1. health and fitness
2. drugs

October 2013
Blue Cross and Blue Shield of Oklahoma Drug Formulary
Contents
Introduction................................................................. I
How formulary drugs are selected ............................. I
How member payment is determined ........................ I
How to use this list .................................................... II
Drugs used to treat multiple conditions ................... III
Generic drugs .......................................................... III
Consider talking to your doctor about
generic drugs ....................................................... III
Coverage considerations ........................................ IV
Prior Authorization (PA) .......................................... IV
Step Therapy (ST) .................................................. IV
Specialty drugs ....................................................... IV
Prime Therapeutics Specialty Pharmacy
Program ............................................................... V
Key ........................................................................... V
Preferred Medication List ......................................... 1
Anti-Infective Drugs .................................................. 1
Cancer Drugs............................................................ 3
Hormones, Diabetes and Related Drugs ................. 3
Heart and Circulatory Drugs ..................................... 5
Respiratory Agents ................................................... 7
Gastrointestinal Drugs .............................................. 8
Genitourinary Drugs ................................................. 9
Central Nervous System Drugs ................................ 9
Pain Relief Drugs.................................................... 11
Neuromuscular Drugs............................................. 12
Supplements ........................................................... 13
Blood Modifying Drugs ........................................... 13
Topical Drugs.......................................................... 13
Miscellaneous Categories ...................................... 16
Index ......................................................................... 17
Please consider talking to your doctor about prescribing formulary medications, which may help reduce your
out-of-pocket costs. This list may help guide you and your doctor in selecting an appropriate medication for you.
The drug formulary is regularly updated. Please visit bcbsok.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.
2920-A OK © Prime Therapeutics LLC 10/13
Introduction
Blue Cross and Blue Shield of Oklahoma is pleased to present the 2013 Drug Formulary. This is a list of formulary
drugs which includes Formulary Brand drugs and a partial listing of generic drugs. 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.
Drug Formulary Updates – This list is regularly updated as generic drugs become available and changes take
place in the pharmaceuticals market. For the most up-to-date information, visit bcbsok.com and log in to
Blue Access for MembersSM or call the number on the back of your ID card. Physicians can access the list from
the provider portal at bcbsok.com.
How formulary drugs are selected
Drugs on this list are selected based on the recommendations of a committee made up of physicians and pharmacists
from throughout the country. The committee, which includes at least one representative from your health plan, reviews
drugs regulated by the U.S. Food and Drug Administration (FDA).
Both drugs that are newly approved by the 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.
How member payment is determined
This list shows prescription drug products in tiers. Generally, each drug is placed into one of three or four member
payment tiers: generic, Formulary Brand or Non-Formulary Brand (not listed in this document). Specialty drugs can
either be within the previous three tiers or can be a separate fourth tier depending on your benefit design. To verify
your payment amount for a specialty drug, visit bcbsok.com and log in to Blue Access for MembersSM or call the
number on the back of your ID card.
Your pharmacy benefit includes coverage for almost all prescription drugs, although some exclusions may apply. For
example, drugs indicated for cosmetic purposes, e.g., Propecia, for hair growth, may not be covered. Prescription
products that have over-the-counter (OTC) equivalents may not be covered. Some drugs may only be available
through your medical benefit (example: Testopel).
I
Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary
How to use this list
This list is organized into broad therapeutic categories. For example, Hormones, Diabetes and Related Drugs is a
broad category. Within most categories, drugs are sub-grouped based upon drug class, for example under Hormones,
Diabetes and Related Drugs you will find Estrogens. All drugs listed, whether generic or brand, are formulary drugs.
T
The first column of the chart lists the drug name. Generic drugs are shown in lower-case boldface type.
Most generic drugs are followed by a reference brand drug in (parentheses). The reference brand drug is a
non-formulary (NF) brand and is only included as a reference to the brand. Some generic products have no
reference brand.
Example: budesonide ext-release (Entocort EC – brand is NF)
Preferred brand drugs are listed in all CAPITAL letters.
Example: DIASTAT
The following examples are given to assist you and your doctor in reading listings that include specific strengths
and dosage forms. These examples can be applied to other drugs on the formulary. Any exceptions are noted
and some listings contain additional information about specific products or dosage forms.
•
Extended-release and delayed-release products require their own entry.
Example: DETROL LA
The long-acting product Detrol LA is on the preferred drug list, but requires a separate entry from the
non ext-release product Detrol.
•
Some products may show a strength, if so only that strength indicated is on the formulary.
Example: XIFAXAN 550 mg
The Xifaxan 550 mg is on preferred drug list in this case, but the Xifaxan 200 mg is not because it is not listed.
The second column indicates if the drug is a specialty drug. Note: Additional information about specialty drugs
can be found in this document under the header for Specialty Drugs.
T
The remaining columns indicate the Utilization Management (UM) program(s) that apply to the prescription drug
(e.g., Prior Authorization, Dispensing Limits, and Step Therapy). If an indicator is present in the column(s), then
the UM program noted is possibly applied to your benefit. Some plans may have UM on additional medications
beyond those noted in this document.
Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary
II
Drugs used to treat multiple conditions
Some drugs in the same dosage form may be used to treat more than one medical condition. In these instances,
each medication is classified according to its first FDA-approved use. Please check the index if you do not find your
particular medication in the class/condition section that corresponds to your use.
Generic drugs
Using generic drugs, when right for you, can help you save on your out-of-pocket medication costs. Generic drugs
must be approved by the FDA just as brand drugs are, and must meet the same strict standards.
There are two types of generic drugs:
•
A generic equivalent is made with the same active ingredient(s) at the same dosage as the reference drug.
•
A generic alternative is a drug typically used to treat the same condition, but the active ingredient(s) differs
from the brand drug.
According to the FDA, compared to its brand counterpart, an FDA-approved generic drug:
•
Is chemically the same
•
Works just as well in the body
•
Is as safe and effective
•
Meets the same standards set by the FDA
The main difference between the reference brand drug and the generic equivalent is that the generic often costs
much less.
Brand drugs in Tier 2 typically move to Tier 3 after a generic equivalent becomes available. You may be responsible
for the generic member payment amount plus the difference in cost between the brand and generic drug if you or your
doctor requests the reference brand rather than the generic. Generic drugs have the lowest member payment amount.
Consider talking to your doctor about generic drugs
If your doctor writes a prescription for a brand drug that does not have a generic equivalent, consider asking if an
appropriate generic alternative is available.
You can also let your pharmacist know that you would like a generic equivalent for a brand drug, whenever one is
available. Your pharmacist can usually substitute a generic equivalent for its brand counterpart without a new
prescription from your doctor.
Only your doctor can determine whether a generic alternative is right for you and must prescribe the medication.
III
Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary
Coverage considerations
Most prescription drug benefit plans provide coverage for up to a 30- to 34-day supply of medication, with some
exceptions. Your plan may also provide coverage for up to a 90-day supply of maintenance medications. Maintenance
medications are those drugs you may take on an ongoing basis for conditions such as high blood pressure, diabetes
or high cholesterol. Some plans may exclude coverage for certain agents or drug categories, like those used for
erectile dysfunction (example: Viagra) or infertility (example: Follistim AQ).
Over-the-counter exclusions: Some benefit plans do not provide coverage for prescription medications that have an
over-the-counter version. You should refer to your benefit plan booklet for details about your particular benefits.
Compounded medications: Some benefit plans do not provide coverage for compounded medications. Please see
your plan materials or call the number on the back of your ID card to determine whether compounded medications are
covered and/or verify your payment amount.
Repackaged medications: Repackaged versions of medications already available on the market are not covered.
Prior Authorization (PA): 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. For the formulary medications listed in this document, if a prior authorization is commonly required,
it will be noted next to the medication with a dot under the prior authorization column as noted in the section
“How To Use This List.” Some plans may have prior authorization on additional medications beyond those noted
in this document.
Step Therapy (ST): 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. For the formulary
medications listed in this document, if a step therapy is commonly required it will be noted next to the medication with
a dot under the step therapy column as noted in the section “How To Use This List.” Some plans may have step
therapy programs on additional medications beyond those noted in this document.
Remember, medication decisions are between you and your doctor. Only your doctor can determine which
medication is right for you. Discuss any questions or concerns you have about medications you are taking or are
prescribed with your doctor.
Specialty drugs
Specialty drugs are used in the treatment of medical conditions such as hepatitis, hemophilia, 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. For a current list of specialty medications, visit myprime.com or
bcbsok.com and log in to Blue Access for MembersSM.
Note that some drug classes may be excluded by some plans and therefore may not be covered under your
pharmacy benefit. Your plan may have a different coverage level for specialty drugs. If you have questions about your
coverage for specialty medications or your prescription drug benefit, call the number on the back of your ID card.
Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary
IV
Prime Therapeutics Specialty Pharmacy Program
Through Prime Therapeutics Specialty Pharmacy, members can have covered specialty medications delivered directly
to them or their doctor’s office. When you receive specialty medications through Prime, you also receive at no
additional charge the following services:
•
Coordination of coverage between you, your doctor and your health plan
•
Educational materials about your particular condition and information about managing potential medication
side effects
•
Syringes, sharps containers and other supplies with every shipment for self-injectables
•
24/7/365 phone access to a pharmacist for urgent medication issues
To order through Prime Therapeutics Specialty Pharmacy:
•
Have your doctor call or fax your prescription to Prime Therapeutics Specialty Pharmacy. Your doctor can
call 877.627.6337 or fax to 877.828.3939.
•
If you have an existing prescription for a covered specialty medication, you can call 877.627.6337 to transfer
your prescription.
•
A Prime Therapeutics coordinator will contact you to arrange delivery of your medication.
•
The prescription can be shipped directly to you or your prescribing doctor’s office. Each package is
individually marked for each member. Refrigerated drugs are shipped in temperature-controlled packaging.
If you have questions, please contact Prime Therapeutics Specialty Pharmacy at 877.627.6337, visit
www.PrimeTherapeutics.com/specialty, or call the number on the back of your ID card.
* Blue Cross and Blue Shield of Oklahoma is a Division of Health Care Service Corporation, a Mutual Legal Reserve Company (“HCSC”).
HCSC is an independent licensee of the Blue Cross Blue Shield Association. HCSC contracts with Prime Therapeutics to provide pharmacy
benefit management and mail order pharmacy services and to administer this specialty pharmacy program. HCSC, as well as several other
independent Blue Cross and Blue Shield licensees, has an ownership interest in Prime Therapeutics LLC.
Key
caps ............................................................... capsules
chew tabs ..........................................chewable tablets
conc ........................................................... concentrate
crm ......................................................................cream
DL ....................................................... dispensing limits
ext-release ........................................extended-release
inhal .............................................................. inhalation
inj..................................................................... injection
lotn ....................................................................... lotion
NF ........................................................... non-formulary
ODT ....................................orally disintegrating tablets
V
oint .................................................................. ointment
ophth........................................................... ophthalmic
OSM .................................................... osmotic-release
PA.....................................................prior authorization
SL ................................................................. sublingual
soln .................................................................. solution
supp ........................................................ suppositories
susp ........................................................... suspension
ST ..............................................................step therapy
tabs .................................................................... tablets
Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary
ANTI-INFECTIVE DRUGS
amoxicillin/potassium
clavulanate (Augmentin – brand is
NF)
minocycline (Dynacin, Minocin –
brands are NF)
amoxicillin/potassium clavulanate
ext-release (Augmentin XR – brand is
NF)
ciprofloxacin (Cipro – brand is NF)
Step Therapy
FLUOROQUINOLONES
•
ciprofloxacin ext-release
levofloxacin (Levaquin – brand is NF)
amoxicillin, NF = chew tabs
ofloxacin tabs
ampicillin caps
AMINOGLYCOSIDES
dicloxacillin
neomycin sulfate
penicillin v potassium
paromomycin
CEPHALOSPORINS
TUBERCULOSIS
cefaclor caps
ethambutol (Myambutol – brand is NF)
cefadroxil
isoniazid tabs
cefdinir
cefpodoxime
isoniazid/rifampin (Rifamate – brand is
NF)
cefprozil
MYCOBUTIN
ceftriaxone (Rocephin – brand is NF)
PRIFTIN
cefuroxime (Ceftin – brand is NF)
pyrazinamide
cephalexin, NF = tabs (Keflex – brand
is NF)
rifampin (Rifadin – brand is NF)
FUNGAL INFECTIONS
SUPRAX tabs
fluconazole (Diflucan – brand is NF)
MACROLIDES
flucytosine (Ancobon – brand is NF)
azithromycin susp (Zithromax – brand
is NF)
•
griseofulvin microsize (Grifulvin V –
brand is NF)
itraconazole (Sporanox – brand is NF)
ketoconazole tabs
clarithromycin (Biaxin – brand is NF)
clarithromycin ext-release (Biaxin XL
– brand is NF)
Dispensing Limits
doxycycline monohydrate (Adoxa,
Monodox - brands are NF)
PENICILLINS
azithromycin tabs (Zithromax – brand
is NF)
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2013
•
NOXAFIL
•
nystatin oral
erythromycin delayed-release caps
terbinafine (Lamisil – brand is NF)
ZITHROMAX packets
VFEND susp
TETRACYCLINES
voriconazole (Vfend – brand is NF)
demeclocycline
VIRAL INFECTIONS
doxycycline hyclate (Vibramycin –
brand is NF)
Cytomegalovirus
•
•
VALCYTE
Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary
1
Hepatitis
SUSTIVA
BARACLUDE
TRIZIVIR
HEPSERA
TRUVADA
ribavirin (Copegus, Rebetol – brands
are NF)
•
VIDEX
VIRACEPT
Herpes
VIRAMUNE susp
acyclovir (Zovirax – brand is NF)
VIRAMUNE XR
famciclovir (Famvir – brand is NF)
VIREAD
valacyclovir (Valtrex – brand is NF)
ZIAGEN soln
HIV/AIDS
abacavir tabs (Ziagen – brand is NF)
APTIVUS
ATRIPLA
CRIXIVAN
didanosine delayed-release (Videx EC
– brand is NF)
EMTRIVA
EPIVIR soln
EPZICOM
INTELENCE
INVIRASE
ISENTRESS
KALETRA
lamivudine (Epivir tabs – brand is NF)
lamivudine/zidovudine (Combivir –
brand is NF)
LEXIVA
nevirapine tabs (Viramune – brand is
NF)
NORVIR
PREZISTA
RESCRIPTOR
REYATAZ
SELZENTRY
stavudine (Zerit – brand is NF)
STRIBILD
2
•
•
•
•
•
zidovudine (Retrovir – brand is NF)
•
•
•
•
•
•
•
•
•
•
MALARIA
atovaquone/proguanil
250-100 mg (Malarone – brand is NF)
chloroquine phosphate (Aralen –
brand is NF)
DARAPRIM
•
•
•
•
•
•
•
•
•
hydroxychloroquine (Plaquenil –
brand is NF)
MALARONE 62.5-25 mg
mefloquine
PRIMAQUINE
WORM INFECTIONS
ALBENZA
BILTRICIDE
STROMECTOL
OTHER ANTI-INFECTIVES
•
•
clindamycin (Cleocin, Cleocin
Pediatric – brands are NF)
DAPSONE
•
•
•
•
•
•
•
erythromycin/sulfisoxazole
metronidazole tabs (Flagyl – brand is
NF)
sulfamethoxazole/
trimethoprim (Bactrim – brand is NF)
trimethoprim
vancomycin (Vancocin – brand is NF)
Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2013
•
•
XIFAXAN 550 mg
ZYVOX
DEXAMETHASONE soln, 0.5 mg/5 mL
ALKERAN tabs
fludrocortisone
anastrozole (Arimidex – brand is NF)
hydrocortisone (Cortef – brand is NF)
bicalutamide (Casodex – brand is NF)
methylprednisolone (Medrol – brand is
NF)
prednisolone sodium soln (Orapred –
brand is NF)
exemestane (Aromasin – brand is NF)
FARESTON
PREDNISONE soln, 5 mg/5 mL; tabs,
50 mg
flutamide
prednisone tabs, 1 mg, 2.5 mg, 5 mg,
10 mg, 20 mg
hydroxyurea (Hydrea – brand is NF)
letrozole (Femara – brand is NF)
LEUCOVORIN CALCIUM tabs, 10 mg,
15 mg
PREDNISONE INTENSOL
leucovorin calcium tabs, 5 mg,
25 mg
ANDRODERM
LEUKERAN
ANDROXY
megestrol (Megace – brand is NF)
danazol
mercaptopurine (Purinethol – brand is
NF)
testosterone cypionate (DepoTestosterone – brand is NF)
MESNEX tabs
methotrexate
testosterone enanthate (Delatestryl –
brand is NF)
MYLERAN
ESTROGENS
NILANDRON
COMBIPATCH
TABLOID
DIVIGEL
tamoxifen
ENJUVIA
tretinoin caps
MALE HORMONES
ANDROGEL
• •
• •
estradiol patches (Climara – brand is
NF)
TREXALL
estradiol tabs (Estrace – brand is NF)
HORMONES, DIABETES AND RELATED DRUGS
estradiol/norethindrone
acetate (Activella – brand is NF)
CORTICOSTEROIDS
budesonide ext-release (Entocort EC –
brand is NF)
CORTISONE
Step Therapy
prednisolone (Prelone – brand is NF)
EMCYT
temozolomide (Temodar – brand is NF)
Dispensing Limits
dexamethasone elixir; tabs, 0.5 mg,
0.75 mg, 1.5 mg, 4 mg, 6 mg
CANCER DRUGS
CYCLOPHOSPHAMIDE tabs
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2013
• •
• •
•
•
• •
• •
•
estropipate, NF = 3 mg
VIVELLE-DOT
•
PROGESTINS
Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary
3
medroxyprogesterone
acetate (Provera – brand is NF)
KOMBIGLYZE XR
norethindrone acetate (Aygestin –
brand is NF)
metformin ext-release (Glucophage
XR – brand is NF)
progesterone micronized (Prometrium
– brand is NF)
metformin ext-release OSM (Fortamet
– brand is NF)
•
•
ELLA
levonorgestrel (Plan B, Plan B OneStep – brands are NF)
ONGLYZA
•
•
ORTHO EVRA
VICTOZA
DIABETES - INSULINS
•
•
•
HUMALOG
NOVOLOG
DIABETES
Short-Acting Insulins
acarbose (Precose – brand is NF)
HUMULIN R
glimepiride (Amaryl – brand is NF)
NOVOLIN R
glipizide (Glucotrol – brand is NF)
Intermediate-Acting Insulins
glipizide ext-release (Glucotrol XL –
brand is NF)
HUMALOG MIX 50/50, 75/25
glipizide/metformin (Metaglip – brand
is NF)
HUMULIN 70/30
GLUCAGON EMERGENCY KIT
NOVOLIN 70/30
glyburide
NOVOLOG MIX 70/30
glyburide micronized (Glynase –
brand is NF)
Basal Insulins
glyburide/metformin (Glucovance –
brand is NF)
LEVEMIR
JUVISYNC
• •
Rapid-Acting Insulins
INFERTILITY
JANUVIA
HUMULIN N
NOVOLIN N
LANTUS
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
THYROID REGULATION
levothyroxine (Synthroid – brand is NF)
liothyronine (Cytomel – brand is NF)
methimazole (Tapazole – brand is NF)
propylthiouracil
4
Step Therapy
pioglitazone (Actos – brand is NF)
repaglinide (Prandin)
oral contraceptives – all generics
JANUMET XR
•
PRANDIN
NUVARING
JANUMET
Dispensing Limits
nateglinide (Starlix – brand is NF)
pioglitazone/metformin (Actoplus Met
– brand is NF)
medroxyprogesterone acetate inj,
150 mg/mL (Depo-Provera – brand is
NF)
clomiphene (Clomid – brand is NF)
•
metformin (Glucophage – brand is NF)
BIRTH CONTROL
chorionic gonadotropin
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2013
Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary
OTHER HORMONES AND RELATED DRUGS
•
•
ACTONEL
alendronate 5 mg, 10 mg, 35 mg,
70 mg (Fosamax – brand is NF)
calcitonin-salmon (Miacalcin – brand is
NF)
quinapril/
hydrochlorothiazide (Accuretic –
brand is NF)
ramipril (Altace – brand is NF)
desmopressin (DDAVP – brand is NF)
trandolapril (Mavik – brand is NF)
EVISTA
•
ibandronate (Boniva – brand is NF)
levocarnitine (Carnitor – brand is NF)
ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS)
AND COMBINATIONS
BENICAR
methylergonovine
•
SENSIPAR
BENICAR HCT
irbesartan (Avapro – brand is NF)
ZEMPLAR caps
irbesartan/
hydrochlorothiazide (Avalide –
brand is NF)
HEART AND CIRCULATORY DRUGS
losartan (Cozaar – brand is NF)
ANGIOTENSIN CONVERTING ENZYME (ACE)
INHIBITORS AND COMBINATIONS
losartan/hydrochlorothiazide (Hyzaar
– brand is NF)
benazepril (Lotensin – brand is NF)
valsartan/hydrochlorothiazide (Diovan
HCT – brand is NF)
STIMATE
benazepril/
hydrochlorothiazide (Lotensin HCT
– brand is NF)
BETA BLOCKERS AND COMBINATIONS
acebutolol (Sectral – brand is NF)
captopril
atenolol (Tenormin – brand is NF)
enalapril (Vasotec – brand is NF)
atenolol/chlorthalidone (Tenoretic –
brand is NF)
enalapril/
hydrochlorothiazide (Vaseretic –
brand is NF)
bisoprolol (Zebeta – brand is NF)
fosinopril
bisoprolol/hydrochlorothiazide (Ziac
– brand is NF)
fosinopril/hydrochlorothiazide
carvedilol (Coreg – brand is NF)
lisinopril (Prinivil, Zestril – brands are
NF)
INNOPRAN XL
lisinopril/
hydrochlorothiazide (Zestoretic –
brand is NF)
metoprolol succinate extrelease (Toprol XL – brand is NF)
moexipril (Univasc – brand is NF)
Step Therapy
perindopril (Aceon – brand is NF)
quinapril (Accupril – brand is NF)
octreotide (Sandostatin – brand is NF)
Dispensing Limits
moexipril/
hydrochlorothiazide (Uniretic –
brand is NF)
cabergoline
calcitriol (Rocaltrol – brand is NF)
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2013
labetalol (Trandate – brand is NF)
metoprolol tartrate (Lopressor – brand
is NF)
Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary
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nadolol (Corgard – brand is NF)
PROPRANOLOL soln
propranolol tabs
propranolol ext-release (Inderal LA –
brand is NF)
TIMOLOL tabs
CALCIUM CHANNEL BLOCKERS AND
COMBINATIONS
fenofibrate micronized (Lofibra –
brand is NF)
fenofibric acid delayed-release
caps (Trilipix)
gemfibrozil (Lopid – brand is NF)
lovastatin (Mevacor – brand is NF)
NIASPAN
amlodipine/benazepril (Lotrel – brand
is NF)
pravastatin (Pravachol – brand is NF)
diltiazem (Cardizem – brand is NF)
TRILIPIX
diltiazem ext-release (Cardizem CD/
LA, Dilacor XR, Tiazac – brands are
NF)
WELCHOL
nifedipine ext-release (Adalat CC,
Procardia XL – brands are NF)
verapamil ext-release (Calan SR,
Isoptin SR, Verelan/PM – brands are
NF)
verapamil, NF = 40 mg (Calan – brand
is NF)
simvastatin (Zocor – brand is NF)
FLUID RETENTION
acetazolamide 250 mg
acetazolamide ext-release (Diamox
Sequels – brand is NF)
amiloride
amiloride/hydrochlorothiazide
bumetanide
chlorothiazide
CHEST PAIN
furosemide, NF = soln, 8 mg/
mL (Lasix – brand is NF)
isosorbide dinitrate, NF = SL
tabs (Isordil – brand is NF)
hydrochlorothiazide caps (Microzide –
brand is NF)
isosorbide mononitrate (Monoket –
brand is NF)
hydrochlorothiazide tabs
isosorbide mononitrate extrelease (Imdur – brand is NF)
methazolamide (Neptazane – brand is
NF)
nitroglycerin (Nitro-Dur – brand is NF)
metolazone (Zaroxolyn – brand is NF)
NITROSTAT
spironolactone (Aldactone – brand is
NF)
CHOLESTEROL LOWERING
atorvastatin (Lipitor – brand is NF)
indapamide
cholestyramine (Questran, Questran
Light – brands are NF)
spironolactone/
hydrochlorothiazide (Aldactazide –
brand is NF)
colestipol (Colestid – brand is NF)
torsemide (Demadex – brand is NF)
CRESTOR
6
Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary
Step Therapy
Dispensing Limits
fenofibrate (Lofibra, Tricor – brands
are NF)
amlodipine (Norvasc – brand is NF)
felodipine ext-release
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2013
triamterene/hydrochlorothiazide
(Dyazide, Maxzide, Maxzide-25 –
brands are NF)
Step Therapy
RESPIRATORY AGENTS
ANTIHISTAMINES
cyproheptadine
amiodarone (Cordarone, Pacerone –
brands are NF)
promethazine, NF = supp, 50 mg
disopyramide (Norpace – brand is NF)
NASAL PRODUCTS
flecainide (Tambocor – brand is NF)
ASTEPRO
mexiletine
azelastine (Astelin – brand is NF)
MULTAQ
flunisolide
propafenone (Rythmol – brand is NF)
fluticasone propionate (Flonase –
brand is NF)
propafenone ext-release (Rythmol SR
– brand is NF)
ipratropium (Atrovent – brand is NF)
quinidine gluconate ext-release
NASONEX
quinidine sulfate, NF = ext-release
triamcinolone (Nasacort AQ – brand is
NF)
sotalol (Betapace, Betapace AF –
brands are NF)
•
•
•
•
•
•
•
COUGH/COLD/ALLERGY
OTHER HEART RELATED DRUGS
acetylcysteine
clonidine (Catapres, Catapres-TTS –
brands are NF)
ASTHMA/COPD
DIBENZYLINE
ADVAIR HFA
digoxin tabs (Lanoxin – brand is NF)
albuterol inhal soln, 0.083%, 0.5%
doxazosin (Cardura – brand is NF)
albuterol 0.63 mg/3 mL,
1.25 mg/3 mL (Accuneb – brand is
NF)
ADVAIR DISKUS
eplerenone (Inspra – brand is NF)
guanfacine (Tenex – brand is NF)
•
•
•
•
albuterol syrup, tabs
hydralazine
ASMANEX
methyldopa
ATROVENT HFA
midodrine
budesonide (Pulmicort Respules –
brand is NF)
minoxidil
prazosin (Minipress – brand is NF)
• • •
terazosin
COMBIVENT
COMBIVENT RESPIMAT
cromolyn inhal soln
ERECTILE DYSFUNCTION
CIALIS
Dispensing Limits
EPIPEN-JR 2-PAK
HEART RHYTHM
sildenafil (Revatio – brand is NF)
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2013
• •
DULERA
FLOVENT DISKUS
BEE STING KITS
FLOVENT HFA
EPIPEN 2-PAK
FORADIL AEROLIZER
Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary
•
•
•
•
•
•
•
•
•
•
7
ipratropium inhal soln
ipratropium/albuterol (Duoneb – brand
is NF)
•
•
QVAR
SPIRIVA HANDIHALER
SYMBICORT
•
•
•
•
terbutaline
EMEND caps
granisetron
ondansetron (Zofran, Zofran ODT –
brands are NF)
ondansetron 24 mg
•
CREON
GASTROINTESTINAL DRUGS
ZENPEP
LAXATIVES
OTHER GASTROINTESTINAL DRUGS
lactulose
ASACOL
PEG – electrolytes for soln (Colyte,
Golytely, Nulytely – brands are NF)
ASACOL HD
ULCER/GERD
calcium acetate (Eliphos, Phoslo –
brands are NF)
dicyclomine caps, tabs (Bentyl –
brand is NF)
CANASA
famotidine (Pepcid – brand is NF)
diphenoxylate/atropine tabs (Lomotil –
brand is NF)
hyoscyamine (Anaspaz, Levsin,
Levsin/SL – brands are NF)
lactulose
hyoscyamine ext-release (Levbid,
Symax DuoTab – brands are NF)
loperamide
LIALDA
•
methscopolamine (Pamine, Pamine
Forte – brands are NF)
8
mesalamine
metoclopramide (Reglan – brand is
NF)
PENTASA
RENVELA
misoprostol (Cytotec – brand is NF)
pantoprazole delayedrelease (Protonix – brand is NF)
• •
•
•
sulfasalazine (Azulfidine – brand is NF)
sulfasalazine delayedrelease (Azulfidine EN-Tabs – brand
is NF)
ursodiol (Actigall, Urso 250, Urso Forte
– brands are NF)
Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary
Step Therapy
Dispensing Limits
DELZICOL
glycopyrrolate (Robinul – brand is NF)
omeprazole delayed-release (Prilosec
– brand is NF)
•
balsalazide (Colazal – brand is NF)
cimetidine
NEXIUM
•
•
•
DIGESTIVE ENZYMES
zafirlukast (Accolate – brand is NF)
lansoprazole delayedrelease (Prevacid – brand is NF)
Prior Authorization
sucralfate (Carafate – brand is NF)
trimethobenzamide (Tigan – brand is
NF)
theophylline ext-release
VENTOLIN HFA
ranitidine (Zantac – brand is NF)
NAUSEA AND VOMITING
montelukast (Singulair – brand is NF)
PROAIR HFA
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2013
GENITOURINARY DRUGS
tamsulosin (Flomax – brand is NF)
URINARY TRACT INFECTIONS
CENTRAL NERVOUS SYSTEM DRUGS
nitrofurantoin (Furadantin – brand is
NF)
ANXIETY
nitrofurantoin
macrocrystalline (Macrodantin –
brand is NF)
alprazolam ext-release (Xanax XR –
brand is NF)
nitrofurantoin monohydrate/
macrocrystalline (Macrobid – brand
is NF)
DIAZEPAM oral soln, 1 mg/mL
hydroxyzine pamoate 25 mg,
50 mg (Vistaril – brand is NF)
oxybutynin
lorazepam (Ativan – brand is NF)
oxybutynin ext-release (Ditropan XL –
brand is NF)
tolterodine (Detrol – brand is NF)
lorazepam conc (Lorazepam Intensol –
brand is NF)
VESICARE
DEPRESSION
VAGINAL PRODUCTS
amitriptyline
CLEOCIN supp
bupropion (Wellbutrin – brand is NF)
clindamycin (Cleocin – brand is NF)
bupropion ext-release (Wellbutrin SR,
Wellbutrin XL – brands are NF)
•
citalopram (Celexa – brand is NF)
clomipramine (Anafranil – brand is NF)
desipramine (Norpramin – brand is NF)
terconazole (Terazol – brand is NF)
doxepin, NF = caps, 75 mg
VAGIFEM
escitalopram (Lexapro – brand is NF)
OTHER GENITOURINARY DRUGS
fluoxetine, NF = 60 mg (Prozac –
brand is NF)
alfuzosin ext-release (Uroxatral –
brand is NF)
fluvoxamine
AVODART
imipramine hcl (Tofranil – brand is NF)
CYSTAGON
mirtazapine (Remeron, Remeron
SolTab – brands are NF)
finasteride (Proscar – brand is NF)
POTASSIUM CITRATE
nortriptyline caps (Pamelor – brand is
NF)
potassium citrate/citric acid
powder (Polycitra-K – brand is NF)
paroxetine hcl (Paxil – brand is NF)
sodium citrate/citric acid (Shohl's –
brand is NF)
Step Therapy
diazepam tabs (Valium – brand is NF)
DETROL LA
metronidazole (MetroGel-Vaginal –
brand is NF)
•
buspirone
hydroxyzine hcl
ESTRACE crm
Dispensing Limits
alprazolam (Xanax – brand is NF)
URINARY TRACT SPASMS
CRINONE
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2013
paroxetine hcl ext-release (Paxil CR –
brand is NF)
phenelzine (Nardil – brand is NF)
Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary
9
sertraline (Zoloft – brand is NF)
zaleplon (Sonata – brand is NF)
tranylcypromine (Parnate – brand is
NF)
zolpidem (Ambien – brand is NF)
•
•
•
trazodone
zolpidem ext-release (Ambien CR –
brand is NF)
venlafaxine
HYPERACTIVITY/NARCOLEPSY
venlafaxine ext-release caps (Effexor
XR – brand is NF)
amphetamine/
dextroamphetamine (Adderall –
brand is NF)
•
amphetamine/dextroamphetamine
ext-release (Adderall XR – brand is
NF)
•
venlafaxine ext-release tabs, NF =
225 mg
PSYCHOTIC AND BIPOLAR DISORDERS
chlorpromazine
clozapine (Clozaril – brand is NF)
FLUPHENAZINE HCL conc, elixir
•
caffeine citrate (Cafcit – brand is NF)
haloperidol tabs
dextroamphetamine extrelease (Dexedrine Spansule – brand
is NF)
haloperidol lactate oral conc
INTUNIV
lithium carbonate
methylphenidate tabs (Ritalin – brand
is NF)
fluphenazine hcl tabs
lithium carbonate ext-release
300 mg (Lithobid – brand is NF)
lithium carbonate ext-release 450 mg
loxapine (Loxitane – brand is NF)
olanzapine (Zyprexa, Zyprexa Zydis –
brands are NF)
•
•
dextroamphetamine
•
•
•
methylphenidate ext-release caps;
tabs, 20 mg (Metadate CD, Ritalin
LA, Ritalin SR - brands are NF)
modafinil (Provigil – brand is NF)
•
VYVANSE
perphenazine
OTHER CENTRAL NERVOUS SYSTEM DRUGS
prochlorperazine
bupropion ext-release (Zyban – brand
is NF)
quetiapine (Seroquel – brand is NF)
risperidone (Risperdal, Risperdal MTab – brands are NF)
SEROQUEL XR
CHANTIX (Member benefits determine
coverage)
disulfiram (Antabuse – brand is NF)
thiothixene
donepezil (Aricept, Aricept ODT –
brands are NF)
trifluoperazine
EXELON patches, soln
ziprasidone (Geodon – brand is NF)
galantamine (Razadyne – brand is NF)
SLEEP AIDS
galantamine ext-release (Razadyne
ER – brand is NF)
estazolam
phenobarbital, NF = tabs, 64.8 mg,
97.2 mg
•
naltrexone (ReVia – brand is NF)
•
NICOTROL INHALER
temazepam (Restoril – brand is NF)
10
Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2013
NICOTROL NS
morphine sulfate conc, soln
NUEDEXTA
morphine sulfate ext-release (Kadian)
ORAP
rivastigmine (Exelon – brand is NF)
morphine sulfate ext-release (MS
Contin – brand is NF)
PAIN RELIEF DRUGS
MORPHINE SULFATE supp, tabs
NON-NARCOTIC DRUGS
NUCYNTA ER
butalbital/acetaminophen
oxycodone (Roxicodone – brand is NF)
butalbital/acetaminophen/caffeine
(Esgic, Esgic-Plus, Fioricet – brands
are NF)
oxycodone caps
butalbital/aspirin/caffeine
caps (Fiorinal – brand is NF)
oxycodone/aspirin (Percodan – brand
is NF)
salsalate
OXYCONTIN
NARCOTIC DRUGS
SUBOXONE SL film
acetaminophen/codeine (Tylenol w/
Codeine – brand is NF)
tramadol (Ultram – brand is NF)
buprenorphine (Subutex – brand is NF)
buprenorphine/naloxone SL
tabs (Suboxone – brand is NF)
• •
• •
• •
•
Step Therapy
Dispensing Limits
• •
diclofenac sodium extrelease (Voltaren-XR – brand is NF)
etodolac
flurbiprofen
ibuprofen
indomethacin
ketoprofen
leflunomide (Arava – brand is NF)
meloxicam tabs (Mobic – brand is NF)
hydromorphone soln, tabs (Dilaudid –
brand is NF)
methadone tabs (Dolophine – brand is
NF)
RHEUMATOID AND OSTEOARTHRITIS
diclofenac sodium delayed-release
hydrocodone/ibuprofen (Ibudone,
Reprexain, Vicoprofen – brands are
NF)
methadone conc, soln
•
• •
•
diclofenac potassium (Cataflam –
brand is NF)
hydrocodone/acetaminophen, NF =
tabs, 2.5-325 mg (Lortab – brand is
NF)
KADIAN
•
tramadol/acetaminophen (Ultracet –
brand is NF)
CELEBREX
CODEINE SULFATE 15 mg
fentanyl patches (Duragesic – brand is
NF)
•
oxycodone/acetaminophen (Percocet
– brand is NF)
butalbital/aspirin/caffeine/
codeine (Fiorinal w/Codeine – brand
is NF)
fentanyl lollipop (Actiq – brand is NF)
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2013
nabumetone
•
naproxen (Naprosyn – brand is NF)
naproxen delayed-release (ECNaprosyn – brand is NF)
naproxen sodium (Anaprox – brand is
NF)
Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary
11
oxaprozin (Daypro – brand is NF)
lamotrigine (Lamictal – brand is NF)
piroxicam (Feldene – brand is NF)
levetiracetam (Keppra – brand is NF)
sulindac (Clinoril – brand is NF)
LYRICA caps
MIGRAINE HEADACHES
oxcarbazepine (Trileptal – brand is NF)
acetaminophen/isometheptene/
dichloralphenazone
phenytoin chew tabs (Dilantin Infatabs
– brand is NF)
IMITREX nasal spray
MIGRANAL
naratriptan (Amerge – brand is NF)
rizatriptan (Maxalt, Maxalt-MLT –
brands are NF)
sumatriptan inj, tabs (Imitrex – brand
is NF)
•
•
•
•
phenytoin susp (Dilantin – brand is NF)
primidone (Mysoline – brand is NF)
SABRIL
•
TEGRETOL-XR 100 mg
topiramate (Topamax, Topamax
Sprinkle – brands are NF)
allopurinol (Zyloprim – brand is NF)
valproic acid (Depakene – brand is NF)
COLCRYS
zonisamide (Zonegran – brand is NF)
probenecid
PARKINSON'S DISEASE
probenecid/colchicine
amantadine, NF = tabs
NEUROMUSCULAR DRUGS
AZILECT
SEIZURES
benztropine
carbamazepine (Tegretol – brand is
NF)
bromocriptine (Parlodel – brand is NF)
carbidopa/levodopa (Parcopa,
Sinemet – brands are NF)
carbamazepine ext-release
(Carbatrol, Tegretol-XR – brands are
NF)
carbidopa/levodopa extrelease (Sinemet CR – brand is NF)
CELONTIN
entacapone (Comtan)
clonazepam (Klonopin – brand is NF)
•
pramipexole (Mirapex – brand is NF)
ropinirole (Requip – brand is NF)
DILANTIN 30 mg
selegiline caps (Eldepryl – brand is NF)
divalproex delayed-release
(Depakote, Depakote Sprinkles –
brands are NF)
selegiline tabs
divalproex ext-release (Depakote ER –
brand is NF)
MUSCLE RELAXANTS
ethosuximide (Zarontin – brand is NF)
gabapentin (Neurontin – brand is NF)
chlorzoxazone (Parafon Forte DSC –
brand is NF)
GABITRIL 12 mg, 16 mg
cyclobenzaprine
12
trihexyphenidyl
baclofen
Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary
Step Therapy
Dispensing Limits
phenytoin sodium ext-release
(Dilantin, Phenytek – brands are NF)
GOUT
DIASTAT
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2013
dantrolene (Dantrium – brand is NF)
methocarbamol (Robaxin – brand is
NF)
•
cilostazol (Pletal – brand is NF)
clopidogrel (Plavix – brand is NF)
MESTINON syrup
cyanocobalamin inj
MESTINON TIMESPAN
dipyridamole (Persantine – brand is
NF)
DROXIA
RILUTEK
enoxaparin (Lovenox – brand is NF)
riluzole (Rilutek)
folic acid tabs, 1 mg
SUPPLEMENTS
pentoxifylline ext-release (Trental –
brand is NF)
MEPHYTON
MULTIVITAMINS
pediatric multivitamins
pediatric vitamins ADC
PRENAPLUS
PRENATABS FA
PRENATAL LOW IRON, PLUS, PLUS/
IRON, VITAMINS PLUS, 19
SE-NATAL 19
•
warfarin (Coumadin – brand is NF)
XARELTO
•
TOPICAL DRUGS
EYE
Anti-infectives
BACITRACIN oint
bacitracin/polymyxin B oint
ciprofloxacin soln (Ciloxan – brand is
NF)
erythromycin oint
MINERALS AND ELECTROLYTES
gentamicin oint, soln (Garamycin –
brand is NF)
K-PHOS
NATACYN
potassium bicarbonate/chloride
effervescent tabs, 25 mEq
neomycin/polymyxin B/bacitracin
oint
potassium chloride packets; soln,
10%
neomycin/polymyxin B/gramicidin
soln (Neosporin – brand is NF)
potassium chloride ext-release (KTabs – brand is NF)
ofloxacin soln (Ocuflox – brand is NF)
potassium chloride ext-release
caps (Micro-K – brand is NF)
Step Therapy
anagrelide (Agrylin – brand is NF)
OTHER NEUROMUSCULAR DRUGS
ergocalciferol (Drisdol – brand is NF)
Dispensing Limits
BLOOD MODIFYING DRUGS
orphenadrine/aspirin/caffeine
25-385-30 mg
VITAMINS
Prior Authorization
sodium fluoride chew tabs,
soln (Luride – brand is NF)
orphenadrine citrate ext-release
pyridostigmine (Mestinon – brand is
NF)
Specialty
Drug Name
potassium phosphate/sodium
phosphates (K-Phos Neutral – brand
is NF)
metaxalone (Skelaxin – brand is NF)
tizanidine (Zanaflex – brand is NF)
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2013
polymyxin B/trimethoprim
soln (Polytrim – brand is NF)
Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary
13
sulfacetamide sodium soln (Bleph-10
– brand is NF)
latanoprost soln (Xalatan – brand is
NF)
tobramycin soln (Tobrex – brand is
NF)
levobunolol soln, 0.5% (Betagan –
brand is NF)
trifluridine soln (Viroptic – brand is NF)
LUMIGAN
VIGAMOX
Steroids and Combination Products
metipranolol soln (Optipranolol –
brand is NF)
dexamethasone sodium phosphate
soln
pilocarpine soln (Isopto Carpine –
brand is NF)
fluorometholone susp (FML Liquifilm –
brand is NF)
timolol maleate soln (Timoptic,
Timoptic-XE – brands are NF)
LOTEMAX
TRAVATAN Z
neomycin/polymyxin B/bacitracin/
hydrocortisone oint
Other Eye Products
neomycin/polymyxin B/
dexamethasone oint, susp (Maxitrol
– brand is NF)
diclofenac soln (Voltaren – brand is
NF)
sulfacetamide sodium/prednisolone
soln
flurbiprofen soln (Ocufen – brand is
NF)
TOBRADEX oint
homatropine soln (Isopto Homatropine
– brand is NF)
ZYLET
ketorolac soln (Acular, Acular LS –
brands are NF)
Glaucoma
PATADAY
ALPHAGAN P 0.1%
tropicamide soln (Mydriacyl – brand is
NF)
brimonidine soln, 0.15% (Alphagan P
– brand is NF)
EAR
brimonidine soln, 0.2%
benzocaine/antipyrine soln
carteolol soln
CIPRODEX
dorzolamide soln (Trusopt – brand is
NF)
hydrocortisone/acetic acid
soln (Vosol HC – brand is NF)
dorzolamide/timolol maleate
soln (Cosopt – brand is NF)
neomycin/polymyxin B/
hydrocortisone soln,
susp (Cortisporin – brand is NF)
acetic acid soln
Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary
Step Therapy
Dispensing Limits
•
cromolyn soln
PREDNISOLONE SODIUM
PHOSPHATE soln, 1%
14
•
azelastine soln (Optivar – brand is NF)
cyclopentolate soln (Cyclogyl – brand
is NF)
AZOPT
•
atropine sulfate soln (Isopto Atropine –
brand is NF)
prednisolone acetate susp (Pred Forte
– brand is NF)
tobramycin/dexamethasone
susp (Tobradex – brand is NF)
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2013
ofloxacin soln
TAZORAC
MOUTH AND THROAT (local)
tretinoin (Retin-A – brand is NF)
cevimeline (Evoxac - brand is NF)
tretinoin microsphere gel,
0.1% (Retin-A Micro – brand is NF)
chlorhexidine oral rinse (Peridex –
brand is NF)
lidocaine viscous
ciclopirox crm, gel, shampoo,
susp (Loprox – brand is NF)
nystatin susp
ciclopirox soln (Penlac – brand is NF)
pilocarpine (Salagen – brand is NF)
econazole
sodium fluoride (Prevident – brand is
NF)
ketoconazole (Nizoral – brand is NF)
triamcinolone dental paste
nystatin topical
ANORECTAL AGENTS
silver sulfadiazine (Silvadene – brand
is NF)
alclometasone (Aclovate – brand is
NF)
hydrocortisone acetate crm, supp
(Anusol-HC, Protocort – brands are
NF)
amcinonide crm
betamethasone dipropionate
SKIN CONDITIONS/PRODUCTS
betamethasone dipropionate,
augmented (Diprolene – brand is NF)
Acne
•
clindamycin (Cleocin-T – brand is NF)
betamethasone valerate
clobetasol (Clobex, Olux, Temovate –
brands are NF)
clindamycin/benzoyl peroxide
(Benzaclin, Duac – brands are NF)
erythromycin/benzoyl
peroxide (Benzamycin – brand is NF)
Step Therapy
Corticosteroids
hydrocortisone enema (Cortenema –
brand is NF)
erythromycin pads, soln
Dispensing Limits
mupirocin (Bactroban – brand is NF)
CORTIFOAM
DIFFERIN gel, 0.3%
•
•
Anti-infectives
clotrimazole troche
adapalene (Differin – brand is NF)
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2013
desonide (Desowen – brand is NF)
•
desoximetasone crm, 0.25%; gel;
oint, 0.25% (Topicort – brand is NF)
diflorasone oint
FINACEA
fluocinolone (Derma-Smoothe/FS,
Synalar – brands are NF)
isotretinoin, NF = 30 mg
fluocinonide
metronidazole (Metrocream,
Metrolotion – brands are NF)
fluticasone propionate (Cutivate –
brand is NF)
metronidazole topical gel (Metrogel –
brand is NF)
halobetasol (Ultravate – brand is NF)
sulfacetamide sodium/sulfur, NF =
susp, 10-5%
hydrocortisone valerate (Westcort –
brand is NF)
hydrocortisone topical
Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary
15
mometasone (Elocon – brand is NF)
nystatin/triamcinolone crm
LANCETS – BAYER FINGERSTIX,
MICROLET, SINGLE-LET
triamcinolone crm; lotn; oint,
0.025%, 0.1%
LANCETS – BD MICROTAINER
ULTRAFINE
Other Skin Products
LANCETS – ROCHE ACCU-CHEK
FASTCLIX, MULTICLIX, SOFT
TOUCH, SOFTCLIX
acitretin (Soriatane)
aluminum chloride (Drysol – brand is
NF)
calcipotriene crm, soln (Dovonex –
brand is NF)
CARAC
ELIDEL
FLUOROPLEX
fluorouracil (Efudex – brand is NF)
imiquimod (Aldara – brand is NF)
•
•
TEST STRIPS – ROCHE ACCU-CHEK
ACTIVE, AVIVA, AVIVA PLUS,
COMFORT CURVE, COMPACT,
SMARTVIEW
•
TEST STRIPS – ROCHE
ACCUTREND
•
RESPIRATORY INHALER-ASSIST DEVICES
BREATHERITE
lidocaine/prilocaine crm (Emla –
brand is NF)
azathioprine (Imuran – brand is NF)
MISCELLANEOUS DRUGS
lindane
CELLCEPT oral susp
malathion (Ovide – brand is NF)
CHEMET
permethrin (Elimite – brand is NF)
CUPRIMINE
podofilox (Condylox – brand is NF)
cyclosporine (Sandimmune – brand is
NF)
PROTOPIC
cyclosporine modified caps, 25 mg,
100 mg; soln (Neoral – brand is NF)
selenium sulfide (Selsun – brand is
NF)
CYCLOSPORINE modified caps,
50 mg
SOLARAZE
SORIATANE
XERAC AC
mycophenolate mofetil (Cellcept –
brand is NF)
ZYCLARA
MYFORTIC
ZYCLARA PUMP
RAPAMUNE
MISCELLANEOUS CATEGORIES
sodium polystyrene sulfonate
DIABETIC SUPPLIES
tacrolimus (Prograf – brand is NF)
INSULIN PEN NEEDLES – BD
ULTRAFINE, NOVOFINE,
NOVOTWIST
•
INSULIN SYRINGES – BD
•
ZORTRESS
Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary
Step Therapy
Dispensing Limits
TEST STRIPS – BAYER ASCENSIA
AUTODISC, BREEZE 2, CONTOUR,
CONTOUR NEXT
lidocaine topical, NF = lotn (Xylocaine
– brand is NF)
16
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2013
2013
INDEX
A
abacavir tabs...................................................................2
acarbose.......................................................................... 4
acebutolol........................................................................ 5
acetaminophen/codeine............................................... 11
acetaminophen/isometheptene/dichloralphenazone 12
acetazolamide 250 mg................................................... 6
acetazolamide ext-release............................................. 6
acetic acid ear soln...................................................... 14
acetylcysteine................................................................. 7
acitretin.......................................................................... 16
ACTONEL......................................................................... 5
acyclovir.......................................................................... 2
adapalene...................................................................... 15
ADVAIR DISKUS..............................................................7
ADVAIR HFA.................................................................... 7
ALBENZA..........................................................................2
albuterol 0.63 mg/3 mL, 1.25 mg/3 mL......................... 7
albuterol inhal soln, 0.083%, 0.5%................................ 7
albuterol syrup, tabs...................................................... 7
alclometasone............................................................... 15
alendronate 5 mg, 10 mg, 35 mg, 70 mg...................... 5
alfuzosin ext-release...................................................... 9
ALKERAN tabs................................................................. 3
allopurinol......................................................................12
ALPHAGAN P 0.1%....................................................... 14
alprazolam....................................................................... 9
alprazolam ext-release................................................... 9
aluminum chloride........................................................16
amantadine, NF = tabs................................................. 12
amcinonide crm............................................................ 15
amiloride.......................................................................... 6
amiloride/hydrochlorothiazide.......................................6
amiodarone......................................................................7
amitriptyline.....................................................................9
amlodipine....................................................................... 6
amlodipine/benazepril.................................................... 6
amoxicillin, NF = chew tabs.......................................... 1
amoxicillin/potassium clavulanate................................1
amoxicillin/potassium clavulanate ext-release............ 1
amphetamine/dextroamphetamine..............................10
amphetamine/dextroamphetamine ext-release..........10
ampicillin caps................................................................1
anagrelide...................................................................... 13
anastrozole...................................................................... 3
ANDRODERM.................................................................. 3
ANDROGEL......................................................................3
ANDROXY........................................................................ 3
APTIVUS...........................................................................2
ASACOL........................................................................... 8
ASACOL HD.....................................................................8
ASMANEX........................................................................ 7
ASTEPRO.........................................................................7
atenolol............................................................................ 5
atenolol/chlorthalidone.................................................. 5
atorvastatin......................................................................6
atovaquone/proguanil 250-100 mg............................... 2
ATRIPLA........................................................................... 2
atropine sulfate eye soln............................................. 14
ATROVENT HFA..............................................................7
AVODART.........................................................................9
azathioprine...................................................................16
azelastine.........................................................................7
azelastine eye soln.......................................................14
AZILECT......................................................................... 12
azithromycin susp.......................................................... 1
azithromycin tabs........................................................... 1
AZOPT............................................................................ 14
B
bacitracin/polymyxin B eye oint................................. 13
BACITRACIN eye oint.................................................... 13
baclofen......................................................................... 12
balsalazide.......................................................................8
BARACLUDE.................................................................... 2
benazepril........................................................................ 5
benazepril/hydrochlorothiazide.....................................5
BENICAR.......................................................................... 5
BENICAR HCT................................................................. 5
benzocaine/antipyrine ear soln................................... 14
benztropine....................................................................12
betamethasone dipropionate.......................................15
betamethasone dipropionate, augmented................. 15
betamethasone valerate...............................................15
bicalutamide.................................................................... 3
BILTRICIDE...................................................................... 2
bisoprolol.........................................................................5
bisoprolol/hydrochlorothiazide..................................... 5
BREATHERITE...............................................................16
brimonidine eye soln, 0.15%....................................... 14
brimonidine eye soln, 0.2%......................................... 14
bromocriptine................................................................12
budesonide......................................................................7
budesonide ext-release..................................................3
bumetanide......................................................................6
buprenorphine...............................................................11
buprenorphine/naloxone SL tabs............................... 11
bupropion........................................................................ 9
bupropion ext-release.................................................... 9
bupropion ext-release.................................................. 10
buspirone.........................................................................9
butalbital/acetaminophen.............................................11
butalbital/acetaminophen/caffeine.............................. 11
butalbital/aspirin/caffeine/codeine.............................. 11
butalbital/aspirin/caffeine caps................................... 11
C
cabergoline......................................................................5
Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary
17
2013
caffeine citrate.............................................................. 10
calcipotriene crm, soln................................................ 16
calcitonin-salmon........................................................... 5
calcitriol........................................................................... 5
calcium acetate...............................................................8
CANASA........................................................................... 8
captopril...........................................................................5
CARAC........................................................................... 16
carbamazepine.............................................................. 12
carbamazepine ext-release.......................................... 12
carbidopa/levodopa...................................................... 12
carbidopa/levodopa ext-release.................................. 12
carteolol eye soln......................................................... 14
carvedilol......................................................................... 5
cefaclor caps...................................................................1
cefadroxil......................................................................... 1
cefdinir............................................................................. 1
cefpodoxime....................................................................1
cefprozil........................................................................... 1
ceftriaxone.......................................................................1
cefuroxime.......................................................................1
CELEBREX.....................................................................11
CELLCEPT oral susp..................................................... 16
CELONTIN......................................................................12
cephalexin, NF = tabs.................................................... 1
cevimeline......................................................................15
CHANTIX (Member benefits determine coverage)......... 10
CHEMET.........................................................................16
chlorhexidine oral rinse............................................... 15
chloroquine phosphate.................................................. 2
chlorothiazide..................................................................6
chlorpromazine............................................................. 10
chlorzoxazone............................................................... 12
cholestyramine................................................................6
chorionic gonadotropin................................................. 4
CIALIS...............................................................................7
ciclopirox crm, gel, shampoo, susp........................... 15
ciclopirox soln.............................................................. 15
cilostazol........................................................................13
cimetidine........................................................................ 8
CIPRODEX..................................................................... 14
ciprofloxacin....................................................................1
ciprofloxacin ext-release................................................1
ciprofloxacin eye soln..................................................13
citalopram........................................................................9
clarithromycin................................................................. 1
clarithromycin ext-release............................................. 1
CLEOCIN supp.................................................................9
clindamycin..................................................................... 2
clindamycin................................................................... 15
clindamycin/benzoyl peroxide.....................................15
clindamycin crm............................................................. 9
clobetasol...................................................................... 15
clomiphene...................................................................... 4
clomipramine...................................................................9
clonazepam................................................................... 12
18
clonidine.......................................................................... 7
clopidogrel.....................................................................13
clotrimazole troche.......................................................15
clozapine........................................................................10
CODEINE SULFATE 15 mg...........................................11
COLCRYS.......................................................................12
colestipol......................................................................... 6
COMBIPATCH.................................................................. 3
COMBIVENT.....................................................................7
COMBIVENT RESPIMAT................................................. 7
CORTIFOAM.................................................................. 15
CORTISONE.....................................................................3
CREON............................................................................. 8
CRESTOR........................................................................ 6
CRINONE......................................................................... 9
CRIXIVAN......................................................................... 2
cromolyn eye soln........................................................14
cromolyn inhal soln....................................................... 7
CUPRIMINE....................................................................16
cyanocobalamin inj...................................................... 13
cyclobenzaprine............................................................12
cyclopentolate eye soln............................................... 14
CYCLOPHOSPHAMIDE tabs........................................... 3
cyclosporine..................................................................16
CYCLOSPORINE........................................................... 16
cyclosporine modified caps, 25 mg, 100 mg; soln.... 16
cyproheptadine............................................................... 7
CYSTAGON......................................................................9
D
danazol.............................................................................3
dantrolene......................................................................13
DAPSONE........................................................................ 2
DARAPRIM....................................................................... 2
DELZICOL........................................................................ 8
demeclocycline............................................................... 1
desipramine.....................................................................9
desmopressin..................................................................5
desonide........................................................................ 15
desoximetasone crm, 0.25%; gel; oint, 0.25%........... 15
DETROL LA......................................................................9
dexamethasone elixir; tabs, 0.5 mg, 0.75 mg, 1.5 mg,
4 mg, 6 mg.................................................................... 3
dexamethasone sodium phosphate eye soln............ 14
DEXAMETHASONE soln, 0.5 mg/5 mL........................... 3
dextroamphetamine......................................................10
dextroamphetamine ext-release..................................10
DIASTAT.........................................................................12
DIAZEPAM oral soln, 1 mg/mL........................................ 9
diazepam tabs.................................................................9
DIBENZYLINE.................................................................. 7
diclofenac eye soln...................................................... 14
diclofenac potassium................................................... 11
diclofenac sodium delayed-release............................ 11
diclofenac sodium ext-release.................................... 11
dicloxacillin..................................................................... 1
Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary
2013
dicyclomine caps, tabs.................................................. 8
didanosine delayed-release...........................................2
DIFFERIN gel, 0.3%.......................................................15
diflorasone oint.............................................................15
digoxin tabs.................................................................... 7
DILANTIN 30 mg............................................................ 12
diltiazem...........................................................................6
diltiazem ext-release...................................................... 6
diphenoxylate/atropine tabs.......................................... 8
dipyridamole..................................................................13
disopyramide...................................................................7
disulfiram.......................................................................10
divalproex delayed-release..........................................12
divalproex ext-release.................................................. 12
DIVIGEL............................................................................3
donepezil....................................................................... 10
dorzolamide/timolol maleate eye soln........................14
dorzolamide eye soln...................................................14
doxazosin........................................................................ 7
doxepin, NF = caps, 75 mg............................................9
doxycycline hyclate........................................................1
doxycycline monohydrate............................................. 1
DROXIA.......................................................................... 13
DULERA........................................................................... 7
E
econazole.......................................................................15
ELIDEL............................................................................16
ELLA................................................................................. 4
EMCYT............................................................................. 3
EMEND caps.................................................................... 8
EMTRIVA.......................................................................... 2
enalapril........................................................................... 5
enalapril/hydrochlorothiazide........................................5
ENJUVIA...........................................................................3
enoxaparin.....................................................................13
entacapone.................................................................... 12
EPIPEN 2-PAK................................................................. 7
EPIPEN-JR 2-PAK........................................................... 7
EPIVIR soln...................................................................... 2
eplerenone.......................................................................7
EPZICOM..........................................................................2
ergocalciferol................................................................ 13
erythromycin/benzoyl peroxide...................................15
erythromycin/sulfisoxazole............................................2
erythromycin delayed-release caps..............................1
erythromycin eye oint.................................................. 13
erythromycin pads, soln.............................................. 15
escitalopram....................................................................9
estazolam.......................................................................10
ESTRACE crm..................................................................9
estradiol/norethindrone acetate.................................... 3
estradiol patches............................................................ 3
estradiol tabs.................................................................. 3
estropipate, NF = 3 mg.................................................. 3
ethambutol.......................................................................1
ethosuximide.................................................................12
etodolac......................................................................... 11
EVISTA............................................................................. 5
EXELON patches, soln...................................................10
exemestane..................................................................... 3
F
famciclovir....................................................................... 2
famotidine........................................................................8
FARESTON...................................................................... 3
felodipine ext-release..................................................... 6
fenofibrate....................................................................... 6
fenofibrate micronized................................................... 6
fenofibric acid delayed-release caps............................6
fentanyl.......................................................................... 11
fentanyl lollipop............................................................ 11
FINACEA........................................................................ 15
finasteride........................................................................9
flecainide......................................................................... 7
FLOVENT DISKUS...........................................................7
FLOVENT HFA.................................................................7
fluconazole...................................................................... 1
flucytosine....................................................................... 1
fludrocortisone................................................................3
flunisolide........................................................................ 7
fluocinolone...................................................................15
fluocinonide...................................................................15
fluorometholone eye susp...........................................14
FLUOROPLEX................................................................16
fluorouracil.................................................................... 16
fluoxetine, NF = 60 mg...................................................9
FLUPHENAZINE HCL conc, elixir..................................10
fluphenazine hcl tabs...................................................10
flurbiprofen....................................................................11
flurbiprofen eye soln....................................................14
flutamide.......................................................................... 3
fluticasone propionate................................................... 7
fluticasone propionate................................................. 15
fluvoxamine..................................................................... 9
folic acid tabs, 1 mg.................................................... 13
FORADIL AEROLIZER.....................................................7
fosinopril..........................................................................5
fosinopril/hydrochlorothiazide...................................... 5
furosemide, NF = soln, 8 mg/mL...................................6
G
gabapentin.....................................................................12
GABITRIL 12 mg, 16 mg................................................12
galantamine................................................................... 10
galantamine ext-release............................................... 10
gemfibrozil.......................................................................6
gentamicin eye oint, soln............................................ 13
glimepiride.......................................................................4
glipizide............................................................................4
glipizide/metformin......................................................... 4
glipizide ext-release....................................................... 4
Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary
19
2013
GLUCAGON EMERGENCY KIT...................................... 4
glyburide..........................................................................4
glyburide/metformin....................................................... 4
glyburide micronized..................................................... 4
glycopyrrolate................................................................. 8
granisetron...................................................................... 8
griseofulvin microsize....................................................1
guanfacine....................................................................... 7
H
halobetasol.................................................................... 15
haloperidol lactate oral conc.......................................10
haloperidol tabs............................................................10
HEPSERA.........................................................................2
homatropine eye soln.................................................. 14
HUMALOG........................................................................4
HUMALOG MIX 50/50, 75/25...........................................4
HUMULIN 70/30............................................................... 4
HUMULIN N......................................................................4
HUMULIN R......................................................................4
hydralazine...................................................................... 7
hydrochlorothiazide caps.............................................. 6
hydrochlorothiazide tabs............................................... 6
hydrocodone/acetaminophen, NF = tabs, 2.5-325
mg.................................................................................11
hydrocodone/ibuprofen................................................11
hydrocortisone................................................................3
hydrocortisone/acetic acid ear soln........................... 14
hydrocortisone acetate rectal crm, supp................... 15
hydrocortisone enema................................................. 15
hydrocortisone topical................................................. 15
hydrocortisone valerate............................................... 15
hydromorphone soln, tabs.......................................... 11
hydroxychloroquine....................................................... 2
hydroxyurea.................................................................... 3
hydroxyzine hcl.............................................................. 9
hydroxyzine pamoate 25 mg, 50 mg.............................9
hyoscyamine................................................................... 8
hyoscyamine ext-release............................................... 8
I
ibandronate..................................................................... 5
ibuprofen....................................................................... 11
imipramine hcl................................................................ 9
imiquimod......................................................................16
IMITREX nasal spray..................................................... 12
indapamide...................................................................... 6
indomethacin.................................................................11
INNOPRAN XL................................................................. 5
INSULIN PEN NEEDLES – BD ULTRAFINE,
NOVOFINE, NOVOTWIST........................................... 16
INSULIN SYRINGES – BD............................................ 16
INTELENCE......................................................................2
INTUNIV..........................................................................10
INVIRASE......................................................................... 2
ipratropium/albuterol......................................................8
20
ipratropium inhal soln....................................................8
ipratropium nasal........................................................... 7
irbesartan.........................................................................5
irbesartan/hydrochlorothiazide..................................... 5
ISENTRESS......................................................................2
isoniazid/rifampin........................................................... 1
isoniazid tabs..................................................................1
isosorbide dinitrate, NF = SL tabs................................6
isosorbide mononitrate..................................................6
isosorbide mononitrate ext-release.............................. 6
isotretinoin, NF = 30 mg.............................................. 15
itraconazole..................................................................... 1
J
JANUMET......................................................................... 4
JANUMET XR...................................................................4
JANUVIA...........................................................................4
JUVISYNC........................................................................ 4
K
KADIAN...........................................................................11
KALETRA..........................................................................2
ketoconazole................................................................. 15
ketoconazole tabs.......................................................... 1
ketoprofen..................................................................... 11
ketorolac eye soln........................................................ 14
KOMBIGLYZE XR............................................................ 4
K-PHOS.......................................................................... 13
L
labetalol........................................................................... 5
lactulose.......................................................................... 8
lactulose.......................................................................... 8
lamivudine....................................................................... 2
lamivudine/zidovudine................................................... 2
lamotrigine.....................................................................12
LANCETS – BAYER FINGERSTIX, MICROLET,
SINGLE-LET................................................................. 16
LANCETS – BD MICROTAINER ULTRAFINE............... 16
LANCETS – ROCHE ACCU-CHEK FASTCLIX,
MULTICLIX, SOFT TOUCH, SOFTCLIX...................... 16
lansoprazole delayed-release........................................8
LANTUS............................................................................4
latanoprost eye soln.................................................... 14
leflunomide....................................................................11
letrozole........................................................................... 3
LEUCOVORIN CALCIUM tabs, 10 mg, 15 mg.................3
leucovorin calcium tabs, 5 mg, 25 mg......................... 3
LEUKERAN.......................................................................3
LEVEMIR.......................................................................... 4
levetiracetam................................................................. 12
levobunolol eye soln, 0.5%..........................................14
levocarnitine....................................................................5
levofloxacin..................................................................... 1
levonorgestrel................................................................. 4
levothyroxine...................................................................4
Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary
2013
LEXIVA............................................................................. 2
LIALDA..............................................................................8
lidocaine/prilocaine crm...............................................16
lidocaine topical, NP = lotn......................................... 16
lidocaine viscous..........................................................15
lindane........................................................................... 16
liothyronine..................................................................... 4
lisinopril........................................................................... 5
lisinopril/hydrochlorothiazide........................................5
lithium carbonate..........................................................10
lithium carbonate ext-release 300 mg........................ 10
lithium carbonate ext-release 450 mg........................ 10
loperamide.......................................................................8
lorazepam........................................................................ 9
lorazepam conc.............................................................. 9
losartan............................................................................ 5
losartan/hydrochlorothiazide.........................................5
LOTEMAX.......................................................................14
lovastatin......................................................................... 6
loxapine......................................................................... 10
LUMIGAN........................................................................14
LYRICA caps.................................................................. 12
M
MALARONE 62.5-25 mg.................................................. 2
malathion....................................................................... 16
medroxyprogesterone acetate...................................... 4
medroxyprogesterone acetate inj, 150 mg/mL............ 4
mefloquine.......................................................................2
megestrol.........................................................................3
meloxicam tabs.............................................................11
MEPHYTON....................................................................13
mercaptopurine...............................................................3
mesalamine..................................................................... 8
MESNEX tabs...................................................................3
MESTINON syrup...........................................................13
MESTINON TIMESPAN................................................. 13
metaxalone.................................................................... 13
metformin........................................................................ 4
metformin ext-release.................................................... 4
metformin ext-release OSM........................................... 4
methadone conc, soln................................................. 11
methadone tabs............................................................ 11
methazolamide................................................................ 6
methimazole.................................................................... 4
methocarbamol............................................................. 13
methotrexate................................................................... 3
methscopolamine........................................................... 8
methyldopa......................................................................7
methylergonovine........................................................... 5
methylphenidate ext-release caps; tabs, 20 mg........ 10
methylphenidate tabs...................................................10
methylprednisolone........................................................3
metipranolol eye soln.................................................. 14
metoclopramide.............................................................. 8
metolazone...................................................................... 6
metoprolol succinate ext-release..................................5
metoprolol tartrate..........................................................5
metronidazole..................................................................9
metronidazole................................................................15
metronidazole tabs.........................................................2
metronidazole topical gel............................................ 15
mexiletine........................................................................ 7
midodrine.........................................................................7
MIGRANAL..................................................................... 12
minocycline..................................................................... 1
minoxidil.......................................................................... 7
mirtazapine...................................................................... 9
misoprostol..................................................................... 8
modafinil........................................................................ 10
moexipril.......................................................................... 5
moexipril/hydrochlorothiazide.......................................5
mometasone..................................................................16
montelukast.....................................................................8
morphine sulfate conc, soln........................................11
morphine sulfate ext-release.......................................11
morphine sulfate ext-release.......................................11
MORPHINE SULFATE supp, tabs................................. 11
MULTAQ........................................................................... 7
mupirocin.......................................................................15
MYCOBUTIN.................................................................... 1
mycophenolate mofetil.................................................16
MYFORTIC..................................................................... 16
MYLERAN.........................................................................3
N
nabumetone...................................................................11
nadolol............................................................................. 6
naltrexone......................................................................10
naproxen........................................................................11
naproxen delayed-release............................................11
naproxen sodium..........................................................11
naratriptan..................................................................... 12
NASONEX........................................................................ 7
NATACYN.......................................................................13
nateglinide....................................................................... 4
neomycin/polymyxin B/bacitracin/hydrocortisone
eye oint........................................................................ 14
neomycin/polymyxin B/bacitracin eye oint................ 13
neomycin/polymyxin B/dexamethasone eye oint,
susp..............................................................................14
neomycin/polymyxin B/gramicidin eye soln.............. 13
neomycin/polymyxin B/hydrocortisone ear soln,
susp..............................................................................14
neomycin sulfate............................................................ 1
nevirapine tabs............................................................... 2
NEXIUM............................................................................ 8
NIASPAN.......................................................................... 6
NICOTROL INHALER.................................................... 10
NICOTROL NS............................................................... 11
nifedipine ext-release..................................................... 6
NILANDRON.....................................................................3
Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary
21
2013
nitrofurantoin.................................................................. 9
nitrofurantoin macrocrystalline.....................................9
nitrofurantoin monohydrate/macrocrystalline............. 9
nitroglycerin.................................................................... 6
NITROSTAT......................................................................6
norethindrone acetate.................................................... 4
nortriptyline caps........................................................... 9
NORVIR............................................................................ 2
NOVOLIN 70/30............................................................... 4
NOVOLIN N......................................................................4
NOVOLIN R......................................................................4
NOVOLOG........................................................................4
NOVOLOG MIX 70/30......................................................4
NOXAFIL...........................................................................1
NUCYNTA ER................................................................ 11
NUEDEXTA.................................................................... 11
NUVARING....................................................................... 4
nystatin/triamcinolone crm..........................................16
nystatin oral.................................................................... 1
nystatin susp................................................................ 15
nystatin topical............................................................. 15
O
octreotide.........................................................................5
ofloxacin ear soln.........................................................15
ofloxacin eye soln........................................................ 13
ofloxacin tabs................................................................. 1
olanzapine..................................................................... 10
omeprazole delayed-release..........................................8
ondansetron.................................................................... 8
ondansetron 24 mg........................................................ 8
ONGLYZA.........................................................................4
oral contraceptives – all generics.................................4
ORAP..............................................................................11
orphenadrine/aspirin/caffeine 25-385-30 mg..............13
orphenadrine citrate ext-release................................. 13
ORTHO EVRA..................................................................4
oxaprozin....................................................................... 12
oxcarbazepine............................................................... 12
oxybutynin.......................................................................9
oxybutynin ext-release...................................................9
oxycodone..................................................................... 11
oxycodone/acetaminophen..........................................11
oxycodone/aspirin........................................................ 11
oxycodone caps........................................................... 11
OXYCONTIN...................................................................11
P
pantoprazole delayed-release....................................... 8
paromomycin.................................................................. 1
paroxetine hcl................................................................. 9
paroxetine hcl ext-release............................................. 9
PATADAY....................................................................... 14
pediatric multivitamins.................................................13
pediatric vitamins ADC................................................ 13
PEG – electrolytes for soln........................................... 8
22
penicillin v potassium....................................................1
PENTASA......................................................................... 8
pentoxifylline ext-release.............................................13
perindopril....................................................................... 5
permethrin..................................................................... 16
perphenazine.................................................................10
phenelzine....................................................................... 9
phenobarbital, NF = tabs, 64.8 mg, 97.2 mg...............10
phenytoin chew tabs....................................................12
phenytoin sodium ext-release.....................................12
phenytoin susp............................................................. 12
pilocarpine.....................................................................15
pilocarpine eye soln.....................................................14
pioglitazone..................................................................... 4
pioglitazone/metformin.................................................. 4
piroxicam....................................................................... 12
podofilox........................................................................16
polymyxin B/trimethoprim eye soln............................13
potassium bicarbonate/chloride effervescent tabs,
25 mEq......................................................................... 13
potassium chloride ext-release...................................13
potassium chloride ext-release caps..........................13
potassium chloride packets; soln, 10%..................... 13
POTASSIUM CITRATE.................................................... 9
potassium citrate/citric acid powder............................ 9
potassium phosphate/sodium phosphates................13
pramipexole...................................................................12
PRANDIN..........................................................................4
pravastatin.......................................................................6
prazosin........................................................................... 7
prednisolone................................................................... 3
prednisolone acetate eye susp................................... 14
PREDNISOLONE SODIUM PHOSPHATE eye soln,
1%................................................................................. 14
prednisolone sodium soln.............................................3
PREDNISONE INTENSOL............................................... 3
PREDNISONE soln, 5 mg/5 mL; tabs, 50 mg.................. 3
prednisone tabs, 1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg... 3
PRENAPLUS.................................................................. 13
PRENATABS FA............................................................ 13
PRENATAL LOW IRON, PLUS, PLUS/IRON, VITAMINS
PLUS, 19...................................................................... 13
PREZISTA........................................................................ 2
PRIFTIN............................................................................ 1
PRIMAQUINE................................................................... 2
primidone.......................................................................12
PROAIR HFA....................................................................8
probenecid.....................................................................12
probenecid/colchicine.................................................. 12
prochlorperazine...........................................................10
progesterone micronized...............................................4
promethazine, NF = supp, 50 mg..................................7
propafenone.................................................................... 7
propafenone ext-release................................................ 7
propranolol ext-release.................................................. 6
PROPRANOLOL soln.......................................................6
Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary
2013
propranolol tabs............................................................. 6
propylthiouracil...............................................................4
PROTOPIC..................................................................... 16
pyrazinamide................................................................... 1
pyridostigmine.............................................................. 13
Q
quetiapine...................................................................... 10
quinapril...........................................................................5
quinapril/hydrochlorothiazide....................................... 5
quinidine gluconate ext-release....................................7
quinidine sulfate, NF = ext-release............................... 7
QVAR................................................................................8
R
ramipril.............................................................................5
ranitidine..........................................................................8
RAPAMUNE....................................................................16
RENVELA......................................................................... 8
repaglinide.......................................................................4
RESCRIPTOR.................................................................. 2
REYATAZ......................................................................... 2
ribavirin............................................................................2
rifampin............................................................................1
RILUTEK.........................................................................13
riluzole........................................................................... 13
risperidone.................................................................... 10
rivastigmine...................................................................11
rizatriptan.......................................................................12
ropinirole....................................................................... 12
S
SABRIL........................................................................... 12
salsalate.........................................................................11
selegiline caps.............................................................. 12
selegiline tabs...............................................................12
selenium sulfide........................................................... 16
SELZENTRY.....................................................................2
SE-NATAL 19................................................................. 13
SENSIPAR........................................................................5
SEROQUEL XR..............................................................10
sertraline........................................................................10
sildenafil.......................................................................... 7
silver sulfadiazine.........................................................15
simvastatin...................................................................... 6
sodium citrate/citric acid............................................... 9
sodium fluoride.............................................................15
sodium fluoride chew tabs, soln.................................13
sodium polystyrene sulfonate.....................................16
SOLARAZE.....................................................................16
SORIATANE................................................................... 16
sotalol.............................................................................. 7
SPIRIVA HANDIHALER................................................... 8
spironolactone................................................................ 6
spironolactone/hydrochlorothiazide.............................6
stavudine......................................................................... 2
STIMATE.......................................................................... 5
STRIBILD..........................................................................2
STROMECTOL................................................................. 2
SUBOXONE SL film....................................................... 11
sucralfate......................................................................... 8
sulfacetamide sodium/prednisolone eye soln........... 14
sulfacetamide sodium/sulfur, NF = susp, 10-5%....... 15
sulfacetamide sodium eye soln.................................. 14
sulfamethoxazole/trimethoprim.....................................2
sulfasalazine....................................................................8
sulfasalazine delayed-release....................................... 8
sulindac......................................................................... 12
sumatriptan inj, tabs.................................................... 12
SUPRAX tabs................................................................... 1
SUSTIVA...........................................................................2
SYMBICORT.....................................................................8
T
TABLOID...........................................................................3
tacrolimus......................................................................16
tamoxifen......................................................................... 3
tamsulosin....................................................................... 9
TAZORAC.......................................................................15
TEGRETOL-XR 100 mg.................................................12
temazepam.................................................................... 10
temozolomide..................................................................3
terazosin.......................................................................... 7
terbinafine........................................................................1
terbutaline........................................................................8
terconazole...................................................................... 9
testosterone cypionate.................................................. 3
testosterone enanthate.................................................. 3
TEST STRIPS – BAYER ASCENSIA AUTODISC,
BREEZE 2, CONTOUR, CONTOUR NEXT..................16
TEST STRIPS – ROCHE ACCU-CHEK ACTIVE,
AVIVA, AVIVA PLUS, COMFORT CURVE, COMPACT,
SMARTVIEW................................................................ 16
TEST STRIPS – ROCHE ACCUTREND........................16
theophylline ext-release.................................................8
thiothixene.....................................................................10
timolol maleate eye soln..............................................14
TIMOLOL tabs.................................................................. 6
tizanidine....................................................................... 13
TOBRADEX eye oint...................................................... 14
tobramycin/dexamethasone eye susp........................14
tobramycin eye soln.....................................................14
tolterodine....................................................................... 9
topiramate......................................................................12
torsemide.........................................................................6
tramadol.........................................................................11
tramadol/acetaminophen............................................. 11
trandolapril...................................................................... 5
tranylcypromine............................................................ 10
TRAVATAN Z................................................................. 14
trazodone.......................................................................10
tretinoin..........................................................................15
Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary
23
2013
tretinoin caps.................................................................. 3
tretinoin microsphere gel, 0.1%.................................. 15
TREXALL.......................................................................... 3
triamcinolone.................................................................. 7
triamcinolone crm; lotn; oint, 0.025%, 0.1%.............. 16
triamcinolone dental paste.......................................... 15
triamterene/hydrochlorothiazide................................... 7
trifluoperazine............................................................... 10
trifluridine eye soln...................................................... 14
trihexyphenidyl............................................................. 12
TRILIPIX........................................................................... 6
trimethobenzamide......................................................... 8
trimethoprim....................................................................2
TRIZIVIR........................................................................... 2
tropicamide eye soln....................................................14
TRUVADA.........................................................................2
U
ursodiol............................................................................8
V
Y
Z
zafirlukast........................................................................ 8
zaleplon..........................................................................10
ZEMPLAR caps................................................................ 5
ZENPEP............................................................................8
ZIAGEN soln.....................................................................2
zidovudine....................................................................... 2
ziprasidone.................................................................... 10
ZITHROMAX packets....................................................... 1
zolpidem........................................................................ 10
zolpidem ext-release.................................................... 10
zonisamide.................................................................... 12
ZORTRESS.................................................................... 16
ZYCLARA....................................................................... 16
ZYCLARA PUMP............................................................16
ZYLET.............................................................................14
ZYVOX..............................................................................3
VAGIFEM..........................................................................9
valacyclovir..................................................................... 2
VALCYTE..........................................................................1
valproic acid..................................................................12
valsartan/hydrochlorothiazide.......................................5
vancomycin..................................................................... 2
venlafaxine.................................................................... 10
venlafaxine ext-release caps....................................... 10
venlafaxine ext-release tabs, NF = 225 mg................ 10
VENTOLIN HFA............................................................... 8
verapamil, NF = 40 mg...................................................6
verapamil ext-release..................................................... 6
VESICARE........................................................................9
VFEND susp.....................................................................1
VICTOZA.......................................................................... 4
VIDEX............................................................................... 2
VIGAMOX....................................................................... 14
VIRACEPT........................................................................ 2
VIRAMUNE susp.............................................................. 2
VIRAMUNE XR.................................................................2
VIREAD.............................................................................2
VIVELLE-DOT...................................................................3
voriconazole.................................................................... 1
VYVANSE....................................................................... 10
W
warfarin.......................................................................... 13
WELCHOL........................................................................ 6
X
XARELTO....................................................................... 13
XERAC AC..................................................................... 16
XIFAXAN 550 mg............................................................. 3
24
Blue Cross and Blue Shield of Oklahoma October 2013 Drug Formulary