 105 hydrocodone-ibuprofen tab 2.5-200 mg (Reprexain)....................................................................105 hydrocodone-ibuprofen tab 5-200 mg (Reprexain).....105 hydrocodone-ibuprofen tab 7.5-200 mg (Vicoprofen).................................................................. 105 hydrocodone w/ homatropine syrup 5-1.5 mg/5ml....... 65 hydrocodone w/ homatropine tab 5-1.5 mg.................. 65 hydrocod polst-chlorphen polst cr susp 10-8 mg/5ml (Tussionex pennkineti).................................................. 65 hydrocortisone acetate-aloe vera gel 2% (Nuzon)...... 156 hydrocortisone acetate suppos 25 mg (Anusolhc).................................................................................. 148 hydrocortisone acetate suppos 30 mg (Proctocort)...................................................................148 hydrocortisone acetate w/ pramoxine rectal cream 1-1% (Analpram-hc)..................................................... 148 212 hydrocortisone acetate w/ pramoxine rectal cream 2.5-1% (Analpram-hc).................................................. 148 hydrocortisone butyrate cream 0.1% (Locoid)............156 hydrocortisone butyrate hydrophilic lipo base cream 0.1% (Locoid lipocream)..............................................156 hydrocortisone butyrate oint 0.1% (Locoid)................156 hydrocortisone butyrate soln 0.1% (Locoid)...............156 hydrocortisone cream 1%.............................................156 hydrocortisone cream 2.5%..........................................156 hydrocortisone enema 100 mg/60ml (Cortenema)......148 hydrocortisone lotion 2.5%...........................................156 hydrocortisone lotion 2% (Ala scalp).......................... 156 hydrocortisone oint 1%.................................................156 hydrocortisone oint 2.5%..............................................156 hydrocortisone rectal cream 1% (Proctocort).............148 hydrocortisone rectal cream 2.5% (Anusol-hc).......... 148 hydrocortisone tab 10 mg (Cortef).................................23 hydrocortisone tab 20 mg (Cortef).................................23 hydrocortisone tab 5 mg (Cortef).................................. 23 hydrocortisone valerate cream 0.2%........................... 156 hydrocortisone valerate oint 0.2% (Westcort).............156 hydrocortisone w/ acetic acid otic soln 1-2% (Vosol hc).................................................................................. 146 HYDROFERA BLUE 4"X4" - wound dressings - pads ....................................................................................... 156 HYDROFERA BLUE FOAM DRESS - wound dressings pads .............................................................................. 156 HYDROGEN PEROXIDE -hydrogen peroxide soln 30%................................................................................ 167 HYDROGEN PEROXIDE -hydrogen peroxide soln 35%................................................................................ 167 HYDROMORPHONE HCL DOSETTE -hydromorphone hcl inj 2 mg/ml..................................................................... 105 HYDROMORPHONE HCL ER -hydromorphone hcl tab er 24hr deter 32 mg........................................................... 105 HYDROMORPHONE HCL -hydromorphone hcl inj 2 mg/ ml....................................................................................105 HYDROMORPHONE HCL -hydromorphone hcl suppos 3 mg.................................................................................. 105 hydromorphone hcl liqd 1 mg/ml (Dilaudid)............... 105 hydromorphone hcl preservative free (pf) inj 10 mg/ml (Dilaudid-hp)................................................................. 105 hydromorphone hcl preservative free (pf) inj 1 mg/ml (Dilaudid).......................................................................105 hydromorphone hcl preservative free (pf) inj 2 mg/ml (Dilaudid).......................................................................105 hydromorphone hcl preservative free (pf) inj 4 mg/ml (Dilaudid).......................................................................105 hydromorphone hcl tab 2 mg (Dilaudid)..................... 105 hydromorphone hcl tab 4 mg (Dilaudid)..................... 105 hydromorphone hcl tab 8 mg (Dilaudid)..................... 105 hydromorphone hcl tab er 24hr deter 12 mg (Exalgo)......................................................................... 105 hydromorphone hcl tab er 24hr deter 16 mg (Exalgo)......................................................................... 105 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 HYQVIA -immun glob inj 2.5 gm/25ml-hyaluron inj 200 unt/1.25 ml kit.................................................................. 17 HYQVIA -immun glob inj 20 gm/200ml-hyaluron inj 1600 unt/10 ml kit..................................................................... 17 HYQVIA -immun glob inj 30 gm/300ml-hyaluron inj 2400 unt/15 ml kit..................................................................... 17 HYQVIA -immun glob inj 5 gm/50ml-hyaluron inj 400 unt/2.5 ml kit.................................................................... 17 HYZAAR -losartan potassium & hydrochlorothiazide tab 100-12.5 mg.....................................................................53 HYZAAR -losartan potassium & hydrochlorothiazide tab 100-25 mg........................................................................53 HYZAAR -losartan potassium & hydrochlorothiazide tab 50-12.5 mg.......................................................................53 hydromorphone hcl tab er 24hr deter 8 mg (Exalgo)......................................................................... 105 HYDROXOCOBALAMIN -hydroxocobalamin inj 1000 mcg/ ml....................................................................................136 hydroxychloroquine sulfate tab 200 mg (Plaquenil).....12 hydroxyurea cap 500 mg (Hydrea).................................19 HYDROXYZINE HCL -hydroxyzine hcl im soln 25 mg/ ml......................................................................................81 hydroxyzine hcl im soln 50 mg/ml................................. 81 hydroxyzine hcl syrup 10 mg/5ml.................................. 81 hydroxyzine hcl tab 10 mg............................................. 82 hydroxyzine hcl tab 25 mg............................................. 82 hydroxyzine hcl tab 50 mg............................................. 82 hydroxyzine pamoate cap 25 mg (Vistaril).................... 82 hydroxyzine pamoate cap 50 mg (Vistaril).................... 82 HYDROXYZINE PAMOATE -hydroxyzine pamoate cap 100 mg............................................................................. 82 HYLASE WOUND - hyaluronate sodium gel .................. 156 HYLATOPIC - emollient - aerosol foam ......................... 156 HYLATOPIC PLUS/AURSTAT -emollient foam & wound dressing gel kit...............................................................156 HYLATOPIC PLUS - emollient - aerosol foam ............... 156 HYLATOPIC PLUS - emollient - cream ..........................156 HYLENEX -hyaluronidase human inj 150 unit/ml............ 171 HYLIRA -hyaluronate sodium (emollient) gel 0.2%..........156 HYLIRA -hyaluronate sodium (emollient) lotion 0.1%...... 156 hyoscyamine sulfate elixir 0.125 mg/5ml...................... 72 hyoscyamine sulfate soln 0.125 mg/ml......................... 72 hyoscyamine sulfate tab 0.125 mg (Levsin)..................72 hyoscyamine sulfate tab disp 0.125 mg (Anaspaz)...... 72 hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl).......... 72 hyoscyamine sulfate tab sr 12hr 0.375 mg (Levbid)..... 72 HYPERHEP B S/D -hepatitis b immune globulin (human) im inj soln.........................................................................17 HYPERRAB S/D -rabies immune globulin (human) inj 150 unit/ml...............................................................................17 HYPERRHO S/D MINI-DOSE -rho d immune globulin (human) im inj 50 mcg.....................................................17 HYPERRHO S/D -rho d immune globulin (human) im inj 300 mcg........................................................................... 17 HYPERRHO S/D -rho d immune globulin (human) im inj 50 mcg...................................................................................17 HYPERSAL -sodium chloride soln nebu 3.5%.................. 65 HYPERSAL -sodium chloride soln nebu 7%..................... 65 HYPER-SAL -sodium chloride soln nebu 7%.................... 65 HYPERTENEVIDE-12.5 -carvedilol tab 12.5 mg & dietary management cap pack.................................................... 44 HYPERTENIPINE-2.5 -amlodipine tab 2.5 mg & dietary management cap pack.................................................... 47 HYPERTENSOLOL -metoprolol tab 50 mg & dietary management cap pack.................................................... 53 HYPERTET S/D -tetanus immune globulin (human) inj 250 unit/ml...............................................................................17 HYQVIA -immun glob inj 10 gm/100ml-hyaluron inj 800 unt/5 ml kit....................................................................... 17 I ibandronate sodium tab 150 mg (base equivalent) (Boniva)........................................................................... 40 IBUDONE -hydrocodone-ibuprofen tab 10-200 mg......... 105 IBUPROFEN COMFORT PAC -ibuprofen tab 800 mg & liniment topical gel kit.................................................... 112 ibuprofen susp 100 mg/5ml.......................................... 112 ibuprofen tab 400 mg.................................................... 112 ibuprofen tab 600 mg.................................................... 112 ibuprofen tab 800 mg.................................................... 112 IC 400 -ibuprofen tab 400 mg & caffeine-vitamins cap kit....................................................................................112 IC 800 -ibuprofen tab 800 mg & caffeine-vitamins cap kit....................................................................................112 ICAR -carbonyl iron chew tab 15 mg (elemental iron)..... 136 ICAR-C PLUS -iron-vit c-vit b12-folic acid tab 100-250-0.025-1 mg...................................................... 136 ICAR PEDIATRIC -carbonyl iron susp 15 mg/1.25ml (elemental iron).............................................................. 136 ICLUSIG -ponatinib hcl tab 15 mg (base equiv)................ 19 ICLUSIG -ponatinib hcl tab 45 mg (base equiv)................ 19 ILARIS -canakinumab for inj 180 mg...............................112 ILEVRO -nepafenac ophth susp 0.3%.............................143 IMBRUVICA -ibrutinib cap 140 mg....................................19 IMDUR -isosorbide mononitrate tab sr 24hr 120 mg......... 43 IMDUR -isosorbide mononitrate tab sr 24hr 30 mg........... 43 IMDUR -isosorbide mononitrate tab sr 24hr 60 mg........... 43 imipramine hcl tab 10 mg (Tofranil)...............................84 imipramine hcl tab 25 mg (Tofranil)...............................84 imipramine hcl tab 50 mg (Tofranil)...............................84 imipramine pamoate cap 100 mg (Tofranil-pm)............ 84 imipramine pamoate cap 125 mg (Tofranil-pm)............ 84 imipramine pamoate cap 150 mg (Tofranil-pm)............ 84 imipramine pamoate cap 75 mg (Tofranil-pm).............. 84 imiquimod cream 5% (Aldara)...................................... 156 IMITREX STATDOSE REFILL -sumatriptan succinate solution cartridge 4 mg/0.5ml.........................................115 IMITREX STATDOSE REFILL -sumatriptan succinate solution cartridge 6 mg/0.5ml.........................................115 IMITREX STATDOSE SYSTEM -sumatriptan succinate solution auto-injector 4 mg/0.5ml...................................115 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 213 2015 IMITREX STATDOSE SYSTEM -sumatriptan succinate solution auto-injector 6 mg/0.5ml...................................115 IMITREX -sumatriptan nasal spray 20 mg/act................. 115 IMITREX -sumatriptan nasal spray 5 mg/act................... 115 IMITREX -sumatriptan succinate inj 6 mg/0.5ml..............115 IMITREX -sumatriptan succinate tab 100 mg.................. 115 IMITREX -sumatriptan succinate tab 25 mg.................... 115 IMITREX -sumatriptan succinate tab 50 mg.................... 115 IMOGAM RABIES-HT -rabies immune globulin (human) inj 150 unit/ml....................................................................... 17 IMOVAX RABIES (H.D.C.V.) -rabies virus vaccine, hdc inj......................................................................................15 IMPLANON -etonogestrel subdermal implant 68 mg.........29 IMURAN -azathioprine tab 50 mg................................... 171 INCIVEK -telaprevir tab 375 mg.......................................... 8 INCRELEX -mecasermin inj 40 mg/4ml (10 mg/ml)...........40 indapamide tab 1.25 mg..................................................58 indapamide tab 2.5 mg....................................................58 INDERAL LA -propranolol hcl cap sr 24hr 120 mg............ 45 INDERAL LA -propranolol hcl cap sr 24hr 160 mg............ 45 INDERAL LA -propranolol hcl cap sr 24hr 60 mg.............. 44 INDERAL LA -propranolol hcl cap sr 24hr 80 mg.............. 45 INDERAL XL -propranolol hcl sustained-release beads cap sr 24hr 120 mg................................................................ 45 INDERAL XL -propranolol hcl sustained-release beads cap sr 24hr 80 mg.................................................................. 45 INDOCIN -indomethacin suppos 50 mg.......................... 112 INDOCIN -indomethacin susp 25 mg/5ml........................112 indomethacin cap 25 mg.............................................. 112 indomethacin cap 50 mg.............................................. 112 indomethacin cap cr 75 mg.......................................... 112 INFANRIX -diph, acellular pert & tet tox inj 25 lf-58 mcg-10 lf/0.5ml..............................................................................16 INFASURF -calfactant in nacl 0.9% intratracheal susp 35 mg/ml................................................................................70 INFERGEN -interferon alfacon-1 inj 15 mcg/0.5ml.............. 8 INFERGEN -interferon alfacon-1 inj 9 mcg/0.3ml................8 INFLUENZA A (H1N1) MONOVA -influenza a (h1n1) monovalent vaccine live intranasal liquid.........................15 INFUMORPH 200 -morphine sulfate for microinfusion inj 200 mg/20ml (10mg/ml)................................................. 105 INFUMORPH 500 -morphine sulfate for microinfusion inj 500 mg/20ml (25mg/ml)................................................. 105 INLYTA -axitinib tab 1 mg................................................. 19 INLYTA -axitinib tab 5 mg................................................. 19 INNOPRAN XL -propranolol hcl sustained-release beads cap sr 24hr 120 mg......................................................... 45 INNOPRAN XL -propranolol hcl sustained-release beads cap sr 24hr 80 mg........................................................... 45 INOVA 4/1 ACNE CONTROL TH -benzoyl perox pad 4% & salicylic ac pad 1% & vit e 5% kit..................................157 INOVA 8/2 ACNE CONTROL TH -benzoyl perox pad 8% & salicylic ac pad 2% & vit e 5% kit..................................157 INOVA -benzoyl peroxide pad 4% & vitamin e topical 5% kit....................................................................................156 214 INOVA -benzoyl peroxide pad 8% & vitamin e topical 5% kit....................................................................................157 INSPRA -eplerenone tab 25 mg........................................53 INSPRA -eplerenone tab 50 mg........................................53 INSULIN PEN NEEDLES – VARIOUS............................ 169 INSULIN SYRINGES – VARIOUS...................................169 INTEGRA F - fe fum-fe poly-fa-c-b3 cap 62.5-62.5-1-40-3mg(125 mg fe) ....................................136 INTEGRA PLUS - fe fum-iron polysacch complex-fa-b complex-c-biotin cap .....................................................136 INTELENCE -etravirine tab 100 mg.................................... 8 INTELENCE -etravirine tab 200 mg.................................... 8 INTELENCE -etravirine tab 25 mg...................................... 8 INTERARTICULAR JOINT KIT -triamcinolone inj 40 mg/ml & lidocaine 1% & ammonia inh kit................................... 23 INTERMEZZO -zolpidem tartrate sl tab 1.75 mg...............92 INTERMEZZO -zolpidem tartrate sl tab 3.5 mg.................92 INTROL -glycerin soln 75%...............................................58 INTRON A -interferon alfa-2b for inj 10000000 unit...........19 INTRON A -interferon alfa-2b for inj 18000000 unit...........19 INTRON A -interferon alfa-2b for inj 50000000 unit...........19 INTRON-A -interferon alfa-2b inj 10000000 unit/ml........... 20 INTRON-A -interferon alfa-2b inj 6000000 unit/ml............. 19 INTRON-A W/DILUENT -interferon alfa-2b for inj 10000000 unit.................................................................. 20 INTRON-A W/DILUENT -interferon alfa-2b for inj 18000000 unit.................................................................. 20 INTRON-A W/DILUENT -interferon alfa-2b for inj 50000000 unit.................................................................. 20 INTUNIV -guanfacine hcl tab sr 24hr 1 mg (base equiv)................................................................................94 INTUNIV -guanfacine hcl tab sr 24hr 2 mg (base equiv)................................................................................95 INTUNIV -guanfacine hcl tab sr 24hr 3 mg (base equiv)................................................................................95 INTUNIV -guanfacine hcl tab sr 24hr 4 mg (base equiv)................................................................................95 INVANZ -ertapenem sodium for inj 1 gm (base equivalent)........................................................................13 INVEGA -paliperidone tab sr 24hr 1.5 mg.........................89 INVEGA -paliperidone tab sr 24hr 3 mg............................89 INVEGA -paliperidone tab sr 24hr 6 mg............................89 INVEGA -paliperidone tab sr 24hr 9 mg............................89 INVEGA SUSTENNA -paliperidone palmitate im extendedrelease susp 156 mg/ml.................................................. 89 INVEGA SUSTENNA -paliperidone palmitate im extendedrelease susp 234 mg/1.5ml............................................. 89 INVEGA SUSTENNA -paliperidone palmitate im extendedrelease susp 39 mg/0.25ml............................................. 89 INVEGA SUSTENNA -paliperidone palmitate im extendedrelease susp 78 mg/0.5ml............................................... 89 INVEGA SUSTENNA -paliperidone palmitate im extendrelease susp 117 mg/0.75ml............................................89 INVIRASE -saquinavir mesylate cap 200 mg...................... 8 INVIRASE -saquinavir mesylate tab 500 mg.......................8 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 irrigation solution, physiological ................................ 170 IS 24/6 - fe asp gly-fe polys-succ acd-b cmplx-c-ca-fa tab ther pk ...........................................................................136 ISCAR MALI -european mistletoe (viscum album) inj 5 mg/ ml....................................................................................168 ISENTRESS -raltegravir potassium chew tab 100 mg (base equiv)....................................................................... 9 ISENTRESS -raltegravir potassium chew tab 25 mg (base equiv)..................................................................................9 ISENTRESS -raltegravir potassium packet for susp 100 mg (base equiv)................................................................. 9 ISENTRESS -raltegravir potassium tab 400 mg (base equiv)..................................................................................9 ISOMETHEPTENE/CAFFEINE/AC -acetaminophenisometheptene-caffeine tab 500-130-20 mg.................. 115 isoniazid & rifampin cap 150-300 mg.............................. 6 ISONIAZID -isoniazid inj 100 mg/ml....................................6 ISONIAZID -isoniazid syrup 50 mg/5ml...............................6 isoniazid tab 100 mg......................................................... 6 isoniazid tab 300 mg......................................................... 6 ISOPROPANOL -isopropyl alcohol 70%......................... 168 isopropyl alcohol, rubbing 70%................................... 168 ISOPROPYL ALCOHOL -isopropyl alcohol 70%.............168 ISOPTIN SR -verapamil hcl tab cr 120 mg........................47 ISOPTIN SR -verapamil hcl tab cr 180 mg........................47 ISOPTIN SR -verapamil hcl tab cr 240 mg........................47 ISOPTO ATROPINE -atropine sulfate ophth soln 1%......143 ISOPTO CARBACHOL -carbachol ophth soln 1.5%....... 143 ISOPTO CARBACHOL -carbachol ophth soln 3%.......... 143 ISOPTO CARPINE -pilocarpine hcl ophth soln 1%......... 143 ISOPTO CARPINE -pilocarpine hcl ophth soln 2%......... 143 ISOPTO CARPINE -pilocarpine hcl ophth soln 4%......... 143 ISOPTO HOMATROPINE -homatropine hbr ophth soln 2%.................................................................................. 143 ISOPTO HOMATROPINE -homatropine hbr ophth soln 5%.................................................................................. 143 ISOPTO HYOSCINE -scopolamine hbr ophth soln 0.25%............................................................................. 143 ISORDIL TITRADOSE -isosorbide dinitrate tab 40 mg......43 ISORDIL TITRADOSE -isosorbide dinitrate tab 5 mg........43 ISOSORBIDE DINITRATE -isosorbide dinitrate sl tab 2.5 mg.................................................................................... 43 ISOSORBIDE DINITRATE -isosorbide dinitrate tab 30 mg.................................................................................... 43 isosorbide dinitrate tab 10 mg....................................... 43 isosorbide dinitrate tab 20 mg....................................... 43 isosorbide dinitrate tab 30 mg....................................... 43 isosorbide dinitrate tab 5 mg (Isordil titradose)........... 43 isosorbide dinitrate tab cr 40 mg...................................43 isosorbide mononitrate tab 10 mg.................................43 isosorbide mononitrate tab 20 mg.................................43 isosorbide mononitrate tab sr 24hr 120 mg (Imdur)..... 43 isosorbide mononitrate tab sr 24hr 30 mg (Imdur)....... 43 isosorbide mononitrate tab sr 24hr 60 mg (Imdur)....... 43 isotretinoin cap 10 mg.................................................. 157 INVOKAMET -canagliflozin-metformin hcl tab 150-1000 mg.................................................................................... 33 INVOKAMET -canagliflozin-metformin hcl tab 150-500 mg.................................................................................... 33 INVOKAMET -canagliflozin-metformin hcl tab 50-1000 mg.................................................................................... 33 INVOKAMET -canagliflozin-metformin hcl tab 50-500 mg.................................................................................... 33 INVOKANA -canagliflozin tab 100 mg............................... 33 INVOKANA -canagliflozin tab 300 mg............................... 33 IODINE STRONG -iodine solution strong 5% (lugol's)........................................................................... 132 IODINE TINCTURE - iodine tincture .............................. 167 IODINE TINCTURE MILD - iodine tincture .....................167 IODINE TINCTURE STRONG DE - iodine tincture strong ....................................................................................... 167 IODINE TINCTURE STRONG - iodine tincture strong ....................................................................................... 167 IODOPEN -sodium iodide inj 100 mcg/ml....................... 132 iodoquinol-hc cream 1%............................................... 157 IOPIDINE -apraclonidine hcl ophth soln 0.5% (base equivalent)......................................................................143 IOPIDINE -apraclonidine hcl ophth soln 1% (base equivalent)......................................................................143 IPOL INACTIVATED IPV -poliovirus vaccine, ipv injection............................................................................ 15 ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml.......68 ipratropium bromide inhal soln 0.02%.......................... 68 ipratropium bromide nasal soln 0.03% (21 mcg/spray) (Atrovent)........................................................................ 64 ipratropium bromide nasal soln 0.06% (42 mcg/spray) (Atrovent)........................................................................ 64 IPRIVASK -desirudin for inj 15 mg.................................. 139 irbesartan-hydrochlorothiazide tab 150-12.5 mg (Avalide).......................................................................... 53 irbesartan-hydrochlorothiazide tab 300-12.5 mg (Avalide).......................................................................... 53 irbesartan tab 150 mg (Avapro)..................................... 53 irbesartan tab 300 mg (Avapro)..................................... 53 irbesartan tab 75 mg (Avapro)....................................... 53 IRON ASP GLY/ POLYSACCH C - fe asp gly-fe polysacch-succ ac-c-threon ac-b12-fa cap ................... 136 iron combination cap ................................................... 134 iron dextran inj 50 mg/ml (elemental iron).................. 136 iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1 mg (Hematron-af)................................................................134 iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg (Corvite 150)................................................................. 136 IRON - iron combination tab .......................................... 136 iron polysacch complex-vit b12-fa cap 150-0.025-1 mg.................................................................................. 136 iron-vit c-vit b12-folic acid tab 100-250-0.025-1 mg (Icar-c plus)...................................................................136 IROSPAN 24/6 - fe asp gly-fe polys-succ acd-b cmplx-cca-fa tab ther pk ........................................................... 136 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 215 2015 isotretinoin cap 20 mg.................................................. 157 isotretinoin cap 40 mg.................................................. 157 ISOXSUPRINE HCL -isoxsuprine hcl tab 20 mg............... 62 isoxsuprine hcl tab 10 mg.............................................. 62 ISRADIPINE -isradipine cap 2.5 mg..................................47 ISRADIPINE -isradipine cap 5 mg.....................................47 ISTALOL -timolol maleate ophth soln 0.5% (oncedaily)...............................................................................143 ISUPREL -isoproterenol hcl inj 0.2 mg/ml......................... 68 itraconazole cap 100 mg (Sporanox)............................... 7 ivermectin tab 3 mg (Stromectol).................................. 12 IV PREP WIPES - antiseptic products misc - pads .........167 J K JAKAFI -ruxolitinib phosphate tab 10 mg (base equivalent)........................................................................20 JAKAFI -ruxolitinib phosphate tab 15 mg (base equivalent)........................................................................20 JAKAFI -ruxolitinib phosphate tab 20 mg (base equivalent)........................................................................20 JAKAFI -ruxolitinib phosphate tab 25 mg (base equivalent)........................................................................20 JAKAFI -ruxolitinib phosphate tab 5 mg (base equivalent)........................................................................20 JALYN -dutasteride-tamsulosin hcl cap 0.5-0.4 mg...........80 JANUMET -sitagliptin-metformin hcl tab 50-1000 mg........ 33 JANUMET -sitagliptin-metformin hcl tab 50-500 mg..........33 JANUMET XR -sitagliptin-metformin hcl tab sr 24hr 100-1000 mg....................................................................33 JANUMET XR -sitagliptin-metformin hcl tab sr 24hr 50-1000 mg......................................................................33 JANUMET XR -sitagliptin-metformin hcl tab sr 24hr 50-500 mg.................................................................................... 33 JANUVIA -sitagliptin phosphate tab 100 mg (base equiv)................................................................................34 JANUVIA -sitagliptin phosphate tab 25 mg (base equiv)................................................................................33 JANUVIA -sitagliptin phosphate tab 50 mg (base equiv)................................................................................34 JARDIANCE -empagliflozin tab 10 mg.............................. 34 JARDIANCE -empagliflozin tab 25 mg.............................. 34 J-COF DHC -pseudoephed-bromphen-dihydrocodeine liqd 15-3-7.5 mg/5ml...............................................................65 JENTADUETO -linagliptin-metformin hcl tab 2.5-1000 mg.................................................................................... 34 JENTADUETO -linagliptin-metformin hcl tab 2.5-500 mg.................................................................................... 34 JENTADUETO -linagliptin-metformin hcl tab 2.5-850 mg.................................................................................... 34 JETREA -ocriplasmin intravitreal inj 0.5 mg/0.2ml (2.5 mg/ ml).................................................................................. 143 JINTELI -norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg......................................................................... 28 J-MAX DHC -dihydrocodeine-guaifenesin liquid 7.5-100 mg/5ml..............................................................................65 JUBLIA -efinaconazole soln 10%.................................... 157 216 JUVISYNC -sitagliptin-simvastatin tab 100-10 mg.............34 JUVISYNC -sitagliptin-simvastatin tab 100-20 mg.............34 JUVISYNC -sitagliptin-simvastatin tab 100-40 mg.............34 JUVISYNC -sitagliptin-simvastatin tab 50-10 mg...............34 JUVISYNC -sitagliptin-simvastatin tab 50-20 mg...............34 JUVISYNC -sitagliptin-simvastatin tab 50-40 mg...............34 JUXTAPID -lomitapide mesylate cap 10 mg (base equiv)................................................................................60 JUXTAPID -lomitapide mesylate cap 20 mg (base equiv)................................................................................60 JUXTAPID -lomitapide mesylate cap 5 mg (base equiv)................................................................................60 K.B.G.L. IN TERODERM CREA - ketoprofen-baclofengabapent-lido crm 15-4-10-2% (cmp kit) ...................... 157 KADIAN -morphine sulfate cap sr 24hr 100 mg...............106 KADIAN -morphine sulfate cap sr 24hr 10 mg................ 105 KADIAN -morphine sulfate cap sr 24hr 130 mg...............106 KADIAN -morphine sulfate cap sr 24hr 150 mg...............106 KADIAN -morphine sulfate cap sr 24hr 200 mg...............106 KADIAN -morphine sulfate cap sr 24hr 20 mg................ 105 KADIAN -morphine sulfate cap sr 24hr 30 mg................ 105 KADIAN -morphine sulfate cap sr 24hr 40 mg................ 105 KADIAN -morphine sulfate cap sr 24hr 50 mg................ 105 KADIAN -morphine sulfate cap sr 24hr 60 mg................ 105 KADIAN -morphine sulfate cap sr 24hr 70 mg................ 106 KADIAN -morphine sulfate cap sr 24hr 80 mg................ 106 KALBITOR -ecallantide inj 10 mg/ml............................... 140 KALETRA -lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml)................................................................................ 9 KALETRA -lopinavir-ritonavir tab 100-25 mg.......................9 KALETRA -lopinavir-ritonavir tab 200-50 mg.......................9 KALYDECO -ivacaftor tab 150 mg.................................... 70 KANAMYCIN SULFATE -kanamycin sulfate inj 333 mg/ ml........................................................................................6 KAPVAY -clonidine hcl tab sr 12hr 0.1 mg........................95 KAPVAY DOSE PACK -clonidine hcl tab sr 12hr therapy pack 0.1 & 0.2 mg........................................................... 95 KARBINAL ER -carbinoxamine maleate er susp 4 mg/5ml..............................................................................63 KAYEXALATE - sodium polystyrene sulfonate powder ....................................................................................... 171 KAZANO -alogliptin-metformin hcl tab 12.5-1000 mg........34 KAZANO -alogliptin-metformin hcl tab 12.5-500 mg..........34 KEFLEX -cephalexin cap 250 mg....................................... 3 KEFLEX -cephalexin cap 500 mg....................................... 3 KEFLEX -cephalexin cap 750 mg....................................... 3 KENALOG-10 -triamcinolone acetonide inj susp 10 mg/ ml......................................................................................23 KENALOG-40 -triamcinolone acetonide inj susp 40 mg/ ml......................................................................................23 KENALOG -triamcinolone acetonide aerosol soln........... 157 KENDALL AMORPHOUS HYDROGE - wound dressings gel ................................................................................. 157 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 KHEDEZLA -desvenlafaxine tab sr 24hr 100 mg.............. 84 KHEDEZLA -desvenlafaxine tab sr 24hr 50 mg................ 84 KINERET -anakinra subcutaneous soln prefilled syringe 100 mg/0.67ml............................................................... 113 KINLYTIC -urokinase for inj 250000 unit......................... 140 KINRIX -diph-tetanus tox ad-acell pert & polio virus, ipv vac inj...............................................................................16 KLARON -sulfacetamide sodium lotion 10% (acne)........ 157 KLONOPIN -clonazepam tab 0.5 mg.............................. 121 KLONOPIN -clonazepam tab 1 mg................................. 121 KLONOPIN -clonazepam tab 2 mg................................. 121 KLOR-CON 25 -potassium chloride powder packet 25 meq................................................................................ 132 KLOR-CON M15 -potassium chloride microencapsulated crys cr tab 15 meq.........................................................132 KOMBIGLYZE XR -saxagliptin-metformin hcl tab sr 24hr 2.5-1000 mg.....................................................................34 KOMBIGLYZE XR -saxagliptin-metformin hcl tab sr 24hr 5-1000 mg........................................................................34 KOMBIGLYZE XR -saxagliptin-metformin hcl tab sr 24hr 5-500 mg..........................................................................34 KORLYM -mifepristone tab 300 mg.................................. 34 K-PHOS NEUTRAL -pot phos monobasic w/sod phos di & monobas tab 155-852-130mg........................................132 K-PHOS NO 2 -potassium & sodium acid phosphates tab 305-700 mg......................................................................80 K-PHOS -potassium phosphate monobasic tab 500 mg.................................................................................. 132 KRISTALOSE -lactulose oral crystal packet 10 gm........... 70 KRISTALOSE -lactulose oral crystal packet 20 gm........... 70 K-TAB -potassium chloride tab cr 10 meq.......................132 K-TAB -potassium chloride tab cr 20 meq (1500 mg)...... 132 KUVAN -sapropterin dihydrochloride powder packet 100 mg.................................................................................... 40 KUVAN -sapropterin dihydrochloride soluble tab 100 mg.................................................................................... 40 KYNAMRO -mipomersen sodium soln prefilled syringe 200 mg/ml................................................................................60 KENDALL HYDROGEL IMPREGNA - hydroactive (sterile) dressing ........................................................................ 157 KENDALL HYDROGEL WOUND DR - hydroactive (sterile) dressing ........................................................................ 157 KENDALL ZINC CALCIUM ALGI - wound dressings - misc ....................................................................................... 157 KENDALL ZINC CALCIUM ALGI - wound dressings - pads ....................................................................................... 157 KEPPRA -levetiracetam oral soln 100 mg/ml.................. 120 KEPPRA -levetiracetam tab 1000 mg............................. 120 KEPPRA -levetiracetam tab 250 mg............................... 120 KEPPRA -levetiracetam tab 500 mg............................... 120 KEPPRA -levetiracetam tab 750 mg............................... 120 KEPPRA XR -levetiracetam tab sr 24hr 500 mg............. 120 KEPPRA XR -levetiracetam tab sr 24hr 750 mg............. 120 KERAFOAM 42 -urea foam 42%.....................................157 KERAFOAM -urea foam 30%..........................................157 KERALAC -urea cream 47%........................................... 157 KERALYT -salicylic acid gel 6%......................................157 KERALYT SCALP -salicylic acid shampoo 6% & salicylic acid gel 6% kit............................................................... 157 KERLONE -betaxolol hcl tab 10 mg.................................. 45 KERLONE -betaxolol hcl tab 20 mg.................................. 45 KERR TRIPLE DYE -triple dye swabs............................ 167 KERYDIN -tavaborole soln 5%........................................157 KETEK -telithromycin tab 300 mg..................................... 13 KETEK -telithromycin tab 400 mg..................................... 13 ketoconazole cream 2%................................................ 157 ketoconazole foam 2% (Extina)....................................157 ketoconazole shampoo 2% (Nizoral)........................... 157 ketoconazole tab 200 mg..................................................7 KETODAN KIT -ketoconazole foam 2% & cleanser kit....................................................................................157 ketoprofen cap 50 mg................................................... 112 ketoprofen cap 75 mg................................................... 112 KETOPROFEN ER -ketoprofen cap sr 24hr 200 mg....... 112 KETOROCAINE-L -ketorolac trometh inj 30 mg/ml & lidocaine hcl 1% kit........................................................ 112 KETOROCAINE-LM -ketorolac inj 30 mg/ml & bupivacaine 0.25% & lido 1% kit....................................................... 112 KETOROLAC 2% GEL - ketorolac tromethamine gel 2% (cmpd kit) (base equiv).................................................. 157 ketorolac tromethamine im inj 60 mg/2ml (30 mg/ ml).................................................................................. 113 ketorolac tromethamine inj 15 mg/ml.......................... 113 ketorolac tromethamine inj 30 mg/ml.......................... 113 ketorolac tromethamine inj 60 mg/2ml (30 mg/ml)......113 KETOROLAC TROMETHAMINE -ketorolac tromethamine im inj 30 mg/ml.............................................................. 112 KETOROLAC TROMETHAMINE -ketorolac tromethamine inj 300 mg/10ml (30 mg/ml)........................................... 112 ketorolac tromethamine ophth soln 0.4% (Acular ls)................................................................................... 143 ketorolac tromethamine ophth soln 0.5% (Acular)..... 143 ketorolac tromethamine tab 10 mg.............................. 113 L labetalol hcl tab 100 mg (Trandate)............................... 45 labetalol hcl tab 200 mg (Trandate)............................... 45 labetalol hcl tab 300 mg (Trandate)............................... 45 LAC-HYDRIN -lactic acid (ammonium lactate) cream 12%................................................................................ 157 LAC-HYDRIN -lactic acid (ammonium lactate) lotion 12%................................................................................ 157 LACRISERT - artificial tear ophth insert .........................143 lactated ringer's for irrigation.......................................171 lactic acid (ammonium lactate) cream 12% (Lachydrin)........................................................................... 157 lactic acid (ammonium lactate) lotion 10%................. 157 lactic acid (ammonium lactate) lotion 12% (Lachydrin)........................................................................... 157 lactic acid w/ vitamin e cream 10%-3500 unit/30gm...................................................................... 157 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 217 2015 lactulose (encephalopathy) solution 10 gm/15ml......... 76 lactulose solution 10 gm/15ml....................................... 70 LAMICTAL CHEWABLE DISPERS -lamotrigine tab chewable dispersible 25 mg.......................................... 121 LAMICTAL CHEWABLE DISPERS -lamotrigine tab chewable dispersible 5 mg............................................ 121 LAMICTAL -lamotrigine tab 100 mg................................ 121 LAMICTAL -lamotrigine tab 150 mg................................ 121 LAMICTAL -lamotrigine tab 200 mg................................ 121 LAMICTAL -lamotrigine tab 25 mg.................................. 121 LAMICTAL -lamotrigine tab chewable dispersible 2 mg.................................................................................. 121 LAMICTAL ODT -lamotrigine orally disintegrating tab 100 mg.................................................................................. 121 LAMICTAL ODT -lamotrigine orally disintegrating tab 200 mg.................................................................................. 121 LAMICTAL ODT -lamotrigine orally disintegrating tab 25 mg.................................................................................. 121 LAMICTAL ODT -lamotrigine orally disintegrating tab 50 mg.................................................................................. 121 LAMICTAL ODT -lamotrigine tab disp 25 (14) & 50 mg (14) & 100 mg (7) kit.............................................................121 LAMICTAL ODT -lamotrigine tab disp 25 mg (21) & 50 mg (7) titration kit................................................................. 121 LAMICTAL ODT -lamotrigine tab disp 50 mg (42) & 100 mg (14) titration kit.........................................................121 LAMICTAL STARTER/NOT TAKI -lamotrigine tab 25 mg (42) & 100 mg (7) starter kit.......................................... 121 LAMICTAL STARTER/TAKING C -lamotrigine tab 25 mg (84) & 100 mg (14) starter kit........................................ 121 LAMICTAL STARTER/TAKING V -lamotrigine tab 25 mg (35) starter kit................................................................ 121 LAMICTAL XR -lamotrigine tab sr 24hr 100 mg.............. 121 LAMICTAL XR -lamotrigine tab sr 24hr 200 mg.............. 121 LAMICTAL XR -lamotrigine tab sr 24hr 25 (14) & 50 mg (14) & 100 mg(7) kit...................................................... 121 LAMICTAL XR -lamotrigine tab sr 24hr 250 mg.............. 121 LAMICTAL XR -lamotrigine tab sr 24hr 25 mg................ 121 LAMICTAL XR -lamotrigine tab sr 24hr 25 mg (21) & 50 mg (7) titration kit...........................................................121 LAMICTAL XR -lamotrigine tab sr 24hr 300 mg.............. 121 LAMICTAL XR -lamotrigine tab sr 24hr 50 (14) & 100 mg(14) & 200 mg(7) kit..................................................121 LAMICTAL XR -lamotrigine tab sr 24hr 50 mg................ 121 LAMISIL SPRAY -terbinafine hcl soln 1%....................... 157 LAMISIL -terbinafine hcl oral granules packet 125 mg........ 7 LAMISIL -terbinafine hcl oral granules packet 187.5 mg..... 7 LAMISIL -terbinafine hcl tab 250 mg................................... 7 lamivudine tab 100 mg (Epivir hbv)................................. 9 lamivudine tab 150 mg (Epivir)........................................ 9 lamivudine tab 300 mg (Epivir)........................................ 9 lamivudine-zidovudine tab 150-300 mg (Combivir)........ 9 lamotrigine tab 100 mg (Lamictal)............................... 121 lamotrigine tab 150 mg (Lamictal)............................... 121 lamotrigine tab 200 mg (Lamictal)............................... 121 218 lamotrigine tab 25 mg (Lamictal)................................. 121 lamotrigine tab chewable dispersible 25 mg (Lamictal chewable di)................................................................. 121 lamotrigine tab chewable dispersible 5 mg (Lamictal chewable di)................................................................. 121 lamotrigine tab sr 24hr 100 mg (Lamictal xr).............. 121 lamotrigine tab sr 24hr 200 mg (Lamictal xr).............. 121 lamotrigine tab sr 24hr 250 mg (Lamictal xr).............. 121 lamotrigine tab sr 24hr 25 mg (Lamictal xr)................ 121 lamotrigine tab sr 24hr 300 mg (Lamictal xr).............. 121 lamotrigine tab sr 24hr 50 mg (Lamictal xr)................ 121 LANCETS – VARIOUS....................................................169 LANOXIN -digoxin inj 0.25 mg/ml......................................43 LANOXIN -digoxin tab 125 mcg (0.125 mg)...................... 43 LANOXIN -digoxin tab 187.5 mcg (0.1875 mg)................. 43 LANOXIN -digoxin tab 250 mcg (0.25 mg)........................ 43 LANOXIN -digoxin tab 62.5 mcg (0.0625 mg)................... 43 LANOXIN PEDIATRIC -digoxin inj 0.1 mg/ml....................43 lansoprazole cap delayed release 15 mg (Prevacid)........................................................................ 72 lansoprazole cap delayed release 30 mg (Prevacid)........................................................................ 72 LANTUS -insulin glargine inj 100 unit/ml........................... 36 LANTUS SOLOSTAR -insulin glargine soln pen-injector 100 unit/ml....................................................................... 36 LARTUS -phenyleph-chlorphen w/ dm-gg liquid 5-2-15-150 mg/5ml..............................................................................65 LASIX -furosemide tab 20 mg........................................... 58 LASIX -furosemide tab 40 mg........................................... 58 LASIX -furosemide tab 80 mg........................................... 58 LASTACAFT -alcaftadine ophth soln 0.25%....................143 latanoprost ophth soln 0.005% (Xalatan).................... 143 LATRIX XM -urea in zinc undecylenate-lactic acid vehicle emulsion 45%................................................................ 157 LATUDA -lurasidone hcl tab 120 mg.................................89 LATUDA -lurasidone hcl tab 20 mg...................................89 LATUDA -lurasidone hcl tab 40 mg...................................89 LATUDA -lurasidone hcl tab 60 mg...................................89 LATUDA -lurasidone hcl tab 80 mg...................................89 LAVARE WOUND WASH - wound cleansers - gel .........157 LAVOCLEN-4 CREAMY WASH -benzoyl peroxide liq 4%.................................................................................. 157 LAVOCLEN-8 CREAMY WASH -benzoyl peroxide liq 8%.................................................................................. 157 LAZANDA -fentanyl citrate nasal spray 100 mcg/act (base equiv)..............................................................................106 LAZANDA -fentanyl citrate nasal spray 400 mcg/act (base equiv)..............................................................................106 LECITHIN -lecithin granules............................................ 133 leflunomide tab 10 mg (Arava)..................................... 113 leflunomide tab 20 mg (Arava)..................................... 113 LESCOL XL -fluvastatin sodium tab sr 24 hr 80 mg.......... 60 LETAIRIS -ambrisentan tab 10 mg................................... 62 LETAIRIS -ambrisentan tab 5 mg..................................... 62 letrozole tab 2.5 mg (Femara).........................................20 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 levofloxacin tab 250 mg (Levaquin).................................6 levofloxacin tab 500 mg (Levaquin).................................6 levofloxacin tab 750 mg (Levaquin).................................6 levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg................................................................... 29 levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg.................................................................................. 29 levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg.................................................................................. 29 levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg.................................29 levonorgestrel tab 0.75 mg (Plan b)...............................29 levonorgestrel tab 1.5 mg (Plan b one-step)................. 29 levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) (Loseasonique).............................................29 levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) (Seasonique).................................................29 LEVOPHED -norepinephrine bitartrate inj 1 mg/ml............59 LEVORPHANOL TARTRATE -levorphanol tartrate tab 2 mg.................................................................................. 106 levothyroxine sodium tab 100 mcg (Synthroid)............37 levothyroxine sodium tab 112 mcg (Synthroid)............37 levothyroxine sodium tab 125 mcg (Synthroid)............37 levothyroxine sodium tab 137 mcg (Synthroid)............37 levothyroxine sodium tab 150 mcg (Synthroid)............37 levothyroxine sodium tab 175 mcg (Synthroid)............37 levothyroxine sodium tab 200 mcg (Synthroid)............37 levothyroxine sodium tab 25 mcg (Synthroid)..............37 levothyroxine sodium tab 300 mcg (Synthroid)............37 levothyroxine sodium tab 50 mcg (Synthroid)..............37 levothyroxine sodium tab 75 mcg (Synthroid)..............37 levothyroxine sodium tab 88 mcg (Synthroid)..............37 LEVSIN/SL -hyoscyamine sulfate tab sl 0.125 mg............ 73 LEVSIN -hyoscyamine sulfate inj 0.5 mg/ml......................73 LEVSIN -hyoscyamine sulfate tab 0.125 mg..................... 73 LEVULAN KERASTICK -aminolevulinic acid hcl for soln 20% (stick applicator).................................................... 157 LEXAPRO -escitalopram oxalate soln 5 mg/5ml (base equiv)................................................................................85 LEXAPRO -escitalopram oxalate tab 10 mg (base equiv)................................................................................85 LEXAPRO -escitalopram oxalate tab 20 mg (base equiv)................................................................................85 LEXAPRO -escitalopram oxalate tab 5 mg (base equiv)................................................................................85 LEXIVA -fosamprenavir calcium susp 50 mg/ml (base equiv)..................................................................................9 LEXIVA -fosamprenavir calcium tab 700 mg (base equiv)..................................................................................9 LIALDA -mesalamine tab delayed release 1.2 gm............ 76 LIBRAX -clidinium & chlordiazepoxide cap 2.5-5 mg.........73 LIDOCAINE/PRILOCAINE -lidocaine-prilocaine kit 2.5-2.5%......................................................................... 158 lidocaine hcl cream 3%.................................................157 lidocaine hcl gel 2%...................................................... 157 LETS KIT -lidocaine & tetracaine w/ epineph kit (compounding kit).......................................................... 117 leucovorin calcium for inj 100 mg................................. 20 leucovorin calcium for inj 200 mg................................. 20 leucovorin calcium for inj 350 mg................................. 20 leucovorin calcium for inj 50 mg................................... 20 LEUCOVORIN CALCIUM -leucovorin calcium for inj 500 mg.................................................................................... 20 LEUCOVORIN CALCIUM -leucovorin calcium tab 10 mg.................................................................................... 20 LEUCOVORIN CALCIUM -leucovorin calcium tab 15 mg.................................................................................... 20 leucovorin calcium tab 25 mg........................................ 20 leucovorin calcium tab 5 mg.......................................... 20 LEUKERAN -chlorambucil tab 2 mg..................................20 LEUKINE -sargramostim inj 500 mcg/ml......................... 136 leuprolide acetate inj kit 5 mg/ml...................................20 LEVACET -aspirin-apap-salicylamide-caffeine tab 500-250-150-32.5 mg.................................................... 101 levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv) (Xopenex)........................................................................ 68 levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv) (Xopenex)........................................................................ 68 levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) (Xopenex)........................................................................ 68 LEVALBUTEROL -levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv)..................................................... 68 LEVAQUIN -levofloxacin oral soln 25 mg/ml....................... 5 LEVAQUIN -levofloxacin tab 250 mg.................................. 5 LEVAQUIN -levofloxacin tab 500 mg.................................. 5 LEVAQUIN -levofloxacin tab 750 mg.................................. 5 LEVATOL -penbutolol sulfate tab 20 mg........................... 45 LEVBID -hyoscyamine sulfate tab sr 12hr 0.375 mg......... 73 LEVEMIR FLEXPEN -insulin detemir soln pen-injector 100 unit/ml...............................................................................36 LEVEMIR FLEXTOUCH -insulin detemir soln pen-injector 100 unit/ml....................................................................... 36 LEVEMIR -insulin detemir inj 100 unit/ml.......................... 36 levetiracetam oral soln 100 mg/ml (Keppra)............... 121 levetiracetam tab 1000 mg (Keppra)............................ 122 levetiracetam tab 250 mg (Keppra).............................. 122 levetiracetam tab 500 mg (Keppra).............................. 122 levetiracetam tab 750 mg (Keppra).............................. 122 levetiracetam tab sr 24hr 500 mg (Keppra xr).............121 levetiracetam tab sr 24hr 750 mg (Keppra xr).............122 LEVOBUNOLOL HCL -levobunolol hcl ophth soln 0.25%............................................................................. 143 levobunolol hcl ophth soln 0.5% (Betagan)................ 143 levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)...... 41 levocarnitine tab 330 mg (Carnitor)............................... 41 levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ ml) (Xyzal)....................................................................... 63 levocetirizine dihydrochloride tab 5 mg (Xyzal)............63 levofloxacin ophth soln 0.5%....................................... 143 levofloxacin oral soln 25 mg/ml (Levaquin).................... 6 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 219 2015 LIDOCAINE HCL-HYDROCORTIS -lidocainehydrocortisone acetate rectal gel 2.8-0.55%..................148 lidocaine hcl laryngotracheal soln 4% (Lta 360 kit).................................................................................. 147 LIDOCAINE HCL -lidocaine hcl lotion 3%....................... 157 lidocaine hcl local inj 0.5% (Xylocaine)....................... 117 lidocaine hcl local inj 1.5% (Xylocaine-mpf)............... 117 lidocaine hcl local inj 1% (Xylocaine).......................... 117 lidocaine hcl local inj 2% (Xylocaine).......................... 117 lidocaine hcl local inj 4% (Xylocaine-mpf).................. 117 lidocaine hcl local preservative free (pf) inj 0.5% (Xylocaine-mpf)............................................................ 117 lidocaine hcl local preservative free (pf) inj 1% (Xylocaine-mpf)............................................................ 117 lidocaine hcl local preservative free (pf) inj 2% (Xylocaine-mpf)............................................................ 117 lidocaine hcl soln 4% (Xylocaine)................................ 157 lidocaine hcl viscous soln 2%......................................147 lidocaine-hydrocortisone acetate rectal cream 3-0.5%............................................................................ 148 lidocaine-hydrocortisone acetate rectal cream kit 2-2%............................................................................... 148 lidocaine-hydrocortisone acetate rectal cream kit 3-0.5%............................................................................ 148 lidocaine-hydrocortisone acetate rectal cream kit 3-1%............................................................................... 148 lidocaine-hydrocortisone acetate rectal gel kit 3-2.5%............................................................................ 148 lidocaine inj 0.5% w/ epinephrine-1:200000 (Xylocaine/ epinephrin)....................................................................117 lidocaine inj 1.5% w/ epinephrine-1:200000 (Xylocainempf/epinep)................................................................... 117 lidocaine inj 1% w/ epinephrine-1:100000 (Xylocaine/ epinephrin)....................................................................117 lidocaine inj 2% w/ epinephrine-1:100000 (Xylocaine/ epinephrin)....................................................................117 lidocaine inj 2% w/ epinephrine-1:200000 (Xylocainempf/epinep)................................................................... 117 lidocaine inj 2% w/ epinephrine-1:50000..................... 118 lidocaine oint 5%........................................................... 157 lidocaine patch 5% (Lidoderm).................................... 157 lidocaine-prilocaine cream 2.5-2.5% (Emla)................ 157 LIDODERM -lidocaine patch 5%..................................... 158 LIDODEXTRAPINE -lidocaine-menthol patch 4-1%........ 158 LIDOLOG KIT -triamcinolone inj 40 mg/ml & lidocaine hcl inj 2% kit.......................................................................... 23 LIDOPROFEN - ketoprofen-ketamine-lidocaine cream 5-5-2% (compound kit) ................................................. 158 LIDORX -lidocaine hcl gel 3%......................................... 158 LIDOVIR - acyclovir-lidocaine hcl oint 4-4% (compounding kit) ................................................................................. 158 LINCOCIN -lincomycin hcl inj 300 mg/ml.......................... 13 lindane lotion 1%........................................................... 158 lindane shampoo 1%.....................................................158 LINZESS -linaclotide cap 145 mcg....................................76 220 LINZESS -linaclotide cap 290 mcg....................................76 LIORESAL INTRATHECAL -baclofen intrathecal inj 0.05 mg/ml (50 mcg/ml)......................................................... 127 LIORESAL INTRATHECAL -baclofen intrathecal inj 10 mg/20ml (500 mcg/ml)................................................... 127 LIORESAL INTRATHECAL -baclofen intrathecal inj 10 mg/5ml (2000 mcg/ml)................................................... 127 LIORESAL INTRATHECAL -baclofen intrathecal inj 40 mg/20ml (2000 mcg/ml)................................................. 127 liothyronine sodium tab 25 mcg (Cytomel)................... 37 liothyronine sodium tab 50 mcg (Cytomel)................... 37 liothyronine sodium tab 5 mcg (Cytomel)..................... 37 LIPOFEN -fenofibrate cap 150 mg.................................... 60 LIPOFEN -fenofibrate cap 50 mg...................................... 60 LIPTRUZET -ezetimibe-atorvastatin tab 10-10 mg............60 LIPTRUZET -ezetimibe-atorvastatin tab 10-20 mg............60 LIPTRUZET -ezetimibe-atorvastatin tab 10-40 mg............60 LIPTRUZET -ezetimibe-atorvastatin tab 10-80 mg............60 LIQUICET -hydrocodone-acetaminophen soln 10-500 mg/15ml..........................................................................106 LIQUIHEP BD 3ML PREFILLED - arterial blood gas kit ....................................................................................... 168 LIQUIHEP BD 3ML PREFIL SY - arterial blood gas kit ....................................................................................... 168 LIQUIHEP II BD 3ML LL SYR - arterial blood gas kit ..... 168 LIQUIHEP II BD 3ML PREFIL - arterial blood gas kit ..... 168 lisinopril & hydrochlorothiazide tab 10-12.5 mg (Zestoretic)......................................................................53 lisinopril & hydrochlorothiazide tab 20-12.5 mg (Zestoretic)......................................................................53 lisinopril & hydrochlorothiazide tab 20-25 mg (Zestoretic)......................................................................53 lisinopril tab 10 mg (Prinivil).......................................... 53 lisinopril tab 2.5 mg (Zestril).......................................... 53 lisinopril tab 20 mg (Prinivil).......................................... 53 lisinopril tab 30 mg (Zestril)........................................... 53 lisinopril tab 40 mg (Zestril)........................................... 53 lisinopril tab 5 mg (Prinivil)............................................ 53 lithium carbonate cap 150 mg (Lithium carbonate)...... 89 lithium carbonate cap 300 mg........................................89 lithium carbonate cap 600 mg (Lithium carbonate)...... 89 LITHIUM CARBONATE -lithium carbonate cap 150 mg.................................................................................... 89 LITHIUM CARBONATE -lithium carbonate cap 600 mg.................................................................................... 89 lithium carbonate tab 300 mg.........................................89 lithium carbonate tab cr 300 mg (Lithobid)................... 89 lithium carbonate tab cr 450 mg.................................... 89 LITHIUM -lithium oral solution 8 meq/5ml......................... 89 LITHOBID -lithium carbonate tab cr 300 mg..................... 89 LITHOSTAT -acetohydroxamic acid tab 250 mg............... 80 LIVALO -pitavastatin calcium tab 1 mg (base equiv)......... 60 LIVALO -pitavastatin calcium tab 2 mg (base equiv)......... 60 LIVALO -pitavastatin calcium tab 4 mg (base equiv)......... 60 LOCOID -hydrocortisone butyrate cream 0.1%............... 158 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 LORTAB -hydrocodone-acetaminophen soln 7.5-500 mg/15ml..........................................................................106 LORTAB -hydrocodone-acetaminophen tab 10-500 mg.................................................................................. 106 LORTAB -hydrocodone-acetaminophen tab 5-500 mg.................................................................................. 106 LORTAB -hydrocodone-acetaminophen tab 7.5-500 mg.................................................................................. 106 LORZONE -chlorzoxazone tab 375 mg...........................127 LORZONE -chlorzoxazone tab 750 mg...........................127 losartan potassium & hydrochlorothiazide tab 100-12.5 mg (Hyzaar).................................................................... 53 losartan potassium & hydrochlorothiazide tab 100-25 mg (Hyzaar).................................................................... 53 losartan potassium & hydrochlorothiazide tab 50-12.5 mg (Hyzaar).................................................................... 54 losartan potassium tab 100 mg (Cozaar)...................... 54 losartan potassium tab 25 mg (Cozaar)........................ 54 losartan potassium tab 50 mg (Cozaar)........................ 54 LOSEASONIQUE -levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7)...................................................... 29 LOTEMAX -loteprednol etabonate ophth gel 0.5%..........143 LOTEMAX -loteprednol etabonate ophth oint 0.5%.........143 LOTEMAX -loteprednol etabonate ophth susp 0.5%....... 143 LOTENSIN -benazepril hcl tab 10 mg............................... 54 LOTENSIN -benazepril hcl tab 20 mg............................... 54 LOTENSIN -benazepril hcl tab 40 mg............................... 54 LOTENSIN HCT -benazepril & hydrochlorothiazide tab 10-12.5 mg.......................................................................54 LOTENSIN HCT -benazepril & hydrochlorothiazide tab 20-12.5 mg.......................................................................54 LOTENSIN HCT -benazepril & hydrochlorothiazide tab 20-25 mg..........................................................................54 LOTREL -amlodipine besylate-benazepril hcl cap 10-20 mg.................................................................................... 54 LOTREL -amlodipine besylate-benazepril hcl cap 10-40 mg.................................................................................... 54 LOTREL -amlodipine besylate-benazepril hcl cap 2.5-10 mg.................................................................................... 54 LOTREL -amlodipine besylate-benazepril hcl cap 5-10 mg.................................................................................... 54 LOTREL -amlodipine besylate-benazepril hcl cap 5-20 mg.................................................................................... 54 LOTREL -amlodipine besylate-benazepril hcl cap 5-40 mg.................................................................................... 54 LOTRISONE -clotrimazole w/ betamethasone cream 1-0.05%.......................................................................... 158 LOTRONEX -alosetron hcl tab 0.5 mg (base equiv)..........76 LOTRONEX -alosetron hcl tab 1 mg (base equiv).............76 LOUTREX - antiseborrheic products misc - cream .........158 lovastatin tab 10 mg........................................................60 lovastatin tab 20 mg (Mevacor)......................................60 lovastatin tab 40 mg (Mevacor)......................................60 LOVAZA -omega-3-acid ethyl esters cap 1 gm................. 60 LOVENOX -enoxaparin sodium inj 100 mg/ml................ 139 LOCOID -hydrocortisone butyrate lotion 0.1%................ 158 LOCOID -hydrocortisone butyrate oint 0.1%................... 158 LOCOID -hydrocortisone butyrate soln 0.1%.................. 158 LOCOID LIPOCREAM -hydrocortisone butyrate hydrophilic lipo base cream 0.1%.................................. 158 LODOSYN -carbidopa tab 25 mg....................................124 LOESTRIN 1/20-21 -norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg............................................................. 29 LOESTRIN 1.5/30-21 -norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg............................................ 29 LOESTRIN 24 FE -norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24)......................................................29 LOESTRIN FE 1/20 -norethindrone ace & ethinyl estradiolfe tab 1 mg-20 mcg......................................................... 29 LOESTRIN FE 1.5/30 -norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg........................................29 LOFIBRA -fenofibrate micronized cap 134 mg.................. 60 LOFIBRA -fenofibrate micronized cap 200 mg.................. 60 LOFIBRA -fenofibrate micronized cap 67 mg.................... 60 LOFIBRA -fenofibrate tab 160 mg.....................................60 LOFIBRA -fenofibrate tab 54 mg.......................................60 LO LOESTRIN FE -norethin-eth estradiol-fe tab 1 mg-10 mcg (24)/10 mcg (2)........................................................ 29 LOMEDIA 24 FE -norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24)......................................................29 LO MINASTRIN FE -norethin-eth estrad-fe chew/tab 1 mg-10 mcg/10 mcg ther pack.......................................... 29 LOMOTIL -diphenoxylate w/ atropine tab 2.5-0.025 mg.................................................................................... 71 LOMUSTINE -lomustine cap 100 mg................................ 20 LOMUSTINE -lomustine cap 10 mg.................................. 20 LOMUSTINE -lomustine cap 40 mg.................................. 20 loperamide hcl cap 2 mg................................................ 71 LOPID -gemfibrozil tab 600 mg......................................... 60 LOPRESSOR HCT -metoprolol & hydrochlorothiazide tab 100-25 mg........................................................................53 LOPRESSOR HCT -metoprolol & hydrochlorothiazide tab 50-25 mg..........................................................................53 LOPRESSOR -metoprolol tartrate tab 100 mg.................. 45 LOPRESSOR -metoprolol tartrate tab 50 mg.................... 45 LOPROX -ciclopirox gel 0.77%....................................... 158 LOPROX SHAMPOO -ciclopirox shampoo 1%............... 158 lorazepam conc 2 mg/ml (Lorazepam intensol)............ 82 lorazepam inj 2 mg/ml (Ativan)...................................... 82 lorazepam inj 4 mg/ml (Ativan)...................................... 82 LORAZEPAM INTENSOL -lorazepam conc 2 mg/ml........ 82 lorazepam tab 0.5 mg (Ativan)....................................... 82 lorazepam tab 1 mg (Ativan).......................................... 82 lorazepam tab 2 mg (Ativan).......................................... 82 LORCET 10/650 -hydrocodone-acetaminophen tab 10-650 mg.................................................................................. 106 LORCET PLUS -hydrocodone-acetaminophen tab 7.5-650 mg.................................................................................. 106 LORTAB -hydrocodone-acetaminophen soln 10-300 mg/15ml..........................................................................106 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 221 2015 LOVENOX -enoxaparin sodium inj 120 mg/0.8ml............139 LOVENOX -enoxaparin sodium inj 150 mg/ml................ 139 LOVENOX -enoxaparin sodium inj 300 mg/3ml.............. 139 LOVENOX -enoxaparin sodium inj 30 mg/0.3ml............. 139 LOVENOX -enoxaparin sodium inj 40 mg/0.4ml............. 139 LOVENOX -enoxaparin sodium inj 60 mg/0.6ml............. 139 LOVENOX -enoxaparin sodium inj 80 mg/0.8ml............. 139 loxapine succinate cap 10 mg........................................89 loxapine succinate cap 25 mg........................................89 loxapine succinate cap 50 mg........................................89 loxapine succinate cap 5 mg......................................... 89 LOXITANE -loxapine succinate cap 10 mg....................... 89 LOXITANE -loxapine succinate cap 25 mg....................... 89 LOXITANE -loxapine succinate cap 50 mg....................... 89 LOXITANE -loxapine succinate cap 5 mg......................... 89 LOZI-FLUR -sodium fluoride lozenge 1 mg f (from 2.2 mg naf)................................................................................. 132 LTA 360 KIT -lidocaine hcl laryngotracheal soln 4%....... 147 LUCENTIS -ranibizumab intravitreal inj 0.3 mg/0.05ml (6 mg/ml)............................................................................ 143 LUCENTIS -ranibizumab intravitreal inj 0.5 mg/0.05ml (10 mg/ml)............................................................................ 143 LUFYLLIN -dyphylline tab 200 mg.................................... 68 LUFYLLIN -dyphylline tab 400 mg.................................... 68 LUGOLS STRONG IODINE - iodine solution ................. 167 LUMIGAN -bimatoprost ophth soln 0.01%.......................143 LUMIGAN -bimatoprost ophth soln 0.03%.......................143 LUMINAL -phenobarbital sodium inj 130 mg/ml................ 92 LUNESTA -eszopiclone tab 1 mg......................................92 LUNESTA -eszopiclone tab 2 mg......................................92 LUNESTA -eszopiclone tab 3 mg......................................92 LUPANETA PACK -leuprolide (1 mon) inj 3.75 mg & norethindrone tab 5 mg kit...............................................41 LUPANETA PACK -leuprolide (3 mon) inj 11.25 mg & norethindrone tab 5 mg kit...............................................41 LUPRON DEPOT -leuprolide acetate (3 month) for inj kit 11.25 mg.......................................................................... 20 LUPRON DEPOT -leuprolide acetate (3 month) for inj kit 22.5 mg............................................................................ 20 LUPRON DEPOT -leuprolide acetate (4 month) for inj kit 30 mg............................................................................... 20 LUPRON DEPOT -leuprolide acetate (6 month) for inj kit 45 mg............................................................................... 20 LUPRON DEPOT -leuprolide acetate for inj kit 3.75 mg.................................................................................... 20 LUPRON DEPOT -leuprolide acetate for inj kit 7.5 mg......20 LUPRON DEPOT-PED -leuprolide acetate (3 month) for inj pediatric kit 11.25 mg...................................................... 41 LUPRON DEPOT-PED -leuprolide acetate (3 month) for inj pediatric kit 30 mg........................................................... 41 LUPRON DEPOT-PED -leuprolide acetate for inj pediatric kit 11.25 mg..................................................................... 41 LUPRON DEPOT-PED -leuprolide acetate for inj pediatric kit 15 mg.......................................................................... 41 222 LUPRON DEPOT-PED -leuprolide acetate for inj pediatric kit 7.5 mg......................................................................... 41 LURIDE -sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf)...........................................................................132 LURIDE -sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)................................................................................. 132 LURIDE -sodium fluoride chew tab 1 mg f (from 2.2 mg naf)................................................................................. 132 LURIDE -sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)................................................................................. 132 LUVOX CR -fluvoxamine maleate cap sr 24hr 100 mg......85 LUVOX CR -fluvoxamine maleate cap sr 24hr 150 mg......85 LUXIQ -betamethasone valerate aerosol foam 0.12%.....158 LUZU -luliconazole cream 1%......................................... 158 LYCELLE - nit remover - gel ..........................................158 LYRICA -pregabalin cap 100 mg.....................................122 LYRICA -pregabalin cap 150 mg.....................................122 LYRICA -pregabalin cap 200 mg.....................................122 LYRICA -pregabalin cap 225 mg.....................................122 LYRICA -pregabalin cap 25 mg.......................................122 LYRICA -pregabalin cap 300 mg.....................................122 LYRICA -pregabalin cap 50 mg.......................................122 LYRICA -pregabalin cap 75 mg.......................................122 LYRICA -pregabalin soln 20 mg/ml................................. 122 LYSODREN -mitotane tab 500 mg....................................20 LYSTEDA -tranexamic acid tab 650 mg..........................140 LYTENSOPRIL-90 KIT -lisinopril tab 20 mg & dietary management cap pack.................................................... 54 LYTENSOPRIL-90 -lisinopril tab 20 mg & dietary management cap pack.................................................... 54 LYTENSOPRIL KIT -lisinopril tab 20 mg & dietary management cap pack.................................................... 54 M MACROBID -nitrofurantoin monohydrate macrocrystalline cap 100 mg......................................................................77 MACRODANTIN -nitrofurantoin macrocrystalline cap 100 mg.................................................................................... 77 MACRODANTIN -nitrofurantoin macrocrystalline cap 25 mg.................................................................................... 77 MACRODANTIN -nitrofurantoin macrocrystalline cap 50 mg.................................................................................... 77 MACUGEN -pegaptanib sodium intravitreous inj 0.3 mg/90 microliter.........................................................................143 mafenide acetate packet for topical soln 5% (50 gm) (Sulfamylon)..................................................................158 MAGNACET -oxycodone w/ acetaminophen tab 10-400 mg.................................................................................. 106 MAGNACET -oxycodone w/ acetaminophen tab 5-400 mg.................................................................................. 106 MAGNACET -oxycodone w/ acetaminophen tab 7.5-400 mg.................................................................................. 106 MAGNEBIND 400 -magnesium-calcium-folic acid tab 400-200-1 mg.................................................................132 magnesium chloride inj 200 mg/ml..............................132 magnesium sulfate inj 50%.......................................... 132 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 MAXALT -rizatriptan benzoate tab 5 mg......................... 115 MAXARON FORTE - fe gly-fe fum-vit c-vit b12methylfolate tab ............................................................ 136 MAXFE - iron-fa-vit b12-biotin-vit c-docusate-mg-zn tab 160-1 mg ...................................................................... 136 MAXIDEX -dexamethasone ophth susp 0.1%................. 143 MAXIDONE -hydrocodone-acetaminophen tab 10-750 mg.................................................................................. 106 MAXIFED CD -pseudoephedrine w/ cod-gg tab 60-10-400 mg.................................................................................... 65 MAXIFED CDX -pseudoephedrine w/ cod-gg tab 60-20-400 mg...................................................................65 MAXIFED-G CD -pseudoephedrine w/ cod-gg tab 40-10-400 mg...................................................................65 MAXIFED-G CDX -pseudoephedrine w/ cod-gg tab 40-20-400 mg...................................................................65 MAXIFLU CD -pseudoephed-codeine-guaifenesin-apap tab 40-10-400-500 mg..................................................... 65 MAXIFLU CDX -pseudoephed-codeine-guaifenesin-apap tab 60-20-400-500 mg..................................................... 65 MAXIPHEN CD -phenylephrine w/ codeine-gg tab 10-10-400 mg...................................................................65 MAXIPHEN CDX -phenylephrine w/ codeine-gg tab 10-20-400 mg...................................................................65 MAXIPIME -cefepime hcl for inj 1 gm................................. 3 MAXIPIME -cefepime hcl for inj 2 gm................................. 3 MAXITROL -neomycin-polymyxin-dexamethasone ophth oint 0.1%........................................................................ 143 MAXITROL -neomycin-polymyxin-dexamethasone ophth susp 0.1%...................................................................... 143 MAXZIDE-25 -triamterene & hydrochlorothiazide tab 37.5-25 mg.......................................................................58 MAXZIDE -triamterene & hydrochlorothiazide tab 75-50 mg.................................................................................... 58 MB HYDROGEL -emollient cream & wound dressing gel kit....................................................................................158 meclizine hcl tab 12.5 mg............................................... 74 meclizine hcl tab 25 mg.................................................. 74 meclizine hcl tab 32 mg.................................................. 74 MECLOFENAMATE SODIUM -meclofenamate sodium cap 100 mg....................................................................113 MECLOFENAMATE SODIUM -meclofenamate sodium cap 50 mg......................................................................113 MEDI-DERM/L-RX -lidocaine-capsaicin-menthol-methyl sal cream 2-0.035-5-20%...............................................158 MEDI-DERM-RX -capsaicin-menthol-methyl salicylate cream 0.035-5-20%....................................................... 158 MEDIHONEY CALCIUM ALGINAT - wound dressings pads .............................................................................. 158 MEDI-PATCH RX -lidocaine-capsaicin-menthol-methyl sal patch 0.5-0.035-5-20%...................................................158 MEDROL DOSEPAK -methylprednisolone tab 4 mg dose pack..................................................................................24 MEDROL -methylprednisolone tab 16 mg......................... 24 MEDROL -methylprednisolone tab 2 mg...........................24 MAGNESIUM SULFATE -magnesium sulfate inj 4%.......132 MAGNESIUM SULFATE -magnesium sulfate inj 8%.......132 MAKENA -hydroxyprogesterone caproate im in oil 250 mg/ ml......................................................................................31 MALARONE -atovaquone-proguanil hcl tab 250-100 mg.................................................................................... 12 MALARONE -atovaquone-proguanil hcl tab 62.5-25 mg.................................................................................... 12 malathion lotion 0.5% (Ovide)...................................... 158 MAPROTILINE HCL -maprotiline hcl tab 25 mg................85 MAPROTILINE HCL -maprotiline hcl tab 50 mg................85 MAPROTILINE HCL -maprotiline hcl tab 75 mg................85 MARBETA-25 -betamethasone sod phos & ace inj 6 mg/ml & bupiv 0.25% kit.............................................................23 MARBETA-L -betameth na pho&ace inj 6 mg/ml & bupiv 0.25% & lido1% kit.......................................................... 23 MARCAINE/EPINEPHRINE -bupivacaine inj 0.25% w/ epinephrine.....................................................................118 MARCAINE/EPINEPHRINE -bupivacaine inj 0.25% w/ epinephrine preservative free (pf).................................. 118 MARCAINE/EPINEPHRINE -bupivacaine inj 0.5% w/ epinephrine.....................................................................118 MARCAINE/EPINEPHRINE -bupivacaine inj 0.5% w/ epinephrine preservative free (pf).................................. 118 MARCAINE -bupivacaine hcl inj 0.25%...........................118 MARCAINE -bupivacaine hcl inj 0.5%.............................118 MARCAINE -bupivacaine hcl preservative free (pf) inj 0.25%............................................................................. 118 MARCAINE -bupivacaine hcl preservative free (pf) inj 0.5%............................................................................... 118 MARCAINE SPINAL -bupivacaine 0.75% in dextrose inj 8.25%............................................................................. 118 MARCAINE W/O EPI -bupivacaine hcl preservative free (pf) inj 0.75%................................................................. 118 MARDEX-25 -dexamethasone sod phos pf inj 10 mg/ml & bupiv 0.25% kit................................................................ 24 MARINOL -dronabinol cap 10 mg..................................... 74 MARINOL -dronabinol cap 2.5 mg.................................... 74 MARINOL -dronabinol cap 5 mg....................................... 74 MARLIDO-25 -lidocaine hcl inj 1% & bupivacaine hcl inj 0.25% kit........................................................................ 118 MARLIDO KIT -lidocaine hcl inj 2% & bupivacaine hcl inj 0.5% kit.......................................................................... 118 MARPLAN -isocarboxazid tab 10 mg................................ 85 MATULANE -procarbazine hcl cap 50 mg.........................20 MAVIK -trandolapril tab 1 mg............................................ 54 MAVIK -trandolapril tab 2 mg............................................ 54 MAVIK -trandolapril tab 4 mg............................................ 54 MAXAIR AUTOHALER -pirbuterol acetate breath activated inhal aerosol 200mcg/inh................................................. 69 MAXALT-MLT -rizatriptan benzoate orally disintegrating tab 10 mg.......................................................................115 MAXALT-MLT -rizatriptan benzoate orally disintegrating tab 5 mg.........................................................................115 MAXALT -rizatriptan benzoate tab 10 mg....................... 115 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 223 2015 MEDROL -methylprednisolone tab 32 mg......................... 24 MEDROL -methylprednisolone tab 4 mg...........................24 MEDROL -methylprednisolone tab 8 mg...........................24 MEDROX-RX -capsaicin-menthol-methyl salicylate oint 0.05-7-20%.....................................................................158 medroxyprogesterone acetate im susp 150 mg/ml (Depo-provera contrac)................................................. 29 medroxyprogesterone acetate tab 10 mg (Provera)..... 31 medroxyprogesterone acetate tab 2.5 mg (Provera)..........................................................................31 medroxyprogesterone acetate tab 5 mg (Provera)....... 31 mefenamic acid cap 250 mg (Ponstel).........................113 mefloquine hcl tab 250 mg............................................. 12 MEGACE ES -megestrol acetate susp 625 mg/5ml.......... 31 MEGACE ORAL -megestrol acetate susp 40 mg/ml......... 20 megestrol acetate susp 40 mg/ml (Megace oral).......... 20 megestrol acetate tab 20 mg.......................................... 20 megestrol acetate tab 40 mg.......................................... 20 MEKINIST -trametinib dimethyl sulfoxide tab 0.5 mg (base equivalent)........................................................................20 MEKINIST -trametinib dimethyl sulfoxide tab 2 mg (base equivalent)........................................................................20 MELOXICAM COMFORT PAC -meloxicam tab 15 mg & liniment topical gel kit.................................................... 113 MELOXICAM -meloxicam susp 7.5 mg/5ml.................... 113 meloxicam tab 15 mg (Mobic)...................................... 113 meloxicam tab 7.5 mg (Mobic)..................................... 113 MENACTRA -meningococcal (a, c, y, and w-135) conjugate vaccine inj....................................................... 15 MENEST -esterified estrogens tab 0.3 mg........................ 28 MENEST -esterified estrogens tab 0.625 mg.................... 28 MENEST -esterified estrogens tab 1.25 mg...................... 28 MENEST -esterified estrogens tab 2.5 mg........................ 28 MENHIBRIX -meningococcal (c & y)-haemophilus b tet tox conj vac for inj................................................................. 15 MENOMUNE-A/C/Y/W-135 -meningococcal vaccine a, c, y, and w-135 inj............................................................... 15 MENOSTAR -estradiol td patch weekly 14 mcg/24hr........ 28 MENTAX -butenafine hcl cream 1%................................158 MENVEO -meningococcal (a, c, y, and w-135) oligo conj vac for inj......................................................................... 15 MEPERIDINE HCL/PROMETHAZI -meperidine w/ promethazine cap 50-25 mg.......................................... 106 meperidine hcl inj 100 mg/ml (Demerol)......................106 meperidine hcl inj 25 mg/ml (Demerol)........................106 meperidine hcl inj 50 mg/ml (Demerol)........................106 MEPERIDINE HCL -meperidine hcl inj 10 mg/ml............ 106 MEPERIDINE HCL -meperidine hcl oral soln 50 mg/5ml............................................................................106 meperidine hcl tab 100 mg (Demerol)..........................106 meperidine hcl tab 50 mg (Demerol)........................... 106 MEPHYTON -phytonadione tab 5 mg............................. 128 mepivacaine hcl inj 1.5% (Carbocaine)........................118 mepivacaine hcl inj 1% (Carbocaine).......................... 118 mepivacaine hcl inj 2% (Carbocaine).......................... 118 224 MEPIVACAINE HCL -mepivacaine hcl inj 3%................. 118 mepivacaine hcl preservative free (pf) inj 1% (Carbocaine)................................................................. 118 mepivacaine hcl preservative free (pf) inj 2% (Carbocaine)................................................................. 118 meprobamate tab 200 mg............................................... 82 meprobamate tab 400 mg............................................... 82 MEPRON -atovaquone susp 750 mg/5ml......................... 13 mercaptopurine tab 50 mg (Purinethol).........................20 mesalamine enema 4 gm................................................ 76 mesalamine rectal enema 4 gm & cleanser wipe kit (Rowasa)......................................................................... 75 MESNEX -mesna tab 400 mg........................................... 20 MESTINON -pyridostigmine bromide syrup 60 mg/5ml............................................................................128 MESTINON -pyridostigmine bromide tab 60 mg............. 128 MESTINON TIMESPAN -pyridostigmine bromide tab cr 180 mg........................................................................... 128 METADATE CD -methylphenidate hcl cap cr 10 mg......... 95 METADATE CD -methylphenidate hcl cap cr 20 mg......... 95 METADATE CD -methylphenidate hcl cap cr 30 mg......... 95 METADATE CD -methylphenidate hcl cap cr 40 mg......... 95 METADATE CD -methylphenidate hcl cap cr 50 mg......... 95 METADATE CD -methylphenidate hcl cap cr 60 mg......... 95 METAPROTERENOL SULFATE -metaproterenol sulfate syrup 10 mg/5ml.............................................................. 69 METAPROTERENOL SULFATE -metaproterenol sulfate tab 10 mg.........................................................................69 METAPROTERENOL SULFATE -metaproterenol sulfate tab 20 mg.........................................................................69 metaxalone tab 800 mg (Skelaxin)............................... 127 metformin hcl tab 1000 mg (Glucophage)..................... 34 metformin hcl tab 500 mg (Glucophage).......................34 metformin hcl tab 850 mg (Glucophage).......................34 metformin hcl tab sr 24hr 500 mg (Glucophage xr)...... 34 metformin hcl tab sr 24hr 750 mg (Glucophage xr)...... 34 metformin hcl tab sr 24hr osmotic 1000 mg (Fortamet)........................................................................34 metformin hcl tab sr 24hr osmotic 500 mg (Fortamet)........................................................................34 methadone hcl conc 10 mg/ml (Methadose)............... 106 METHADONE HCL -methadone hcl inj 10 mg/ml............106 METHADONE HCL -methadone hcl soln 10 mg/5ml.......106 METHADONE HCL -methadone hcl soln 5 mg/5ml.........106 methadone hcl soln 10 mg/5ml (Methadone hcl)........ 106 methadone hcl soln 5 mg/5ml (Methadone hcl).......... 106 methadone hcl tab 10 mg (Dolophine)........................ 106 methadone hcl tab 5 mg (Dolophine hcl).................... 106 methadone hcl tab for oral susp 40 mg...................... 106 METHADOSE -methadone hcl conc 10 mg/ml................106 METHADOSE SUGAR-FREE -methadone hcl conc 10 mg/ ml....................................................................................106 methamphetamine hcl tab 5 mg (Desoxyn)...................95 methazolamide tab 25 mg (Neptazane)......................... 58 methazolamide tab 50 mg (Neptazane)......................... 58 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 methylphenidate hcl tab 5 mg (Ritalin)..........................95 methylphenidate hcl tab cr 20 mg (Ritalin sr)............... 95 methylphenidate hcl tab sa osm 18 mg (Concerta)...... 95 methylphenidate hcl tab sa osm 27 mg (Concerta)...... 95 methylphenidate hcl tab sa osm 36 mg (Concerta)...... 95 methylphenidate hcl tab sa osm 54 mg (Concerta)...... 95 methylprednisolone acetate inj susp 40 mg/ml (Depomedrol)............................................................................ 24 methylprednisolone acetate inj susp 80 mg/ml (Depomedrol)............................................................................ 24 methylprednisolone sodium succinate for inj 1000 mg (Solu-medrol).................................................................. 24 methylprednisolone sodium succinate for inj 125 mg (Solu-medrol).................................................................. 24 methylprednisolone sodium succinate for inj 40 mg (Solu-medrol).................................................................. 24 methylprednisolone tab 16 mg (Medrol)........................24 methylprednisolone tab 32 mg (Medrol)........................24 methylprednisolone tab 4 mg (Medrol)......................... 24 methylprednisolone tab 4 mg dose pack (Medrol dosepak)..........................................................................24 methylprednisolone tab 8 mg (Medrol)......................... 24 METHYL SALICYLATE - methyl salicylate liquid ............158 METIPRANOLOL -metipranolol ophth soln 0.3%............ 143 metoclopramide hcl inj 5 mg/ml.....................................76 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)......... 76 metoclopramide hcl tab 10 mg (Reglan)....................... 76 metoclopramide hcl tab 5 mg (Reglan)......................... 76 metolazone tab 10 mg.....................................................58 metolazone tab 2.5 mg (Zaroxolyn)............................... 58 metolazone tab 5 mg (Zaroxolyn).................................. 58 metoprolol & hydrochlorothiazide tab 100-25 mg (Lopressor hct)...............................................................54 metoprolol & hydrochlorothiazide tab 100-50 mg........ 54 metoprolol & hydrochlorothiazide tab 50-25 mg (Lopressor hct)...............................................................54 metoprolol succinate tab sr 24hr 100 mg (Toprol xl)..................................................................................... 45 metoprolol succinate tab sr 24hr 200 mg (Toprol xl)..................................................................................... 45 metoprolol succinate tab sr 24hr 25 mg (Toprol xl)......45 metoprolol succinate tab sr 24hr 50 mg (Toprol xl)......45 metoprolol tartrate tab 100 mg (Lopressor).................. 45 metoprolol tartrate tab 25 mg.........................................45 metoprolol tartrate tab 50 mg (Lopressor).................... 45 METOZOLV ODT -metoclopramide hcl orally disintegrating tab 5 mg...........................................................................76 METROCREAM -metronidazole cream 0.75%................ 158 METROGEL -metronidazole gel 1%................................158 METROGEL-VAGINAL -metronidazole vaginal gel 0.75%............................................................................... 79 METROLOTION -metronidazole lotion 0.75%................. 158 metronidazole cap 375 mg (Flagyl)................................13 metronidazole cream 0.75% (Metrocream).................. 158 metronidazole gel 0.75%...............................................158 methenamine hippurate tab 1 gm (Hiprex)....................77 methenamine-hyosamine-meth blue-sod phos tab 81.6 mg (Urogesic-blue)........................................................ 77 methenamine-hyosc-meth blue-benz acid-phenyl sal tab 81.6mg (Prosed/ds)................................................. 77 methenamine-hyosc-meth blue-sod phos-phen sal cap 120 mg ........................................................................... 77 methenamine-hyos-meth blue-sod phos-phen sal tab 81.6 mg .......................................................................... 77 METHENAMINE MANDELATE -methenamine mandelate tab 0.5 gm........................................................................77 methenamine mandelate tab 1 gm.................................77 methimazole tab 10 mg (Tapazole)................................ 37 methimazole tab 5 mg (Tapazole).................................. 37 METHITEST -methyltestosterone oral tab 10 mg.............. 26 methocarbamol tab 500 mg (Robaxin)........................ 127 methocarbamol tab 750 mg (Robaxin-750)................. 127 methotrexate sodium for inj 1 gm..................................20 methotrexate sodium inj 25 mg/ml................................ 20 methotrexate sodium inj pf 25 mg/ml............................ 20 methotrexate sodium tab 2.5 mg (base equiv)..............20 methoxsalen rapid cap 10 mg (Oxsoralen ultra).........158 methscopolamine bromide tab 2.5 mg (Pamine).......... 73 methscopolamine bromide tab 5 mg (Pamine forte)................................................................................ 73 METHYCLOTHIAZIDE -methyclothiazide tab 5 mg...........58 METHYLDOPA/HYDROCHLOROTHI -methyldopa & hydrochlorothiazide tab 250-15 mg................................. 54 METHYLDOPA/HYDROCHLOROTHI -methyldopa & hydrochlorothiazide tab 250-25 mg................................. 54 methyldopa tab 250 mg.................................................. 54 methyldopa tab 500 mg.................................................. 54 methylene blue inj 1%...................................................167 methylergonovine maleate inj 0.2 mg/ml.......................39 methylergonovine maleate tab 0.2 mg.......................... 39 METHYLIN -methylphenidate hcl chew tab 10 mg............ 95 METHYLIN -methylphenidate hcl chew tab 2.5 mg........... 95 METHYLIN -methylphenidate hcl chew tab 5 mg.............. 95 METHYLIN -methylphenidate hcl soln 10 mg/5ml............. 95 METHYLIN -methylphenidate hcl soln 5 mg/5ml............... 95 methylphenidate hcl cap cr 10 mg (Metadate cd)......... 95 methylphenidate hcl cap cr 20 mg (Metadate cd)......... 95 methylphenidate hcl cap cr 30 mg (Metadate cd)......... 95 methylphenidate hcl cap cr 40 mg (Metadate cd)......... 95 methylphenidate hcl cap cr 50 mg (Metadate cd)......... 95 methylphenidate hcl cap cr 60 mg (Metadate cd)......... 95 methylphenidate hcl cap sr 24hr 20 mg (Ritalin la)...... 95 methylphenidate hcl cap sr 24hr 30 mg (Ritalin la)...... 95 methylphenidate hcl cap sr 24hr 40 mg (Ritalin la)...... 95 METHYLPHENIDATE HCL ER -methylphenidate hcl tab cr 10 mg............................................................................... 95 methylphenidate hcl soln 10 mg/5ml (Methylin)........... 95 methylphenidate hcl soln 5 mg/5ml (Methylin)............. 95 methylphenidate hcl tab 10 mg (Ritalin)........................95 methylphenidate hcl tab 20 mg (Ritalin)........................95 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 225 2015 metronidazole gel 1% (Metrogel)................................. 158 metronidazole lotion 0.75% (Metrolotion)....................158 metronidazole tab 250 mg (Flagyl).................................13 metronidazole tab 500 mg (Flagyl).................................13 metronidazole vaginal gel 0.75% (Metrogelvaginal)............................................................................79 METVIXIA -methyl aminolevulinate hcl cream 16.8% (base equiv)..............................................................................158 mexiletine hcl cap 150 mg..............................................49 mexiletine hcl cap 200 mg..............................................49 mexiletine hcl cap 250 mg..............................................49 MIACALCIN -calcitonin (salmon) inj 200 unit/ml................41 MIACALCIN -calcitonin (salmon) nasal soln 200 unit/ act.....................................................................................41 MICARDIS HCT -telmisartan-hydrochlorothiazide tab 40-12.5 mg.......................................................................54 MICARDIS HCT -telmisartan-hydrochlorothiazide tab 80-12.5 mg.......................................................................54 MICARDIS HCT -telmisartan-hydrochlorothiazide tab 80-25 mg..........................................................................54 MICARDIS -telmisartan tab 20 mg.................................... 54 MICARDIS -telmisartan tab 40 mg.................................... 54 MICARDIS -telmisartan tab 80 mg.................................... 54 MICONAZOLE 3 -miconazole nitrate vaginal suppos 200 mg.................................................................................... 79 miconazole nitrate vaginal supp 200 mg & 2% cream 9 gm kit.............................................................................. 79 MICRHOGAM ULTRA-FILTERED -rho d immune globulin (human) im inj 50 mcg.....................................................17 MICROCLENS WIPES - antiseptic products misc - pads ....................................................................................... 167 MICRO-K -potassium chloride cap cr 10 meq................. 132 MICRO-K -potassium chloride cap cr 8 meq................... 132 MICROZIDE -hydrochlorothiazide cap 12.5 mg................ 58 midodrine hcl tab 10 mg.................................................59 midodrine hcl tab 2.5 mg................................................59 midodrine hcl tab 5 mg...................................................59 MIGERGOT -ergotamine w/ caffeine suppos 2-100 mg.................................................................................. 115 MIGRALAM -acetaminophen-isometheptene-caffeine cap 325-65-100 mg...............................................................115 MIGRAL -isometheptene mucate tab 130 mg................. 115 MIGRANAL -dihydroergotamine mesylate nasal spray 4 mg/ml..............................................................................115 MILLIPRED DP -prednisolone tab 5 mg dose pack...........24 MILLIPRED -prednisolone sod phosphate oral soln 10 mg/5ml (base equiv)........................................................ 24 MILLIPRED -prednisolone tab 5 mg..................................24 MIMYX - emollient - cream ............................................ 158 MINASTRIN 24 FE -norethindrone ace-eth estradiol-fe chew tab 1 mg-20 mcg (24)............................................ 29 MINERAL OIL HEAVY -mineral oil....................................70 MINIPRESS -prazosin hcl cap 1 mg................................. 54 MINIPRESS -prazosin hcl cap 2 mg................................. 54 MINIPRESS -prazosin hcl cap 5 mg................................. 54 226 MINIVELLE -estradiol td patch biweekly 0.0375 mg/24hr............................................................................ 28 MINIVELLE -estradiol td patch biweekly 0.05 mg/24hr......28 MINIVELLE -estradiol td patch biweekly 0.075 mg/24hr............................................................................ 28 MINIVELLE -estradiol td patch biweekly 0.1 mg/24hr........28 minocycline hcl cap 100 mg (Minocin)............................ 5 minocycline hcl cap 50 mg (Minocin)..............................5 minocycline hcl cap 75 mg (Minocin)..............................5 minocycline hcl tab 100 mg............................................. 5 minocycline hcl tab 50 mg............................................... 5 minocycline hcl tab 75 mg............................................... 5 minocycline hcl tab sr 24hr 135 mg................................ 5 minocycline hcl tab sr 24hr 45 mg.................................. 5 minocycline hcl tab sr 24hr 90 mg.................................. 5 minoxidil tab 10 mg.........................................................54 minoxidil tab 2.5 mg........................................................54 MIOCHOL-E -acetylcholine chloride intraocular for soln 1:100 (20 mg)................................................................ 143 MIOSTAT -carbachol intraocular inj 0.01%..................... 143 MI PASTE - dentifrices - paste .......................................169 MI PASTE PLUS - dentifrices - paste ............................ 169 MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr 0.375 mg........................................................................ 124 MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr 0.75 mg.......................................................................... 124 MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr 1.5 mg.................................................................................. 125 MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr 2.25 mg.......................................................................... 125 MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr 3.75 mg.......................................................................... 125 MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr 3 mg.................................................................................. 125 MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr 4.5 mg.................................................................................. 125 MIRAPEX -pramipexole dihydrochloride tab 0.125 mg.................................................................................. 124 MIRAPEX -pramipexole dihydrochloride tab 0.25 mg......124 MIRAPEX -pramipexole dihydrochloride tab 0.5 mg........124 MIRAPEX -pramipexole dihydrochloride tab 0.75 mg......124 MIRAPEX -pramipexole dihydrochloride tab 1.5 mg........124 MIRAPEX -pramipexole dihydrochloride tab 1 mg...........124 MIRCETTE -desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5)...................................................29 MIRENA -levonorgestrel releasing iud 20 mcg/24hr (52 mg total)................................................................................. 29 mirtazapine orally disintegrating tab 15 mg (Remeron soltab)..............................................................................85 mirtazapine orally disintegrating tab 30 mg (Remeron soltab)..............................................................................85 mirtazapine orally disintegrating tab 45 mg (Remeron soltab)..............................................................................85 mirtazapine tab 15 mg (Remeron)..................................85 mirtazapine tab 30 mg (Remeron)..................................85 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 morphine sulfate (concentrate) oral soln 20 mg/ ml................................................................................... 107 morphine sulfate beads cap sr 24hr 120 mg (Avinza)......................................................................... 107 morphine sulfate beads cap sr 24hr 30 mg (Avinza)......................................................................... 107 morphine sulfate beads cap sr 24hr 45 mg (Avinza)......................................................................... 107 morphine sulfate beads cap sr 24hr 60 mg (Avinza)......................................................................... 107 morphine sulfate beads cap sr 24hr 75 mg (Avinza)......................................................................... 107 morphine sulfate beads cap sr 24hr 90 mg (Avinza)......................................................................... 107 morphine sulfate cap sr 24hr 100 mg (Kadian)........... 107 morphine sulfate cap sr 24hr 10 mg (Kadian).............107 morphine sulfate cap sr 24hr 20 mg (Kadian).............107 morphine sulfate cap sr 24hr 30 mg (Kadian).............107 morphine sulfate cap sr 24hr 50 mg (Kadian).............107 morphine sulfate cap sr 24hr 60 mg (Kadian).............107 morphine sulfate cap sr 24hr 80 mg (Kadian).............107 morphine sulfate inj 10 mg/ml......................................107 morphine sulfate inj 15 mg/ml......................................107 morphine sulfate inj 8 mg/ml........................................107 morphine sulfate inj pf 0.5 mg/ml................................ 107 morphine sulfate inj pf 1 mg/ml................................... 107 MORPHINE SULFATE -morphine sulfate im inj device 10 mg/0.7ml.........................................................................107 MORPHINE SULFATE -morphine sulfate inj 2 mg/ml..... 107 MORPHINE SULFATE -morphine sulfate inj 4 mg/ml..... 107 MORPHINE SULFATE -morphine sulfate inj 5 mg/ml..... 107 MORPHINE SULFATE -morphine sulfate suppos 10 mg.................................................................................. 107 MORPHINE SULFATE -morphine sulfate suppos 20 mg.................................................................................. 107 MORPHINE SULFATE -morphine sulfate suppos 30 mg.................................................................................. 107 MORPHINE SULFATE -morphine sulfate suppos 5 mg.................................................................................. 107 MORPHINE SULFATE -morphine sulfate tab 15 mg.......106 MORPHINE SULFATE -morphine sulfate tab 30 mg.......107 morphine sulfate oral soln 10 mg/5ml......................... 107 morphine sulfate oral soln 20 mg/5ml......................... 107 morphine sulfate tab cr 100 mg (Ms contin)............... 107 morphine sulfate tab cr 15 mg (Ms contin)................. 107 morphine sulfate tab cr 200 mg (Ms contin)............... 107 morphine sulfate tab cr 30 mg (Ms contin)................. 107 morphine sulfate tab cr 60 mg (Ms contin)................. 107 MOTOFEN -difenoxin w/ atropine tab 1-0.025 mg............ 71 mouthwashes - liquid ...................................................146 MOVIPREP -peg 3350-kcl-nacl-na sulfate-na acorbate-c for soln 100 gm................................................................71 MOXATAG -amoxicillin (trihydrate) tab sr 24hr 775 mg.......1 MOXEZA -moxifloxacin hcl ophth soln 0.5% (base eq) (2 times daily).....................................................................143 mirtazapine tab 45 mg (Remeron)..................................85 mirtazapine tab 7.5 mg....................................................85 MIRVASO -brimonidine tartrate gel 0.33% (base equivalent)......................................................................158 misoprostol tab 100 mcg (Cytotec)................................73 misoprostol tab 200 mcg (Cytotec)................................73 MITIGARE -colchicine cap 0.6 mg.................................. 116 MITOSOL -mitomycin for ophth soln kit 0.2 mg...............143 MLK F1 KIT -triamcinolone inj 40 mg/ml & bupiv 0.5% & lido 2% kit........................................................................ 24 MLK F2 KIT -triamcinolone inj 40 mg/ml & bupiv 0.5% & lido 2% kit........................................................................ 24 MLK F3 KIT -triamcinolone inj 40 mg/ml & bupiv 0.5% & lido 2% kit........................................................................ 24 MLK F4 KIT -triamcinolone inj 40 mg/ml & bupiv 0.5% & lido 2% kit........................................................................ 24 M-M-R II W/DILUENT 10 DOS -measles, mumps & rubella virus vaccines for inj........................................................ 15 MOBIC -meloxicam susp 7.5 mg/5ml.............................. 113 MOBIC -meloxicam tab 15 mg........................................ 113 MOBIC -meloxicam tab 7.5 mg....................................... 113 modafinil tab 100 mg (Provigil)...................................... 95 modafinil tab 200 mg (Provigil)...................................... 95 MODERIBA 1200 DOSE PACK -ribavirin tab 600 mg......... 9 MODERIBA 800 DOSE PACK -ribavirin tab 400 mg........... 9 MODERIBA -ribavirin tab 200 mg & ribavirin tab 400 mg dose pack...........................................................................9 MODERIBA -ribavirin tab 400 mg & ribavirin tab 600 mg dose pack...........................................................................9 MODICON -norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg....................................................................... 29 moexipril hcl tab 15 mg (Univasc)................................. 54 moexipril hcl tab 7.5 mg (Univasc)................................ 54 moexipril-hydrochlorothiazide tab 15-12.5 mg (Uniretic)..........................................................................54 moexipril-hydrochlorothiazide tab 15-25 mg................ 54 moexipril-hydrochlorothiazide tab 7.5-12.5 mg............ 54 mometasone furoate cream 0.1% (Elocon)................. 158 mometasone furoate oint 0.1% (Elocon)..................... 158 mometasone furoate solution 0.1% (lotion) (Elocon)......................................................................... 159 MONOJECT BONE MARROW BIOP -lidocaine hcl local inj kit 1%............................................................................. 118 MONSELS FERRIC SUBSULFATE - ferric subsulfate soln ....................................................................................... 140 montelukast sodium chew tab 4 mg (base equiv) (Singulair)........................................................................69 montelukast sodium chew tab 5 mg (base equiv) (Singulair)........................................................................69 montelukast sodium oral granules packet 4 mg (base equiv) (Singulair)............................................................69 montelukast sodium tab 10 mg (base equiv) (Singulair)........................................................................69 MONUROL -fosfomycin tromethamine powd pack 3 gm (base equivalent)............................................................. 77 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 227 2015 moxifloxacin hcl tab 400 mg (base equiv) (Avelox)........6 MOZOBIL -plerixafor subcutaneous inj 24 mg/1.2ml (20 mg/ml)............................................................................ 136 MS CONTIN -morphine sulfate tab cr 100 mg.................107 MS CONTIN -morphine sulfate tab cr 15 mg...................107 MS CONTIN -morphine sulfate tab cr 200 mg.................107 MS CONTIN -morphine sulfate tab cr 30 mg...................107 MS CONTIN -morphine sulfate tab cr 60 mg...................107 MUCOTROL - oral wound care products - wafer ............147 MULTAQ -dronedarone hcl tab 400 mg (base equivalent)........................................................................49 MULTIGEN - fe asparto gly-succ acd-c-threonic acd-b12des stom tab .................................................................136 MULTIGEN FOLIC - fe asparto gly-succinic acd-vit cthreonic acd-b12-fa tab .................................................136 MULTIGEN PLUS - fe aspart gly-fe fum-succ acd-cthreonic acd-b12-fa tab .................................................136 multiple vitamins w/ minerals & fa tab 1.25 mg (Corvite).........................................................................129 multiple vitamins w/ minerals cap .............................. 129 multiple vitamins w/ minerals tab (Strovite forte)....... 129 MULTI-SPECIALTY KIT -methylprednisolone inj 40 mg/ml & lidocaine inj 1% kit....................................................... 24 mupirocin calcium cream 2% (Bactroban).................. 159 mupirocin oint 2% (Bactroban).................................... 159 MUSTARGEN -mechlorethamine hcl for inj 10 mg............20 MV FE ASPARTO GLY/FE FUM/ - fe aspart gly-fe fumsucc acd-c-threonic acd-b12-fa tab .............................. 137 MV FE ASPARTO GLY/VIT C/V - fe asparto gly-succ acdc-threonic acd-b12-des stom tab .................................. 137 MYALEPT -metreleptin for subcutaneous inj 11.3 mg....... 41 MYAMBUTOL -ethambutol hcl tab 100 mg......................... 6 MYAMBUTOL -ethambutol hcl tab 400 mg......................... 6 MYCOBUTIN -rifabutin cap 150 mg.................................... 6 mycophenolate mofetil cap 250 mg (Cellcept)............171 mycophenolate mofetil tab 500 mg (Cellcept).............171 mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) (Myfortic)...................................................171 mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) (Myfortic)...................................................171 MYDFRIN -phenylephrine hcl ophth soln 2.5%............... 143 MYFORTIC -mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv)............................................. 171 MYFORTIC -mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv)............................................. 171 MYKIDZ IRON 10 -iron susp 15 mg/1.5ml...................... 137 MYKIDZ IRON FL -pediatric vitamins acd fluoride & fe susp 0.25-10 mg/2ml..................................................... 130 MYLERAN -busulfan tab 2 mg.......................................... 20 MYOBLOC -rimabotulinumtoxinb inj 10000 unit/2ml....... 126 MYOBLOC -rimabotulinumtoxinb inj 2500 unit/0.5ml.......126 MYOBLOC -rimabotulinumtoxinb inj 5000 unit/ml........... 126 MYOXIN -benzocaine-chloroxylenol-hc otic soln 15-1-10 mg/ml..............................................................................146 MYRBETRIQ -mirabegron tab sr 24 hr 25 mg...................78 228 MYRBETRIQ -mirabegron tab sr 24 hr 50 mg...................78 MYSOLINE -primidone tab 250 mg................................. 122 MYSOLINE -primidone tab 50 mg...................................122 N NABI-HB -hepatitis b immune globulin (human) im inj soln...................................................................................17 nabumetone tab 500 mg............................................... 113 nabumetone tab 750 mg............................................... 113 nadolol & bendroflumethiazide tab 40-5 mg (Corzide)..........................................................................54 nadolol & bendroflumethiazide tab 80-5 mg (Corzide)..........................................................................55 nadolol tab 20 mg (Corgard).......................................... 45 nadolol tab 40 mg (Corgard).......................................... 45 nadolol tab 80 mg (Corgard).......................................... 45 nafcillin sodium for inj 10 gm.......................................... 1 nafcillin sodium for inj 1 gm............................................ 1 nafcillin sodium for inj 2 gm............................................ 1 NAFRINSE DAILY/ACIDULATED -sodium fluoridephosphoric acid for soln 1 mg/5ml (f equiv)................... 147 NAFRINSE DAILY/NEUTRAL -sodium fluoride for soln rinse 0.05%.................................................................... 147 NAFRINSE WEEKLY -sodium fluoride for soln rinse 0.2%............................................................................... 147 NAFTIN -naftifine hcl cream 1%......................................159 NAFTIN -naftifine hcl cream 2%......................................159 NAFTIN -naftifine hcl gel 1%...........................................159 NAFTIN -naftifine hcl gel 2%........................................... 159 nalbuphine hcl inj 10 mg/ml......................................... 107 nalbuphine hcl inj 20 mg/ml......................................... 107 NALFON -fenoprofen calcium cap 400 mg......................113 naloxone hcl inj 0.4 mg/ml........................................... 167 naloxone hcl inj 1 mg/ml.............................................. 167 naltrexone hcl tab 50 mg (Revia)................................. 167 NAMENDA -memantine hcl oral solution 2 mg/ml............. 98 NAMENDA -memantine hcl tab 10 mg..............................98 NAMENDA -memantine hcl tab 5 mg................................98 NAMENDA TITRATION PAK -memantine hcl tab 5 mg (28) & 10 mg (21) titration pak........................................ 98 NAMENDA XR -memantine hcl cap sr 24hr 14 mg........... 98 NAMENDA XR -memantine hcl cap sr 24hr 21 mg........... 98 NAMENDA XR -memantine hcl cap sr 24hr 28 mg........... 98 NAMENDA XR -memantine hcl cap sr 24hr 7 mg............. 98 NAMENDA XR TITRATION PACK -memantine hcl cap sr 24hr 7 mg & 14 mg & 21 mg & 28 mg pack.................... 98 NAPHAZOLINE HCL -naphazoline hcl ophth soln 0.1%............................................................................... 143 NAPRELAN -naproxen sodium tab sr 24hr 375 mg (base equiv)..............................................................................113 NAPRELAN -naproxen sodium tab sr 24hr 500 mg (14) & 750 mg (6) pack............................................................ 113 NAPRELAN -naproxen sodium tab sr 24hr 500 mg (base equiv)..............................................................................113 NAPRELAN -naproxen sodium tab sr 24hr 750 mg (base equiv)..............................................................................113 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 NECON 10/11-28 -norethindrone-eth estradiol tab 0.5-35/1-35 mg-mcg (10/11)............................................ 30 NEFAZODONE HCL -nefazodone hcl tab 100 mg............ 85 NEFAZODONE HCL -nefazodone hcl tab 150 mg............ 85 NEFAZODONE HCL -nefazodone hcl tab 200 mg............ 85 NEFAZODONE HCL -nefazodone hcl tab 50 mg.............. 85 nefazodone hcl tab 250 mg............................................ 85 NEMBUTAL -pentobarbital sodium inj 50 mg/ml............... 92 NEMBUTAL SODIUM -pentobarbital sodium inj 50 mg/ ml......................................................................................92 NEOMYCIN/POLYMYXIN/HYDROC -neomycinpolymyxin-hc ophth susp............................................... 144 neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin............................... 144 neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml (Neosporin)..............144 neomycin-polymyxin b gu irrigation soln (Neosporin gu irrigan)....................................................................... 80 neomycin-polymyxin-dexamethasone ophth oint 0.1% (Maxitrol)....................................................................... 144 neomycin-polymyxin-dexamethasone ophth susp 0.1% (Maxitrol)....................................................................... 144 neomycin-polymyxin-hc otic soln 1% (Cortisporin)..................................................................146 neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%..................................................................... 146 neomycin sulfate tab 500 mg........................................... 6 NEORAL -cyclosporine modified cap 100 mg................. 171 NEORAL -cyclosporine modified cap 25 mg................... 171 NEORAL -cyclosporine modified oral soln 100 mg/ml..... 171 NEOSALUS CP - emollient - cream ...............................159 NEOSALUS - emollient - aerosol foam .......................... 159 NEOSALUS - emollient - cream .....................................159 NEOSALUS - emollient - lotion ...................................... 159 NEOSPORIN GU IRRIGANT -neomycin-polymyxin b gu irrigation soln....................................................................80 NEOSPORIN -neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml.....................................144 neostigmine methylsulfate inj 0.5 mg/ml (1:2000) (Prostigmin).................................................................. 128 neostigmine methylsulfate inj 1 mg/ml........................128 NEO-SYNALAR KIT -neomycin-fluocinolone cream 0.35-0.025% & emollient cr kit.......................................159 NEO-SYNALAR -neomycin-fluocinolone cream 0.35-0.025%................................................................... 159 NEO-SYNEPHRINE -phenylephrine hcl inj 10 mg/ml........ 59 NEOTUSS-D -pseudoephed-chlorphen w/ dm-gg liqd 30-2-30-200 mg/5ml.........................................................65 NEOTUSS PLUS -phenylephrine-chlorphen-dm liquid 7.5-4-30 mg/5ml...............................................................65 NEPHPLEX RX -b-complex w/ c-zn & folic acid tab 1 mg.................................................................................. 130 NEPHROCAPS -b-complex w/ c & folic acid cap 1 mg.................................................................................. 130 NAPRO 15% COMPOUNDING KIT -naproxen cream 15%................................................................................ 159 NAPRODERM COMPOUNDING KIT -naproxen cream 15%................................................................................ 159 NAPROSYN -naproxen susp 125 mg/5ml....................... 113 NAPROSYN -naproxen tab 250 mg................................ 113 NAPROSYN -naproxen tab 375 mg................................ 113 NAPROSYN -naproxen tab 500 mg................................ 113 NAPROXEN COMFORT PAC -naproxen tab 500 mg & liniment topical gel kit.................................................... 113 naproxen sodium tab 275 mg (Anaprox)..................... 113 naproxen sodium tab 550 mg (Anaprox ds)................113 naproxen susp 125 mg/5ml (Naprosyn).......................113 naproxen tab 250 mg (Naprosyn).................................113 naproxen tab 375 mg (Naprosyn).................................113 naproxen tab 500 mg (Naprosyn).................................113 naproxen tab ec 375 mg (Ec-naprosyn)...................... 113 naproxen tab ec 500 mg (Ec-naprosyn)...................... 113 naratriptan hcl tab 1 mg (base equiv) (Amerge)......... 115 naratriptan hcl tab 2.5 mg (base equiv) (Amerge)...... 115 NARDIL -phenelzine sulfate tab 15 mg............................. 85 NAROPIN -ropivacaine hcl inj 10 mg/ml..........................118 NAROPIN -ropivacaine hcl inj 2 mg/ml........................... 118 NAROPIN -ropivacaine hcl inj 5 mg/ml........................... 118 NAROPIN -ropivacaine hcl inj 7.5 mg/ml.........................118 NASCOBAL -cyanocobalamin nasal spray 500 mcg/0.1ml.......................................................................137 NATACYN -natamycin ophth susp 5%............................ 143 NATALVIRT FLT - fe carbonyl-fe gluconate-fa-vit b12-vit cdss tab 90-1 mg ........................................................... 137 NATAZIA -estradiol valerate-dienogest tab 3 mg /2-2 mg/2-3 mg/1 mg...............................................................30 nateglinide tab 120 mg (Starlix)..................................... 34 nateglinide tab 60 mg (Starlix)....................................... 34 NATROBA -spinosad susp 0.9%.....................................159 NATURE-THROID NT-2.5 -thyroid tab 162.5 mg (2 1/2 grain)................................................................................ 37 NATURE-THROID -thyroid tab 113.75 mg........................ 37 NATURE-THROID -thyroid tab 130 mg.............................37 NATURE-THROID -thyroid tab 146.25 mg........................ 37 NATURE-THROID -thyroid tab 16.25 mg.......................... 37 NATURE-THROID -thyroid tab 195 mg.............................37 NATURE-THROID -thyroid tab 260 mg.............................37 NATURE-THROID -thyroid tab 32.5 mg............................37 NATURE-THROID -thyroid tab 325 mg (5 grain)...............37 NATURE-THROID -thyroid tab 48.75 mg (3/4 grain).........37 NATURE-THROID -thyroid tab 65 mg...............................37 NATURE-THROID -thyroid tab 81.25 mg.......................... 37 NATURE-THROID -thyroid tab 97.5 mg............................37 NEBUPENT -pentamidine isethionate for nebulization soln 300 mg............................................................................. 13 NEBUSAL -sodium chloride soln nebu 6%........................65 NECON 1/50-28 -norethindrone & mestranol tab 1 mg-50 mcg...................................................................................30 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 229 2015 NEPHROCAPS QT -b-complex w/ c-biotin-d & folic acid tab disp 1 mg.................................................................130 NEPHRON FA - ferrous fumarate w/ fa-dss-b complex-vit c tab ................................................................................. 137 NEPHRO-VITE RX -b-complex w/ c & folic acid tab 1 mg.................................................................................. 130 NEPTAZANE -methazolamide tab 25 mg......................... 58 NEPTAZANE -methazolamide tab 50 mg......................... 58 NESACAINE -chloroprocaine hcl inj 1%..........................118 NESACAINE -chloroprocaine hcl inj 2%..........................118 NESACAINE-MPF -chloroprocaine hcl inj 2%................. 118 NESACAINE-MPF -chloroprocaine hcl inj 3%................. 118 NESINA -alogliptin benzoate tab 12.5 mg (base equiv).....34 NESINA -alogliptin benzoate tab 25 mg (base equiv)........34 NESINA -alogliptin benzoate tab 6.25 mg (base equiv).....34 NEUAC KIT -clindamycin-benzoyl perox gel 1.2-5% & moisturizer cr kit.............................................................159 NEULASTA -pegfilgrastim inj 6 mg/0.6ml........................137 NEUMEGA -oprelvekin for inj 5 mg.................................137 NEUPOGEN -filgrastim inj 300 mcg/0.5ml (600 mcg/ ml).................................................................................. 137 NEUPOGEN -filgrastim inj 300 mcg/ml........................... 137 NEUPOGEN -filgrastim inj 480 mcg/0.8ml (600 mcg/ ml).................................................................................. 137 NEUPOGEN -filgrastim inj 480 mcg/1.6ml (300 mcg/ ml).................................................................................. 137 NEUPRO -rotigotine td patch 24hr 1 mg/24hr................. 125 NEUPRO -rotigotine td patch 24hr 2 mg/24hr................. 125 NEUPRO -rotigotine td patch 24hr 3 mg/24hr................. 125 NEUPRO -rotigotine td patch 24hr 4 mg/24hr................. 125 NEUPRO -rotigotine td patch 24hr 6 mg/24hr................. 125 NEUPRO -rotigotine td patch 24hr 8 mg/24hr................. 125 NEURIN-SL -cyanocobalamin-methylcobalamin tab sl 600-600 mcg.................................................................. 137 NEURODEP - b-complex w/ c inj ................................... 130 NEURONTIN -gabapentin cap 100 mg........................... 122 NEURONTIN -gabapentin cap 300 mg........................... 122 NEURONTIN -gabapentin cap 400 mg........................... 122 NEURONTIN -gabapentin oral soln 250 mg/5ml............. 122 NEURONTIN -gabapentin tab 600 mg............................ 122 NEURONTIN -gabapentin tab 800 mg............................ 122 NEUTRASAL - artificial saliva - packet .......................... 147 NEVANAC -nepafenac ophth susp 0.1%........................ 144 NEVIRAPINE -nevirapine susp 50 mg/5ml..........................9 nevirapine tab 200 mg (Viramune)...................................9 nevirapine tab sr 24hr 400 mg (Viramune xr)..................9 NEXAVAR -sorafenib tosylate tab 200 mg (base equivalent)........................................................................20 NEXAVIR -liver derivative complex inj 25.5 mg/ml.......... 171 NEXPLANON -etonogestrel subdermal implant 68 mg......30 niacin tab cr 1000 mg (antihyperlipidemic) (Niaspan)......................................................................... 60 niacin tab cr 500 mg (antihyperlipidemic) (Niaspan)......................................................................... 60 230 niacin tab cr 750 mg (antihyperlipidemic) (Niaspan)......................................................................... 61 NIACOR -niacin (antihyperlipidemic) tab 500 mg.............. 61 NIASPAN -niacin tab cr 1000 mg (antihyperlipidemic)...... 61 NIASPAN -niacin tab cr 500 mg (antihyperlipidemic)........ 61 NIASPAN -niacin tab cr 750 mg (antihyperlipidemic)........ 61 NICADAN - multiple vitamins w/ minerals tab ................ 130 nicardipine hcl cap 20 mg.............................................. 47 nicardipine hcl cap 30 mg.............................................. 47 NICAZEL FORTE - multiple vitamins w/ minerals tab .....130 NICAZEL - multiple vitamins w/ minerals tab ................. 130 NICODERM CQ -nicotine td patch 24hr 14 mg/24hr......... 98 NICODERM CQ -nicotine td patch 24hr 21 mg/24hr......... 98 NICODERM CQ -nicotine td patch 24hr 7 mg/24hr........... 98 NICOMIDE - niacinamide w/ zn-cu-methylfolate tab 750-25-1.5-0.5 mg ........................................................ 130 NICORETTE MINI -nicotine polacrilex lozenge 2 mg........ 98 NICORETTE MINI -nicotine polacrilex lozenge 4 mg........ 98 NICORETTE -nicotine polacrilex gum 2 mg...................... 98 NICORETTE -nicotine polacrilex gum 4 mg...................... 98 NICORETTE -nicotine polacrilex lozenge 2 mg.................98 NICORETTE -nicotine polacrilex lozenge 4 mg.................98 NICORETTE STARTER KIT -nicotine polacrilex gum 2 mg.................................................................................... 98 NICORETTE STARTER KIT -nicotine polacrilex gum 4 mg.................................................................................... 98 nicotine polacrilex gum 2 mg.........................................98 nicotine polacrilex gum 4 mg.........................................98 nicotine polacrilex lozenge 2 mg................................... 98 nicotine polacrilex lozenge 4 mg................................... 98 nicotine td patch 24hr 14 mg/24hr................................. 98 nicotine td patch 24hr 21 mg/24hr................................. 98 nicotine td patch 24hr 7 mg/24hr................................... 98 NICOTINE TRANSDERMAL SYST -nicotine td patch 24 hr kit 21-14-7 mg/24hr..........................................................98 NICOTROL INHALER -nicotine inhaler system 10 mg (4 mg delivered)................................................................... 98 NICOTROL NS -nicotine nasal spray 10 mg/ml (0.5 mg/ spray)............................................................................... 99 nifedipine cap 10 mg (Procardia)...................................47 nifedipine cap 20 mg.......................................................47 nifedipine tab sr 24hr 30 mg (Adalat cc)....................... 47 nifedipine tab sr 24hr 60 mg (Adalat cc)....................... 47 nifedipine tab sr 24hr 90 mg (Adalat cc)....................... 47 nifedipine tab sr 24hr osmotic 30 mg (Procardia xl).....47 nifedipine tab sr 24hr osmotic 60 mg (Procardia xl).....47 nifedipine tab sr 24hr osmotic 90 mg (Procardia xl).....47 NILANDRON -nilutamide tab 150 mg................................20 nimodipine cap 30 mg.....................................................47 NIRAVAM -alprazolam orally disintegrating tab 0.25 mg.................................................................................... 82 NIRAVAM -alprazolam orally disintegrating tab 0.5 mg..... 82 NIRAVAM -alprazolam orally disintegrating tab 1 mg........82 NIRAVAM -alprazolam orally disintegrating tab 2 mg........82 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 NORDITROPIN CARTRIDGE -somatropin inj 5 mg/1.5ml...........................................................................41 NORDITROPIN FLEXPRO -somatropin inj 10 mg/1.5ml...........................................................................41 NORDITROPIN FLEXPRO -somatropin inj 15 mg/1.5ml...........................................................................41 NORDITROPIN FLEXPRO -somatropin inj 5 mg/1.5ml.....41 NORDITROPIN NORDIFLEX PEN -somatropin inj 30 mg/3ml..............................................................................41 norelgestromin-ethinyl estradiol td ptwk 150-35 mcg/24hr (Ortho evra)................................................... 30 norepinephrine bitartrate inj 1 mg/ml (Levophed)........ 59 norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg (Femcon fe)................................................ 30 norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg (Ovcon-35).......................................................................30 norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg (Brevicon-28).................................................................. 30 norethindrone & ethinyl estradiol tab 1 mg-35 mcg (Norinyl 1+35)................................................................. 30 norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg (Loestrin fe 1.5/30)................................................ 30 norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg (Loestrin fe 1/20)................................................... 30 norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg (Loestrin 1.5/30-21)................................................30 norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg (Loestrin 1/20-21)........................................................... 30 norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24) (Lomedia 24 fe).............................................. 30 norethindrone acetate tab 5 mg (Aygestin)...................31 norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg (Estrostep fe)...................................................30 norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mgmcg (Ortho-novum 7/7/7).............................................. 30 norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mgmcg (Tri-norinyl 28)....................................................... 30 norethindrone tab 0.35 mg (Nor-qd).............................. 30 NORFLEX -orphenadrine citrate inj 30 mg/ml................. 127 norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg (Ortho-cyclen).................................................................30 norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg (Ortho tri-cyclen).............................................30 norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg.........30 NORINYL 1+35 -norethindrone & ethinyl estradiol tab 1 mg-35 mcg....................................................................... 30 NORINYL 1+50 -norethindrone & mestranol tab 1 mg-50 mcg...................................................................................30 NORITATE -metronidazole cream 1%.............................159 NOROXIN -norfloxacin tab 400 mg..................................... 6 NORPACE CR -disopyramide phosphate cap sr 12hr 100 mg.................................................................................... 49 NORPACE CR -disopyramide phosphate cap sr 12hr 150 mg.................................................................................... 49 NORPACE -disopyramide phosphate cap 100 mg............ 49 NIRON KOMPLETE - fe bisglycinate-fe fum-vit c-vit b12-vit e-fa tab 30-1 mg ...........................................................137 NISOLDIPINE ER -nisoldipine tab sr 24hr 25.5 mg...........47 NISOLDIPINE -nisoldipine tab sr 24hr 20 mg................... 47 NISOLDIPINE -nisoldipine tab sr 24hr 30 mg................... 47 NISOLDIPINE -nisoldipine tab sr 24hr 40 mg................... 47 nisoldipine tab sr 24hr 17 mg (Sular)............................ 48 nisoldipine tab sr 24hr 34 mg (Sular)............................ 48 nisoldipine tab sr 24hr 8.5 mg (Sular)........................... 48 NITRO-BID -nitroglycerin oint 2%......................................43 NITRO-DUR -nitroglycerin td patch 24hr 0.1 mg/hr........... 43 NITRO-DUR -nitroglycerin td patch 24hr 0.2 mg/hr........... 43 NITRO-DUR -nitroglycerin td patch 24hr 0.3 mg/hr........... 43 NITRO-DUR -nitroglycerin td patch 24hr 0.4 mg/hr........... 43 NITRO-DUR -nitroglycerin td patch 24hr 0.6 mg/hr........... 43 NITRO-DUR -nitroglycerin td patch 24hr 0.8 mg/hr........... 43 nitrofurantoin macrocrystalline cap 100 mg (Macrodantin)..................................................................77 nitrofurantoin macrocrystalline cap 50 mg (Macrodantin)..................................................................77 nitrofurantoin monohydrate macrocrystalline cap 100 mg (Macrobid)................................................................ 77 nitrofurantoin susp 25 mg/5ml (Furadantin)................. 77 nitroglycerin cap cr 2.5 mg............................................ 43 nitroglycerin cap cr 6.5 mg............................................ 43 nitroglycerin cap cr 9 mg............................................... 43 NITROGLYCERIN LINGUAL -nitroglycerin lingual aerosol 400 mcg/spray................................................................. 43 nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)..........43 nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur)..........44 nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur)..........44 nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)..........44 nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray) (Nitrolingual pumpspr).................................................. 44 NITROLINGUAL PUMPSPRAY -nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray)............................................... 44 NITROMIST -nitroglycerin lingual aerosol 400 mcg/ spray.................................................................................44 NITROSTAT -nitroglycerin sl tab 0.3 mg........................... 44 NITROSTAT -nitroglycerin sl tab 0.4 mg........................... 44 NITROSTAT -nitroglycerin sl tab 0.6 mg........................... 44 NIVATOPIC PLUS - dermatological products misc - cream ....................................................................................... 159 nizatidine cap 150 mg..................................................... 73 nizatidine cap 300 mg (Axid).......................................... 73 nizatidine oral soln 15 mg/ml (Axid).............................. 73 NIZORAL -ketoconazole shampoo 2%............................159 NORCO -hydrocodone-acetaminophen tab 10-325 mg.................................................................................. 107 NORCO -hydrocodone-acetaminophen tab 5-325 mg.....107 NORCO -hydrocodone-acetaminophen tab 7.5-325 mg.................................................................................. 108 NORDETTE-28 -levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg....................................................................... 30 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 231 2015 NORPACE -disopyramide phosphate cap 150 mg............ 49 NORPRAMIN -desipramine hcl tab 100 mg...................... 85 NORPRAMIN -desipramine hcl tab 10 mg........................ 85 NORPRAMIN -desipramine hcl tab 150 mg...................... 85 NORPRAMIN -desipramine hcl tab 25 mg........................ 85 NORPRAMIN -desipramine hcl tab 50 mg........................ 85 NORPRAMIN -desipramine hcl tab 75 mg........................ 85 NOR-QD -norethindrone tab 0.35 mg................................30 NORTHERA -droxidopa cap 100 mg.................................59 NORTHERA -droxidopa cap 200 mg.................................59 NORTHERA -droxidopa cap 300 mg.................................59 nortriptyline hcl cap 10 mg (Pamelor)........................... 85 nortriptyline hcl cap 25 mg (Pamelor)........................... 85 nortriptyline hcl cap 50 mg (Pamelor)........................... 85 nortriptyline hcl cap 75 mg (Pamelor)........................... 85 NORTRIPTYLINE HCL -nortriptyline hcl soln 10 mg/5ml..............................................................................85 NORTUSS-EX -dextromethorphan-guaifenesin liquid 20-200 mg/5ml................................................................. 65 NORVASC -amlodipine besylate tab 10 mg......................48 NORVASC -amlodipine besylate tab 2.5 mg..................... 48 NORVASC -amlodipine besylate tab 5 mg........................48 NORVIR -ritonavir cap 100 mg........................................... 9 NORVIR -ritonavir oral soln 80 mg/ml................................. 9 NORVIR -ritonavir tab 100 mg............................................ 9 NOVACORT - hydrocortisone ace-pramoxine-aloe polysacch gel 2-1-1% ................................................... 159 NOVAFERRUM -polysacch iron complex-vit c-fa for soln 100-60-1 mg/5ml............................................................137 NOVOLIN 70/30 -insulin isophane & regular (human) inj 100 unit/ml (70-30)...........................................................36 NOVOLIN 70/30 RELION -insulin isophane & regular (human) inj 100 unit/ml (70-30)....................................... 36 NOVOLIN N -insulin isophane (human) inj 100 unit/ml......36 NOVOLIN N RELION -insulin isophane (human) inj 100 unit/ml...............................................................................36 NOVOLIN R -insulin regular (human) inj 100 unit/ml......... 36 NOVOLIN R RELION -insulin regular (human) inj 100 unit/ ml......................................................................................36 NOVOLOG FLEXPEN -insulin aspart soln pen-injector 100 unit/ml...............................................................................35 NOVOLOG -insulin aspart inj 100 unit/ml..........................35 NOVOLOG MIX 70/30 -insulin aspart prot & aspart (human) inj 100 unit/ml (70-30)....................................... 36 NOVOLOG MIX 70/30 PREFILL -insulin aspart prot & aspart sus pen-inj 100 unit/ml (70-30)............................. 36 NOVOLOG PENFILL -insulin aspart inj 100 unit/ml...........35 NOVOLOG PENFILL -insulin aspart soln cartridge 100 unit/ml...............................................................................35 NOXAFIL -posaconazole susp 40 mg/ml............................ 7 NOXAFIL -posaconazole tab delayed release 100 mg........7 NP #2 DRUG PREPARATION KI - tramadol-flurbipamitrip-gaba-clonidine-lido crm (cmp kit) ...................... 159 NPLATE -romiplostim for inj 250 mcg............................. 137 NPLATE -romiplostim for inj 500 mcg............................. 137 232 NUCORT -hydrocortisone acetate lotion 2%................... 159 NUCYNTA ER -tapentadol hcl tab sr 12hr 100 mg..........108 NUCYNTA ER -tapentadol hcl tab sr 12hr 150 mg..........108 NUCYNTA ER -tapentadol hcl tab sr 12hr 200 mg..........108 NUCYNTA ER -tapentadol hcl tab sr 12hr 250 mg..........108 NUCYNTA ER -tapentadol hcl tab sr 12hr 50 mg............108 NUCYNTA -tapentadol hcl tab 100 mg........................... 108 NUCYNTA -tapentadol hcl tab 50 mg............................. 108 NUCYNTA -tapentadol hcl tab 75 mg............................. 108 NUEDEXTA -dextromethorphan hbr-quinidine sulfate cap 20-10 mg..........................................................................99 NULYTELY/FLAVOR PACKS -peg 3350-kcl-sod bicarbnacl for soln 420 gm........................................................71 NUMOISYN - artificial saliva - lozenge ...........................147 NUMOISYN - artificial saliva - solution ...........................147 NUOX -benzoyl peroxide-sulfur gel 6-3%........................159 NUTRESTORE -glutamine powd pack 5 gm................... 133 NUTRICAP - multiple vitamins w/ minerals tab .............. 130 nutritional supplement liquid ...................................... 133 NUTRIVIT -b-complex w/ lysine-min-fe & fa liqd 800-15-1 mg/15ml..........................................................................130 NUTROPIN AQ NUSPIN 10 -somatropin inj 10 mg/2ml..............................................................................41 NUTROPIN AQ NUSPIN 20 -somatropin inj 20 mg/2ml..............................................................................41 NUTROPIN AQ NUSPIN 5 -somatropin inj 5 mg/2ml........ 41 NUTROPIN AQ PEN -somatropin inj 10 mg/2ml............... 41 NUTROPIN AQ PEN -somatropin inj 20 mg/2ml............... 41 NUTROPIN -somatropin for inj 10 mg...............................41 NUVAIL - dermatological products misc - solution ..........159 NUVARING -etonogestrel-ethinyl estradiol va ring 0.120-0.015 mg/24hr........................................................30 NUVIGIL -armodafinil tab 150 mg..................................... 95 NUVIGIL -armodafinil tab 200 mg..................................... 95 NUVIGIL -armodafinil tab 250 mg..................................... 96 NUVIGIL -armodafinil tab 50 mg....................................... 95 NUZON -hydrocortisone acetate-aloe vera gel 2%..........159 NYMALIZE -nimodipine oral soln 60 mg/20ml...................48 nystatin cream 100000 unit/gm.................................... 159 nystatin oint 100000 unit/gm........................................ 159 nystatin oral powder ........................................................ 7 nystatin susp 100000 unit/ml........................................147 nystatin tab 500000 unit....................................................7 nystatin topical powder ............................................... 148 nystatin-triamcinolone cream 100000-0.1 unit/gm%.................................................................................... 159 nystatin-triamcinolone oint 100000-0.1 unit/gm-%..... 159 O octreotide acetate inj 1000 mcg/ml (1 mg/ml) (Sandostatin).................................................................. 41 octreotide acetate inj 100 mcg/ml (0.1 mg/ml) (Sandostatin).................................................................. 41 octreotide acetate inj 200 mcg/ml (0.2 mg/ml) (Sandostatin).................................................................. 41 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 omeprazole-sodium bicarbonate cap 20-1100 mg (Zegerid).......................................................................... 73 omeprazole-sodium bicarbonate cap 40-1100 mg (Zegerid).......................................................................... 73 OMNIFLEX DIAPHRAGM - diaphragms ........................ 169 OMNIPRED -prednisolone acetate ophth susp 1%......... 144 OMNITROPE -somatropin for inj 5.8 mg........................... 41 OMNITROPE -somatropin inj 10 mg/1.5ml........................41 OMNITROPE -somatropin inj 5 mg/1.5ml......................... 41 OMONTYS -peginesatide acetate soln inj 10 mg/ml....... 137 OMONTYS -peginesatide acetate soln inj 20 mg/2ml......137 ONCASPAR -pegaspargase inj 750 unit/ml...................... 21 ondansetron hcl inj 40 mg/20ml (2 mg/ml) (Zofran)......74 ondansetron hcl inj 4 mg/2ml (2 mg/ml)........................74 ondansetron hcl oral soln 4 mg/5ml (Zofran)................74 ondansetron hcl tab 24 mg............................................ 74 ondansetron hcl tab 4 mg (Zofran)................................ 74 ondansetron hcl tab 8 mg (Zofran)................................ 74 ondansetron orally disintegrating tab 4 mg (Zofran odt)...................................................................................74 ondansetron orally disintegrating tab 8 mg (Zofran odt)...................................................................................74 ONFI -clobazam suspension 2.5 mg/ml.......................... 122 ONFI -clobazam tab 10 mg............................................. 122 ONFI -clobazam tab 20 mg............................................. 122 ONFI -clobazam tab 5 mg............................................... 122 ONGLYZA -saxagliptin hcl tab 2.5 mg (base equiv).......... 34 ONGLYZA -saxagliptin hcl tab 5 mg (base equiv)............. 34 ONMEL -itraconazole tab 200 mg....................................... 7 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 10 mg.......................................................108 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 15 mg.......................................................108 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 20 mg.......................................................108 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 30 mg.......................................................108 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 40 mg.......................................................108 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 5 mg.........................................................108 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 7.5 mg......................................................108 OPANA -oxymorphone hcl inj 1 mg/ml............................ 108 OPANA -oxymorphone hcl tab 10 mg............................. 108 OPANA -oxymorphone hcl tab 5 mg............................... 108 ophthalmic irrigation solution - intraocular (Bss plus)...............................................................................141 OPIUM TINCTURE (PAREGORIC -paregoric 2 mg/5ml..............................................................................71 opium tincture 1% (10 mg/ml) (morphine equiv)...........71 OPSUMIT -macitentan tab 10 mg..................................... 62 OPTASE -trypsin w/ castor oil & peruvian balsam gel..... 159 OPTIONS CONCEPTROL VAGINA -nonoxynol-9 gel 4%.................................................................................... 79 octreotide acetate inj 500 mcg/ml (0.5 mg/ml) (Sandostatin).................................................................. 41 octreotide acetate inj 50 mcg/ml (0.05 mg/ml) (Sandostatin).................................................................. 41 OCUFEN -flurbiprofen sodium ophth soln 0.03%............ 144 OCUFLOX -ofloxacin ophth soln 0.3%............................ 144 OCUVEL -multiple vitamins w/ minerals & fa cap 1 mg.................................................................................. 130 OFEV -nintedanib esylate cap 100 mg (base equivalent)........................................................................70 OFEV -nintedanib esylate cap 150 mg (base equivalent)........................................................................70 OFLOXACIN -ofloxacin tab 400 mg.................................... 6 ofloxacin ophth soln 0.3% (Ocuflox)........................... 144 ofloxacin otic soln 0.3%................................................146 ofloxacin tab 200 mg.........................................................6 ofloxacin tab 300 mg.........................................................6 ofloxacin tab 400 mg.........................................................6 OGESTREL -norgestrel & ethinyl estradiol tab 0.5 mg-50 mcg...................................................................................30 olanzapine-fluoxetine hcl cap 12-25 mg (Symbyax)..... 99 olanzapine-fluoxetine hcl cap 12-50 mg (Symbyax)..... 99 olanzapine-fluoxetine hcl cap 3-25 mg (Symbyax)....... 99 olanzapine-fluoxetine hcl cap 6-25 mg (Symbyax)....... 99 olanzapine-fluoxetine hcl cap 6-50 mg (Symbyax)....... 99 olanzapine for im inj 10 mg (Zyprexa)........................... 89 olanzapine orally disintegrating tab 10 mg (Zyprexa zydis)............................................................................... 89 olanzapine orally disintegrating tab 15 mg (Zyprexa zydis)............................................................................... 90 olanzapine orally disintegrating tab 20 mg (Zyprexa zydis)............................................................................... 90 olanzapine orally disintegrating tab 5 mg (Zyprexa zydis)............................................................................... 90 olanzapine tab 10 mg (Zyprexa).....................................90 olanzapine tab 15 mg (Zyprexa).....................................90 olanzapine tab 2.5 mg (Zyprexa)....................................90 olanzapine tab 20 mg (Zyprexa).....................................90 olanzapine tab 5 mg (Zyprexa).......................................90 olanzapine tab 7.5 mg (Zyprexa)....................................90 OLEPTRO -trazodone hcl tab sr 24hr 150 mg.................. 85 OLEPTRO -trazodone hcl tab sr 24hr 300 mg.................. 85 olopatadine hcl nasal soln 0.6% (Patanase)................. 64 OLUX -clobetasol propionate foam 0.05%...................... 159 OLUX-E -clobetasol propionate emulsion foam 0.05%............................................................................. 159 OLYSIO -simeprevir sodium cap 150 mg (base equivalent)..........................................................................9 OMECLAMOX-PAK -amoxicillin cap-clarithro tab w/ omepraz cap dr therapy pack.......................................... 73 omega-3-acid ethyl esters cap 1 gm (Lovaza).............. 61 omeprazole cap delayed release 10 mg (Prilosec)....... 73 omeprazole cap delayed release 20 mg (Prilosec)....... 73 omeprazole cap delayed release 40 mg (Prilosec)....... 73 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 233 2015 OPTIONS GYNOL II VAGINAL -nonoxynol-9 gel 3%........79 OPTIVAR -azelastine hcl ophth soln 0.05%.................... 144 ORACIT -sodium citrate & citric acid soln 490-640 mg/5ml..............................................................................80 ORAFATE - sucralfate-malate paste 10% ......................147 ORALAIR - grass mixed pollen ext tab sl 300 ir (index of reactivity) .........................................................................18 ORAMAGICRX - oral wound care products - for susp rinse ....................................................................................... 147 ORAP -pimozide tab 1 mg................................................ 99 ORAP -pimozide tab 2 mg................................................ 99 ORAPRED ODT -prednisolone sod phos orally disintegr tab 10 mg (base eq)........................................................ 24 ORAPRED ODT -prednisolone sod phos orally disintegr tab 15 mg (base eq)........................................................ 24 ORAPRED ODT -prednisolone sod phos orally disintegr tab 30 mg (base eq)........................................................ 24 ORAPRED -prednisolone sod phosphate oral soln 15 mg/5ml (base equiv)........................................................ 24 ORAVIG -miconazole buccal tab 50 mg (mouththroat)............................................................................. 147 ORBIVAN -butalbital-acetaminophen-caffeine cap 50-300-40 mg.................................................................101 ORBIVAN CF -butalbital-acetaminophen tab 50-300 mg.................................................................................. 101 ORENCIA -abatacept subcutaneous soln prefilled syringe 125 mg/ml...................................................................... 113 ORENITRAM -treprostinil diolamine tab cr 0.125 mg (base equiv)................................................................................62 ORENITRAM -treprostinil diolamine tab cr 0.25 mg (base equiv)................................................................................62 ORENITRAM -treprostinil diolamine tab cr 1 mg (base equiv)................................................................................62 ORENITRAM -treprostinil diolamine tab cr 2.5 mg (base equiv)................................................................................62 ORFADIN -nitisinone cap 10 mg....................................... 41 ORFADIN -nitisinone cap 2 mg......................................... 41 ORFADIN -nitisinone cap 5 mg......................................... 41 orphenadrine citrate inj 30 mg/ml (Norflex)................ 127 orphenadrine citrate tab sr 12hr 100 mg..................... 127 orphenadrine w/ aspirin & caffeine tab 25-385-30 mg.................................................................................. 127 ORTHO-CEPT -desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg....................................................................... 30 ORTHO-CYCLEN -norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg...............................................................30 ORTHO DIAPHRAGM ALL-FLEX/ -diaphragm arc-spring 65 mm............................................................................ 169 ORTHO DIAPHRAGM ALL-FLEX/ -diaphragm arc-spring 70 mm............................................................................ 169 ORTHO DIAPHRAGM ALL-FLEX/ -diaphragm arc-spring 75 mm............................................................................ 169 ORTHO DIAPHRAGM ALL-FLEX/ -diaphragm arc-spring 80 mm............................................................................ 169 234 ORTHO DIAPHRAGM COIL SPRI -diaphragm coil spring kit 100 mm..................................................................... 169 ORTHO DIAPHRAGM COIL SPRI -diaphragm coil spring kit 105 mm..................................................................... 169 ORTHO DIAPHRAGM COIL SPRI -diaphragm coil spring kit 50 mm....................................................................... 169 ORTHO DIAPHRAGM FLAT SPRI -diaphragm flat spring kit 55 mm....................................................................... 169 ORTHO DIAPHRAGM FLAT SPRI -diaphragm flat spring kit 60 mm....................................................................... 169 ORTHO DIAPHRAGM FLAT SPRI -diaphragm flat spring kit 65 mm....................................................................... 169 ORTHO DIAPHRAGM FLAT SPRI -diaphragm flat spring kit 70 mm....................................................................... 169 ORTHO DIAPHRAGM FLAT SPRI -diaphragm flat spring kit 75 mm....................................................................... 169 ORTHO DIAPHRAGM FLAT SPRI -diaphragm flat spring kit 80 mm....................................................................... 169 ORTHO DIAPHRAGM FLAT SPRI -diaphragm flat spring kit 85 mm....................................................................... 169 ORTHO DIAPHRAGM FLAT SPRI -diaphragm flat spring kit 90 mm....................................................................... 169 ORTHO DIAPHRAGM FLAT SPRI -diaphragm flat spring kit 95 mm....................................................................... 169 ORTHO EVRA -norelgestromin-ethinyl estradiol td ptwk 150-35 mcg/24hr..............................................................30 ORTHO MICRONOR -norethindrone tab 0.35 mg.............30 ORTHO-NOVUM 1/35 -norethindrone & ethinyl estradiol tab 1 mg-35 mcg............................................................. 30 ORTHO-NOVUM 7/7/7 -norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg............................................30 ORTHO TRI-CYCLEN LO -norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg...................................30 ORTHO TRI-CYCLEN -norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg...................................30 OSENI -alogliptin-pioglitazone tab 12.5-15 mg..................34 OSENI -alogliptin-pioglitazone tab 12.5-30 mg..................34 OSENI -alogliptin-pioglitazone tab 12.5-45 mg..................34 OSENI -alogliptin-pioglitazone tab 25-15 mg.....................34 OSENI -alogliptin-pioglitazone tab 25-30 mg.....................34 OSENI -alogliptin-pioglitazone tab 25-45 mg.....................34 OSMOPREP -sod phos mono-sod phos di tabs 1.102-0.398 gm(1.5gm na phos)..................................... 71 OSPHENA -ospemifene tab 60 mg................................... 41 OTEZLA -apremilast tab 30 mg.......................................113 OTEZLA -apremilast tab starter therapy pack 10 mg & 20 mg & 30 mg................................................................... 113 OTICIN HC NR -pramoxine-hc-chloroxylenol otic soln 10-10-1 mg/ml................................................................146 OTOZIN -antipyrine-benzocaine-glycerin-zinc ace otic liqd 5.4-1-2-1%......................................................................146 OTREXUP -methotrexate soln pf auto-injector 10mg/0.4ml.....................................................................113 OTREXUP -methotrexate soln pf auto-injector 15mg/0.4ml.....................................................................113 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter 40 mg............................................................................. 108 OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter 80 mg............................................................................. 108 OXYCODONE HCL -oxycodone hcl conc 100 mg/5ml (20 mg/ml)............................................................................ 108 OXYCODONE HCL -oxycodone hcl soln 5 mg/5ml.........108 oxycodone hcl soln 5 mg/5ml (Oxycodone hcl)..........108 oxycodone hcl tab 10 mg............................................. 108 oxycodone hcl tab 15 mg (Roxicodone)......................108 oxycodone hcl tab 20 mg............................................. 108 oxycodone hcl tab 30 mg (Roxicodone)......................108 oxycodone hcl tab 5 mg (Roxicodone)........................108 oxycodone-ibuprofen tab 5-400 mg............................. 109 oxycodone w/ acetaminophen cap 5-500 mg.............. 108 oxycodone w/ acetaminophen tab 10-325 mg (Percocet)......................................................................108 oxycodone w/ acetaminophen tab 10-650 mg.............108 oxycodone w/ acetaminophen tab 2.5-325 mg (Percocet)......................................................................108 oxycodone w/ acetaminophen tab 5-325 mg (Percocet)......................................................................108 oxycodone w/ acetaminophen tab 7.5-325 mg (Percocet)......................................................................108 oxycodone w/ acetaminophen tab 7.5-500 mg............109 OXYCONTIN -oxycodone hcl tab er 12hr deter 10 mg.................................................................................. 109 OXYCONTIN -oxycodone hcl tab er 12hr deter 15 mg.................................................................................. 109 OXYCONTIN -oxycodone hcl tab er 12hr deter 20 mg.................................................................................. 109 OXYCONTIN -oxycodone hcl tab er 12hr deter 30 mg.................................................................................. 109 OXYCONTIN -oxycodone hcl tab er 12hr deter 40 mg.................................................................................. 109 OXYCONTIN -oxycodone hcl tab er 12hr deter 60 mg.................................................................................. 109 OXYCONTIN -oxycodone hcl tab er 12hr deter 80 mg.................................................................................. 109 oxymorphone hcl tab 10 mg (Opana).......................... 109 oxymorphone hcl tab 5 mg (Opana)............................ 109 oxymorphone hcl tab sr 12hr 10 mg............................109 oxymorphone hcl tab sr 12hr 15 mg............................109 oxymorphone hcl tab sr 12hr 20 mg............................109 oxymorphone hcl tab sr 12hr 30 mg............................109 oxymorphone hcl tab sr 12hr 40 mg............................109 oxymorphone hcl tab sr 12hr 5 mg............................. 109 oxymorphone hcl tab sr 12hr 7.5 mg...........................109 oxytocin inj 10 unit/ml (Pitocin)..................................... 39 OXYTROL -oxybutynin td patch biweekly 3.9 mg/24hr......78 OZURDEX -dexamethasone intravitreal implant 0.7 mg.................................................................................. 144 OTREXUP -methotrexate soln pf auto-injector 20mg/0.4ml.....................................................................113 OTREXUP -methotrexate soln pf auto-injector 25mg/0.4ml.....................................................................113 OVACE PLUS -sulfacetamide sodium cream 10%..........159 OVACE PLUS -sulfacetamide sodium lotion 9.8%.......... 159 OVACE PLUS -sulfacetamide sodium shampoo 10%..... 159 OVACE PLUS WASH -sulfacetamide sodium cleansing gel 10%................................................................................ 159 OVACE PLUS WASH -sulfacetamide sodium liquid 10%................................................................................ 159 OVACE WASH -sulfacetamide sodium liquid 10%.......... 159 OVCON-35 -norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg....................................................................... 31 OVIDE -malathion lotion 0.5%.........................................159 oxacillin sodium for inj 10 gm......................................... 2 oxacillin sodium for inj 1 gm........................................... 1 oxacillin sodium for inj 2 gm........................................... 2 OXANDRIN -oxandrolone tab 10 mg.................................26 OXANDRIN -oxandrolone tab 2.5 mg................................26 oxandrolone tab 10 mg (Oxandrin)................................ 26 oxandrolone tab 2.5 mg (Oxandrin)............................... 26 oxaprozin tab 600 mg (Daypro)....................................113 oxazepam cap 10 mg...................................................... 82 oxazepam cap 15 mg...................................................... 82 oxazepam cap 30 mg...................................................... 82 oxcarbazepine susp 300 mg/5ml (60 mg/ml) (Trileptal)....................................................................... 122 oxcarbazepine tab 150 mg (Trileptal).......................... 122 oxcarbazepine tab 300 mg (Trileptal).......................... 122 oxcarbazepine tab 600 mg (Trileptal).......................... 122 OXECTA -oxycodone hcl tab abuse deter 5 mg..............108 OXECTA -oxycodone hcl tab abuse deter 7.5 mg........... 108 OXISTAT -oxiconazole nitrate cream 1%........................ 159 OXISTAT -oxiconazole nitrate lotion 1%......................... 159 OXSORALEN -methoxsalen lotion 1%............................ 159 OXSORALEN ULTRA -methoxsalen rapid cap 10 mg.....159 OXTELLAR XR -oxcarbazepine tab sr 24hr 150 mg....... 122 OXTELLAR XR -oxcarbazepine tab sr 24hr 300 mg....... 122 OXTELLAR XR -oxcarbazepine tab sr 24hr 600 mg....... 122 oxybutynin chloride syrup 5 mg/5ml............................. 78 oxybutynin chloride tab 5 mg........................................ 78 oxybutynin chloride tab sr 24hr 10 mg (Ditropan xl)..................................................................................... 78 oxybutynin chloride tab sr 24hr 15 mg (Ditropan xl)..................................................................................... 78 oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl)...... 78 oxycodone-aspirin tab 4.8355-325 mg (Percodan)..... 109 oxycodone hcl cap 5 mg.............................................. 108 oxycodone hcl conc 100 mg/5ml (20 mg/ml) (Oxycodone hcl)........................................................... 108 OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter 10 mg............................................................................. 108 OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter 20 mg............................................................................. 108 P PALGIC -carbinoxamine maleate soln 4 mg/5ml...............63 PALGIC -carbinoxamine maleate tab 4 mg....................... 63 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 235 2015 PAMELOR -nortriptyline hcl cap 10 mg.............................85 PAMELOR -nortriptyline hcl cap 25 mg.............................85 PAMELOR -nortriptyline hcl cap 50 mg.............................85 PAMELOR -nortriptyline hcl cap 75 mg.............................85 PAMINE FORTE -methscopolamine bromide tab 5 mg.....73 PAMINE FQ -methscopolamine tab 5 mg & misc intestinal flora reg cap.....................................................................73 PAMINE -methscopolamine bromide tab 2.5 mg...............73 PANATUSS DXP -phenylephrine-dexbromphen-dm-gg liquid 5-1-15-100 mg/5ml................................................. 65 PANCREAZE -pancrelipase (lip-prot-amyl) dr cap 10500-25000-43750 unit.................................................. 75 PANCREAZE -pancrelipase (lip-prot-amyl) dr cap 16800-40000-70000 unit.................................................. 75 PANCREAZE -pancrelipase (lip-prot-amyl) dr cap 21000-37000-61000 unit.................................................. 75 PANCREAZE -pancrelipase (lip-prot-amyl) dr cap 4200-10000-17500 unit.................................................... 75 PANCRELIPASE -pancrelipase (lip-prot-amyl) dr cap 5000-17000-27000 unit.................................................... 75 PANDEL -hydrocortisone probutate cream 0.1%............ 159 PANRETIN -alitretinoin gel 0.1%.....................................159 pantoprazole sodium ec tab 20 mg (base equiv) (Protonix)........................................................................ 73 pantoprazole sodium ec tab 40 mg (base equiv) (Protonix)........................................................................ 73 papaverine hcl inj 30 mg/ml........................................... 62 PARAFON FORTE DSC -chlorzoxazone tab 500 mg......127 PARAGARD INTRAUTERINE COP - copper iud ............. 31 PARCOPA -carbidopa & levodopa orally disintegrating tab 10-100 mg......................................................................125 PARCOPA -carbidopa & levodopa orally disintegrating tab 25-100 mg......................................................................125 PARCOPA -carbidopa & levodopa orally disintegrating tab 25-250 mg......................................................................125 paricalcitol cap 1 mcg (Zemplar)................................... 41 paricalcitol cap 2 mcg (Zemplar)................................... 41 paricalcitol cap 4 mcg (Zemplar)................................... 41 PARLODEL -bromocriptine mesylate cap 5 mg.............. 125 PARLODEL -bromocriptine mesylate tab 2.5 mg............ 125 PARNATE -tranylcypromine sulfate tab 10 mg..................85 paromomycin sulfate cap 250 mg....................................6 paroxetine hcl tab 10 mg (Paxil).................................... 85 paroxetine hcl tab 20 mg (Paxil).................................... 85 paroxetine hcl tab 30 mg (Paxil).................................... 85 paroxetine hcl tab 40 mg (Paxil).................................... 85 paroxetine hcl tab sr 24hr 12.5 mg (Paxil cr)................ 85 paroxetine hcl tab sr 24hr 25 mg (Paxil cr)................... 85 paroxetine hcl tab sr 24hr 37.5 mg (Paxil cr)................ 85 PASER -aminosalicylic acid cr granules packet 4 gm......... 6 PATADAY -olopatadine hcl ophth soln 0.2%...................144 PATANASE -olopatadine hcl nasal soln 0.6%...................64 PATANOL -olopatadine hcl ophth soln 0.1%...................144 PAXIL CR -paroxetine hcl tab sr 24hr 12.5 mg................. 86 PAXIL CR -paroxetine hcl tab sr 24hr 25 mg.................... 86 236 PAXIL CR -paroxetine hcl tab sr 24hr 37.5 mg................. 86 PAXIL -paroxetine hcl oral susp 10 mg/5ml (base equiv)................................................................................86 PAXIL -paroxetine hcl tab 10 mg...................................... 86 PAXIL -paroxetine hcl tab 20 mg...................................... 86 PAXIL -paroxetine hcl tab 30 mg...................................... 86 PAXIL -paroxetine hcl tab 40 mg...................................... 86 PBZ -tripelennamine hcl tab 50 mg................................... 63 PCE -erythromycin w/ enteric coated particles tab 333 mg...................................................................................... 4 PCE -erythromycin w/ enteric coated particles tab 500 mg...................................................................................... 4 PEDIADERM AF COMPLETE KIT -nystatin cream 100000 unit/gm & diaper rash cream kit.....................................160 PEDIADERM HC -hydrocortisone lot 2% & emollient cream kit........................................................................ 160 PEDIADERM TA -triamcinolone cream 0.1% & emollient cream kit........................................................................ 160 PEDIAPRED -prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base)..................................................24 PEDIARIX -diph-tetanus tox-acell pert-hepatitis b-polio ipv vac inj...............................................................................16 PEDIATEX TDM -pseudoephed-triprolidine-dm susp 10-0.938-4 mg/ml.............................................................65 PEDIATEX TD -triprolidine & pseudoephedrine liquid 0.938-10 mg/ml................................................................ 65 pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/ml ....................................................................................... 129 pediatric multiple vitamins w/ fluoride chew tab 0.25 mg .................................................................................129 pediatric multiple vitamins w/ fluoride chew tab 0.5 mg ....................................................................................... 129 pediatric multiple vitamins w/ fluoride chew tab 1 mg ....................................................................................... 129 pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml ....................................................................................... 129 pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml ....................................................................................... 129 pediatric multiple vitamin w/ minerals & c drops 45 mg/ml.............................................................................129 pediatric vitamins acd w/ fluoride soln 0.25 mg/ml ....................................................................................... 129 pediatric vitamins acd w/ fluoride soln 0.5 mg/ml ..... 129 PEDIPIROX-4 NAIL -ciclopirox soln 8% & lacquer removal pads & foot powd kit......................................................160 PEDVAX HIB -haemophilus b polysaccharide conj vac im susp 7.5 mcg/0.5 ml........................................................ 16 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm (Golytely).........................................................................71 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm (Colyte-flavor packs)......................................................71 peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/flavor pack).....................................................71 PEGANONE -ethotoin tab 250 mg.................................. 122 PEGASYS -peginterferon alfa-2a inj 180 mcg/0.5ml........... 9 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 PENTAM 300 -pentamidine isethionate for soln 300 mg.................................................................................... 13 PENTASA -mesalamine cap cr 250 mg............................ 76 PENTASA -mesalamine cap cr 500 mg............................ 76 pentazocine-acetaminophen tab 25-650 mg................109 pentazocine w/ naloxone tab 50-0.5 mg...................... 109 PENTETATE CALCIUM TRISODI -pentetate calcium trisodium iv or inhalation soln 200 mg/ml.......................167 PENTETATE ZINC TRISODIUM -pentetate zinc trisodium iv or inhalation soln 200 mg/ml......................................167 pentoxifylline tab cr 400 mg......................................... 140 PEPCID -famotidine for susp 40 mg/5ml...........................73 PEPCID -famotidine tab 20 mg......................................... 73 PEPCID -famotidine tab 40 mg......................................... 73 PERCOCET -oxycodone w/ acetaminophen tab 10-325 mg.................................................................................. 109 PERCOCET -oxycodone w/ acetaminophen tab 10-650 mg.................................................................................. 109 PERCOCET -oxycodone w/ acetaminophen tab 2.5-325 mg.................................................................................. 109 PERCOCET -oxycodone w/ acetaminophen tab 5-325 mg.................................................................................. 109 PERCOCET -oxycodone w/ acetaminophen tab 7.5-325 mg.................................................................................. 109 PERCOCET -oxycodone w/ acetaminophen tab 7.5-500 mg.................................................................................. 109 PERCODAN -oxycodone-aspirin tab 4.8355-325 mg...... 109 PERFOROMIST -formoterol fumarate soln nebu 20 mcg/2ml............................................................................69 PERIDEX -chlorhexidine gluconate soln 0.12%.............. 147 perindopril erbumine tab 2 mg.......................................55 perindopril erbumine tab 4 mg (Aceon)........................ 55 perindopril erbumine tab 8 mg (Aceon)........................ 55 peritoneal dialysis solutions 346 mosm/l ...................170 permethrin cream 5% (Elimite).....................................160 PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 2-10 mg................................................. 99 PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 2-25 mg................................................. 99 PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 4-10 mg................................................. 99 PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 4-25 mg................................................. 99 PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 4-50 mg................................................. 99 perphenazine tab 16 mg................................................. 90 perphenazine tab 2 mg................................................... 90 perphenazine tab 4 mg................................................... 90 perphenazine tab 8 mg................................................... 90 PERSANTINE -dipyridamole tab 25 mg.......................... 140 PERSANTINE -dipyridamole tab 50 mg.......................... 140 PERSANTINE -dipyridamole tab 75 mg.......................... 140 PERTZYE -pancrelipase (lip-prot-amyl) dr cap 16000-57500-60500 unit.................................................. 75 PEGASYS -peginterferon alfa-2a inj 180 mcg/ml................ 9 PEGASYS -peginterferon alfa-2a inj kit 180 mcg/0.5ml.......9 PEGASYS PROCLICK -peginterferon alfa-2a inj 135 mcg/0.5ml...........................................................................9 PEGASYS PROCLICK -peginterferon alfa-2a inj 180 mcg/0.5ml...........................................................................9 PEGINTRON -peginterferon alfa-2b for inj kit 120 mcg/0.5ml.........................................................................10 PEG-INTRON -peginterferon alfa-2b for inj kit 120 mcg/0.5ml...........................................................................9 PEGINTRON -peginterferon alfa-2b for inj kit 150 mcg/0.5ml.........................................................................10 PEG-INTRON -peginterferon alfa-2b for inj kit 150 mcg/0.5ml...........................................................................9 PEGINTRON -peginterferon alfa-2b for inj kit 50 mcg/0.5ml.........................................................................10 PEG-INTRON -peginterferon alfa-2b for inj kit 50 mcg/0.5ml...........................................................................9 PEGINTRON -peginterferon alfa-2b for inj kit 80 mcg/0.5ml.........................................................................10 PEG-INTRON -peginterferon alfa-2b for inj kit 80 mcg/0.5ml...........................................................................9 PEG-INTRON REDIPEN PAK 4 -peginterferon alfa-2b for inj kit 120 mcg/0.5ml..........................................................9 PEG-INTRON REDIPEN PAK 4 -peginterferon alfa-2b for inj kit 150 mcg/0.5ml..........................................................9 PEG-INTRON REDIPEN PAK 4 -peginterferon alfa-2b for inj kit 50 mcg/0.5ml............................................................9 PEG-INTRON REDIPEN PAK 4 -peginterferon alfa-2b for inj kit 80 mcg/0.5ml............................................................9 PEG-INTRON REDIPEN -peginterferon alfa-2b for inj kit 120 mcg/0.5ml................................................................... 9 PEG-INTRON REDIPEN -peginterferon alfa-2b for inj kit 150 mcg/0.5ml................................................................... 9 PEG-INTRON REDIPEN -peginterferon alfa-2b for inj kit 50 mcg/0.5ml..................................................................... 9 PEG-INTRON REDIPEN -peginterferon alfa-2b for inj kit 80 mcg/0.5ml..................................................................... 9 penicillin g potassium for inj 20000000 unit (Pfizerpeng)........................................................................................ 2 penicillin g potassium for inj 5000000 unit (Pfizerpeng)........................................................................................ 2 PENICILLIN G PROCAINE -penicillin g procaine intramuscular susp 600000 unit/ml.................................... 2 PENICILLIN G SODIUM -penicillin g sodium for inj 5000000 unit...................................................................... 2 penicillin v potassium for soln 125 mg/5ml.................... 2 penicillin v potassium for soln 250 mg/5ml.................... 2 penicillin v potassium tab 250 mg................................... 2 penicillin v potassium tab 500 mg................................... 2 PENLAC NAIL LACQUER -ciclopirox solution 8%.......... 160 PENNSAID -diclofenac sodium soln 1.5%.......................160 PENNSAID -diclofenac sodium soln 2%......................... 160 PENTACEL -diph-ac per-tet tox ad-poliov-haemoph b poly vac for im susp................................................................ 16 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 237 2015 PERTZYE -pancrelipase (lip-prot-amyl) dr cap 8000-28750-30250 unit.................................................... 75 PEXEVA -paroxetine mesylate tab 10 mg (base equiv).....86 PEXEVA -paroxetine mesylate tab 20 mg (base equiv).....86 PEXEVA -paroxetine mesylate tab 30 mg (base equiv).....86 PEXEVA -paroxetine mesylate tab 40 mg (base equiv).....86 PFIZERPEN-G -penicillin g potassium for inj 20000000 unit......................................................................................2 PFIZERPEN-G -penicillin g potassium for inj 5000000 unit......................................................................................2 phenazopyridine hcl tab 100 mg (Pyridium)................. 80 phenazopyridine hcl tab 200 mg (Pyridium)................. 80 phenelzine sulfate tab 15 mg (Nardil)............................ 86 PHENERGAN -promethazine hcl inj 25 mg/ml.................. 63 PHENERGAN -promethazine hcl inj 50 mg/ml.................. 63 PHENFLU CD -phenylephrine-codeine-guaifenesin-apap tab 10-10-400-500 mg..................................................... 66 PHENFLU CDX -phenylephrine-codeine-guaifenesin-apap tab 10-20-400-500 mg..................................................... 66 phenobarbital elixir 20 mg/5ml.......................................92 PHENOBARBITAL -phenobarbital tab 100 mg..................92 PHENOBARBITAL -phenobarbital tab 15 mg....................92 PHENOBARBITAL -phenobarbital tab 30 mg....................92 PHENOBARBITAL -phenobarbital tab 60 mg....................92 PHENOBARBITAL -phenobarbital tab 64.8 mg.................92 PHENOBARBITAL -phenobarbital tab 97.2 mg.................92 PHENOBARBITAL SODIUM -phenobarbital sodium inj 130 mg/ml................................................................................92 PHENOBARBITAL SODIUM -phenobarbital sodium inj 65 mg/ml................................................................................92 phenobarbital tab 16.2 mg..............................................92 phenobarbital tab 32.4 mg..............................................92 PHENTOLAMINE MESYLATE -phentolamine mesylate for inj 5 mg............................................................................ 55 PHENTOLAMINE MESYLATE -phentolamine mesylate inj 5 mg/ml............................................................................ 55 phenylephrine-brompheniramine-dm liquid 7.5-4-15 mg/5ml.............................................................................66 phenylephrine-guaifenesin liqd 7.5-100 mg/5ml (1.5-20 mg/ml)..............................................................................66 phenylephrine hcl inj 10 mg/ml......................................59 phenylephrine hcl ophth soln 10%.............................. 144 phenylephrine hcl ophth soln 2.5%............................. 144 PHENYLEPHRINE HCL -phenylephrine hcl inj 10 mg/ ml......................................................................................59 phenylephrine-promethazine w/ codeine syrup 5-6.25-10 mg/5ml............................................................ 66 phenylephrine w/ dm-gg liqd 10-15-300 mg/5ml........... 66 phenylephrine w/ dm-gg liqd 10-30-200 mg/5ml........... 66 phenylephrine w/ dm-gg liqd 2.5-5-50 mg/ml................ 66 phenylephrine w/ dm-gg liqd 2.5-7.5-88 mg/ml............. 66 phenyltoloxamine-acetaminophen tab 30-500 mg...... 101 phenyltoloxamine-acetaminophen tab 50-500 mg...... 101 phenyltoloxamine-acetaminophen tab 55-500 mg...... 101 238 PHENYTEK -phenytoin sodium extended cap 200 mg.................................................................................. 122 PHENYTEK -phenytoin sodium extended cap 300 mg.................................................................................. 122 phenytoin chew tab 50 mg (Dilantin infatabs)............ 122 phenytoin sodium extended cap 100 mg (Dilantin)........................................................................122 phenytoin sodium extended cap 200 mg (Phenytek)..................................................................... 122 phenytoin sodium extended cap 300 mg (Phenytek)..................................................................... 122 phenytoin sodium inj 50 mg/ml....................................122 phenytoin susp 125 mg/5ml (Dilantin)......................... 122 PHISOHEX -hexachlorophene liq 3%..............................167 PHOSLO -calcium acetate (phosphate binder) cap 667 mg (169 mg ca)..................................................................... 76 PHOSLYRA -calcium acetate (phosphate binder) oral soln 667 mg/5ml...................................................................... 76 PHOSPHOLINE IODIDE -echothiophate iodide ophth for soln 0.125%................................................................... 144 PHRENILIN FORTE -butalbital-acetaminophen cap 50-650 mg.................................................................................. 101 PHYSICIANS EZ USE B-12 CO -cyanocobalamin inj kit 1000 mcg/ml.................................................................. 137 PHYSICIANS EZ USE JOINT T -triamcinolone inj 40 mg/ ml & lidocaine 1% & ammonia inh kit.............................. 24 PHYSICIANS EZ USE M-PRED -methylprednisolone ace 40 mg/ml & bupivacaine inj 0.5% kit................................24 PHYSIOSOL IRRIGATION PH 7 - irrigation solution, physiological ................................................................. 171 PHYSOSTIGMINE SALICYLATE -physostigmine salicylate inj 1 mg/ml..................................................................... 167 phytonadione inj 1 mg/0.5ml (2 mg/ml)....................... 129 PICATO -ingenol mebutate gel 0.015%.......................... 160 PICATO -ingenol mebutate gel 0.05%............................ 160 PICO SINGLE USE NEGATIVE - wound dressings - kit ....................................................................................... 160 pilocarpine hcl ophth soln 1% (Isopto carpine).......... 144 pilocarpine hcl ophth soln 2% (Isopto carpine).......... 144 pilocarpine hcl ophth soln 4% (Isopto carpine).......... 144 pilocarpine hcl tab 5 mg (Salagen).............................. 147 pilocarpine hcl tab 7.5 mg (Salagen)........................... 147 PILOPINE HS -pilocarpine hcl ophth gel 4%...................144 pindolol tab 10 mg.......................................................... 45 pindolol tab 5 mg............................................................ 45 PINNACAINE OTIC -benzocaine otic soln 20%.............. 146 pioglitazone hcl-glimepiride tab 30-2 mg (Duetact)...... 35 pioglitazone hcl-glimepiride tab 30-4 mg (Duetact)...... 35 pioglitazone hcl-metformin hcl tab 15-500 mg (Actoplus met)................................................................35 pioglitazone hcl-metformin hcl tab 15-850 mg (Actoplus met)................................................................35 pioglitazone hcl tab 15 mg (base equiv) (Actos)...........34 pioglitazone hcl tab 30 mg (base equiv) (Actos)...........34 pioglitazone hcl tab 45 mg (base equiv) (Actos)...........34 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 POLY-VI-FLOR/IRON - ped multiple vitamin w/ fl-fe biphasic susp 0.25-7 mg/ml ..........................................130 POLY-VI-FLOR/IRON - ped multiple vit w/ fl-fe biphasic chew tab 0.5-10 mg ......................................................130 POLY-VI-FLOR - ped multiple vit w/ fluoride biphasic chew tab 0.25 mg .................................................................. 130 POLY-VI-FLOR - ped multiple vit w/ fluoride biphasic chew tab 0.5 mg .................................................................... 130 POLY-VI-FLOR - ped multiple vit w/ fluoride biphasic chew tab 1 mg ....................................................................... 130 POLY-VI-FLOR - ped multiple vit w/ fluoride biphasic susp 0.25 mg/ml ....................................................................130 POMALYST -pomalidomide cap 1 mg...............................21 POMALYST -pomalidomide cap 2 mg...............................21 POMALYST -pomalidomide cap 3 mg...............................21 POMALYST -pomalidomide cap 4 mg...............................21 PONSTEL -mefenamic acid cap 250 mg.........................113 PONTOCAINE -tetracaine hcl inj 1%.............................. 118 pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml.............................................................................80 POTABA -potassium aminobenzoate cap 500 mg.......... 129 POTABA -potassium aminobenzoate tab 500 mg........... 129 potassium bicarbonate effer tab 25 meq.....................133 potassium chloride cap cr 10 meq (Micro-k)...............133 potassium chloride cap cr 8 meq (Micro-k).................133 POTASSIUM CHLORIDE ER -potassium chloride tab cr 20 meq (1500 mg)......................................................... 133 potassium chloride microencapsulated crys cr tab 10 meq................................................................................ 133 potassium chloride microencapsulated crys cr tab 20 meq................................................................................ 133 potassium chloride oral liq 10% (20 meq/15ml).......... 133 potassium chloride oral liq 20% (40 meq/15ml).......... 133 potassium chloride powder packet 20 meq................ 133 potassium chloride tab cr 10 meq (K-tab)................... 133 potassium chloride tab cr 8 meq (600 mg)..................133 potassium citrate & citric acid powder pack 3300-1002 mg.................................................................................... 80 potassium citrate & citric acid soln 1100-334 mg/5ml.............................................................................80 potassium citrate tab cr 10 meq (1080 mg) (Urocit-k 10).................................................................................... 80 potassium citrate tab cr 15 meq (1620 mg) (Urocit-k 15).................................................................................... 80 potassium citrate tab cr 5 meq (540 mg) (Urocit-k 5)...................................................................................... 80 POTASSIUM HYDROXIDE -potassium hydroxide solution 5%.................................................................................. 168 pot bicarbonate & chloride effer tab 25 meq...............132 POTIGA -ezogabine tab 200 mg..................................... 122 POTIGA -ezogabine tab 300 mg..................................... 122 POTIGA -ezogabine tab 400 mg..................................... 122 POTIGA -ezogabine tab 50 mg....................................... 122 pot phos monobasic w/sod phos di & monobas tab 155-852-130mg (K-phos neutral)................................ 132 piroxicam cap 10 mg (Feldene)....................................113 piroxicam cap 20 mg (Feldene)....................................113 PITOCIN -oxytocin inj 10 unit/ml....................................... 39 PITRESSIN SYNTHETIC -vasopressin inj 20 unit/ml........ 41 PKU EASY MICROTABS - nutritional supplement tabs delayed release ............................................................ 133 PLAN B -levonorgestrel tab 0.75 mg.................................31 PLAN B ONE-STEP -levonorgestrel tab 1.5 mg................31 PLAQUENIL -hydroxychloroquine sulfate tab 200 mg....... 12 PLAVIX -clopidogrel bisulfate tab 300 mg (base equiv)..............................................................................141 PLAVIX -clopidogrel bisulfate tab 75 mg (base equiv).....141 PLEGRIDY -peginterferon beta-1a soln pen-injector 125 mcg/0.5ml.........................................................................99 PLEGRIDY -peginterferon beta-1a soln prefilled syringe 125 mcg/0.5ml................................................................. 99 PLEGRIDY STARTER PACK -peginterferon beta-1a soln pen-inj 63 & 94 mcg/0.5ml pack...................................... 99 PLEGRIDY STARTER PACK -peginterferon beta-1a soln pref syr 63 & 94 mcg/0.5ml pack.....................................99 PLETAL -cilostazol tab 100 mg....................................... 141 PLETAL -cilostazol tab 50 mg......................................... 141 PLEXION CLEANSER -sulfacetamide sodium w/ sulfur cleanser 9.8-4.8%.......................................................... 160 PLEXION CLEANSING CLOTHS -sulfacetamide sodium w/ sulfur cleansing cloth 9.8-4.8%................................. 160 PLEXION -sulfacetamide sodium w/ sulfur cream 9.8-4.8%......................................................................... 160 PLEXION -sulfacetamide sodium w/ sulfur lotion 9.8-4.8%......................................................................... 160 PLIAGLIS -lidocaine-tetracaine cream 7-7%................... 160 PNEUMOVAX 23/1 DOSE -pneumococcal vaccine polyvalent inj 25 mcg/0.5ml............................................. 16 PNEUMOVAX 23/5 DOSE -pneumococcal vaccine polyvalent inj 25 mcg/0.5ml............................................. 16 PNEUMOVAX 23 -pneumococcal vaccine polyvalent inj 25 mcg/0.5ml.........................................................................16 PODOCON 25 IN BENZOIN TIN -podophyllum resin soln 25%................................................................................ 160 podofilox soln 0.5% (Condylox)................................... 160 polyethylene glycol 3350 oral packet............................ 71 polyethylene glycol 3350 oral powder...........................71 POLY HIST DHC -phenylephrine-pyrilamine-dihydrocod liqd 5-7.5-7.5 mg/5ml....................................................... 66 POLY HIST NC -pseudoephedrine-triprolidine w/ cod liquid 15-1.25-10 mg/5ml...........................................................66 polymyxin b sulfate for inj 500000 unit......................... 13 polymyxin b-trimethoprim ophth soln 10000 unit/ ml-0.1% (Polytrim)........................................................144 POLYTRIM -polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%................................................................... 144 POLY-TUSSIN DHC -phenylephrine-bromphendihydrocodeine liqd 7.5-4-3 mg/5ml.................................66 POLY-TUSSIN EX -phenylephrine-dihydrocodeine-gg syrup 5-7.5-50 mg/5ml.....................................................66 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 239 2015 PRADAXA -dabigatran etexilate mesylate cap 150 mg (etexilate base eq)......................................................... 139 PRADAXA -dabigatran etexilate mesylate cap 75 mg (etexilate base eq)......................................................... 139 PRALIDOXIME CHLORIDE -pralidoxime chloride im soln auto-injector 600 mg/2ml............................................... 167 pramipexole dihydrochloride tab 0.125 mg (Mirapex)....................................................................... 125 pramipexole dihydrochloride tab 0.25 mg (Mirapex)....................................................................... 125 pramipexole dihydrochloride tab 0.5 mg (Mirapex)....................................................................... 125 pramipexole dihydrochloride tab 0.75 mg (Mirapex)....................................................................... 125 pramipexole dihydrochloride tab 1.5 mg (Mirapex)....................................................................... 125 pramipexole dihydrochloride tab 1 mg (Mirapex)....... 125 PRAMOSONE E -pramoxine-hc emollient base cream 1-2.5%............................................................................ 160 PRAMOSONE -pramoxine-hc cream 1-1%..................... 160 PRAMOSONE -pramoxine-hc cream 1-2.5%.................. 160 PRAMOSONE -pramoxine-hc lotion 1-1%...................... 160 PRAMOSONE -pramoxine-hc lotion 1-2.5%................... 160 PRAMOSONE -pramoxine-hc oint 1-1%......................... 160 PRAMOSONE -pramoxine-hc oint 1-2.5%...................... 160 PRAMOTIC -pramoxine-chloroxylenol otic liquid 1-0.1%............................................................................ 146 pramoxine-chloroxylenol otic liquid 1-0.1% (Pramotic)......................................................................146 pramoxine-hc-chloroxylenol aqueous otic soln 10-10-1 mg/ml (Cortane-b aqueous)........................................ 146 pramoxine-hc-chloroxylenol otic soln 10-10-1 mg/ml (Cortane-b-otic)............................................................ 146 pramoxine-hc cream 1-2.5% (Pramosone).................. 160 pramoxine hcl gel 1%....................................................160 PRANDIMET -repaglinide-metformin hcl tab 1-500 mg..... 35 PRANDIMET -repaglinide-metformin hcl tab 2-500 mg..... 35 PRANDIN -repaglinide tab 0.5 mg.................................... 35 PRANDIN -repaglinide tab 1 mg....................................... 35 PRANDIN -repaglinide tab 2 mg....................................... 35 PRASTERA -prasterone cap 200 mg & ibuprofen tab 400 mg kit............................................................................. 114 pravastatin sodium tab 10 mg........................................61 pravastatin sodium tab 20 mg (Pravachol)................... 61 pravastatin sodium tab 40 mg (Pravachol)................... 61 pravastatin sodium tab 80 mg (Pravachol)................... 61 PRAZOLAMINE -carisoprodol tab 350 mg & dietary management cap pack.................................................. 127 prazosin hcl cap 1 mg (Minipress).................................55 prazosin hcl cap 2 mg (Minipress).................................55 prazosin hcl cap 5 mg (Minipress).................................55 PR CREAM - dermatological products misc - kit ............ 160 PRECOSE -acarbose tab 100 mg.....................................35 PRECOSE -acarbose tab 25 mg.......................................35 PRECOSE -acarbose tab 50 mg.......................................35 240 PRED FORTE -prednisolone acetate ophth susp 1%......144 PRED-G -gentamicin-prednisolone ace ophth susp 0.3-1%............................................................................ 144 PRED-G S.O.P. -gentamicin-prednisolone ace ophth oint 0.3-0.6%......................................................................... 144 PRED MILD -prednisolone acetate ophth susp 0.12%............................................................................. 144 prednicarbate cream 0.1% (Dermatop)........................ 160 prednicarbate oint 0.1% (Dermatop)............................ 160 prednisolone acetate ophth susp 1% (Pred forte)...... 144 PREDNISOLONE SODIUM PHOSP -prednisolone sodium phosphate ophth soln 1%.............................................. 144 PREDNISOLONE SODIUM PHOSP -prednisolone sodium phosphate oral soln 25 mg/5ml (base eq)....................... 25 prednisolone sod phosphate oral soln 15 mg/5ml (base equiv).................................................................... 24 prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) (Pediapred)............................................. 24 prednisolone syrup 15 mg/5ml (usp solution equivalent) (Prelone)......................................................25 PREDNISONE INTENSOL -prednisone conc 5 mg/ml...... 25 PREDNISONE -prednisone oral soln 5 mg/5ml.................25 PREDNISONE -prednisone tab 10 mg dose pack.............25 PREDNISONE -prednisone tab 50 mg..............................25 PREDNISONE -prednisone tab 5 mg dose pack...............25 prednisone tab 10 mg..................................................... 25 prednisone tab 10 mg dose pack.................................. 25 prednisone tab 1 mg....................................................... 25 prednisone tab 2.5 mg.................................................... 25 prednisone tab 20 mg..................................................... 25 prednisone tab 5 mg....................................................... 25 prednisone tab 5 mg dose pack.................................... 25 PREFEST -estradiol tab 1 mg(15)/estrad-norgestimate tab 1-0.09mg(15)....................................................................28 PRE-FOLIC -folic acid-vitamin c tab 1-100 mg................137 PRELONE -prednisolone syrup 15 mg/5ml (usp solution equivalent)........................................................................25 PREMARIN -estrogens, conjugated for inj 25 mg............. 28 PREMARIN -estrogens, conjugated tab 0.3 mg................ 28 PREMARIN -estrogens, conjugated tab 0.45 mg.............. 28 PREMARIN -estrogens, conjugated tab 0.625 mg............ 28 PREMARIN -estrogens, conjugated tab 0.9 mg................ 28 PREMARIN -estrogens, conjugated tab 1.25 mg.............. 28 PREMARIN -estrogens, conjugated vaginal cream 0.625 mg/gm.............................................................................. 79 PREMPHASE -conj est 0.625(14)/conj est-medroxypro ac tab 0.625-5mg(14)........................................................... 28 PREMPRO -conjugated estrogen-medroxyprogest acetate tab 0.3-1.5 mg................................................................. 28 PREMPRO -conjugated estrogen-medroxyprogest acetate tab 0.45-1.5 mg............................................................... 28 PREMPRO -conjugated estrogen-medroxyprogest acetate tab 0.625-2.5 mg..............................................................28 PREMPRO -conjugated estrogen-medroxyprogest acetate tab 0.625-5 mg................................................................ 28 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 PREVNAR 13 -pneumococcal 13-valent conjugate vaccine inj......................................................................................16 PREVPAC -amoxicillin cap-clarithro tab-lansopraz cap dr therapy pack.................................................................... 73 PREZISTA -darunavir ethanolate susp 100 mg/ml (base equiv)................................................................................10 PREZISTA -darunavir ethanolate tab 150 mg (base equiv)................................................................................10 PREZISTA -darunavir ethanolate tab 400 mg (base equiv)................................................................................10 PREZISTA -darunavir ethanolate tab 600 mg (base equiv)................................................................................10 PREZISTA -darunavir ethanolate tab 75 mg (base equiv)................................................................................10 PREZISTA -darunavir ethanolate tab 800 mg (base equiv)................................................................................10 PRIALT -ziconotide acetate intrathecal inj 100 mcg/ ml....................................................................................101 PRIALT -ziconotide acetate intrathecal inj 500 mcg/20ml (25 mcg/ml).................................................................... 101 PRIALT -ziconotide acetate intrathecal inj 500 mcg/5ml..........................................................................101 PRIFTIN -rifapentine tab 150 mg........................................ 6 PRIMAQUINE PHOSPHATE -primaquine phosphate tab 26.3 mg............................................................................ 12 primidone tab 250 mg (Mysoline).................................122 primidone tab 50 mg (Mysoline).................................. 122 PRIMLEV -oxycodone w/ acetaminophen tab 10-300 mg.................................................................................. 109 PRIMLEV -oxycodone w/ acetaminophen tab 5-300 mg.................................................................................. 109 PRIMLEV -oxycodone w/ acetaminophen tab 7.5-300 mg.................................................................................. 109 PRIMSOL -trimethoprim hcl oral soln 50 mg/5ml (base equiv)................................................................................13 PRINIVIL -lisinopril tab 10 mg........................................... 55 PRINIVIL -lisinopril tab 20 mg........................................... 55 PRINIVIL -lisinopril tab 5 mg............................................. 55 PRINZIDE -lisinopril & hydrochlorothiazide tab 10-12.5 mg.................................................................................... 55 PRINZIDE -lisinopril & hydrochlorothiazide tab 20-12.5 mg.................................................................................... 55 PRISTIQ -desvenlafaxine succinate tab sr 24hr 100 mg (base equiv)..................................................................... 86 PRISTIQ -desvenlafaxine succinate tab sr 24hr 50 mg (base equiv)..................................................................... 86 PROAIR HFA -albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv)......................................................... 69 probenecid tab 500 mg................................................. 116 PROCAINAMIDE HCL -procainamide hcl inj 100 mg/ ml......................................................................................49 PROCAINAMIDE HCL -procainamide hcl inj 500 mg/ ml......................................................................................49 PROCARDIA -nifedipine cap 10 mg..................................48 PRENAPLUS - prenatal vit w/ fe fumarate-fa tab 27-1 mg ....................................................................................... 130 PRENATABS FA - prenatal vit w/ fe fumarate-fa tab 29-1 mg ................................................................................. 130 PRENATABS RX - prenatal vit w/ iron carbonyl-fa tab 29-1 mg ................................................................................. 130 PRENATAL 19 - prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg ................................................................................. 130 PRENATAL 19 - prenatal vit w/ fe fumarate-fa chew tab 29-1 mg ........................................................................ 130 PRENATAL AD - prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg ........................................................................ 130 PRENATAL PLUS - prenatal vit w/ fe fumarate-fa tab 27-1 mg ................................................................................. 130 PRENATAL-U - prenatal w/o a vit w/ fe fumarate-fa cap 106.5-1 mg ................................................................... 130 PRENATAL VITAMINS PLUS - prenatal vit w/ fe fumaratefa tab 27-1 mg ..............................................................130 PRENTIF CAVITY-RIM CERVIC -cervical cap 22 mm................................................................................. 169 PRENTIF CAVITY-RIM CERVIC -cervical cap 25 mm................................................................................. 169 PRENTIF CAVITY-RIM CERVIC -cervical cap 28 mm................................................................................. 170 PRENTIF CAVITY-RIM CERVIC -cervical cap 31 mm................................................................................. 170 PRENTIF FITTING SET - cervical caps ......................... 170 PREPIDIL -dinoprostone cervical gel 0.5 mg/3gm.............39 PREPOPIK -sod picosulfate-mg oxide-citric acid pack 10 mg-3.5 gm-12 gm............................................................ 71 PRESERA - emollient - aerosol foam .............................160 PRESET 1ML LS SYR/PREFILL - arterial blood gas kit ....................................................................................... 168 PRESET 3ML LL SYR/PREFILL - arterial blood gas kit ....................................................................................... 168 PRESET 3ML SYR/PREFILLED - arterial blood gas kit ....................................................................................... 168 PRESET 3ML SYR/PREFILL LY - arterial blood gas kit ....................................................................................... 168 PREVIDENT 5000 BOOSTER PL -sodium fluoride paste 1.1%............................................................................... 147 PREVIDENT 5000 BOOSTER -sodium fluoride paste 1.1%............................................................................... 147 PREVIDENT 5000 DRY MOUTH -sodium fluoride gel 1.1% (0.5% f)................................................................. 147 PREVIDENT 5000 ENAMEL PRO -sodium fluoridepotassium nitrate paste 1.1-5%..................................... 147 PREVIDENT 5000 PLUS -sodium fluoride cream 1.1%............................................................................... 147 PREVIDENT 5000 SENSITIVE -sodium fluoride-potassium nitrate paste 1.1-5%.......................................................147 PREVIDENT FLUORIDE -sodium fluoride gel 1.1% (0.5% f)..................................................................................... 147 PREVIDENT -sodium fluoride rinse 0.2%........................147 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 241 2015 PROCARDIA XL -nifedipine tab sr 24hr osmotic 30 mg.................................................................................... 48 PROCARDIA XL -nifedipine tab sr 24hr osmotic 60 mg.................................................................................... 48 PROCARDIA XL -nifedipine tab sr 24hr osmotic 90 mg.................................................................................... 48 PROCENTRA -dextroamphetamine sulfate oral solution 5 mg/5ml..............................................................................96 prochlorperazine edisylate inj 5 mg/ml......................... 90 prochlorperazine maleate tab 10 mg (Compazine)....... 90 prochlorperazine maleate tab 5 mg (Compazine)......... 90 prochlorperazine suppos 25 mg.................................... 90 PROCORT -hydrocortisone acetate w/ pramoxine rectal cream 1.85-1.15%..........................................................148 PROCRIT -epoetin alfa inj 10000 unit/ml........................ 137 PROCRIT -epoetin alfa inj 20000 unit/ml........................ 137 PROCRIT -epoetin alfa inj 2000 unit/ml.......................... 137 PROCRIT -epoetin alfa inj 3000 unit/ml.......................... 137 PROCRIT -epoetin alfa inj 40000 unit/ml........................ 137 PROCRIT -epoetin alfa inj 4000 unit/ml.......................... 137 PROCTOCORT -hydrocortisone acetate suppos 30 mg.................................................................................. 148 PROCTOCORT -hydrocortisone rectal cream 1%...........148 PROCTOFOAM HC -hydrocortisone acetate w/ pramoxine rectal foam 1-1%............................................................148 PROCYSBI -cysteamine bitartrate cap delayed release 25 mg (base equiv)............................................................... 80 PROCYSBI -cysteamine bitartrate cap delayed release 75 mg (base equiv)............................................................... 80 PRODRIN -acetaminophen-isometheptene-caffeine tab 325-65-20 mg.................................................................115 PRODRIN -acetaminophen-isometheptene-caffeine tab 500-130-20 mg...............................................................115 PROFERRIN-FORTE -iron heme polypeptide-folic acid tab 12-1 mg (fe equiv)......................................................... 137 progesterone im in oil 50 mg/ml.................................... 31 progesterone micronized cap 100 mg (Prometrium)...................................................................31 progesterone micronized cap 200 mg (Prometrium)...................................................................31 PROGLYCEM -diazoxide susp 50 mg/ml.......................... 35 PROGRAF -tacrolimus cap 0.5 mg................................. 171 PROGRAF -tacrolimus cap 1 mg.................................... 172 PROGRAF -tacrolimus cap 5 mg.................................... 172 PROLENSA -bromfenac sodium ophth soln 0.07% (base equivalent)......................................................................144 PROLIA -denosumab inj 60 mg/ml....................................41 PROMACTA -eltrombopag olamine tab 12.5 mg (base equiv)..............................................................................137 PROMACTA -eltrombopag olamine tab 25 mg (base equiv)..............................................................................137 PROMACTA -eltrombopag olamine tab 50 mg (base equiv)..............................................................................137 PROMACTA -eltrombopag olamine tab 75 mg (base equiv)..............................................................................137 242 PROMAR -iron & b12 w/ vitamin cap.............................. 130 promethazine & phenylephrine syrup 6.25-5 mg/5ml.............................................................................66 promethazine-dm syrup 6.25-15 mg/5ml....................... 66 promethazine hcl inj 25 mg/ml (Phenergan)................. 63 promethazine hcl inj 50 mg/ml (Phenergan)................. 63 promethazine hcl suppos 12.5 mg.................................63 promethazine hcl suppos 25 mg....................................63 promethazine hcl suppos 50 mg....................................63 promethazine hcl syrup 6.25 mg/5ml.............................63 promethazine hcl tab 12.5 mg........................................ 63 promethazine hcl tab 25 mg........................................... 63 promethazine hcl tab 50 mg...........................................63 PROMETHAZINE VC/CODEINE -phenylephrinepromethazine w/ codeine syrup 5-6.25-10 mg/5ml.......... 66 PROMETHAZINE VC PLAIN -promethazine & phenylephrine syrup 6.25-5 mg/5ml.................................66 promethazine w/ codeine syrup 6.25-10 mg/5ml...........66 PROMETRIUM -progesterone micronized cap 100 mg..... 31 PROMETRIUM -progesterone micronized cap 200 mg..... 31 PROMISEB - antiseborrheic products misc - cream ....... 160 PROMISEB COMPLETE - antiseborrheic products misc kit .................................................................................. 160 propafenone hcl cap sr 12hr 225 mg (Rythmol sr)....... 49 propafenone hcl cap sr 12hr 325 mg (Rythmol sr)....... 49 propafenone hcl cap sr 12hr 425 mg (Rythmol sr)....... 49 propafenone hcl tab 150 mg (Rythmol)......................... 49 propafenone hcl tab 225 mg (Rythmol)......................... 49 propafenone hcl tab 300 mg.......................................... 49 PROPANTHELINE BROMIDE -propantheline bromide tab 15 mg............................................................................... 73 proparacaine hcl ophth soln 0.5% (Alcaine)............... 144 PROPRANOLOL/HYDROCHLOROTH -propranolol & hydrochlorothiazide tab 40-25 mg................................... 55 PROPRANOLOL/HYDROCHLOROTH -propranolol & hydrochlorothiazide tab 80-25 mg................................... 55 propranolol hcl cap sr 24hr 120 mg (Inderal la)............45 propranolol hcl cap sr 24hr 160 mg (Inderal la)............45 propranolol hcl cap sr 24hr 60 mg (Inderal la)..............45 propranolol hcl cap sr 24hr 80 mg (Inderal la)..............45 PROPRANOLOL HCL -propranolol hcl oral soln 20 mg/5ml..............................................................................45 PROPRANOLOL HCL -propranolol hcl oral soln 40 mg/5ml..............................................................................45 propranolol hcl tab 10 mg.............................................. 45 propranolol hcl tab 20 mg.............................................. 45 propranolol hcl tab 40 mg.............................................. 45 propranolol hcl tab 60 mg.............................................. 45 propranolol hcl tab 80 mg.............................................. 45 propylthiouracil tab 50 mg............................................. 37 PROQUAD -measles-mumps-rubella-varicella virus vaccines for inj................................................................. 16 PROSCAR -finasteride tab 5 mg.......................................80 PROSED/DS -methenamine-hyosc-meth blue-benz acidphenyl sal tab 81.6mg..................................................... 77 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 PUREFE PLUS - ferrous fumarate-fa-b complex-c-zn-mgmn-cu cap 106-1 mg .................................................... 137 PURINETHOL -mercaptopurine tab 50 mg....................... 21 PURIXAN -mercaptopurine susp 2000 mg/100ml (20 mg/ ml).................................................................................... 21 PYLERA -bismuth subcit-metronidazole-tetracycline cap 140-125-125 mg...............................................................73 pyrazinamide tab 500 mg..................................................6 PYRIDIUM -phenazopyridine hcl tab 100 mg.................... 80 PYRIDIUM -phenazopyridine hcl tab 200 mg.................... 80 pyridostigmine bromide tab 60 mg (Mestinon)........... 128 PYRIDOXINE HCL -pyridoxine hcl inj 100 mg/ml............ 129 PYROGALLIC ACID -pyrogallol-chlorobutanol oint 25-2%............................................................................. 160 PROSTIGMIN -neostigmine bromide tab 15 mg............. 128 PROSTIGMIN -neostigmine methylsulfate inj 0.5 mg/ml (1:2000).......................................................................... 128 PROSTIN E2 -dinoprostone vaginal suppos 20 mg...........39 PROSTIN VR PEDIATRIC -alprostadil inj 500 mcg/ ml....................................................................................172 PROTECTBONE -multiple vit w/ min & calcium-folic acid wafer 500-1 mg..............................................................130 PROTECT CARDIO - speciality vitamin product cap ......130 PROTECTIRON -iron polysacch-fa-b complex-vit c-e & minerals tab 60-1 mg.....................................................137 PROTECT PLUS - multiple vitamins w/ minerals cap .....130 PROTECT PLUS - multiple vitamins w/ minerals liquid ....................................................................................... 130 PROTECT PLUS NR - multiple vitamins w/ minerals cap ....................................................................................... 130 PROTHELIAL - sucralfate-malate paste 10% .................147 PROTONIX -pantoprazole sodium for delayed release susp packet 40 mg.......................................................... 73 PROTOPIC -tacrolimus oint 0.03%................................. 160 PROTOPIC -tacrolimus oint 0.1%................................... 160 protriptyline hcl tab 10 mg (Vivactil)............................. 86 protriptyline hcl tab 5 mg (Vivactil)............................... 86 PROVENTIL HFA -albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv)......................................................... 69 PROVERA -medroxyprogesterone acetate tab 10 mg...... 31 PROVERA -medroxyprogesterone acetate tab 2.5 mg......31 PROVERA -medroxyprogesterone acetate tab 5 mg........ 31 PROVIGIL -modafinil tab 100 mg......................................96 PROVIGIL -modafinil tab 200 mg......................................96 PROVISC -sodium hyaluronate intraocular inj 10 mg/ ml....................................................................................144 PROZAC -fluoxetine hcl cap 10 mg.................................. 86 PROZAC -fluoxetine hcl cap 20 mg.................................. 86 PROZAC -fluoxetine hcl cap 40 mg.................................. 86 PROZAC WEEKLY -fluoxetine hcl cap delayed release 90 mg.................................................................................... 86 PRUCLAIR - emollient - cream ...................................... 160 PRUDOXIN -doxepin hcl cream 5%................................ 160 PRUMYX - emollient - cream ......................................... 160 PRUTECT - wound dressings - emulsion .......................160 pseudoeph-chlorphen w/ hydrocodone soln 60-4-5 mg/5ml (Zutripro)........................................................... 66 pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml.....66 PULMICORT -budesonide inhalation susp 0.25 mg/2ml..............................................................................69 PULMICORT -budesonide inhalation susp 0.5 mg/2ml..... 69 PULMICORT -budesonide inhalation susp 1 mg/2ml........ 69 PULMICORT FLEXHALER -budesonide inhal aero powd 180 mcg/act (breath activated)........................................ 69 PULMICORT FLEXHALER -budesonide inhal aero powd 90 mcg/act (breath activated).......................................... 69 PULMOPHYLLINE -theophylline tab 50 mg & dietary management cap pack.................................................... 69 PULMOZYME -dornase alfa inhal soln 1 mg/ml................ 70 Q Q-CARE Q2 ORAL CLEANSING/ - oral hygiene products kit .................................................................................. 170 Q-CARE Q4 ORAL CLEANSING/ - oral hygiene products kit .................................................................................. 170 QROXIN -capsaicin-menthol topical patch 0.0375-5%...................................................................... 160 QUALAQUIN -quinine sulfate cap 324 mg........................ 12 QUARTETTE -levonor-eth est tab 0.15-0.02/0.025/0.03 mg ð est 0.01 mg....................................................... 31 QUAZEPAM -quazepam tab 15 mg.................................. 92 QUDEXY XR -topiramate cap er 24hr sprinkle 100 mg.................................................................................. 122 QUDEXY XR -topiramate cap er 24hr sprinkle 150 mg.................................................................................. 122 QUDEXY XR -topiramate cap er 24hr sprinkle 200 mg.................................................................................. 122 QUDEXY XR -topiramate cap er 24hr sprinkle 25 mg..... 122 QUDEXY XR -topiramate cap er 24hr sprinkle 50 mg..... 122 QUELICIN 1000 -succinylcholine chloride inj 100 mg/ ml....................................................................................126 QUELICIN -succinylcholine chloride inj 20 mg/ml............126 QUESTRAN -cholestyramine powder 4 gm/dose.............. 61 QUESTRAN -cholestyramine powder packets 4 gm......... 61 QUESTRAN LIGHT -cholestyramine light powder 4 gm/ dose..................................................................................61 QUESTRAN LIGHT -cholestyramine light powder packets 4 gm................................................................................. 61 quetiapine fumarate tab 100 mg (Seroquel).................. 90 quetiapine fumarate tab 200 mg (Seroquel).................. 90 quetiapine fumarate tab 25 mg (Seroquel).................... 90 quetiapine fumarate tab 300 mg (Seroquel).................. 90 quetiapine fumarate tab 400 mg (Seroquel).................. 90 quetiapine fumarate tab 50 mg (Seroquel).................... 90 QUFLORA PEDIATRIC - pediatric multiple vitamins w/ fluoride chew tab 0.25 mg ............................................ 131 QUFLORA PEDIATRIC - pediatric multiple vitamins w/ fluoride chew tab 0.5 mg .............................................. 131 QUFLORA PEDIATRIC - pediatric multiple vitamins w/ fluoride chew tab 1 mg ................................................. 131 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 243 2015 QUFLORA PEDIATRIC - pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml ............................................... 131 QUFLORA PEDIATRIC - pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml ................................................. 131 QUILLIVANT XR -methylphenidate hcl for er susp 25 mg/5ml (5 mg/ml).............................................................96 quinapril hcl tab 10 mg (Accupril)................................. 55 quinapril hcl tab 20 mg (Accupril)................................. 55 quinapril hcl tab 40 mg (Accupril)................................. 55 quinapril hcl tab 5 mg (Accupril)................................... 55 quinapril-hydrochlorothiazide tab 10-12.5 mg (Accuretic).......................................................................55 quinapril-hydrochlorothiazide tab 20-12.5 mg (Accuretic).......................................................................55 quinapril-hydrochlorothiazide tab 20-25 mg (Accuretic).......................................................................55 QUINIDINE GLUCONATE -quinidine gluconate inj 80 mg/ ml......................................................................................49 quinidine gluconate tab cr 324 mg................................ 49 QUINIDINE SULFATE ER -quinidine sulfate tab cr 300 mg.................................................................................... 49 QUINIDINE SULFATE -quinidine sulfate tab 200 mg........ 49 quinidine sulfate tab 200 mg.......................................... 49 quinidine sulfate tab 300 mg.......................................... 49 quinine sulfate cap 324 mg (Qualaquin)........................12 QUINZYME -coenzyme q10 tab disp 90 mg................... 168 QUTENZA -capsaicin patch 8% & cleansing gel kit.........160 QVAR -beclomethasone dipropionate inhal aero soln 40 mcg/act.............................................................................69 QVAR -beclomethasone dipropionate inhal aero soln 80 mcg/act.............................................................................69 R RABAVERT -rabies vaccine, pcec for inj...........................16 rabeprazole sodium ec tab 20 mg (Aciphex).................73 RADIAGEL - wound dressings - gel ...............................160 RADIAPLEXRX - wound dressings - gel ........................ 160 RADIGEL - dermatological products misc - gel .............. 160 RADIOGARDASE -prussian blue insoluble cap 0.5 gm.................................................................................. 167 RAGWITEK -short ragweed pollen allergen extract tab sl 12 amb a 1-u................................................................... 18 raloxifene hcl tab 60 mg (Evista)................................... 41 ramipril cap 1.25 mg (Altace)......................................... 55 ramipril cap 10 mg (Altace)............................................ 55 ramipril cap 2.5 mg (Altace)........................................... 55 ramipril cap 5 mg (Altace).............................................. 55 RANEXA -ranolazine tab sr 12hr 1000 mg........................44 RANEXA -ranolazine tab sr 12hr 500 mg..........................44 ranitidine hcl cap 150 mg............................................... 73 ranitidine hcl cap 300 mg............................................... 73 ranitidine hcl inj 1000 mg/40ml (25 mg/ml) (Zantac)..... 73 ranitidine hcl inj 150 mg/6ml (25 mg/ml) (Zantac).........73 ranitidine hcl inj 50 mg/2ml (25 mg/ml) (Zantac)...........73 ranitidine hcl syrup 15 mg/ml (75 mg/5ml)....................73 ranitidine hcl tab 150 mg (Zantac)................................. 73 244 ranitidine hcl tab 300 mg (Zantac)................................. 73 RAPAFLO -silodosin cap 4 mg......................................... 80 RAPAFLO -silodosin cap 8 mg......................................... 80 RAPAMUNE -sirolimus oral soln 1 mg/ml....................... 172 RAPAMUNE -sirolimus tab 0.5 mg..................................172 RAPAMUNE -sirolimus tab 1 mg.....................................172 RAPAMUNE -sirolimus tab 2 mg.....................................172 RAPPORT RING LOADING SYST - impotence aid device - kit ................................................................................170 RAPPORT VACUUM THERAPY DE - impotence aid device - kit .................................................................... 170 RASUVO -methotrexate soln pf auto-injector 10 mg/0.2ml.........................................................................114 RASUVO -methotrexate soln pf auto-injector 12.5 mg/0.25ml.......................................................................114 RASUVO -methotrexate soln pf auto-injector 15 mg/0.3ml.........................................................................114 RASUVO -methotrexate soln pf auto-injector 17.5 mg/0.35ml.......................................................................114 RASUVO -methotrexate soln pf auto-injector 20 mg/0.4ml.........................................................................114 RASUVO -methotrexate soln pf auto-injector 22.5 mg/0.45ml.......................................................................114 RASUVO -methotrexate soln pf auto-injector 25 mg/0.5ml.........................................................................114 RASUVO -methotrexate soln pf auto-injector 27.5 mg/0.55ml.......................................................................114 RASUVO -methotrexate soln pf auto-injector 30 mg/0.6ml.........................................................................114 RASUVO -methotrexate soln pf auto-injector 7.5 mg/0.15ml.......................................................................114 RAVICTI -glycerol phenylbutyrate liquid 1.1 gm/ml........... 41 RAYOS -prednisone tab delayed release 1 mg.................25 RAYOS -prednisone tab delayed release 2 mg.................25 RAYOS -prednisone tab delayed release 5 mg.................25 RAZADYNE ER -galantamine hydrobromide cap sr 24hr 16 mg............................................................................... 99 RAZADYNE ER -galantamine hydrobromide cap sr 24hr 24 mg............................................................................... 99 RAZADYNE ER -galantamine hydrobromide cap sr 24hr 8 mg.................................................................................... 99 RAZADYNE -galantamine hydrobromide oral soln 4 mg/ ml......................................................................................99 RAZADYNE -galantamine hydrobromide tab 12 mg..........99 RAZADYNE -galantamine hydrobromide tab 4 mg............99 RAZADYNE -galantamine hydrobromide tab 8 mg............99 REBETOL -ribavirin cap 200 mg....................................... 10 REBETOL -ribavirin soln 40 mg/ml................................... 10 REBIF -interferon beta-1a inj 22 mcg/0.5ml (12mu/ml) (44 mcg/ml).............................................................................99 REBIF -interferon beta-1a inj 44 mcg/0.5ml (24mu/ml) (88 mcg/ml).............................................................................99 REBIF REBIDOSE -interferon beta-1a inj 22 mcg/0.5ml (12mu/ml) (44 mcg/ml).....................................................99 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 REMERON SOLTAB -mirtazapine orally disintegrating tab 45 mg............................................................................... 86 REMESENSE - dental desensitizing product - misc ....... 170 REMODULIN -treprostinil sodium inj 10 mg/ml (base equiv)................................................................................62 REMODULIN -treprostinil sodium inj 1 mg/ml (base equiv)................................................................................62 REMODULIN -treprostinil sodium inj 2.5 mg/ml (base equiv)................................................................................62 REMODULIN -treprostinil sodium inj 5 mg/ml (base equiv)................................................................................62 RENACIDIN -citric acid & d-gluconic acid soln..................80 RENAGEL -sevelamer hcl tab 400 mg..............................76 RENAGEL -sevelamer hcl tab 800 mg..............................77 RENASTART - nutritional supplement pack ................... 134 RENATABS -b-complex w/ c-biotin-vit e & folic acid tab 1 mg.................................................................................. 131 RENATABS WITH IRON -b complex-c-biotin-e-fa tab 1mg & fe cbn tab 100 mg pack............................................. 131 RENAX -multiple vitamins w/ minerals & fa tab 2.5 mg.................................................................................. 131 RENOVO -capsaicin-menthol topical patch 0.0375-5%...................................................................... 161 RENVELA -sevelamer carbonate packet 0.8 gm...............77 RENVELA -sevelamer carbonate packet 2.4 gm...............77 RENVELA -sevelamer carbonate tab 800 mg................... 77 repaglinide tab 0.5 mg (Prandin)....................................35 repaglinide tab 1 mg (Prandin).......................................35 repaglinide tab 2 mg (Prandin).......................................35 REPREXAIN -hydrocodone-ibuprofen tab 2.5-200 mg.................................................................................. 109 REPREXAIN -hydrocodone-ibuprofen tab 5-200 mg....... 109 REQ 49+ - multiple vitamins w/ minerals tab ..................131 REQUIP -ropinirole hydrochloride tab 0.25 mg............... 125 REQUIP -ropinirole hydrochloride tab 0.5 mg................. 125 REQUIP -ropinirole hydrochloride tab 1 mg.................... 125 REQUIP -ropinirole hydrochloride tab 2 mg.................... 125 REQUIP -ropinirole hydrochloride tab 3 mg.................... 125 REQUIP -ropinirole hydrochloride tab 4 mg.................... 125 REQUIP -ropinirole hydrochloride tab 5 mg.................... 125 REQUIP XL -ropinirole hydrochloride tab sr 24hr 12 mg (base equivalent)........................................................... 125 REQUIP XL -ropinirole hydrochloride tab sr 24hr 2 mg (base equivalent)........................................................... 125 REQUIP XL -ropinirole hydrochloride tab sr 24hr 4 mg (base equivalent)........................................................... 125 REQUIP XL -ropinirole hydrochloride tab sr 24hr 6 mg (base equivalent)........................................................... 125 REQUIP XL -ropinirole hydrochloride tab sr 24hr 8 mg (base equivalent)........................................................... 125 RESCON-JR -chlorpheniramine & phenylephrine tab sr 12hr 4-20 mg................................................................... 66 RESCON-JR -dexchlorpheniramine-phenylephrine tab sr 12hr 3-20 mg................................................................... 66 REBIF REBIDOSE -interferon beta-1a inj 44 mcg/0.5ml (24mu/ml) (88 mcg/ml).....................................................99 REBIF REBIDOSE TITRATION -interferon beta-1a inj 6 x 8.8 mcg/0.2ml & 6 x 22 mcg/0.5ml.................................. 99 REBIF TITRATION PACK -interferon beta-1a inj 6 x 8.8 mcg/0.2ml & 6 x 22 mcg/0.5ml........................................ 99 RECIPHEXAMINE -lidocaine-menthol patch 4-1%..........160 RECOMBIVAX HB -hepatitis b vaccine (recombinant) susp 10 mcg/ml........................................................................ 16 RECOMBIVAX HB -hepatitis b vaccine (recombinant) susp 40 mcg/ml........................................................................ 16 RECOMBIVAX HB -hepatitis b vaccine (recombinant) susp 5 mcg/0.5ml..................................................................... 16 RECOTHROM SPRAY KIT -thrombin (recombinant) for soln 20000 unit.............................................................. 140 RECOTHROM -thrombin (recombinant) for soln 20000 unit..................................................................................140 RECOTHROM -thrombin (recombinant) for soln 5000 unit..................................................................................140 RECTIV -nitroglycerin oint 0.4%......................................148 REGENECARE -lidocaine hcl-collagen-aloe vera gel 2%.................................................................................. 161 REGLAN -metoclopramide hcl tab 10 mg......................... 76 REGLAN -metoclopramide hcl tab 5 mg........................... 76 REGONOL -pyridostigmine bromide inj 5 mg/ml............. 128 REGRANEX -becaplermin gel 0.01%..............................161 RELAGARD -acetic acid-oxyquinoline vaginal gel 0.9-0.025%....................................................................... 79 RELAGESIC -phenyltoloxamine-acetaminophen tab 50-650 mg......................................................................101 RELAMINE - glucosamine-chondroitin-paba-vit e-alpha lipoic acid tab ................................................................168 RELENZA DISKHALER -zanamivir aero powder breath activated 5 mg/blister.......................................................10 RELHIST -bromphen tan-phenyleph tan chew tab 6-15 mg.................................................................................... 66 RELION R -insulin regular (human) inj 100 unit/ml............36 RELISTOR -methylnaltrexone bromide inj 12 mg/0.6ml (20 mg/ml).............................................................................. 76 RELISTOR -methylnaltrexone bromide inj 8 mg/0.4ml (20 mg/ml).............................................................................. 76 RELISTOR -methylnaltrexone bromide inj kit 12 mg/0.6ml...........................................................................76 RELPAX -eletriptan hydrobromide tab 20 mg (base equivalent)......................................................................115 RELPAX -eletriptan hydrobromide tab 40 mg (base equivalent)......................................................................116 RELYYKS -lidocaine-menthol patch 4-5%.......................161 REMERON -mirtazapine tab 15 mg.................................. 86 REMERON -mirtazapine tab 30 mg.................................. 86 REMERON -mirtazapine tab 45 mg.................................. 86 REMERON SOLTAB -mirtazapine orally disintegrating tab 15 mg............................................................................... 86 REMERON SOLTAB -mirtazapine orally disintegrating tab 30 mg............................................................................... 86 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 245 2015 RESCON-MX -dexchlorpheniramine-phenylephrine tab sr 12hr 6-40 mg................................................................... 66 RESCRIPTOR -delavirdine mesylate tab 100 mg............. 10 RESCRIPTOR -delavirdine mesylate tab 200 mg............. 10 RESCULA -unoprostone isopropyl ophth soln 0.15%......144 RESERPINE -reserpine tab 0.1 mg.................................. 55 RESERPINE -reserpine tab 0.25 mg.................................55 RESPA-BR -brompheniramine maleate tab sr 12hr 11 mg.................................................................................... 63 RESTASIS -cyclosporine (ophth) emulsion 0.05%.......... 144 RESTORA RX -lactobacillus casei-folic acid cap 60-1.25 mg.................................................................................... 71 RESTORE SILVER DRESSING 2 - wound dressings pads .............................................................................. 161 RESTORE SILVER DRESSING 4 - wound dressings pads .............................................................................. 161 RESTORE SILVER DRESSING 6 - wound dressings pads .............................................................................. 161 RESTORIL -temazepam cap 15 mg..................................92 RESTORIL -temazepam cap 22.5 mg...............................92 RESTORIL -temazepam cap 30 mg..................................92 RESTORIL -temazepam cap 7.5 mg.................................92 RETIN-A MICRO PUMP -tretinoin microsphere gel 0.04%............................................................................. 161 RETIN-A MICRO PUMP -tretinoin microsphere gel 0.08%............................................................................. 161 RETIN-A MICRO PUMP -tretinoin microsphere gel 0.1%............................................................................... 161 RETIN-A MICRO -tretinoin microsphere gel 0.04%.........161 RETIN-A MICRO -tretinoin microsphere gel 0.1%...........161 RETIN-A -tretinoin cream 0.025%................................... 161 RETIN-A -tretinoin cream 0.05%..................................... 161 RETIN-A -tretinoin cream 0.1%....................................... 161 RETIN-A -tretinoin gel 0.01%.......................................... 161 RETIN-A -tretinoin gel 0.025%........................................ 161 RETISERT -fluocinolone acetonide intravitreal implant 0.59 mg.......................................................................... 144 RETROVIR -zidovudine cap 100 mg.................................10 RETROVIR -zidovudine syrup 10 mg/ml........................... 10 REVATIO -sildenafil citrate for suspension 10 mg/ml........ 62 REVATIO -sildenafil citrate tab 20 mg...............................62 REVIA -naltrexone hcl tab 50 mg....................................167 REVLIMID -lenalidomide cap 10 mg............................... 172 REVLIMID -lenalidomide cap 15 mg............................... 172 REVLIMID -lenalidomide cap 20 mg............................... 172 REVLIMID -lenalidomide cap 25 mg............................... 172 REVLIMID -lenalidomide cap 5 mg................................. 172 REVLIMID -lenalidomide caps 2.5 mg.............................172 REXAPHENAC -diclofenac sodium cream 1%................ 161 REYATAZ -atazanavir sulfate cap 100 mg (base equiv)................................................................................10 REYATAZ -atazanavir sulfate cap 150 mg (base equiv)................................................................................10 REYATAZ -atazanavir sulfate cap 200 mg (base equiv)................................................................................10 246 REYATAZ -atazanavir sulfate cap 300 mg (base equiv)................................................................................10 REZIRA -pseudoephedrine w/ hydrocodone soln 60-5 mg/5ml..............................................................................66 REZYST IM - probiotic product - chew tab .......................71 REZYST SB -saccharomyces boulardii chew tab 250 mg.................................................................................... 71 RHEUMATREX -methotrexate sodium tab 2.5 mg (antirheumatic)............................................................... 114 RHINOFLEX-650 -phenyltoloxamine-acetaminophen tab 50-650 mg......................................................................101 RHOGAM ULTRA-FILTERED PLU -rho d immune globulin (human) im inj 300 mcg...................................................17 RHOPHYLAC -rho d immune globulin (human) inj 1500 unt/2ml (300 mcg/2ml)..................................................... 17 RIAX -benzoyl peroxide foam 5.5%................................ 161 RIAX -benzoyl peroxide foam 9.5%................................ 161 RIBASPHERE RIBAPAK -ribavirin tab 200 mg & ribavirin tab 400 mg dose pack..................................................... 10 RIBASPHERE RIBAPAK -ribavirin tab 400 mg................. 10 RIBASPHERE RIBAPAK -ribavirin tab 400 mg & ribavirin tab 600 mg dose pack.....................................................10 RIBASPHERE RIBAPAK -ribavirin tab 600 mg................. 10 RIBASPHERE -ribavirin tab 400 mg................................. 10 RIBASPHERE -ribavirin tab 600 mg................................. 10 RIBATAB -ribavirin tab 400 mg......................................... 10 RIBATAB -ribavirin tab 400 mg & ribavirin tab 600 mg dose pack.........................................................................10 RIBATAB -ribavirin tab 600 mg......................................... 10 ribavirin cap 200 mg (Rebetol)....................................... 10 ribavirin tab 200 mg (Copegus)......................................10 RIDAURA -auranofin cap 3 mg....................................... 114 rifabutin cap 150 mg (Mycobutin).................................... 6 RIFADIN -rifampin cap 150 mg........................................... 6 RIFADIN -rifampin cap 300 mg........................................... 6 RIFAMATE -isoniazid & rifampin cap 150-300 mg.............. 6 rifampin cap 150 mg (Rifadin).......................................... 6 rifampin cap 300 mg (Rifadin).......................................... 6 RIFATER -isoniazid-rifampin w/ pyrazinamide tab 50-120-300 mg...................................................................7 RILUTEK -riluzole tab 50 mg.......................................... 126 riluzole tab 50 mg (Rilutek).......................................... 126 rimantadine hydrochloride tab 100 mg (Flumadine).....10 RIMANTALIST -rimantadine tab 100 mg & dietary management cap pack.................................................... 10 RIMSO-50 -dimethyl sulfoxide soln 50%........................... 80 ringer's solution for irrigation...................................... 172 RIOMET -metformin hcl oral soln 500 mg/5ml.................. 35 risedronate sodium tab 150 mg (Actonel)..................... 41 RISPERDAL CONSTA -risperidone microspheres for inj 12.5 mg............................................................................ 90 RISPERDAL CONSTA -risperidone microspheres for inj 25 mg.................................................................................... 90 RISPERDAL CONSTA -risperidone microspheres for inj 37.5 mg............................................................................ 90 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 ROBAXIN-750 -methocarbamol tab 750 mg................... 128 ROBAXIN -methocarbamol inj 100 mg/ml....................... 127 ROBAXIN -methocarbamol tab 500 mg.......................... 127 ROBINUL FORTE -glycopyrrolate tab 2 mg......................73 ROBINUL -glycopyrrolate inj 0.2 mg/ml.............................73 ROBINUL -glycopyrrolate inj 0.4 mg/2ml (0.2 mg/ml)........73 ROBINUL -glycopyrrolate inj 1 mg/5ml (0.2 mg/ml)...........73 ROBINUL -glycopyrrolate inj 4 mg/20ml (0.2 mg/ml).........73 ROBINUL -glycopyrrolate tab 1 mg...................................73 ROCALTROL -calcitriol cap 0.25 mcg...............................41 ROCALTROL -calcitriol cap 0.5 mcg.................................42 ROCALTROL -calcitriol oral soln 1 mcg/ml....................... 42 ROCEPHIN -ceftriaxone sodium for inj 1 gm...................... 3 ROCEPHIN -ceftriaxone sodium for inj 500 mg.................. 3 ropinirole hydrochloride tab 0.25 mg (Requip)........... 125 ropinirole hydrochloride tab 0.5 mg (Requip)............. 126 ropinirole hydrochloride tab 1 mg (Requip)................126 ropinirole hydrochloride tab 2 mg (Requip)................126 ropinirole hydrochloride tab 3 mg (Requip)................126 ropinirole hydrochloride tab 4 mg (Requip)................126 ropinirole hydrochloride tab 5 mg (Requip)................126 ropinirole hydrochloride tab sr 24hr 12 mg (base equivalent) (Requip xl)................................................ 125 ropinirole hydrochloride tab sr 24hr 2 mg (base equivalent) (Requip xl)................................................ 125 ropinirole hydrochloride tab sr 24hr 4 mg (base equivalent) (Requip xl)................................................ 125 ropinirole hydrochloride tab sr 24hr 6 mg (base equivalent) (Requip xl)................................................ 125 ropinirole hydrochloride tab sr 24hr 8 mg (base equivalent) (Requip xl)................................................ 125 ropivacaine hcl inj 10 mg/ml (Naropin)........................118 ropivacaine hcl inj 2 mg/ml (Naropin)..........................118 ropivacaine hcl inj 5 mg/ml (Naropin)..........................118 ropivacaine hcl inj 7.5 mg/ml (Naropin).......................118 ROSADAN KIT -metronidazole cream 0.75% w/ cleanser kit....................................................................................161 ROSADAN KIT -metronidazole gel 0.75% w/ cleanser kit....................................................................................161 ROSANIL -sulfacetamide sod-sulfur emul 10-5% & skin cleanser kit.....................................................................161 ROTARIX -rotavirus vaccine, live for oral susp................. 16 ROTATEQ -rotavirus vaccine, live oral pentavalent soln...................................................................................16 ROWASA -mesalamine rectal enema 4 gm & cleanser wipe kit............................................................................. 77 ROXICET -oxycodone w/ acetaminophen soln 5-325 mg/5ml............................................................................109 ROXICODONE -oxycodone hcl tab 15 mg......................109 ROXICODONE -oxycodone hcl tab 30 mg......................109 ROXICODONE -oxycodone hcl tab 5 mg........................109 ROZEREM -ramelteon tab 8 mg....................................... 92 RTD WOUND CARE DRESSING - wound dressings pads .............................................................................. 161 RISPERDAL CONSTA -risperidone microspheres for inj 50 mg.................................................................................... 90 RISPERDAL M-TAB -risperidone orally disintegrating tab 0.5 mg.............................................................................. 90 RISPERDAL M-TAB -risperidone orally disintegrating tab 1 mg.................................................................................... 90 RISPERDAL M-TAB -risperidone orally disintegrating tab 2 mg.................................................................................... 90 RISPERDAL M-TAB -risperidone orally disintegrating tab 3 mg.................................................................................... 90 RISPERDAL M-TAB -risperidone orally disintegrating tab 4 mg.................................................................................... 90 RISPERDAL -risperidone soln 1 mg/ml.............................90 RISPERDAL -risperidone tab 0.25 mg.............................. 90 RISPERDAL -risperidone tab 0.5 mg................................ 90 RISPERDAL -risperidone tab 1 mg................................... 90 RISPERDAL -risperidone tab 2 mg................................... 90 RISPERDAL -risperidone tab 3 mg................................... 90 RISPERDAL -risperidone tab 4 mg................................... 90 risperidone orally disintegrating tab 0.25 mg............... 90 risperidone orally disintegrating tab 0.5 mg (Risperdal m-tab).............................................................................. 90 risperidone orally disintegrating tab 1 mg (Risperdal m-tab).............................................................................. 90 risperidone orally disintegrating tab 2 mg (Risperdal m-tab).............................................................................. 90 risperidone orally disintegrating tab 3 mg (Risperdal m-tab).............................................................................. 90 risperidone orally disintegrating tab 4 mg (Risperdal m-tab).............................................................................. 90 risperidone soln 1 mg/ml (Risperdal)............................ 90 risperidone tab 0.25 mg (Risperdal).............................. 90 risperidone tab 0.5 mg (Risperdal)................................ 90 risperidone tab 1 mg (Risperdal)................................... 90 risperidone tab 2 mg (Risperdal)................................... 90 risperidone tab 3 mg (Risperdal)................................... 91 risperidone tab 4 mg (Risperdal)................................... 91 RITALIN LA -methylphenidate hcl cap sr 24hr 10 mg........96 RITALIN LA -methylphenidate hcl cap sr 24hr 20 mg........96 RITALIN LA -methylphenidate hcl cap sr 24hr 30 mg........96 RITALIN LA -methylphenidate hcl cap sr 24hr 40 mg........96 RITALIN -methylphenidate hcl tab 10 mg..........................96 RITALIN -methylphenidate hcl tab 20 mg..........................96 RITALIN -methylphenidate hcl tab 5 mg........................... 96 RITALIN SR -methylphenidate hcl tab cr 20 mg................96 rivastigmine tartrate cap 1.5 mg (Exelon)..................... 99 rivastigmine tartrate cap 3 mg (Exelon)........................ 99 rivastigmine tartrate cap 4.5 mg (Exelon)..................... 99 rivastigmine tartrate cap 6 mg (Exelon)........................ 99 rizatriptan benzoate orally disintegrating tab 10 mg (Maxalt-mlt)................................................................... 116 rizatriptan benzoate orally disintegrating tab 5 mg (Maxalt-mlt)................................................................... 116 rizatriptan benzoate tab 10 mg (Maxalt)...................... 116 rizatriptan benzoate tab 5 mg (Maxalt)........................ 116 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 247 2015 RYBIX ODT -tramadol hcl orally disintegrating tab 50 mg.................................................................................. 109 RYTHMOL -propafenone hcl tab 150 mg.......................... 49 RYTHMOL -propafenone hcl tab 225 mg.......................... 49 RYTHMOL SR -propafenone hcl cap sr 12hr 225 mg....... 49 RYTHMOL SR -propafenone hcl cap sr 12hr 325 mg....... 49 RYTHMOL SR -propafenone hcl cap sr 12hr 425 mg....... 49 S SABRIL -vigabatrin powd pack 500 mg...........................122 SABRIL -vigabatrin tab 500 mg.......................................122 SACCHARIN SODIUM -sodium saccharin powder......... 134 SAFYRAL -drospirenone-ethinyl estrad-levomefolate tab 3-0.03-0.451 mg...............................................................31 SAIZEN CLICK.EASY -somatropin (non-refrigerated) for inj 8.8 mg......................................................................... 42 SAIZEN -somatropin (non-refrigerated) for inj 5 mg.......... 42 SAIZEN -somatropin (non-refrigerated) for inj 8.8 mg....... 42 SALAGEN -pilocarpine hcl tab 5 mg............................... 147 SALAGEN -pilocarpine hcl tab 7.5 mg............................ 147 SALEX CREAM -salicylic acid cream 6% & cleanser liqd kit....................................................................................161 SALEX LOTION -salicylic acid lotion 6% & cleanser liqd kit....................................................................................161 SALEX -salicylic acid shampoo 6%.................................161 SALICEPT - oral wound care products - for susp rinse ....................................................................................... 147 salicylic acid cream 6%................................................ 161 salicylic acid cream 6% & cleanser liqd kit (Salex cream)............................................................................148 salicylic acid film forming liquid 27.5% (Virasal)........ 161 salicylic acid foam 6% (Salvax)....................................161 salicylic acid gel 6% (Keralyt)...................................... 161 SALICYLIC ACID IN AMMONIU -salicylic acid in ammonium lactate vehicle foam 6%.............................. 161 salicylic acid lotion 6%................................................. 161 salicylic acid lotion 6% & cleanser liqd kit (Salex lotion)............................................................................ 148 SALICYLIC ACID -salicylic acid soln 26%.......................161 salicylic acid shampoo 6% (Salex).............................. 161 SALKERA -salicylic acid in ammonium lactate vehicle foam 6%.........................................................................161 salsalate tab 500 mg..................................................... 101 salsalate tab 750 mg..................................................... 101 SALVAX DUO PLUS -salicylic acid foam 6% & urea in lactic acid foam 35% kit.................................................161 SALVAX -salicylic acid foam 6%..................................... 161 SAMSCA -tolvaptan tab 15 mg......................................... 42 SAMSCA -tolvaptan tab 30 mg......................................... 42 SANARE SCAR THERAPY - scar treatment products cream ............................................................................ 161 SANCTURA -trospium chloride tab 20 mg........................ 78 SANCTURA XR -trospium chloride cap sr 24hr 60 mg......78 SANCUSO -granisetron td patch 3.1 mg/24hr (contains 34.3 mg)...........................................................................74 SANDIMMUNE -cyclosporine cap 100 mg...................... 172 248 SANDIMMUNE -cyclosporine cap 25 mg........................ 172 SANDIMMUNE -cyclosporine oral soln 100 mg/ml..........172 SANDOSTATIN LAR DEPOT -octreotide acetate for im inj kit 10 mg.......................................................................... 42 SANDOSTATIN LAR DEPOT -octreotide acetate for im inj kit 20 mg.......................................................................... 42 SANDOSTATIN LAR DEPOT -octreotide acetate for im inj kit 30 mg.......................................................................... 42 SANDOSTATIN -octreotide acetate inj 1000 mcg/ml (1 mg/ ml).................................................................................... 42 SANDOSTATIN -octreotide acetate inj 100 mcg/ml (0.1 mg/ml).............................................................................. 42 SANDOSTATIN -octreotide acetate inj 200 mcg/ml (0.2 mg/ml).............................................................................. 42 SANDOSTATIN -octreotide acetate inj 500 mcg/ml (0.5 mg/ml).............................................................................. 42 SANDOSTATIN -octreotide acetate inj 50 mcg/ml (0.05 mg/ml).............................................................................. 42 SANTYL -collagenase oint 250 unit/gm...........................161 SAPHRIS -asenapine maleate sl tab 10 mg (base equiv)................................................................................91 SAPHRIS -asenapine maleate sl tab 5 mg (base equiv)................................................................................91 SARAFEM -fluoxetine hcl (pmdd) tab 10 mg.....................99 SARAFEM -fluoxetine hcl (pmdd) tab 20 mg...................100 SARAPIN - misc natural products inj ............................. 172 SAVELLA -milnacipran hcl tab 100 mg........................... 100 SAVELLA -milnacipran hcl tab 12.5 mg.......................... 100 SAVELLA -milnacipran hcl tab 25 mg............................. 100 SAVELLA -milnacipran hcl tab 50 mg............................. 100 SAVELLA TITRATION PACK -milnacipran hcl tab 12.5 mg (5) & 25 mg (8) & 50 mg (42) pak................................. 100 SCALACORT DK -hc lot 2% & sal acid-sulfur shampoo 2-2% & shampoo kit...................................................... 161 SCLEROSOL INTRAPLEURAL -talc intrapleural aerosol powder 4 gm (0.4 gm/second).........................................70 SCOPOLAMINE HYDROBROMIDE -scopolamine hbr inj 0.4 mg/ml......................................................................... 74 SEASONIQUE -levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7)...................................................... 31 SE BPO 7-5.5 WASH KIT -benzoyl peroxide wash 7% & benzoyl peroxide cream 5.5% kit...................................161 SEB-PREV -sulfacetamide sodium lotion 10%................ 161 SECONAL -secobarbital sodium cap 100 mg....................92 SECTRAL -acebutolol hcl cap 200 mg..............................45 SECTRAL -acebutolol hcl cap 400 mg..............................45 selegiline hcl cap 5 mg (Eldepryl)................................126 selegiline hcl tab 5 mg..................................................126 selenium sulfide lotion 2.5%........................................ 161 selenium sulfide-pyrithione zinc in urea shampoo 2.25%............................................................................. 162 SELENIUM SULFIDE -selenium sulfide-pyrithione zinc in urea shampoo 2.25%.....................................................161 SELRX -selenium sulfide-pyrithione zinc in urea shampoo 2.3%............................................................................... 162 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 sertraline hcl oral conc 20 mg/ml (Zoloft)..................... 86 sertraline hcl tab 100 mg (Zoloft)...................................86 sertraline hcl tab 25 mg (Zoloft).....................................86 sertraline hcl tab 50 mg (Zoloft).....................................86 SEVELAMER CARBONATE -sevelamer carbonate tab 800 mg............................................................................. 77 SFROWASA -mesalamine sulfite-free (sf) enema 4 gm/60ml............................................................................77 SHELLGEL -sodium hyaluronate intraocular inj 12 mg/ ml....................................................................................144 SHOHLS SOLUTION MODIFIED -sodium citrate & citric acid soln 500-334 mg/5ml............................................... 80 SHUR-SEAL -nonoxynol-9 gel 2%.................................... 79 SIDEKICK BLOOD GLUCOSE SY - blood glucose meter disposable device with test strips ................................. 170 SIDEROL - multiple vitamins w/ minerals tab .................131 SIGNIFOR -pasireotide diaspartate inj 0.3 mg/ml (base equiv)................................................................................42 SIGNIFOR -pasireotide diaspartate inj 0.6 mg/ml (base equiv)................................................................................42 SIGNIFOR -pasireotide diaspartate inj 0.9 mg/ml (base equiv)................................................................................42 sildenafil citrate tab 20 mg (Revatio).............................62 SILENOR -doxepin hcl (sleep) tab 3 mg (base equiv)....... 92 SILENOR -doxepin hcl (sleep) tab 6 mg (base equiv)....... 92 SILVADENE -silver sulfadiazine cream 1%.....................162 SILVASORB - wound dressings - gel .............................162 silver nitrate-potassium nitrate applicator 75-25% (Arzol silver nitrate)..................................................... 162 SILVER NITRATE -silver nitrate oint 10%.......................162 SILVER NITRATE -silver nitrate soln 0.5%..................... 162 SILVER NITRATE -silver nitrate soln 10%...................... 162 SILVER NITRATE -silver nitrate soln 25%...................... 162 SILVER NITRATE -silver nitrate soln 50%...................... 162 SILVERSEAL HYDROGEL DRESS - silver - pad 2"x3" ....................................................................................... 162 SILVERSEAL HYDROGEL DRESS - silver - pad 4"x5" ....................................................................................... 162 silver sulfadiazine cream 1% (Silvadene)....................162 SILVRSTAT WOUND DRESSING - silver - gel ..............162 SIMBRINZA -brinzolamide-brimonidine tartrate ophth susp 1-0.2%............................................................................ 144 SIMCOR -niacin-simvastatin tab sr 24hr 1000-20 mg....... 61 SIMCOR -niacin-simvastatin tab sr 24hr 1000-40 mg....... 61 SIMCOR -niacin-simvastatin tab sr 24hr 500-20 mg......... 61 SIMCOR -niacin-simvastatin tab sr 24hr 500-40 mg......... 61 SIMCOR -niacin-simvastatin tab sr 24hr 750-20 mg......... 61 SIMPONI -golimumab subcutaneous soln auto-injector 100 mg/ml..............................................................................114 SIMPONI -golimumab subcutaneous soln auto-injector 50 mg/0.5ml.........................................................................114 SIMPONI -golimumab subcutaneous soln prefilled syringe 100 mg/ml...................................................................... 114 SIMPONI -golimumab subcutaneous soln prefilled syringe 50 mg/0.5ml................................................................... 114 SELSUN SHAMPOO -selenium sulfide lotion 2.5%........ 162 SELZENTRY -maraviroc tab 150 mg................................ 10 SELZENTRY -maraviroc tab 300 mg................................ 10 SEMPREX-D -acrivastine & pseudoephedrine cap 8-60 mg.................................................................................... 66 SENNA LEAVES - senna leaves ..................................... 71 SENNA -senna powder..................................................... 71 SENOPHYLLINE -theophylline tab 200 mg & dietary management cap pack.................................................... 69 SENSIPAR -cinacalcet hcl tab 30 mg (base equiv)........... 42 SENSIPAR -cinacalcet hcl tab 60 mg (base equiv)........... 42 SENSIPAR -cinacalcet hcl tab 90 mg (base equiv)........... 42 SENSORCAINE-MPF/EPINEPHRI -bupivacaine inj 0.75% w/ epinephrine................................................................118 SENTRADINE -ranitidine hcl tab 150 mg & dietary management cap pack.................................................... 74 SENTRAFLOX AM-10 -fluoxetine hcl cap 10 mg & dietary management cap pack.................................................... 86 SENTRALOPRAM AM-10 -citalopram tab 10 mg & dietary management cap pack.................................................... 86 SENTRAMODAFIN AM-100 -modafinil tab 100 mg & dietary management cap pack.........................................96 SENTRAVIL PM-25 -amitriptyline hcl tab 25 mg & diet manage prod cap pack.................................................... 86 SENTRAZOLAM AM 0.25 -alprazolam tab 0.25 mg & dietary management cap pack.........................................82 SENTRAZOLPIDEM PM-5 -zolpidem tab 5 mg & dietary management cap pack.................................................... 92 SENTROXATINE -fluoxetine hcl cap 10 mg & dietary management cap pack.................................................... 86 SEREVENT DISKUS -salmeterol xinafoate aer pow ba 50 mcg/dose (base equiv).................................................... 69 SEROMYCIN -cycloserine cap 250 mg...............................7 SEROQUEL -quetiapine fumarate tab 100 mg..................91 SEROQUEL -quetiapine fumarate tab 200 mg..................91 SEROQUEL -quetiapine fumarate tab 25 mg....................91 SEROQUEL -quetiapine fumarate tab 300 mg..................91 SEROQUEL -quetiapine fumarate tab 400 mg..................91 SEROQUEL -quetiapine fumarate tab 50 mg....................91 SEROQUEL XR -quetiapine fumarate tab sr 24hr 150 mg.................................................................................... 91 SEROQUEL XR -quetiapine fumarate tab sr 24hr 200 mg.................................................................................... 91 SEROQUEL XR -quetiapine fumarate tab sr 24hr 300 mg.................................................................................... 91 SEROQUEL XR -quetiapine fumarate tab sr 24hr 400 mg.................................................................................... 91 SEROQUEL XR -quetiapine fumarate tab sr 24hr 50 mg.................................................................................... 91 SEROSTIM -somatropin (non-refrigerated) for subcutaneous inj 4 mg.....................................................42 SEROSTIM -somatropin (non-refrigerated) for subcutaneous inj 5 mg.....................................................42 SEROSTIM -somatropin (non-refrigerated) for subcutaneous inj 6 mg.....................................................42 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 249 2015 simvastatin tab 10 mg (Zocor)....................................... 61 simvastatin tab 20 mg (Zocor)....................................... 61 simvastatin tab 40 mg (Zocor)....................................... 61 simvastatin tab 5 mg (Zocor)......................................... 61 simvastatin tab 80 mg (Zocor)....................................... 61 SINEMET -carbidopa & levodopa tab 10-100 mg............126 SINEMET -carbidopa & levodopa tab 25-100 mg............126 SINEMET -carbidopa & levodopa tab 25-250 mg............126 SINEMET CR -carbidopa & levodopa tab cr 25-100 mg.................................................................................. 126 SINEMET CR -carbidopa & levodopa tab cr 50-200 mg.................................................................................. 126 SINGULAIR -montelukast sodium chew tab 4 mg (base equiv)................................................................................69 SINGULAIR -montelukast sodium chew tab 5 mg (base equiv)................................................................................69 SINGULAIR -montelukast sodium oral granules packet 4 mg (base equiv)............................................................... 69 SINGULAIR -montelukast sodium tab 10 mg (base equiv)................................................................................69 sirolimus tab 0.5 mg (Rapamune)................................ 172 sirolimus tab 1 mg (Rapamune)...................................172 sirolimus tab 2 mg (Rapamune)...................................172 SIRTURO -bedaquiline fumarate tab 100 mg (base equiv)..................................................................................7 SITAVIG -acyclovir buccal tab 50 mg................................10 SIVEXTRO -tedizolid phosphate tab 200 mg.................... 13 SKELAXIN -metaxalone tab 800 mg............................... 128 SKLICE -ivermectin lotion 0.5%...................................... 162 SKYLA -levonorgestrel releasing iud 13.5 mg................... 31 SM B-COMPLEX/VITAMIN C -b-complex w/ c & folic acid tab.................................................................................. 131 sodium ascorbate inj 250 mg/ml.................................. 129 SODIUM BICARBONATE - sodium bicarbonate powder ......................................................................................... 71 sodium chloride flush iv soln 0.9%............................. 133 sodium chloride inj 0.9%.............................................. 133 sodium chloride inj 2.5 meq/ml (14.6%)...................... 133 sodium chloride irrigation soln 0.9%.............................80 sodium chloride soln nebu 0.9%................................... 66 sodium chloride soln nebu 10%.................................... 66 sodium chloride soln nebu 3%...................................... 66 sodium chloride soln nebu 7% (Hyper-sal)................... 66 sodium citrate & citric acid soln 500-334 mg/5ml (Shohls solution modi).................................................. 80 sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) (Luride).......................................................................... 133 sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) (Luride).......................................................................... 133 sodium fluoride chew tab 1 mg f (from 2.2 mg naf) (Luride).......................................................................... 133 sodium fluoride cream 1.1% (Prevident 5000 plus)...............................................................................147 sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride)......................................................................... 147 250 sodium fluoride paste 1.1% (Prevident 5000 boost)............................................................................ 147 sodium fluoride-potassium nitrate paste 1.1-5% (Prevident 5000 sensi)................................................. 147 sodium fluoride rinse 0.2% (Prevident)....................... 147 SODIUM FLUORIDE -sodium fluoride tab 0.5 mg f (from 1.1 mg naf).................................................................... 133 SODIUM FLUORIDE -sodium fluoride tab 1 mg f (from 2.2 mg naf)...........................................................................133 sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf).................................................................................133 sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) (Luride).......................................................................... 133 SODIUM HYDROXIDE -sodium hydroxide solution 10%................................................................................ 169 sodium phenylbutyrate oral powder 3 gm/teaspoonful (Buphenyl).......................................................................42 sodium polystyrene sulfonate oral susp 15 gm/60ml (Sps).............................................................................. 172 sodium polystyrene sulfonate powder (Kayexalate).................................................................. 170 sodium polystyrene sulfonate rectal susp 30 gm/120ml.......................................................................172 SODIUM SACCHARIN DIHYDRAT -sodium saccharin powder............................................................................134 SODIUM SULFACETAMIDE/SULF -sulfacetamide sodium-sulfur in urea emulsion 10-5%.......................... 162 SODIUM SULFACETAMIDE/SULF -sulfacetamide sodium-sulfur in urea gel 10-5%....................................162 SODIUM SULFACETAMIDE/SULF -sulfacetamide sodium w/ sulfur susp 10-5%..................................................... 162 SODIUM SULFACETAMIDE/UREA -sulfacetamide sodium-urea pad 10%....................................................162 SODIUM SULFACETAMIDE WASH -sulfacetamide sodium in bakuchiol vehicle wash 10%......................... 162 sodium thiosulfate-salicylic acid lotion 25-1%........... 162 SOLAICE -capsaicin-menthol topical patch 0.05-5%.......162 SOLARAZE -diclofenac sodium (actinic keratoses) gel 3%.................................................................................. 162 SOLTAMOX -tamoxifen citrate oral soln 10 mg/5ml (base equivalent)........................................................................21 SOLU-CORTEF -hydrocortisone sodium succinate pf for inj 1000 mg...................................................................... 25 SOLU-CORTEF -hydrocortisone sodium succinate pf for inj 100 mg........................................................................ 25 SOLU-CORTEF -hydrocortisone sodium succinate pf for inj 250 mg........................................................................ 25 SOLU-CORTEF -hydrocortisone sodium succinate pf for inj 500 mg........................................................................ 25 SOLU-MEDROL -methylprednisolone sodium succinate for inj 1000 mg...................................................................... 25 SOLU-MEDROL -methylprednisolone sodium succinate for inj 125 mg........................................................................ 25 SOLU-MEDROL -methylprednisolone sodium succinate for inj 2000 mg...................................................................... 25 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 SPRIX -ketorolac tromethamine nasal spray 15.75 mg/ spray...............................................................................114 SPRYCEL -dasatinib tab 100 mg...................................... 21 SPRYCEL -dasatinib tab 140 mg...................................... 21 SPRYCEL -dasatinib tab 20 mg........................................ 21 SPRYCEL -dasatinib tab 50 mg........................................ 21 SPRYCEL -dasatinib tab 70 mg........................................ 21 SPRYCEL -dasatinib tab 80 mg........................................ 21 SPS -sodium polystyrene sulfonate oral susp 15 gm/60ml..........................................................................172 SSKI -potassium iodide soln 1 gm/ml..............................133 SSS 10-4 -sulfacetamide sodium w/ sulfur foam 10-4%............................................................................. 162 STAFLEX -phenyltoloxamine-acetaminophen tab 55-500 mg.................................................................................. 101 STALEVO 100 -carbidopa-levodopa-entacapone tabs 25-100-200 mg...............................................................126 STALEVO 125 -carbidopa-levodopa-entacapone tabs 31.25-125-200 mg..........................................................126 STALEVO 150 -carbidopa-levodopa-entacapone tabs 37.5-150-200 mg............................................................126 STALEVO 200 -carbidopa-levodopa-entacapone tabs 50-200-200 mg...............................................................126 STALEVO 50 -carbidopa-levodopa-entacapone tabs 12.5-50-200 mg..............................................................126 STALEVO 75 -carbidopa-levodopa-entacapone tabs 18.75-75-200 mg............................................................126 stannous fluoride conc 0.63% (Gel-kam oral care ri)....................................................................................147 stannous fluoride gel 0.4%........................................... 147 STARLIX -nateglinide tab 120 mg.....................................35 STARLIX -nateglinide tab 60 mg.......................................35 stavudine cap 15 mg (Zerit)............................................10 stavudine cap 20 mg (Zerit)............................................10 stavudine cap 30 mg (Zerit)............................................10 stavudine cap 40 mg (Zerit)............................................10 stavudine for oral soln 1 mg/ml (Zerit).......................... 10 STAVZOR -valproic acid cap delayed release 125 mg.................................................................................. 122 STAVZOR -valproic acid cap delayed release 250 mg.................................................................................. 123 STAVZOR -valproic acid cap delayed release 500 mg.................................................................................. 123 STELARA -ustekinumab soln prefilled syringe 45 mg/0.5ml.........................................................................162 STELARA -ustekinumab soln prefilled syringe 90 mg/ ml....................................................................................162 STERILE TALC POWDER -talc intrapleural powder for susp 5 gm........................................................................ 70 STIMATE -desmopressin acetate nasal soln 1.5 mg/ ml......................................................................................42 STIVARGA -regorafenib tab 40 mg...................................21 STRATTERA -atomoxetine hcl cap 100 mg (base equiv)................................................................................96 SOLU-MEDROL -methylprednisolone sodium succinate for inj 40 mg.......................................................................... 25 SOLU-MEDROL -methylprednisolone sodium succinate for inj 500 mg........................................................................ 25 SOMA -carisoprodol tab 250 mg..................................... 128 SOMA -carisoprodol tab 350 mg..................................... 128 SOMATULINE DEPOT -lanreotide acetate extended release inj 120 mg/0.5ml................................................. 42 SOMATULINE DEPOT -lanreotide acetate extended release inj 60 mg/0.2ml................................................... 42 SOMATULINE DEPOT -lanreotide acetate extended release inj 90 mg/0.3ml................................................... 42 SOMAVERT -pegvisomant for inj 10 mg (as protein)........ 42 SOMAVERT -pegvisomant for inj 15 mg (as protein)........ 42 SOMAVERT -pegvisomant for inj 20 mg (as protein)........ 42 SOMAVERT -pegvisomant for inj 25 mg (as protein)........ 42 SOMAVERT -pegvisomant for inj 30 mg (as protein)........ 42 SONAFINE - wound dressings - emulsion ..................... 162 SONATA -zaleplon cap 10 mg.......................................... 92 SONATA -zaleplon cap 5 mg............................................ 92 SORBITOL-MANNITOL -sorbitol-mannitol irrigation soln 2.7-0.54 gm/100ml........................................................... 81 SORBITOL -sorbitol irrigation soln 3.3%........................... 80 SORBITOL -sorbitol irrigation soln 3%.............................. 80 SORIATANE -acitretin cap 10 mg................................... 162 SORIATANE -acitretin cap 17.5 mg................................ 162 SORIATANE -acitretin cap 25 mg................................... 162 SORILUX -calcipotriene foam 0.005%............................ 162 sotalol hcl (afib/afl) tab 120 mg (Betapace af)...............45 sotalol hcl (afib/afl) tab 160 mg (Betapace af)...............45 sotalol hcl (afib/afl) tab 80 mg (Betapace af)................ 45 sotalol hcl tab 120 mg (Betapace)................................. 45 sotalol hcl tab 160 mg (Betapace)................................. 45 sotalol hcl tab 240 mg.................................................... 45 sotalol hcl tab 80 mg (Betapace)................................... 45 SOVALDI -sofosbuvir tab 400 mg..................................... 10 speciality vitamin product tab .....................................129 SPECTRACEF -cefditoren pivoxil tab 200 mg (base equivalent)..........................................................................3 SPECTRACEF -cefditoren pivoxil tab 400 mg (base equivalent)..........................................................................3 SPECTRAGEL - wound dressings - gel ......................... 162 SPINOSAD -spinosad susp 0.9%....................................162 SPIRIVA HANDIHALER -tiotropium bromide monohydrate inhal cap 18 mcg (base equiv)........................................ 69 SPIRIVA RESPIMAT -tiotropium bromide monohydrate inhal aerosol 2.5 mcg/act.................................................69 spironolactone & hydrochlorothiazide tab 25-25 mg (Aldactazide)................................................................... 58 spironolactone tab 100 mg (Aldactone)........................ 58 spironolactone tab 25 mg (Aldactone).......................... 58 spironolactone tab 50 mg (Aldactone).......................... 58 SPORANOX -itraconazole cap 100 mg...............................7 SPORANOX -itraconazole oral soln 10 mg/ml.................... 7 SPORANOX PULSEPAK -itraconazole cap 100 mg........... 7 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 251 2015 STRATTERA -atomoxetine hcl cap 10 mg (base equiv)................................................................................96 STRATTERA -atomoxetine hcl cap 18 mg (base equiv)................................................................................96 STRATTERA -atomoxetine hcl cap 25 mg (base equiv)................................................................................96 STRATTERA -atomoxetine hcl cap 40 mg (base equiv)................................................................................96 STRATTERA -atomoxetine hcl cap 60 mg (base equiv)................................................................................96 STRATTERA -atomoxetine hcl cap 80 mg (base equiv)................................................................................96 STRAZEPAM -temazepam cap 15mg & dietary management cap pack.................................................... 93 STREPTOMYCIN SULFATE -streptomycin sulfate for inj 1 gm...................................................................................... 6 STRIANT -testosterone buccal mucoadhesive system 30 mg.................................................................................... 26 STRIBILD -elvitegrav-cobicis-emtricitab-tenofov tab 150-150-200-300 mg....................................................... 10 STRIVERDI RESPIMAT -olodaterol hcl inhal aerosol soln 2.5 mcg/act (base equiv)................................................. 69 STROMECTOL -ivermectin tab 3 mg................................ 12 STROVITE -b-complex w/ c & folic acid tab.................... 131 STROVITE FORTE -multiple vitamins w/ minerals & fa syrup 1 mg/15ml............................................................ 131 STROVITE FORTE - multiple vitamins w/ minerals tab ....................................................................................... 131 STROVITE ONE - multiple vitamins w/ minerals tab ...... 131 SUBOXONE -buprenorphine hcl-naloxone hcl sl film 12-3 mg (base equiv)............................................................. 110 SUBOXONE -buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (base equiv)............................................................. 109 SUBOXONE -buprenorphine hcl-naloxone hcl sl film 4-1 mg (base equiv)............................................................. 109 SUBOXONE -buprenorphine hcl-naloxone hcl sl film 8-2 mg (base equiv)............................................................. 110 SUBOXONE -buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv)............................................................. 109 SUBOXONE -buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv)............................................................. 109 SUBSYS -fentanyl sublingual spray 100 mcg..................110 SUBSYS -fentanyl sublingual spray 1200 mcg (600 mcg x 2).................................................................................... 110 SUBSYS -fentanyl sublingual spray 1600 mcg (800 mcg x 2).................................................................................... 110 SUBSYS -fentanyl sublingual spray 200 mcg..................110 SUBSYS -fentanyl sublingual spray 400 mcg..................110 SUBSYS -fentanyl sublingual spray 600 mcg..................110 SUBSYS -fentanyl sublingual spray 800 mcg..................110 SUCLEAR -na sulf-k sulf-mg sulf & peg 3350-nacl-na bicarb-kcl kit..................................................................... 71 SUCRAID -sacrosidase soln 8500 unit/ml......................... 75 sucralfate tab 1 gm (Carafate)........................................74 SULAR -nisoldipine tab sr 24hr 17 mg.............................. 48 252 SULAR -nisoldipine tab sr 24hr 34 mg.............................. 48 SULAR -nisoldipine tab sr 24hr 8.5 mg............................. 48 sulfacetamide sodium cleansing gel 10% (Ovace plus wash)............................................................................. 162 sulfacetamide sodium liquid 10% (Ovace wash)........ 162 sulfacetamide sodium lotion 10% (acne) (Klaron)...... 162 sulfacetamide sodium ophth soln 10% (Bleph-10)..... 145 sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)%...............................................................145 sulfacetamide sodium shampoo 10% (Ovace plus)...............................................................................162 SULFACETAMIDE SODIUM -sulfacetamide sodium ophth oint 10%......................................................................... 145 sulfacetamide sodium-sulfur in urea emulsion 10-4%............................................................................. 163 sulfacetamide sodium-sulfur w/ sunscreens cream 10-5% ............................................................................149 sulfacetamide sodium w/ sulfur cleanser 10-2% (Avar ls cleanser)................................................................... 162 sulfacetamide sodium w/ sulfur cleansing cloth 10-5%............................................................................. 162 sulfacetamide sodium w/ sulfur cleansing pad 10-4% (Sumaxin)...................................................................... 162 sulfacetamide sodium w/ sulfur cream 10-2% (Avar-e ls)................................................................................... 163 sulfacetamide sodium w/ sulfur cream 10-5%............ 163 sulfacetamide sodium w/ sulfur emulsion 10-1%....... 163 sulfacetamide sodium w/ sulfur emulsion 10-5%....... 163 sulfacetamide sodium w/ sulfur foam 10-5% (Clarifoam ef)................................................................................... 163 sulfacetamide sodium w/ sulfur lotion 10-5%............. 163 sulfacetamide sodium w/ sulfur susp 8-4% (Sumaxin ts)................................................................................... 163 sulfacetamide sodium w/ sulfur wash 9-4.5% (Sumadan wash).......................................................... 163 sulfacetamide sodium w/ sulfur wash 9-4% (Sumaxin wash)............................................................................. 163 sulfacetamide sod-sulfur wash 9-4.5% & skin cleanser kit (Sumadan kit)..........................................................149 sulfacetamide sod-sulfur wash 9-4.5% & sunscreen kit (Sumadan xlt)............................................................... 149 SULFADIAZINE -sulfadiazine tab 500 mg...........................6 sulfamethoxazole-trimethoprim susp 200-40 mg/5ml.............................................................................13 sulfamethoxazole-trimethoprim tab 400-80 mg (Bactrim)..........................................................................13 sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrim ds).................................................................... 13 SULFAMYLON -mafenide acetate cream 85 mg/gm....... 163 SULFAMYLON -mafenide acetate packet for topical soln 5% (50 gm).................................................................... 163 sulfasalazine tab 500 mg (Azulfidine)............................77 sulfasalazine tab delayed release 500 mg (Azulfidine en-tabs)........................................................................... 77 SULFOAM -sulfur shampoo 2%...................................... 163 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 SUPRAX -cefixime tab 400 mg........................................... 3 SUPREP BOWEL PREP -sodium sulfate-potassium sulfate-magnesium sulfate oral soln................................ 71 SURE-T INFUSION SET 18" - subcutaneous infusion set ....................................................................................... 170 SURE-T INFUSION SET 23" - subcutaneous infusion set ....................................................................................... 170 SURE-T INFUSION SET 32" - subcutaneous infusion set ....................................................................................... 170 SURFAXIN -lucinactant intratracheal susp 30 mg/ml........ 70 SURMONTIL -trimipramine maleate cap 100 mg.............. 86 SURMONTIL -trimipramine maleate cap 25 mg................ 86 SURMONTIL -trimipramine maleate cap 50 mg................ 86 SURVANTA INTRATRACHEAL -beractant in nacl 0.9% intratracheal susp 25 mg/ml............................................ 70 SUSTIVA -efavirenz cap 200 mg...................................... 10 SUSTIVA -efavirenz cap 50 mg........................................ 10 SUSTIVA -efavirenz tab 600 mg....................................... 10 SUTENT -sunitinib malate cap 12.5 mg (base equivalent)........................................................................21 SUTENT -sunitinib malate cap 25 mg (base equivalent)........................................................................21 SUTENT -sunitinib malate cap 37.5 mg (base equivalent)........................................................................21 SUTENT -sunitinib malate cap 50 mg (base equivalent)........................................................................21 SUTTAR-2 -pseudoephedrine w/ cod-gg syrup 30-10-100 mg/5ml..............................................................................66 SUTTAR-SF -pseudoephedrine w/ cod-gg syrup 30-10-100 mg/5ml............................................................66 SYLATRON -peginterferon alfa-2b for inj kit 296 mcg....... 21 SYLATRON -peginterferon alfa-2b for inj kit 444 mcg....... 21 SYLATRON -peginterferon alfa-2b for inj kit 4 x 296 mcg...................................................................................21 SYLATRON -peginterferon alfa-2b for inj kit 4 x 444 mcg...................................................................................21 SYLATRON -peginterferon alfa-2b for inj kit 4 x 888 mcg...................................................................................21 SYLATRON -peginterferon alfa-2b for inj kit 888 mcg....... 21 SYMAX DUOTAB -hyoscyamine sulfate tab cr 0.375 mg (0.125 mg ir/0.25 mg cr).................................................. 74 SYMBICORT -budesonide-formoterol fumarate dihyd aerosol 160-4.5 mcg/act.................................................. 69 SYMBICORT -budesonide-formoterol fumarate dihyd aerosol 80-4.5 mcg/act.................................................... 69 SYMBYAX -olanzapine-fluoxetine hcl cap 12-25 mg....... 100 SYMBYAX -olanzapine-fluoxetine hcl cap 12-50 mg....... 100 SYMBYAX -olanzapine-fluoxetine hcl cap 3-25 mg.........100 SYMBYAX -olanzapine-fluoxetine hcl cap 6-25 mg.........100 SYMBYAX -olanzapine-fluoxetine hcl cap 6-50 mg.........100 SYMLINPEN 120 -pramlintide acetate pen-inj 2700 mcg/2.7ml (1000 mcg/ml)................................................ 35 SYMLINPEN 60 -pramlintide acetate pen-inj 1500 mcg/1.5ml (1000 mcg/ml)................................................ 35 SULFURATED LIME -sulfurated lime solution................ 163 sulindac tab 150 mg...................................................... 114 sulindac tab 200 mg...................................................... 114 SUMADAN KIT -sulfacetamide sod-sulfur wash 9-4.5% & skin cleanser kit............................................................. 163 SUMADAN WASH -sulfacetamide sodium w/ sulfur wash 9-4.5%............................................................................ 163 SUMADAN XLT -sulfacetamide sod-sulfur wash 9-4.5% & sunscreen kit..................................................................163 sumatriptan succinate inj 6 mg/0.5ml (Imitrex)...........116 sumatriptan succinate solution auto-injector 4 mg/0.5ml (Imitrex statdose sys)................................. 116 sumatriptan succinate solution auto-injector 6 mg/0.5ml (Imitrex statdose sys)................................. 116 sumatriptan succinate solution cartridge 4 mg/0.5ml (Imitrex statdose ref)................................................... 116 sumatriptan succinate solution cartridge 6 mg/0.5ml (Imitrex statdose ref)................................................... 116 sumatriptan succinate solution prefilled syringe 6 mg/0.5ml........................................................................116 SUMATRIPTAN SUCCINATE -sumatriptan succinate inj 4 mg/0.5ml.........................................................................116 SUMATRIPTAN SUCCINATE -sumatriptan succinate solution prefilled syringe 6 mg/0.5ml............................. 116 sumatriptan succinate tab 100 mg (Imitrex)................116 sumatriptan succinate tab 25 mg (Imitrex)..................116 sumatriptan succinate tab 50 mg (Imitrex)..................116 SUMATRIPTAN -sumatriptan nasal spray 20 mg/act...... 116 SUMATRIPTAN -sumatriptan nasal spray 5 mg/act........ 116 SUMAVEL DOSEPRO -sumatriptan succinate solution jetinjector 4 mg/0.5ml........................................................ 116 SUMAVEL DOSEPRO -sumatriptan succinate solution jetinjector 6 mg/0.5ml........................................................ 116 SUMAXIN CP KIT -sulfacetamide sod-sulfur pad 10-4% & skin cleanser kit............................................................. 163 SUMAXIN -sulfacetamide sodium w/ sulfur cleansing pad 10-4%............................................................................. 163 SUMAXIN TS -sulfacetamide sodium w/ sulfur susp 8-4%............................................................................... 163 SUMAXIN WASH -sulfacetamide sodium w/ sulfur wash 9-4%............................................................................... 163 SUPERVITE -b-complex w/ lysine-zn & folic acid liquid............................................................................... 131 SUPERVITE EC -multiple vitamins w/ minerals & fa tab dr 1 mg............................................................................... 131 SUPPORT-500 - speciality vitamin product cap ............. 131 SUPPORT - multiple vitamins w/ minerals liquid ............ 131 SUPPRELIN LA -histrelin acetate (cpp) implant kit 50 mg.................................................................................... 42 SUPRAX -cefixime cap 400 mg.......................................... 3 SUPRAX -cefixime chew tab 100 mg..................................3 SUPRAX -cefixime chew tab 200 mg..................................3 SUPRAX -cefixime for susp 100 mg/5ml.............................3 SUPRAX -cefixime for susp 200 mg/5ml.............................3 SUPRAX -cefixime for susp 500 mg/5ml.............................3 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 253 2015 SYNAGEX -multiple vitamins w/ minerals & fa cap 1.25 mg.................................................................................. 131 SYNAGIS -palivizumab im soln 100 mg/ml....................... 18 SYNAGIS -palivizumab im soln 50 mg/0.5ml.................... 18 SYNALAR CREAM KIT - fluocinolone cream 0.025%emollient cream kit ........................................................163 SYNALAR -fluocinolone acetonide cream 0.025%.......... 163 SYNALAR -fluocinolone acetonide oint 0.025%.............. 163 SYNALAR -fluocinolone acetonide soln 0.01%............... 163 SYNALAR OINTMENT KIT - fluocinolone oint 0.025%emollient cream kit ........................................................163 SYNALAR TS -fluocinolone acetonide soln 0.01% & cleanser kit.....................................................................163 SYNALGOS-DC -aspirin-caffeine-dihydrocodeine cap 356.4-30-16 mg..............................................................110 SYNAPRYN FUSEPAQ - tramadol hcl for oral susp 10 mg/ ml (compound kit) ......................................................... 110 SYNAREL -nafarelin acetate nasal soln 2 mg/ml.............. 42 SYNATEK -multiple vitamins w/ minerals & fa cap 1.25 mg.................................................................................. 131 SYNERA -lidocaine-tetracaine topical patch 70-70 mg.................................................................................. 163 SYNRIBO -omacetaxine mepesuccinate for inj 3.5 mg..... 21 SYNTHROID -levothyroxine sodium tab 100 mcg............. 37 SYNTHROID -levothyroxine sodium tab 112 mcg............. 37 SYNTHROID -levothyroxine sodium tab 125 mcg............. 37 SYNTHROID -levothyroxine sodium tab 137 mcg............. 37 SYNTHROID -levothyroxine sodium tab 150 mcg............. 37 SYNTHROID -levothyroxine sodium tab 175 mcg............. 37 SYNTHROID -levothyroxine sodium tab 200 mcg............. 38 SYNTHROID -levothyroxine sodium tab 25 mcg...............37 SYNTHROID -levothyroxine sodium tab 300 mcg............. 38 SYNTHROID -levothyroxine sodium tab 50 mcg...............37 SYNTHROID -levothyroxine sodium tab 75 mcg...............37 SYNTHROID -levothyroxine sodium tab 88 mcg...............37 SYPRINE -trientine hcl cap 250 mg................................ 172 T TABLOID -thioguanine tab 40 mg..................................... 21 TACLONEX -calcipotriene-betamethasone dipropionate oint 0.005-0.064%..........................................................163 TACLONEX -calcipotriene-betamethasone dipropionate susp 0.005-0.064%........................................................ 163 tacrolimus cap 0.5 mg (Prograf).................................. 172 tacrolimus cap 1 mg (Prograf)..................................... 172 tacrolimus cap 5 mg (Prograf)..................................... 172 TAFINLAR -dabrafenib mesylate cap 50 mg (base equivalent)........................................................................21 TAFINLAR -dabrafenib mesylate cap 75 mg (base equivalent)........................................................................21 TALWIN -pentazocine lactate inj 30 mg/ml..................... 110 TAMBOCOR -flecainide acetate tab 100 mg.....................49 TAMBOCOR -flecainide acetate tab 150 mg.....................49 TAMBOCOR -flecainide acetate tab 50 mg.......................49 TAMIFLU -oseltamivir phosphate cap 30 mg (base equiv)................................................................................11 254 TAMIFLU -oseltamivir phosphate cap 45 mg (base equiv)................................................................................11 TAMIFLU -oseltamivir phosphate cap 75 mg (base equiv)................................................................................11 TAMIFLU -oseltamivir phosphate for susp 6 mg/ml (base equiv)................................................................................11 tamoxifen citrate tab 10 mg (base equivalent)..............21 tamoxifen citrate tab 20 mg (base equivalent)..............21 tamsulosin hcl cap 0.4 mg............................................. 81 TANDEM F -ferrous fum-iron polysacch-fa cap 162-115.2-1 mg (106 mg fe)..........................................137 TANDEM PLUS - fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu cap .................................................. 137 TANZEUM -albiglutide for soln pen-injector 30 mg............35 TANZEUM -albiglutide for soln pen-injector 50 mg............35 TAPAZOLE -methimazole tab 10 mg................................ 38 TAPAZOLE -methimazole tab 5 mg.................................. 38 TARCEVA -erlotinib hcl tab 100 mg (base equivalent)...... 21 TARCEVA -erlotinib hcl tab 150 mg (base equivalent)...... 21 TARCEVA -erlotinib hcl tab 25 mg (base equivalent)........ 21 TARGRETIN -bexarotene cap 75 mg................................21 TARGRETIN -bexarotene gel 1%....................................163 TARKA -trandolapril-verapamil hcl tab cr 1-240 mg.......... 55 TARKA -trandolapril-verapamil hcl tab cr 2-180 mg.......... 55 TARKA -trandolapril-verapamil hcl tab cr 2-240 mg.......... 55 TARKA -trandolapril-verapamil hcl tab cr 4-240 mg.......... 55 TARON FORTE - fe bisglycinate-fe polysacch-vit c-vit b12fa cap ............................................................................137 TASIGNA -nilotinib hcl cap 150 mg (base equivalent).......21 TASIGNA -nilotinib hcl cap 200 mg (base equivalent).......21 TASMAR -tolcapone tab 100 mg.....................................126 TAZORAC -tazarotene cream 0.05%.............................. 163 TAZORAC -tazarotene cream 0.1%................................ 163 TAZORAC -tazarotene gel 0.05%................................... 163 TAZORAC -tazarotene gel 0.1%..................................... 163 TECFIDERA -dimethyl fumarate capsule delayed release 120 mg........................................................................... 100 TECFIDERA -dimethyl fumarate capsule delayed release 240 mg........................................................................... 100 TECFIDERA STARTER PACK -dimethyl fumarate capsule dr starter pack 120 mg & 240 mg..................................100 TEGADERM AG MESH DRESSING - wound dressings pads .............................................................................. 163 TEGRETOL -carbamazepine susp 100 mg/5ml.............. 123 TEGRETOL -carbamazepine tab 200 mg........................123 TEGRETOL-XR -carbamazepine tab sr 12hr 100 mg......123 TEGRETOL-XR -carbamazepine tab sr 12hr 200 mg......123 TEGRETOL-XR -carbamazepine tab sr 12hr 400 mg......123 TEKAMLO -aliskiren-amlodipine tab 150-10 mg................55 TEKAMLO -aliskiren-amlodipine tab 150-5 mg................. 55 TEKAMLO -aliskiren-amlodipine tab 300-10 mg................55 TEKAMLO -aliskiren-amlodipine tab 300-5 mg................. 55 TEKTURNA -aliskiren fumarate tab 150 mg (base equivalent)........................................................................55 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 2015 TENORMIN -atenolol tab 50 mg....................................... 45 TERAZOL 3 -terconazole vaginal cream 0.8%..................79 TERAZOL 3 -terconazole vaginal suppos 80 mg.............. 79 TERAZOL 7 -terconazole vaginal cream 0.4%..................79 terazosin hcl cap 10 mg..................................................56 terazosin hcl cap 1 mg................................................... 56 terazosin hcl cap 2 mg................................................... 56 terazosin hcl cap 5 mg................................................... 56 terbinafine hcl tab 250 mg (Lamisil)................................ 7 TERBINEX -terbinafine oral tab 250 mg & hydrxyprop chitosan liq 1% kit..............................................................7 terbutaline sulfate inj 1 mg/ml........................................69 terbutaline sulfate tab 2.5 mg.........................................69 terbutaline sulfate tab 5 mg........................................... 69 terconazole vaginal cream 0.4% (Terazol 7)..................79 terconazole vaginal cream 0.8% (Terazol 3)..................79 terconazole vaginal suppos 80 mg................................ 79 TERSI FOAM -selenium sulfide foam 2.25%...................164 TESSALON PERLES -benzonatate cap 100 mg...............66 TESTIM -testosterone td gel 50 mg/5gm (1%).................. 26 TESTOPEL -testosterone implant pellets 75 mg............... 26 testosterone cypionate im inj in oil 100 mg/ml (Depotestosterone)...................................................................26 testosterone cypionate im inj in oil 200 mg/ml (Depotestosterone)...................................................................26 testosterone enanthate im inj in oil 200 mg/ml.............26 TESTOSTERONE PUMP -testosterone td gel 12.5 mg/act (1%)..................................................................................26 TESTOSTERONE -testosterone td gel 10mg/act (2%)......26 TESTOSTERONE -testosterone td gel 50 mg/5gm (1%)..................................................................................26 TESTRED -methyltestosterone cap 10 mg........................26 TETANUS/DIPHTHERIA TOXOID -tetanus-diphtheria toxoids (td) inj 2-2 lf/0.5ml............................................... 16 TETANUS TOXOID ADSORBED -tetanus toxoid adsorbed inj 5 lf............................................................................... 16 tetracaine hcl ophth soln 0.5%.....................................145 TETRACAINE HCL -tetracaine hcl inj 1%....................... 118 TETRACYCLINE HCL -tetracycline hcl cap 250 mg............5 TETRACYCLINE HCL -tetracycline hcl cap 500 mg............5 TETRIX - dermatological products misc - kit .................. 164 TEVETEN -eprosartan mesylate tab 400 mg.................... 56 TEVETEN -eprosartan mesylate tab 600 mg.................... 56 TEVETEN HCT -eprosartan mesylate-hydrochlorothiazide tab 600-12.5 mg...............................................................56 TEVETEN HCT -eprosartan mesylate-hydrochlorothiazide tab 600-25 mg................................................................. 56 TEV-TROPIN -somatropin for subcutaneous inj 5 mg....... 42 TEXACORT -hydrocortisone soln 2.5%...........................164 TGQ 15DM/5PEH/2CPM -phenylephrine-chlorphen-dm syrup 5-2-15 mg/5ml........................................................66 TGQ 30PSE/150GFN/15DM -pseudoephedrine w/ dm-gg syrup 30-15-150 mg/5ml..................................................66 TGQ 30PSE/3BRM/15DM -pseudoephed-bromphen-dm syrup 30-3-15 mg/5ml......................................................67 TEKTURNA -aliskiren fumarate tab 300 mg (base equivalent)........................................................................55 TEKTURNA HCT -aliskiren-hydrochlorothiazide tab 150-12.5 mg.....................................................................55 TEKTURNA HCT -aliskiren-hydrochlorothiazide tab 150-25 mg.................................................................................... 55 TEKTURNA HCT -aliskiren-hydrochlorothiazide tab 300-12.5 mg.....................................................................55 TEKTURNA HCT -aliskiren-hydrochlorothiazide tab 300-25 mg.................................................................................... 55 telmisartan-amlodipine tab 40-10 mg (Twynsta)...........55 telmisartan-amlodipine tab 40-5 mg (Twynsta).............55 telmisartan-amlodipine tab 80-10 mg (Twynsta)...........56 telmisartan-amlodipine tab 80-5 mg (Twynsta).............56 telmisartan-hydrochlorothiazide tab 40-12.5 mg (Micardis hct)..................................................................56 telmisartan-hydrochlorothiazide tab 80-12.5 mg (Micardis hct)..................................................................56 telmisartan-hydrochlorothiazide tab 80-25 mg (Micardis hct)..................................................................56 telmisartan tab 20 mg (Micardis)................................... 55 telmisartan tab 40 mg (Micardis)................................... 55 telmisartan tab 80 mg (Micardis)................................... 55 temazepam cap 15 mg (Restoril)................................... 93 temazepam cap 22.5 mg (Restoril).................................93 temazepam cap 30 mg (Restoril)................................... 93 temazepam cap 7.5 mg (Restoril).................................. 93 TEMODAR -temozolomide cap 100 mg............................ 21 TEMODAR -temozolomide cap 140 mg............................ 21 TEMODAR -temozolomide cap 180 mg............................ 21 TEMODAR -temozolomide cap 20 mg.............................. 21 TEMODAR -temozolomide cap 250 mg............................ 21 TEMODAR -temozolomide cap 5 mg................................ 21 TEMOVATE -clobetasol propionate cream 0.05%...........163 TEMOVATE -clobetasol propionate gel 0.05%................163 TEMOVATE -clobetasol propionate oint 0.05%...............163 TEMOVATE -clobetasol propionate soln 0.05%.............. 163 TEMOVATE E -clobetasol propionate emollient base cream 0.05%..................................................................163 temozolomide cap 100 mg (Temodar)........................... 21 temozolomide cap 140 mg (Temodar)........................... 21 temozolomide cap 180 mg (Temodar)........................... 21 temozolomide cap 20 mg (Temodar)............................. 21 temozolomide cap 250 mg (Temodar)........................... 21 temozolomide cap 5 mg (Temodar)............................... 21 TENCON -butalbital-acetaminophen tab 50-650 mg....... 101 TENEX -guanfacine hcl tab 1 mg......................................56 TENEX -guanfacine hcl tab 2 mg......................................56 TENIVAC -tetanus-diphtheria toxoids (td) inj 5-2 lfu.......... 16 TENORETIC 100 -atenolol & chlorthalidone tab 100-25 mg.................................................................................... 56 TENORETIC 50 -atenolol & chlorthalidone tab 50-25 mg.................................................................................... 56 TENORMIN -atenolol tab 100 mg..................................... 46 TENORMIN -atenolol tab 25 mg....................................... 45 SM Blue Cross and Blue Shield of Kansas Formulary for BlueCare Products January 2015 255 2015 TGQ 50PSE/3BRM/30DM -pseudoephed-bromphen-dm syrup 50-3-30 mg/5ml......................................................67 THALOMID -thalidomide cap 100 mg..............................172 THALOMID -thalidomide cap 150 mg..............................172 THALOMID -thalidomide cap 200 mg..............................172 THALOMID -thalidomide cap 50 mg................................172 THEO-24 -theophylline cap sr 24hr 100 mg...................... 69 THEO-24 -theophylline cap sr 24hr 200 mg...................... 69 THEO-24 -theophylline cap sr 24hr 300 mg...................... 69 THEO-24 -theophylline cap sr 24hr 400 mg...................... 69 theophylline soln 80 mg/15ml........................................ 70 theophylline tab sr 12hr 100 mg.................................... 70 theophylline tab sr 12hr 200 mg.................................... 70 theophylline tab sr 12hr 300 mg.................................... 70 theophylline tab sr 12hr 450 mg.................................... 70 theophylline tab sr 24hr 400 mg.................................... 70 theophylline tab sr 24hr 600 mg.................................... 70 THERABENZAPRINE-60 -cyclobenzaprine tab 10 mg & dietary management cap pack.......................................128 THERABENZAPRINE-90-5 -cyclobenzaprine tab 5 mg & dietary management cap
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