Blue Cross and Blue Shield of North Carolina Closed
April 2015 Blue Cross and Blue Shield of North Carolina Closed Basic 5 Tier Formulary Click to search for a drug name in this document Contents Preface ............................................................................ I Preferred Medication List............................................. 1 Member guide to covered medications on Anti-Infective Agents.................................................... 1 the Basic Formulary................................................. I Antineoplastic Agents ................................................ 11 Formulary tiers ............................................................ I Endocrine and Metabolic Drugs ................................ 14 5-Tier formulary ........................................................... I Cardiovascular Agents .............................................. 28 Generic drugs .............................................................. I Respiratory Agents .................................................... 45 Compounded prescriptions ........................................ II Gastrointestinal Agents ............................................. 49 Prior review, quantity limitations and Genitourinary Agents ................................................. 54 restricted-access drugs ......................................... II Central Nervous System Drugs ................................. 56 Specialty drugs ........................................................... II Analgesics and Anesthetics ...................................... 68 Using the member guide to the Neuromuscular Drugs................................................ 76 Basic Formulary .................................................... III Nutritional Products ................................................... 83 Abbreviation/acronym key ......................................... IV Hematological Agents................................................ 93 Topical Products ........................................................ 97 Miscellaneous Products .......................................... 110 Index ........................................................................... 113 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 bcbsnc.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. 5154-C NC © Prime Therapeutics LLC 04/15 Member guide to covered medications on the Basic Formulary This guide lists the approved brand name and generic prescription drugs that have been reviewed by Blue Cross and Blue Shield of North Carolina (BCBSNC) and are the only covered medications on BCBSNC’s Basic Formulary, a closed formulary. Please refer to this formulary guide for information about medications covered by this formulary, and present this guide to your doctor if you or another covered family member requires a prescription. This guide was current at the time of printing and is subject to change. For a more complete listing of drug coverage and costs, you may use our drug search at bcbsnc.com. You may also call BCBSNC Customer Service at the number listed on the back of your ID card to verify prescription drug benefits. A formulary is a list of prescription drugs covered by a health plan. BCBSNC Pharmacy & Therapeutics (P&T) Committee reviews medications at least quarterly. This includes ongoing reviews of clinical information about new drugs and reviews of new safety and efficacy information about older drugs. The majority of BCBSNC’s P&T Committee is composed of practicing physicians and pharmacists independent of BCBSNC. Please refer to your member guide for detailed information regarding your pharmacy benefits, including your benefit design, out-of-pocket costs, non-formulary exception requests and applicable exclusions. Formulary tiers The 5-Tier Basic Formulary covers many medications approved by the United States Food & Drug Administration (FDA), within existing benefits. The plan design determines the member’s payment obligation. Note: Drugs listed as covered on Tier 1 and Tier 2 are generics. Brand names listed for Tier 1 and Tier 2 drugs are for reference only. Brands for which generic equivalents are available are listed on Tier 4 unless indicated otherwise. 5-Tier formulary Here are the definitions of each tier for the five-tiered benefit structure: Tier 1: Generic medications. Medications listed in Tier 1 have the lowest co-payment. Tier 2: Non-preferred generic medications. Medications listed in Tier 2 have the second-lowest co-payment. Tier 3: Includes select brand-name drugs recommended by the BCBSNC P&T Committee as preferred brand-name products based on safety, efficacy, and cost. Tier 4: Contains 1) brand-name products that, as recommended by the P&T Committee, usually have preferred and often less costly therapeutic alternatives at a lower tier, 2) some brands with therapeutically equivalent generics, and 3) selected biosimilar specialty drugs. Medications listed in Tier 4 have the second-highest co-payment. Tier 5: Specialty drugs. Those medications, as classified by the P&T Committee, that generally have unique uses, require special dosing or administration, are typically prescribed by a specialist provider and are significantly more costly than alternative drugs or therapies. This may include biosimilar specialty drugs. Medications listed in Tier 5 generally have the highest co-payment or co-insurance amount. Generic drugs In most cases choosing a generic drug equivalent, when available, will mean significant savings to you. We encourage you to discuss with your physician whether a generic alternative is available as these drugs represent safe, effective treatment options. Especially for drugs that are taken daily and refilled frequently, you will experience the long-term savings of a lower drug payment month after month. If you choose a brand name prescription drug and a generic equivalent is available, you may be subject to a reduced benefit and a higher out-of-pocket expense. I Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Compounded prescriptions Compounded prescriptions contain two or more drugs mixed together. Compounded prescriptions are processed according to member benefits. To be eligible for coverage, compounded medications must contain at least one FDA-approved prescription ingredient and must not be a copy of a commercially available product. Compounded medications may be subject to prior review. Prior review, quantity limitations and restricted-access drugs Certain medications may be subject to prior review, quantity limitations, or restricted-access programs. BCBSNC’s P&T Committee reviews the clinical criteria for these programs. Drugs that have prior review requirements must be reviewed by BCBSNC before coverage can be authorized. Certain medications may also have limitations on the quantity and days’ supply coverage. Quantities in excess of the coverage limit must be reviewed and approved by BCBSNC before coverage can be authorized for amounts in excess of the limits. For coverage of restricted-access and non-formulary drugs, BCBSNC requires that the member has tried preferred formulary drugs first. Coverage for restricted-access drugs may be provided without the use of a preferred drug if the provider certifies in writing that the member has previously used preferred drugs and the preferred drug has been detrimental to the member's health or has been ineffective in treating the same condition and, in the opinion of the provider, are likely to be detrimental to the member's health or ineffective in treating the condition in the future. Clinical rationale and documentation for exception requests may be required. If approval of coverage of a non-formulary drug is granted, the non-formulary non-specialty drug will be covered on the non-preferred brand tier (Tier 4) and the non-formulary specialty drug will be covered on the specialty tier (Tier 5). The FDA is responsible for approving medications for use based on clinical data proving the medication is safe and effective for that specific use. BCBSNC’s prior review and quantity limitations programs follow FDA-approved uses for these drugs. However, BCBSNC recognizes that in many cases, “off-label” (non-FDA approved) uses of prescription drugs may be acceptable. In determining the acceptability of off-label uses, BCBSNC utilizes several sources of clinical information including but not limited to 1) nationally recognized clinical references including American Hospital Formulary Service Drug Information; 2) the results of at least two randomized controlled clinical studies that support a specific off-label use, and that are published in peer-reviewed professional medical journals; and 3) consultations with internal and external physician experts regarding community standards. Additional searches for current supporting medical literature may be performed utilizing standard electronic databases. Specialty drugs These medications, as classified by BCBSNC, generally have unique uses, require special dosing or administration, are typically prescribed by a specialist provider and are significantly more costly than alternative drugs or therapies. Most specialty drugs can be found on Tier 5, but some are found on Tier 4. Some of these specialty drugs will need to be filled at a participating specialty pharmacy in our network. These drugs are identified in the specialty column of the formulary guide. Call the customer service number on the back of your ID card to determine which pharmacy can fill your specialty drug prescription. Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary II Using the member guide to the Basic Formulary The Medication List is organized into broad categories (e.g., ANTI-INFECTIVE AGENTS). The graphic below shows the information that is provided in each column of the medication list and is an example only. Please use the drug search function to find current information for drugs on the medication list. The first column of the chart lists the medication name. Generic medications are listed in lowercase boldface . Brand name medications are capitalized. Separate medication entries are required for some dosage forms such as extended-release and delayed-release. The second column indicates the Tier level. The third column indicates if the medication is a Specialty medication and needs to be filled at a participating specialty pharmacy in our network. The remaining columns indicate the Pharmacy Program(s) that apply to the prescription medication (e.g., Prior Review, Restricted Access and Quantity Limitations). If an indicator is present in the column(s), then the Pharmacy Program applies. III Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Abbreviation/acronym key cap ................................................................ capsules chew ............................................................ chewable odt ......................................... orally disintegrating tabs oint ................................................................. ointment conc .........................................................concentrate cr ..................................................... controlled release ophth ........................................................... opthalmic osm .....................................................osmotic release dr ........................................................ delayed release ec ........................................................... enteric coated powd ................................................................ powder sa ....................................................... sustained action effe............................................................ effervescent equiv ........................................................... equivalent sl .................................................................. sublingual soln ..................................................................solution er ...................................................... extended release inhal............................................................. inhalation sr ......................................................sustained release suppos.................................................... suppositories inj .................................................................... injection liq ......................................................................... liquid susp ........................................................... suspension tab ..................................................................... tablets lotn ...................................................................... lotion nebu .............................................................. nebulizer td ............................................................... transdermal Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary IV ANTI-INFECTIVE AGENTS PENICILLINS amoxicillin & k clavulanate tab 250-125 mg 1 AMOXICILLIN – amoxicillin (trihydrate) chew tab 125 mg 1 amoxicillin & k clavulanate tab 500-125 mg (Augmentin) 1 AMOXICILLIN – amoxicillin (trihydrate) chew tab 250 mg 1 amoxicillin & k clavulanate tab 875-125 mg (Augmentin) 1 amoxicillin (trihydrate) cap 250 mg 1 AMPICILLIN – ampicillin for susp 125 mg/5ml 1 amoxicillin (trihydrate) cap 500 mg 1 AMPICILLIN – ampicillin for susp 250 mg/5ml 1 amoxicillin (trihydrate) for susp 125 mg/5ml 1 ampicillin cap 250 mg 1 ampicillin cap 500 mg 1 amoxicillin (trihydrate) for susp 200 mg/5ml 1 AUGMENTIN – amoxicillin & k clavulanate tab 500-125 mg 4 amoxicillin (trihydrate) for susp 250 mg/5ml 1 AUGMENTIN – amoxicillin & k clavulanate tab 875-125 mg 4 amoxicillin (trihydrate) for susp 400 mg/5ml 1 3 amoxicillin (trihydrate) tab 500 mg 1 AUGMENTIN – amoxicillin & k clavulanate for susp 125-31.25 mg/5ml 4 amoxicillin (trihydrate) tab 875 mg 1 AUGMENTIN – amoxicillin & k clavulanate for susp 250-62.5 mg/5ml amoxicillin & k clavulanate chew tab 200-28.5 mg 2 4 amoxicillin & k clavulanate chew tab 400-57 mg 1 AUGMENTIN XR – amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg dicloxacillin sodium cap 250 mg 1 amoxicillin & k clavulanate for susp 200-28.5 mg/5ml 1 dicloxacillin sodium cap 500 mg 1 1 amoxicillin & k clavulanate for susp 250-62.5 mg/5ml (Augmentin) 1 penicillin v potassium for soln 125 mg/5ml penicillin v potassium for soln 250 mg/5ml 1 amoxicillin & k clavulanate for susp 400-57 mg/5ml 1 penicillin v potassium tab 250 mg 1 amoxicillin & k clavulanate for susp 600-42.9 mg/5ml (Augmentin es-600) 1 penicillin v potassium tab 500 mg 1 amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg (Augmentin xr) 2 Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 CEPHALOSPORINS CEFACLOR – cefaclor for susp 125 mg/5ml 3 CEFACLOR – cefaclor for susp 250 mg/5ml 3 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 1 CEFACLOR – cefaclor for susp 375 mg/5ml 3 cefuroxime axetil tab 500 mg (Ceftin) 1 cefaclor cap 250 mg 2 cephalexin cap 250 mg (Keflex) 1 cefaclor cap 500 mg 2 cephalexin cap 500 mg (Keflex) 1 cefadroxil cap 500 mg 1 cephalexin cap 750 mg (Keflex) 2 cefadroxil for susp 250 mg/5ml 2 cephalexin for susp 125 mg/5ml 1 cefadroxil for susp 500 mg/5ml 2 cephalexin for susp 250 mg/5ml 1 cefadroxil tab 1 gm 2 KEFLEX – cephalexin cap 250 mg 4 cefdinir cap 300 mg 1 KEFLEX – cephalexin cap 500 mg 4 cefdinir for susp 125 mg/5ml 1 SUPRAX – cefixime cap 400 mg 4 cefdinir for susp 250 mg/5ml 1 4 cefpodoxime proxetil for susp 100 mg/5ml 2 SUPRAX – cefixime for susp 100 mg/5ml 4 cefpodoxime proxetil for susp 50 mg/5ml 2 SUPRAX – cefixime for susp 200 mg/5ml 4 cefpodoxime proxetil tab 100 mg 2 SUPRAX – cefixime for susp 500 mg/5ml cefpodoxime proxetil tab 200 mg 2 MACROLIDES cefprozil for susp 125 mg/5ml 1 4 cefprozil for susp 250 mg/5ml 1 AZITHROMYCIN – azithromycin powd pack for susp 1 gm 1 azithromycin for susp 100 mg/5ml (Zithromax) 1 cefprozil tab 250 mg cefprozil tab 500 mg 1 1 CEFTIBUTEN – ceftibuten cap 400 mg 4 azithromycin for susp 200 mg/5ml (Zithromax) 4 azithromycin tab 250 mg (Zithromax) 1 CEFTIBUTEN – ceftibuten for susp 180 mg/5ml CEFTIN – cefuroxime axetil tab 250 mg azithromycin tab 500 mg (Zithromax) 1 4 CEFTIN – cefuroxime axetil tab 500 mg azithromycin tab 600 mg (Zithromax) 1 4 4 CEFTIN – cefuroxime axetil for susp 125 mg/5ml 4 BIAXIN – clarithromycin tab 250 mg 3 BIAXIN – clarithromycin tab 500 mg 4 CEFTIN – cefuroxime axetil for susp 250 mg/5ml cefuroxime axetil for susp 125 mg/5ml (Ceftin) BIAXIN – clarithromycin for susp 250 mg/5ml 4 1 cefuroxime axetil tab 250 mg (Ceftin) BIAXIN XL – clarithromycin tab sr 24hr 500 mg 4 1 BIAXIN XL PAC – clarithromycin tab sr 24hr 500 mg 4 2 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Drug Name Specialty Drug Tier 2015 clarithromycin for susp 125 mg/5ml 2 ZITHROMAX – azithromycin for susp 200 mg/5ml 4 clarithromycin for susp 250 mg/5ml (Biaxin) 2 ZITHROMAX – azithromycin powd pack for susp 1 gm 4 clarithromycin tab sr 24hr 500 mg (Biaxin xl pac) 2 ZITHROMAX TRI-PAK – azithromycin tab 500 mg 4 clarithromycin tab 250 mg (Biaxin) 2 ZITHROMAX Z-PAK – azithromycin tab 250 mg 4 clarithromycin tab 500 mg (Biaxin) 2 TETRACYCLINES DIFICID – fidaxomicin tab 200 mg 5 E.E.S. 400 – erythromycin ethylsuccinate tab 400 mg 1 ERY-TAB – erythromycin tab delayed release 250 mg 1 ERY-TAB – erythromycin tab delayed release 333 mg demeclocycline hcl tab 150 mg 2 demeclocycline hcl tab 300 mg 2 doxycycline hyclate cap 100 mg (Vibramycin) 1 doxycycline hyclate cap 50 mg 1 1 doxycycline hyclate tab delayed release 100 mg 2 1 doxycycline hyclate tab delayed release 150 mg (Doryx) 2 ERY-TAB – erythromycin tab delayed release 500 mg 3 doxycycline hyclate tab delayed release 75 mg 2 ERYTHROCIN STEARATE – erythromycin stearate tab 250 mg doxycycline hyclate tab 100 mg 1 ERYTHROMYCIN BASE – erythromycin tab 250 mg 4 doxycycline hyclate tab 20 mg 1 2 ERYTHROMYCIN BASE – erythromycin tab 500 mg 4 doxycycline monohydrate cap 100 mg (Monodox) 2 ERYTHROMYCIN ETHYLSUCCINA – erythromycin ethylsuccinate tab 400 mg 1 doxycycline monohydrate cap 150 mg (Adoxa) doxycycline monohydrate cap 50 mg 2 erythromycin w/ delayed release particles cap 250 mg 1 doxycycline monohydrate cap 75 mg (Monodox) 2 ZITHROMAX – azithromycin tab 250 mg 4 doxycycline monohydrate for susp 25 mg/5ml (Vibramycin) 2 ZITHROMAX – azithromycin tab 500 mg 4 doxycycline monohydrate tab 100 mg (Adoxa pak 1/100) 2 ZITHROMAX – azithromycin tab 600 mg 4 doxycycline monohydrate tab 150 mg (Adoxa pak 1/150) 2 ZITHROMAX – azithromycin for susp 100 mg/5ml 4 doxycycline monohydrate tab 50 mg (Adoxa) 2 • • Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 3 doxycycline monohydrate tab 75 mg (Adoxa) 2 MINOCIN – minocycline hcl cap 50 mg 1 4 CIPROFLOXACIN HCL – ciprofloxacin hcl tab 100 mg (base equiv) 1 MINOCIN – minocycline hcl cap 75 mg 4 ciprofloxacin hcl tab 250 mg (base equiv) (Cipro) 1 MINOCIN – minocycline hcl cap 100 mg 4 ciprofloxacin hcl tab 500 mg (base equiv) (Cipro) 1 minocycline hcl cap 100 mg (Minocin) 1 ciprofloxacin hcl tab 750 mg (base equiv) 1 minocycline hcl cap 50 mg (Minocin) 1 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq) (Cipro xr) minocycline hcl cap 75 mg (Minocin) 1 2 minocycline hcl tab sr 24hr 135 mg 2 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq) (Cipro xr) 4 minocycline hcl tab sr 24hr 45 mg 2 LEVAQUIN – levofloxacin tab 250 mg 4 minocycline hcl tab sr 24hr 90 mg 2 LEVAQUIN – levofloxacin tab 500 mg 4 minocycline hcl tab 100 mg 2 LEVAQUIN – levofloxacin tab 750 mg 2 LEVAQUIN – levofloxacin oral soln 25 mg/ml 4 minocycline hcl tab 50 mg minocycline hcl tab 75 mg 2 TETRACYCLINE HCL – tetracycline hcl cap 250 mg levofloxacin oral soln 25 mg/ml (Levaquin) 2 1 1 levofloxacin tab 250 mg (Levaquin) 1 TETRACYCLINE HCL – tetracycline hcl cap 500 mg levofloxacin tab 500 mg (Levaquin) 1 FLUOROQUINOLONES CIPRO – ciprofloxacin hcl tab 250 mg (base equiv) 4 levofloxacin tab 750 mg (Levaquin) 1 CIPRO – ciprofloxacin hcl tab 500 mg (base equiv) 4 OFLOXACIN – ofloxacin tab 400 mg 2 CIPRO XR – ciprofloxacinciprofloxacin hcl tab sr 24hr 500 mg (base eq) 4 AMINOGLYCOSIDES CIPRO XR – ciprofloxacinciprofloxacin hcl tab sr 24hr 1000 mg(base eq) 4 4 BETHKIS – tobramycin nebu soln 300 mg/4ml 5 • KITABIS PAK – tobramycin nebu soln 300 mg/5ml 5 • neomycin sulfate tab 500 mg 1 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Drug Name Specialty Drug Tier 2015 paromomycin sulfate cap 250 mg 2 TOBI – tobramycin nebu soln 300 mg/5ml 5 TOBI PODHALER – tobramycin inhal cap 28 mg tobramycin nebu soln 300 mg/5ml (Tobi) DIFLUCAN – fluconazole for susp 10 mg/ml 4 • DIFLUCAN – fluconazole for susp 40 mg/ml 4 5 • fluconazole for susp 10 mg/ml (Diflucan) 1 5 • fluconazole for susp 40 mg/ml (Diflucan) 1 fluconazole tab 100 mg (Diflucan) 1 fluconazole tab 150 mg (Diflucan) 1 fluconazole tab 200 mg (Diflucan) 1 fluconazole tab 50 mg (Diflucan) 1 flucytosine cap 250 mg (Ancobon) 2 flucytosine cap 500 mg (Ancobon) 2 GRIFULVIN V – griseofulvin microsize tab 500 mg 4 GRIS-PEG – griseofulvin ultramicrosize tab 125 mg 4 GRIS-PEG – griseofulvin ultramicrosize tab 250 mg 4 griseofulvin microsize susp 125 mg/5ml 2 griseofulvin microsize tab 500 mg (Grifulvin v) 2 griseofulvin ultramicrosize tab 125 mg (Gris-peg) 2 griseofulvin ultramicrosize tab 250 mg (Gris-peg) 2 itraconazole cap 100 mg (Sporanox) 2 ketoconazole tab 200 mg 1 ANTIMYCOBACTERIAL AGENTS ethambutol hcl tab 100 mg (Myambutol) 2 ethambutol hcl tab 400 mg (Myambutol) 2 isoniazid tab 100 mg 1 isoniazid tab 300 mg 1 MYAMBUTOL – ethambutol hcl tab 4 100 mg MYAMBUTOL – ethambutol hcl tab 4 400 mg 2 pyrazinamide tab 500 mg RIFADIN – rifampin cap 150 mg 4 RIFADIN – rifampin cap 300 mg 4 RIFAMATE – isoniazid & rifampin cap 150-300 mg 4 rifampin cap 150 mg (Rifadin) 2 rifampin cap 300 mg (Rifadin) 2 ANTIFUNGALS • • ANCOBON – flucytosine cap 250 mg 4 ANCOBON – flucytosine cap 500 mg 4 DIFLUCAN – fluconazole tab 50 mg 4 4 LAMISIL – terbinafine hcl tab 250 mg 4 DIFLUCAN – fluconazole tab 100 mg 4 NOXAFIL – posaconazole tab delayed release 100 mg 5 DIFLUCAN – fluconazole tab 150 mg • 4 NOXAFIL – posaconazole susp 40 mg/ml 5 DIFLUCAN – fluconazole tab 200 mg • Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 • 5 • SPORANOX – itraconazole cap 100 mg 4 • COMBIVIR – lamivudinezidovudine tab 150-300 mg 5 • SPORANOX PULSEPAK – itraconazole cap 100 mg 4 • COMPLERA – emtricitabinerilpivirine-tenofovir df tab 200-25-300 mg 5 • terbinafine hcl tab 250 mg (Lamisil) 1 COPEGUS – ribavirin tab 200 mg 5 CRIXIVAN – indinavir sulfate cap 200 mg 5 5 • • • • • VFEND – voriconazole tab 50 mg 5 VFEND – voriconazole tab 200 mg 5 VFEND – voriconazole for susp 40 mg/ml CRIXIVAN – indinavir sulfate cap 400 mg 5 • 5 • didanosine delayed release capsule 125 mg (Videx ec) 2 voriconazole for susp 40 mg/ml (Vfend) • 5 didanosine delayed release capsule 200 mg (Videx ec) • voriconazole tab 50 mg (Vfend) 5 • • 2 voriconazole tab 200 mg (Vfend) didanosine delayed release capsule 250 mg (Videx ec) 2 • abacavir sulfate tab 300 mg (base equiv) (Ziagen) 2 • didanosine delayed release capsule 400 mg (Videx ec) 2 • abacavir sulfate-lamivudinezidovudine tab 300-150-300 mg (Trizivir) 5 • EDURANT – rilpivirine hcl tab 25 mg (base equivalent) 5 • acyclovir cap 200 mg (Zovirax) EMTRIVA – emtricitabine caps 200 mg 5 1 acyclovir susp 200 mg/5ml (Zovirax) 1 EMTRIVA – emtricitabine soln 10 mg/ml 5 • acyclovir tab 400 mg (Zovirax) 1 entecavir tab 0.5 mg (Baraclude) 5 acyclovir tab 800 mg (Zovirax) 1 entecavir tab 1 mg (Baraclude) 5 adefovir dipivoxil tab 10 mg (Hepsera) 5 EPIVIR – lamivudine tab 150 mg 5 EPIVIR – lamivudine tab 300 mg 5 APTIVUS – tipranavir cap 250 mg 5 5 APTIVUS – tipranavir oral soln 100 mg/ml 5 EPIVIR – lamivudine oral soln 10 mg/ml • • • • • 5 • EPIVIR HBV – lamivudine tab 100 mg • EPIVIR HBV – lamivudine oral soln 5 mg/ml 5 • • EPZICOM – abacavir sulfatelamivudine tab 600-300 mg 5 • • famciclovir tab 125 mg (Famvir) 2 ANTIVIRALS ATRIPLA – efavirenz-emtricitabine- 5 tenofovir df tab 600-200-300 mg 5 BARACLUDE – entecavir tab 0.5 mg BARACLUDE – entecavir tab 1 mg 5 6 • Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits 5 Restricted Access Specialty BARACLUDE – entecavir oral soln 0.05 mg/ml Drug Name Prior Review Drug Tier 1 Quantity Limits nystatin tab 500000 unit Restricted Access 2 Prior Review nystatin oral powder Specialty Drug Name Drug Tier 2015 FAMVIR – famciclovir tab 500 mg 4 FLUMADINE – rimantadine hydrochloride tab 100 mg 4 FUZEON – enfuvirtide for inj 90 mg 5 5 HARVONI – ledipasvir-sofosbuvir tab 90-400 mg 5 HEPSERA – adefovir dipivoxil tab 10 mg INTELENCE – etravirine tab 25 mg 5 • lamivudine tab 100 mg (Epivir hbv) 5 • lamivudine tab 150 mg (Epivir) 2 lamivudine tab 300 mg (Epivir) 2 lamivudine-zidovudine tab 150-300 mg (Combivir) 2 • • • LEXIVA – fosamprenavir calcium tab 700 mg (base equiv) 5 • • LEXIVA – fosamprenavir calcium susp 50 mg/ml (base equiv) 5 • MODERIBA – ribavirin tab 400 mg & ribavirin tab 600 mg dose pack 5 • MODERIBA 1200 DOSE PACK – ribavirin tab 600 mg 5 • MODERIBA 800 DOSE PACK – ribavirin tab 400 mg 5 • NEVIRAPINE – nevirapine susp 50 mg/5ml 5 • nevirapine tab sr 24hr 400 mg (Viramune xr) 5 • nevirapine tab 200 mg (Viramune) 2 5 NORVIR – ritonavir cap 100 mg • • • INTELENCE – etravirine tab 100 mg 5 • • INTELENCE – etravirine tab 200 mg 5 • INVIRASE – saquinavir mesylate cap 200 mg 5 • INVIRASE – saquinavir mesylate tab 500 mg 5 • ISENTRESS – raltegravir potassium tab 400 mg (base equiv) 5 • ISENTRESS – raltegravir potassium chew tab 25 mg (base equiv) 5 • ISENTRESS – raltegravir potassium chew tab 100 mg (base equiv) 5 ISENTRESS – raltegravir potassium packet for susp 100 mg (base equiv) 5 KALETRA – lopinavir-ritonavir tab 100-25 mg 5 • KALETRA – lopinavir-ritonavir tab 200-50 mg 5 • KALETRA – lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) 5 • • • NORVIR – ritonavir tab 100 mg 5 NORVIR – ritonavir oral soln 80 mg/ml 5 • • • • OLYSIO – simeprevir sodium cap 150 mg (base equivalent) 5 • • PEG-INTRON – peginterferon alfa-2b for inj kit 50 mcg/0.5ml 5 • • PEG-INTRON – peginterferon alfa-2b for inj kit 80 mcg/0.5ml 5 • • PEG-INTRON – peginterferon alfa-2b for inj kit 120 mcg/0.5ml 5 • • PEG-INTRON – peginterferon alfa-2b for inj kit 150 mcg/0.5ml 5 • • PEG-INTRON REDIPEN – peginterferon alfa-2b for inj kit 50 mcg/0.5ml 5 • • Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits 4 5 Restricted Access FAMVIR – famciclovir tab 250 mg lamivudine oral soln 10 mg/ml (Epivir) Drug Name Prior Review 4 Specialty FAMVIR – famciclovir tab 125 mg Drug Tier 2 Quantity Limits famciclovir tab 500 mg (Famvir) Restricted Access 2 Prior Review famciclovir tab 250 mg (Famvir) Specialty Drug Name Drug Tier 2015 7 5 • PEG-INTRON REDIPEN – peginterferon alfa-2b for inj kit 120 mcg/0.5ml 5 PREZISTA – darunavir ethanolate tab 600 mg (base equiv) 5 • PREZISTA – darunavir ethanolate tab 800 mg (base equiv) 5 • PEG-INTRON REDIPEN – peginterferon alfa-2b for inj kit 150 mcg/0.5ml 5 • • PREZISTA – darunavir ethanolate susp 100 mg/ml (base equiv) 5 • PEG-INTRON REDIPEN PAK 4 – peginterferon alfa-2b for inj kit 50 mcg/0.5ml 5 • • REBETOL – ribavirin cap 200 mg 5 RESCRIPTOR – delavirdine mesylate tab 100 mg 5 • • PEG-INTRON REDIPEN PAK 4 – peginterferon alfa-2b for inj kit 80 mcg/0.5ml 5 • • RESCRIPTOR – delavirdine mesylate tab 200 mg 5 • RETROVIR – zidovudine cap 100 mg 5 PEG-INTRON REDIPEN PAK 4 – peginterferon alfa-2b for inj kit 120 mcg/0.5ml 5 • RETROVIR – zidovudine syrup 10 mg/ml 5 • PEG-INTRON REDIPEN PAK 4 – peginterferon alfa-2b for inj kit 150 mcg/0.5ml 5 • • REYATAZ – atazanavir sulfate cap 150 mg (base equiv) 5 • PEGASYS – peginterferon alfa-2a inj 180 mcg/ml 5 REYATAZ – atazanavir sulfate cap 200 mg (base equiv) 5 • • • PEGASYS – peginterferon alfa-2a inj 180 mcg/0.5ml 5 REYATAZ – atazanavir sulfate cap 300 mg (base equiv) 5 • • • • • • PEGASYS PROCLICK – peginterferon alfa-2a inj 135 mcg/0.5ml REYATAZ – atazanavir sulfate oral powder packet 50 mg (base equiv) 5 5 • • • 5 RIBASPHERE – ribavirin tab 400 mg 5 PEGASYS PROCLICK – peginterferon alfa-2a inj 180 mcg/0.5ml 5 • PEGINTRON – peginterferon alfa-2b for inj kit 50 mcg/0.5ml 5 • • RIBASPHERE – ribavirin tab 600 mg • PEGINTRON – peginterferon alfa-2b for inj kit 80 mcg/0.5ml 5 • • PEGINTRON – peginterferon alfa-2b for inj kit 120 mcg/0.5ml 5 • • PEGINTRON – peginterferon alfa-2b for inj kit 150 mcg/0.5ml 5 • • PREZISTA – darunavir ethanolate tab 75 mg (base equiv) 5 • RIBASPHERE RIBAPAK – ribavirin 5 tab 400 mg RIBASPHERE RIBAPAK – ribavirin 5 tab 600 mg RIBASPHERE RIBAPAK – ribavirin 5 tab 400 mg & ribavirin tab 600 mg dose pack 5 RIBATAB – ribavirin tab 400 mg 8 • • • • RIBATAB – ribavirin tab 600 mg 5 • • • • Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits PREZISTA – darunavir ethanolate tab 150 mg (base equiv) Drug Name Restricted Access Specialty • • Drug Name Prior Review Drug Tier 5 Quantity Limits Specialty PEG-INTRON REDIPEN – peginterferon alfa-2b for inj kit 80 mcg/0.5ml Restricted Access Drug Tier Prior Review 2015 TYZEKA – telbivudine tab 600 mg 5 • • ribavirin tab 200 mg (Copegus) 2 • • valacyclovir hcl tab 1 gm (Valtrex) 2 rimantadine hydrochloride tab 100 mg (Flumadine) 2 valacyclovir hcl tab 500 mg (Valtrex) 2 SELZENTRY – maraviroc tab 150 mg 5 • VALCYTE – valganciclovir hcl tab 450 mg 5 • SELZENTRY – maraviroc tab 300 mg 5 • VALCYTE – valganciclovir hcl for soln 50 mg/ml (base equiv) 5 • SOVALDI – sofosbuvir tab 400 mg 5 • 2 valganciclovir hcl tab 450 mg (Valcyte) 5 stavudine cap 15 mg (Zerit) stavudine cap 20 mg (Zerit) 2 2 VALTREX – valacyclovir hcl tab 500 mg 4 stavudine cap 30 mg (Zerit) 2 VALTREX – valacyclovir hcl tab 1 gm 4 stavudine cap 40 mg (Zerit) stavudine for oral soln 1 mg/ml (Zerit) 2 • • • • • • • 5 • • STRIBILD – elvitegrav-cobicisemtricitab-tenofov tab 150-150-200-300 mg 5 • VICTRELIS – boceprevir cap 200 mg VIDEX – didanosine for soln 2 gm 5 VIDEX – didanosine for soln 4 gm 5 SUSTIVA – efavirenz cap 50 mg 5 5 SUSTIVA – efavirenz cap 200 mg 5 VIDEX EC – didanosine delayed release capsule 125 mg • • • 5 VIDEX EC – didanosine delayed release capsule 200 mg 5 SUSTIVA – efavirenz tab 600 mg • TAMIFLU – oseltamivir phosphate cap 30 mg (base equiv) 4 VIDEX EC – didanosine delayed release capsule 250 mg 5 • TAMIFLU – oseltamivir phosphate cap 45 mg (base equiv) 4 VIDEX EC – didanosine delayed release capsule 400 mg 5 • TAMIFLU – oseltamivir phosphate cap 75 mg (base equiv) 4 5 • • TAMIFLU – oseltamivir phosphate for susp 6 mg/ml (base equiv) 4 VIEKIRA PAK – ombitas-paritapreriton & dasab tab pak 12.5-75-50 & 250 mg 5 5 • • TIVICAY – dolutegravir sodium tab 50 mg (base equiv) VIRACEPT – nelfinavir mesylate tab 250 mg • • 5 VIRACEPT – nelfinavir mesylate tab 625 mg 5 TRIZIVIR – abacavir sulfatelamivudine-zidovudine tab 300-150-300 mg VIRAMUNE – nevirapine tab 200 mg 5 • VIRAMUNE – nevirapine susp 50 mg/5ml 5 • Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits ribavirin cap 200 mg (Rebetol) 2 • 5 Restricted Access • TRUVADA – emtricitabine-tenofovir 5 disoproxil fumarate tab 200-300 mg TYBOST – cobicistat tab 150 mg Prior Review 5 • • • Drug Name Specialty RIBATAB – ribavirin tab 400 mg & ribavirin tab 600 mg dose pack Drug Name Drug Tier Quantity Limits Specialty Restricted Access Drug Tier Prior Review 2015 9 2 VIRAMUNE XR – nevirapine tab sr 24hr 400 mg 5 • chloroquine phosphate tab 250 mg 1 VIREAD – tenofovir disoproxil fumarate tab 150 mg 5 • chloroquine phosphate tab 500 mg (Aralen) 1 VIREAD – tenofovir disoproxil fumarate tab 200 mg 5 • COARTEM – artemetherlumefantrine tab 20-120 mg 3 VIREAD – tenofovir disoproxil fumarate tab 250 mg 5 • DARAPRIM – pyrimethamine tab 25 mg 4 VIREAD – tenofovir disoproxil fumarate tab 300 mg 5 • hydroxychloroquine sulfate tab 200 mg (Plaquenil) 1 VIREAD – tenofovir disoproxil fumarate oral powder 40 mg/gm 5 • MALARONE – atovaquoneproguanil hcl tab 62.5-25 mg 4 ZERIT – stavudine cap 15 mg 5 5 MALARONE – atovaquoneproguanil hcl tab 250-100 mg 4 ZERIT – stavudine cap 20 mg ZERIT – stavudine cap 30 mg 5 mefloquine hcl tab 250 mg 1 ZERIT – stavudine cap 40 mg 5 4 PLAQUENIL – hydroxychloroquine sulfate tab 200 mg 4 ZERIT – stavudine for oral soln 1 mg/ml • • • • • 3 ZIAGEN – abacavir sulfate tab 300 mg (base equiv) 5 • PRIMAQUINE PHOSPHATE – primaquine phosphate tab 26.3 mg ZIAGEN – abacavir sulfate soln 20 mg/ml (base equiv) 5 • AMEBICIDES YODOXIN – iodoquinol tab 210 mg 2 zidovudine cap 100 mg (Retrovir) 2 YODOXIN – iodoquinol tab 650 mg 2 zidovudine syrup 10 mg/ml (Retrovir) 2 • • zidovudine tab 300 mg 2 ZOVIRAX – acyclovir cap 200 mg ANTHELMINTICS ALBENZA – albendazole tab 200 mg 4 4 ivermectin tab 3 mg (Stromectol) 2 ZOVIRAX – acyclovir tab 400 mg 4 4 ZOVIRAX – acyclovir tab 800 mg 4 STROMECTOL – ivermectin tab 3 mg ZOVIRAX – acyclovir susp 200 mg/5ml 4 ANTIMALARIALS ARALEN – chloroquine phosphate tab 500 mg 4 atovaquone-proguanil hcl tab 250-100 mg (Malarone) 2 10 • ANTI-INFECTIVE AGENTS - MISC. BACTRIM – sulfamethoxazoletrimethoprim tab 400-80 mg 4 BACTRIM DS – sulfamethoxazoletrimethoprim tab 800-160 mg 4 CAYSTON – aztreonam lysine for inhal soln 75 mg (base equivalent) 5 • Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits atovaquone-proguanil hcl tab 62.5-25 mg (Malarone) Restricted Access • Prior Review 5 Drug Name Specialty VIRAMUNE XR – nevirapine tab sr 24hr 100 mg Drug Name Drug Tier Quantity Limits Specialty Restricted Access Drug Tier Prior Review 2015 CLEOCIN – clindamycin hcl cap 75 4 mg 4 CLEOCIN – clindamycin hcl cap 150 mg 4 CLEOCIN – clindamycin hcl cap 300 mg 4 CLEOCIN PEDIATRIC GRANULE – clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) 1 clindamycin hcl cap 150 mg (Cleocin) 1 clindamycin hcl cap 300 mg (Cleocin) 1 clindamycin hcl cap 75 mg (Cleocin) 2 clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) (Cleocin pediatric gr) 3 DAPSONE – dapsone tab 25 mg TINDAMAX – tinidazole tab 500 mg 4 tinidazole tab 250 mg (Tindamax) 2 tinidazole tab 500 mg (Tindamax) 2 trimethoprim tab 100 mg 1 VANCOCIN HCL – vancomycin hcl cap 125 mg 4 VANCOCIN HCL – vancomycin hcl cap 250 mg 4 vancomycin hcl cap 125 mg (Vancocin hcl) 2 vancomycin hcl cap 250 mg (Vancocin hcl) 2 XIFAXAN – rifaximin tab 200 mg 4 XIFAXAN – rifaximin tab 550 mg 5 ZYVOX – linezolid tab 600 mg 5 Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 ANTINEOPLASTIC AGENTS DAPSONE – dapsone tab 100 mg 3 FLAGYL – metronidazole cap 375 mg 4 FLAGYL – metronidazole tab 250 mg 4 AFINITOR – everolimus tab 7.5 mg 5 AFINITOR – everolimus tab 10 mg 5 5 FLAGYL – metronidazole tab 500 mg 4 AFINITOR DISPERZ – everolimus tab for oral susp 2 mg • • • • • 5 • metronidazole cap 375 mg (Flagyl) 2 AFINITOR DISPERZ – everolimus tab for oral susp 3 mg 5 • metronidazole tab 250 mg (Flagyl) 1 AFINITOR DISPERZ – everolimus tab for oral susp 5 mg ALKERAN – melphalan tab 2 mg 5 • metronidazole tab 500 mg (Flagyl) 1 anastrozole tab 1 mg (Arimidex) 1 ARIMIDEX – anastrozole tab 1 mg 4 sulfamethoxazole-trimethoprim susp 200-40 mg/5ml 1 AROMASIN – exemestane tab 25 mg 4 sulfamethoxazole-trimethoprim tab 400-80 mg (Bactrim) 1 azacitidine for inj 100 mg (Vidaza) 2 sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrim ds) 1 bicalutamide tab 50 mg (Casodex) 1 TINDAMAX – tinidazole tab 250 mg 4 capecitabine tab 150 mg (Xeloda) 5 capecitabine tab 500 mg (Xeloda) 5 AFINITOR – everolimus tab 2.5 mg 5 5 AFINITOR – everolimus tab 5 mg Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary • • • 11 5 • CAPRELSA – vandetanib tab 300 mg 5 FEMARA – letrozole tab 2.5 mg 4 flutamide cap 125 mg 1 CASODEX – bicalutamide tab 50 mg 4 • • COMETRIQ – cabozantinib smalate cap 3 x 20 mg (60 mg dose) kit 5 • GILOTRIF – afatinib dimaleate tab 20 mg (base equivalent) 5 GILOTRIF – afatinib dimaleate tab 30 mg (base equivalent) 5 • 5 • GILOTRIF – afatinib dimaleate tab 40 mg (base equivalent) 5 COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 1 x 20 mg (100 dose) kit • 4 • COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 3 x 20 mg (140 dose) kit 5 GLEEVEC – imatinib mesylate tab 100 mg (base equivalent) GLEEVEC – imatinib mesylate tab 400 mg (base equivalent) 4 • CYCLOPHOSPHAMIDE – cyclophosphamide cap 25 mg 2 CYCLOPHOSPHAMIDE – cyclophosphamide cap 50 mg 2 ELIGARD – leuprolide acetate for subcutaneous inj kit 7.5 mg 5 ELIGARD – leuprolide acetate (3 month) for subcutaneous inj kit 22.5mg 5 ELIGARD – leuprolide acetate (4 month) for subcutaneous inj kit 30 mg 5 • ELIGARD – leuprolide acetate (6 month) for subcutaneous inj kit 45 mg 5 • 5 INLYTA – axitinib tab 5 mg 5 EMCYT – estramustine phosphate sodium cap 140 mg 5 ERIVEDGE – vismodegib cap 150 mg 5 JAKAFI – ruxolitinib phosphate tab 5 mg (base equivalent) • • • 5 • ETOPOSIDE – etoposide cap 50 mg 5 JAKAFI – ruxolitinib phosphate tab 10 mg (base equivalent) 5 • exemestane tab 25 mg (Aromasin) 2 JAKAFI – ruxolitinib phosphate tab 15 mg (base equivalent) 5 • FARESTON – toremifene citrate tab 60 mg (base equivalent) 5 JAKAFI – ruxolitinib phosphate tab 20 mg (base equivalent) JAKAFI – ruxolitinib phosphate tab 25 mg (base equivalent) 5 • 12 • • • • • • • HEXALEN – altretamine cap 50 mg 5 5 HYCAMTIN – topotecan hcl cap 0.25 mg (base equiv) 5 HYCAMTIN – topotecan hcl cap 1 mg (base equiv) 4 HYDREA – hydroxyurea cap 500 mg 1 hydroxyurea cap 500 mg (Hydrea) ICLUSIG – ponatinib hcl tab 15 mg 5 (base equiv) ICLUSIG – ponatinib hcl tab 45 mg 5 (base equiv) 5 INLYTA – axitinib tab 1 mg • • • • • • Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits FASLODEX – fulvestrant inj 250 mg/5ml Restricted Access Specialty 5 Drug Name Prior Review Drug Tier Quantity Limits Restricted Access Prior Review CAPRELSA – vandetanib tab 100 mg Drug Name Specialty Drug Tier 2015 mercaptopurine tab 50 mg (Purinethol) 1 LEUCOVORIN CALCIUM – leucovorin calcium tab 15 mg 2 • MESNEX – mesna tab 400 mg 5 methotrexate sodium inj pf 25 mg/ml 1 leucovorin calcium tab 25 mg 2 leucovorin calcium tab 5 mg 2 methotrexate sodium inj 25 mg/ ml 1 LEUKERAN – chlorambucil tab 2 mg 5 methotrexate sodium tab 2.5 mg (base equiv) 1 leuprolide acetate inj kit 5 mg/ml 5 LOMUSTINE – lomustine cap 10 mg 5 MYLERAN – busulfan tab 2 mg 4 5 • NEXAVAR – sorafenib tosylate tab 200 mg (base equivalent) LOMUSTINE – lomustine cap 40 mg 5 5 • NILANDRON – nilutamide tab 150 mg LOMUSTINE – lomustine cap 100 mg 5 4 • PURINETHOL – mercaptopurine tab 50 mg LUPRON DEPOT – leuprolide acetate for inj kit 3.75 mg 5 SPRYCEL – dasatinib tab 20 mg 5 SPRYCEL – dasatinib tab 50 mg 5 SPRYCEL – dasatinib tab 70 mg 5 SPRYCEL – dasatinib tab 80 mg 5 SPRYCEL – dasatinib tab 100 mg 5 SPRYCEL – dasatinib tab 140 mg 5 SUTENT – sunitinib malate cap 12.5 mg (base equivalent) 5 • • • • • • • LUPRON DEPOT – leuprolide acetate for inj kit 7.5 mg 5 LUPRON DEPOT – leuprolide acetate (3 month) for inj kit 11.25 mg 5 LUPRON DEPOT – leuprolide acetate (3 month) for inj kit 22.5 mg 5 LUPRON DEPOT – leuprolide acetate (4 month) for inj kit 30 mg 5 • SUTENT – sunitinib malate cap 25 mg (base equivalent) 5 • LUPRON DEPOT – leuprolide acetate (6 month) for inj kit 45 mg 5 • SUTENT – sunitinib malate cap 37.5 mg (base equivalent) 5 • SUTENT – sunitinib malate cap 50 mg (base equivalent) 5 • SYLATRON – peginterferon alfa-2b 5 for inj kit 296 mcg SYLATRON – peginterferon alfa-2b 5 for inj kit 444 mcg SYLATRON – peginterferon alfa-2b 5 for inj kit 888 mcg SYLATRON – peginterferon alfa-2b 5 for inj kit 4 x 296 mcg • • • • • • • • • • • Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits • Restricted Access 1 Prior Review megestrol acetate tab 40 mg Specialty Drug Tier 2 Quantity Limits LEUCOVORIN CALCIUM – leucovorin calcium tab 10 mg Restricted Access 1 Prior Review letrozole tab 2.5 mg (Femara) LYSODREN – mitotane tab 500 mg 5 5 MATULANE – procarbazine hcl cap 50 mg 4 MEGACE ORAL – megestrol acetate susp 40 mg/ml megestrol acetate susp 40 mg/ml 2 (Megace oral) 1 megestrol acetate tab 20 mg Drug Name Specialty Drug Name Drug Tier 2015 • • • • • 13 temozolomide cap 250 mg (Temodar) 5 • • temozolomide cap 5 mg (Temodar) 5 • tretinoin cap 10 mg 5 TYKERB – lapatinib ditosylate tab 250 mg (base equiv) 5 • • • VOTRIENT – pazopanib hcl tab 200 mg (base equiv) 5 • • XALKORI – crizotinib cap 200 mg 5 XALKORI – crizotinib cap 250 mg 5 XELODA – capecitabine tab 150 mg 5 • • • XELODA – capecitabine tab 500 mg 5 • tamoxifen citrate tab 10 mg (base equivalent) 1 tamoxifen citrate tab 20 mg (base equivalent) 1 TARCEVA – erlotinib hcl tab 25 mg 5 (base equivalent) 5 TARCEVA – erlotinib hcl tab 100 mg (base equivalent) 5 TARCEVA – erlotinib hcl tab 150 mg (base equivalent) TARGRETIN – bexarotene cap 75 5 mg 5 TASIGNA – nilotinib hcl cap 150 mg (base equivalent) 5 TASIGNA – nilotinib hcl cap 200 mg (base equivalent) 5 TEMODAR – temozolomide cap 5 mg TEMODAR – temozolomide cap 20 5 mg 5 TEMODAR – temozolomide cap 100 mg 5 TEMODAR – temozolomide cap 140 mg 5 TEMODAR – temozolomide cap 180 mg 5 TEMODAR – temozolomide cap 250 mg 5 temozolomide cap 100 mg (Temodar) 5 temozolomide cap 140 mg (Temodar) 5 temozolomide cap 180 mg (Temodar) 5 temozolomide cap 20 mg (Temodar) 14 • • • • • • XTANDI – enzalutamide cap 40 mg 5 ZELBORAF – vemurafenib tab 240 5 mg (base equivalent) ZOLINZA – vorinostat cap 100 mg 5 ZYTIGA – abiraterone acetate tab 250 mg 5 • • • • • • • • ENDOCRINE AND METABOLIC DRUGS • CORTICOSTEROIDS 2 • budesonide cap sr 24hr 3 mg (Entocort ec) 4 • CORTEF – hydrocortisone tab 5 mg 4 • CORTEF – hydrocortisone tab 10 mg 4 • CORTEF – hydrocortisone tab 20 mg 3 • CORTISONE ACETATE – cortisone acetate tab 25 mg 1 • DEXAMETHASONE – dexamethasone tab 1 mg 1 • DEXAMETHASONE – dexamethasone tab 2 mg DEXAMETHASONE – dexamethasone soln 0.5 mg/5ml 4 • • Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits • Drug Name Restricted Access Specialty SYLATRON – peginterferon alfa-2b 5 for inj kit 4 x 444 mcg TABLOID – thioguanine tab 40 mg 4 Drug Name Prior Review Drug Tier Quantity Limits Specialty Restricted Access Drug Tier Prior Review 2015 1 4 methylprednisolone tab 32 mg (Medrol) 1 dexamethasone tab 0.5 mg 1 methylprednisolone tab 4 mg (Medrol) dexamethasone tab 0.75 mg 1 1 dexamethasone tab 1.5 mg 1 methylprednisolone tab 4 mg dose pack (Medrol dosepak) 1 methylprednisolone tab 8 mg (Medrol) 1 dexamethasone tab 4 mg dexamethasone tab 6 mg 1 DEXPAK 10 DAY – dexamethasone tab 1.5 mg taper pack MILLIPRED – prednisolone tab 5 mg 1 4 4 DEXPAK 13 DAY – dexamethasone tab 1.5 mg taper pack 4 MILLIPRED – prednisolone sod phosphate oral soln 10 mg/5ml (base equiv) MILLIPRED DP – prednisolone tab 5 mg dose pack 4 DEXPAK 6 DAY – dexamethasone tab 1.5 mg taper pack 4 1 ENTOCORT EC – budesonide cap sr 24hr 3 mg 4 prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) (Pediapred) fludrocortisone acetate tab 0.1 mg prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) 1 1 hydrocortisone tab 10 mg (Cortef) 1 1 hydrocortisone tab 20 mg (Cortef) 1 prednisolone syrup 15 mg/5ml (usp solution equivalent) (Prelone) hydrocortisone tab 5 mg (Cortef) 1 MEDROL – methylprednisolone tab 4 2 mg MEDROL – methylprednisolone tab 4 4 mg MEDROL – methylprednisolone tab 4 8 mg MEDROL – methylprednisolone tab 4 16 mg MEDROL – methylprednisolone tab 4 32 mg 4 MEDROL DOSEPAK – methylprednisolone tab 4 mg dose pack 1 methylprednisolone tab 16 mg (Medrol) Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits DEXAMETHASONE INTENSOL – dexamethasone conc 1 mg/ml Restricted Access 1 Prior Review dexamethasone elixir 0.5 mg/5ml Specialty Drug Name Drug Tier 2015 PREDNISONE – prednisone tab 50 1 mg 3 PREDNISONE – prednisone oral soln 5 mg/5ml PREDNISONE – prednisone tab 5 1 mg dose pack PREDNISONE – prednisone tab 10 1 mg dose pack 4 PREDNISONE INTENSOL – prednisone conc 5 mg/ml 1 prednisone tab 1 mg prednisone tab 10 mg 1 prednisone tab 2.5 mg 1 prednisone tab 20 mg 1 prednisone tab 5 mg 1 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 15 PRELONE – prednisolone syrup 15 4 mg/5ml (usp solution equivalent) VERIPRED 20 – prednisolone sod 4 phosphate oral soln 20 mg/5ml (base equiv) oxandrolone tab 2.5 mg (Oxandrin) 2 • testosterone cypionate im inj in oil 100 mg/ml (Depotestosterone) 1 • ANDROGEN-ANABOLIC 1 • ANDRODERM – testosterone td patch 24hr 2 mg/24hr 3 • testosterone cypionate im inj in oil 200 mg/ml (Depotestosterone) ANDRODERM – testosterone td patch 24hr 4 mg/24hr 3 • testosterone enanthate im inj in oil 200 mg/ml 1 • ANDROGEL – testosterone td gel 25 mg/2.5gm (1%) 3 • TESTRED – methyltestosterone cap 10 mg 4 • ANDROGEL – testosterone td gel 50 mg/5gm (1%) 3 • ESTROGENS 4 ANDROGEL – testosterone td gel 20.25 mg/1.25gm (1.62%) 3 • ACTIVELLA – estradiol & norethindrone acetate tab 0.5-0.1 mg ANDROGEL – testosterone td gel 40.5 mg/2.5gm (1.62%) 3 • 4 ANDROGEL PUMP – testosterone td gel 12.5 mg/act (1%) 3 • ACTIVELLA – estradiol & norethindrone acetate tab 1-0.5 mg 4 • • ANDROGEL PUMP – testosterone td gel 20.25 mg/act (1.62%) 3 ALORA – estradiol td patch biweekly 0.025 mg/24hr 4 • • ANDROID – methyltestosterone cap 10 mg 4 ALORA – estradiol td patch biweekly 0.05 mg/24hr 4 • • danazol cap 100 mg 2 ALORA – estradiol td patch biweekly 0.075 mg/24hr 2 ALORA – estradiol td patch biweekly 0.1 mg/24hr 4 danazol cap 200 mg • • danazol cap 50 mg 2 DEPO-TESTOSTERONE – testosterone cypionate im inj in oil 100 mg/ml • CLIMARA – estradiol td patch weekly 0.025 mg/24hr 4 4 4 DEPO-TESTOSTERONE – testosterone cypionate im inj in oil 200 mg/ml 4 • CLIMARA – estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) 4 OXANDRIN – oxandrolone tab 2.5 mg 4 • CLIMARA – estradiol td patch weekly 0.05 mg/24hr 4 OXANDRIN – oxandrolone tab 10 mg 4 • CLIMARA – estradiol td patch weekly 0.06 mg/24hr 4 oxandrolone tab 10 mg (Oxandrin) 2 • CLIMARA – estradiol td patch weekly 0.075 mg/24hr CLIMARA – estradiol td patch weekly 0.1 mg/24hr 4 16 • • Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Drug Name Specialty Drug Tier 2015 DELESTROGEN – estradiol valerate im in oil 10 mg/ml 4 estradiol td patch weekly 0.025 mg/24hr (Climara) 1 DELESTROGEN – estradiol valerate im in oil 20 mg/ml 4 1 DELESTROGEN – estradiol valerate im in oil 40 mg/ml 4 estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) (Climara) 1 DIVIGEL – estradiol td gel 0.25 mg/0.25gm (0.1%) 4 estradiol td patch weekly 0.05 mg/24hr (Climara) 1 DIVIGEL – estradiol td gel 0.5 mg/0.5gm (0.1%) 4 estradiol td patch weekly 0.06 mg/24hr (Climara) estradiol td patch weekly 0.075 mg/24hr (Climara) 1 estradiol td patch weekly 0.1 mg/24hr (Climara) 1 estradiol valerate im in oil 20 mg/ ml (Delestrogen) 2 estradiol valerate im in oil 40 mg/ ml (Delestrogen) 2 ESTROPIPATE – estropipate tab 3 mg 1 DIVIGEL – estradiol td gel 1 mg/gm 4 (0.1%) 1 esterified estrogens & methyltestosterone tab 0.625-1.25 mg 1 esterified estrogens & methyltestosterone tab 1.25-2.5 mg 4 ESTRACE – estradiol tab 0.5 mg ESTRACE – estradiol tab 1 mg 4 estropipate tab 0.75 mg 1 ESTRACE – estradiol tab 2 mg 4 estropipate tab 1.5 mg 1 estradiol & norethindrone acetate tab 0.5-0.1 mg (Activella) 2 FEMHRT LOW DOSE – norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg 4 estradiol & norethindrone acetate tab 1-0.5 mg (Activella) 2 JINTELI – norethindrone acetateethinyl estradiol tab 1 mg-5 mcg 2 estradiol tab 0.5 mg (Estrace) 1 3 estradiol tab 1 mg (Estrace) 1 PREMARIN – estrogens, conjugated tab 0.3 mg estradiol tab 2 mg (Estrace) 1 3 estradiol td patch twice weekly 0.025 mg/24hr (Vivelle-dot) 2 PREMARIN – estrogens, conjugated tab 0.45 mg 3 estradiol td patch twice weekly 0.0375 mg/24hr (Vivelle-dot) 2 PREMARIN – estrogens, conjugated tab 0.625 mg 3 estradiol td patch twice weekly 0.05 mg/24hr (Vivelle-dot) 2 PREMARIN – estrogens, conjugated tab 0.9 mg 3 estradiol td patch twice weekly 0.075 mg/24hr (Vivelle-dot) 2 PREMARIN – estrogens, conjugated tab 1.25 mg estradiol td patch twice weekly 0.1 mg/24hr (Vivelle-dot) 2 Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 • • PREMPHASE – conj est 0.625(14)/ 3 conj est-medroxypro ac tab 0.625-5mg(14) Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 17 PREMPRO – conjugated estrogenmedroxyprogest acetate tab 0.3-1.5 mg 3 PREMPRO – conjugated estrogenmedroxyprogest acetate tab 0.45-1.5 mg 3 PREMPRO – conjugated estrogenmedroxyprogest acetate tab 0.625-2.5 mg 3 PREMPRO – conjugated estrogenmedroxyprogest acetate tab 0.625-5 mg 3 VIVELLE-DOT – estradiol td patch biweekly 0.025 mg/24hr 4 VIVELLE-DOT – estradiol td patch biweekly 0.0375 mg/24hr 4 VIVELLE-DOT – estradiol td patch biweekly 0.05 mg/24hr 4 VIVELLE-DOT – estradiol td patch biweekly 0.075 mg/24hr 4 VIVELLE-DOT – estradiol td patch biweekly 0.1 mg/24hr drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz) 2 drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin 28) 2 ELLA – ulipristal acetate tab 30 mg 3 ESTROSTEP FE – norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg 4 ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg 1 FEMCON FE – norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg 4 levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) (Loseasonique) 2 2 4 levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) (Seasonique) 1 4 levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg 1 levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg 1 levonorgestrel tab 0.75 mg (Plan b) 1 levonorgestrel tab 1.5 mg (Plan b one-step) 1 levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mgmcg 1 LOESTRIN FE 1.5/30 – norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg 4 LOESTRIN FE 1/20 – norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg 4 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Tier Quantity Limits Restricted Access 1 4 CYCLESSA – desogestethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mgmg 4 DEPO-PROVERA CONTRACEPTIV – medroxyprogesterone acetate im susp 150 mg/ml DESOGEN – desogestrel & ethinyl 4 estradiol tab 0.15 mg-30 mcg desogest-eth estrad & eth estrad 1 tab 0.15-0.02/0.01 mg(21/5) (Mircette) 1 desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mgmg (Cyclessa) 18 Drug Name desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg (Desogen) CONTRACEPTIVES BREVICON-28 – norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg Prior Review Drug Name Specialty Drug Tier 2015 LOESTRIN 1.5/30-21 – norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg 4 norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg (Loestrin fe 1/20) 1 LOESTRIN 1/20-21 – norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg 4 norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg (Loestrin fe 1.5/30) 1 LOSEASONIQUE – levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) 4 norethindrone tab 0.35 mg (Norqd) 1 1 norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg (Ortho-novum 7/7/7) 1 medroxyprogesterone acetate im susp 150 mg/ml (Depo-provera contrac) MIRCETTE – desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5) norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg (Trinorinyl 28) 1 4 MODICON – norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg (Orthocyclen) 1 4 4 norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mgmcg (Ortho tri-cyclen) 1 NOR-QD – norethindrone tab 0.35 mg norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg 1 NORINYL 1+35 – norethindrone & ethinyl estradiol tab 1 mg-35 mcg 4 NUVARING – etonogestrel-ethinyl estradiol va ring 0.120-0.015 mg/24hr 3 ORTHO EVRA – norelgestrominethinyl estradiol td ptwk 150-35 mcg/24hr 4 ORTHO MICRONOR – norethindrone tab 0.35 mg 4 ORTHO TRI-CYCLEN – norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mgmcg 4 ORTHO-CEPT – desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg 4 ORTHO-CYCLEN – norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg 4 2 norelgestromin-ethinyl estradiol td ptwk 150-35 mcg/24hr (Ortho evra) norethindrone & ethinyl estradiol 1 tab 0.4 mg-35 mcg (Ovcon-35) 1 norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg (Brevicon-28) norethindrone & ethinyl estradiol 1 tab 1 mg-35 mcg (Norinyl 1+35) 2 norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg (Femcon fe) 1 norethindrone ac-ethinyl estradfe tab 1-20/1-30/1-35 mg-mcg (Estrostep fe) 1 norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg (Loestrin 1/20-21) 1 norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg (Loestrin 1.5/30-21) Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 19 ORTHO-NOVUM 1/35 – norethindrone & ethinyl estradiol tab 1 mg-35 mcg 4 ORTHO-NOVUM 7/7/7 – norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg 4 OVCON-35 – norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg 4 PLAN B – levonorgestrel tab 0.75 mg 4 PLAN B ONE-STEP – levonorgestrel tab 1.5 mg 4 QUARTETTE – levonor-eth est tab 0.15-0.02/0.025/0.03 mg ð est 0.01 mg 4 SEASONIQUE – levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) 4 TRI-NORINYL 28 – norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg 4 YASMIN 28 – drospirenone-ethinyl estradiol tab 3-0.03 mg YAZ – drospirenone-ethinyl estradiol tab 3-0.02 mg progesterone micronized cap 200 mg (Prometrium) 2 PROMETRIUM – progesterone micronized cap 100 mg 4 PROMETRIUM – progesterone micronized cap 200 mg 4 2 acarbose tab 25 mg (Precose) 2 acarbose tab 50 mg (Precose) 2 ACTOPLUS MET – pioglitazone hcl-metformin hcl tab 15-500 mg 4 ACTOPLUS MET – pioglitazone hcl-metformin hcl tab 15-850 mg 4 4 ACTOS – pioglitazone hcl tab 15 mg (base equiv) 4 4 ACTOS – pioglitazone hcl tab 30 mg (base equiv) 4 ACTOS – pioglitazone hcl tab 45 mg (base equiv) 4 AMARYL – glimepiride tab 1 mg 4 AMARYL – glimepiride tab 2 mg 4 AMARYL – glimepiride tab 4 mg 4 4 medroxyprogesterone acetate tab 10 mg (Provera) 1 medroxyprogesterone acetate tab 2.5 mg (Provera) 1 DEX4 GLUCOSE – glucose oral liquid 15 gm/59ml 4 medroxyprogesterone acetate tab 5 mg (Provera) 1 DUETACT – pioglitazone hclglimepiride tab 30-2 mg 4 norethindrone acetate tab 5 mg (Aygestin) 2 DUETACT – pioglitazone hclglimepiride tab 30-4 mg 4 progesterone im in oil 50 mg/ml 2 4 progesterone micronized cap 100 mg (Prometrium) 2 FORTAMET – metformin hcl tab sr 24hr osmotic 500 mg FORTAMET – metformin hcl tab sr 24hr osmotic 1000 mg 4 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access ANTIDIABETICS AYGESTIN – norethindrone acetate tab 5 mg 20 Prior Review PROVERA – medroxyprogesterone 4 acetate tab 2.5 mg PROVERA – medroxyprogesterone 4 acetate tab 5 mg PROVERA – medroxyprogesterone 4 acetate tab 10 mg acarbose tab 100 mg (Precose) PROGESTINS Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Drug Name Specialty Drug Tier 2015 glipizide tab sr 24hr 2.5 mg (Glucotrol xl) 1 glipizide tab sr 24hr 5 mg (Glucotrol xl) 1 glipizide tab 10 mg (Glucotrol) 1 glipizide tab 5 mg (Glucotrol) 1 glipizide-metformin hcl tab 2.5-250 mg 2 glipizide-metformin hcl tab 2.5-500 mg 2 glipizide-metformin hcl tab 5-500 mg 2 GLUCAGEN – glucagon hcl (rdna) for inj 1 mg (base equiv) 4 GLUCOTROL XL – glipizide tab sr 24hr 10 mg 4 GLUCOVANCE – glyburidemetformin tab 1.25-250 mg 4 GLUCOVANCE – glyburidemetformin tab 2.5-500 mg 4 GLUCOVANCE – glyburidemetformin tab 5-500 mg 4 GLYBURIDE – glyburide tab 1.25 mg 1 GLYBURIDE – glyburide tab 2.5 mg 1 GLYBURIDE – glyburide tab 5 mg 1 3 glyburide micronized tab 1.5 mg (Glynase) 1 3 glyburide micronized tab 3 mg (Glynase) 1 GLUCAGEN HYPOKIT – glucagon hcl (rdna) for inj 1 mg (base equiv) 1 GLUCAGON EMERGENCY KIT – glucagon (rdna) for inj kit 1 mg 3 glyburide micronized tab 6 mg (Glynase) glyburide tab 1.25 mg 1 GLUCOPHAGE – metformin hcl tab 500 mg 4 glyburide tab 2.5 mg 1 glyburide tab 5 mg 1 GLUCOPHAGE – metformin hcl tab 850 mg 4 glyburide-metformin tab 1.25-250 mg (Glucovance) 1 GLUCOPHAGE – metformin hcl tab 1000 mg 4 glyburide-metformin tab 2.5-500 mg (Glucovance) 1 GLUCOPHAGE XR – metformin hcl tab sr 24hr 500 mg 4 glyburide-metformin tab 5-500 mg (Glucovance) 1 GLUCOPHAGE XR – metformin hcl tab sr 24hr 750 mg 4 GLYNASE – glyburide micronized tab 1.5 mg 4 glucose gel 40% 2 4 glucose oral liquid 15 gm/59ml 2 GLYNASE – glyburide micronized tab 3 mg GLUCOTROL – glipizide tab 5 mg 4 GLYNASE – glyburide micronized tab 6 mg 4 INSTA-GLUCOSE – glucose gel 77.4% 2 GLUCOTROL – glipizide tab 10 mg 4 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits 1 GLUCOTROL XL – glipizide tab sr 24hr 5 mg Restricted Access glipizide tab sr 24hr 10 mg (Glucotrol xl) 4 Prior Review 1 GLUCOTROL XL – glipizide tab sr 24hr 2.5 mg Specialty glimepiride tab 4 mg (Amaryl) Drug Name Drug Tier 1 Quantity Limits glimepiride tab 2 mg (Amaryl) Restricted Access 1 Prior Review glimepiride tab 1 mg (Amaryl) Specialty Drug Name Drug Tier 2015 21 INVOKAMET – canagliflozinmetformin hcl tab 50-500 mg 3 ONGLYZA – saxagliptin hcl tab 5 mg (base equiv) 3 INVOKAMET – canagliflozinmetformin hcl tab 50-1000 mg 3 pioglitazone hcl tab 15 mg (base equiv) (Actos) 2 INVOKAMET – canagliflozinmetformin hcl tab 150-500 mg 3 pioglitazone hcl tab 30 mg (base equiv) (Actos) 2 INVOKAMET – canagliflozinmetformin hcl tab 150-1000 mg 3 pioglitazone hcl tab 45 mg (base equiv) (Actos) 2 INVOKANA – canagliflozin tab 100 mg 3 pioglitazone hcl-glimepiride tab 30-2 mg (Duetact) 2 INVOKANA – canagliflozin tab 300 mg 3 pioglitazone hcl-glimepiride tab 30-4 mg (Duetact) 2 KOMBIGLYZE XR – saxagliptinmetformin hcl tab sr 24hr 2.5-1000 mg 3 pioglitazone hcl-metformin hcl tab 15-500 mg (Actoplus met) 2 2 KOMBIGLYZE XR – saxagliptinmetformin hcl tab sr 24hr 5-500 mg 3 pioglitazone hcl-metformin hcl tab 15-850 mg (Actoplus met) PRANDIN – repaglinide tab 0.5 mg 4 3 PRANDIN – repaglinide tab 1 mg 4 KOMBIGLYZE XR – saxagliptinmetformin hcl tab sr 24hr 5-1000 mg PRANDIN – repaglinide tab 2 mg 4 PRECOSE – acarbose tab 25 mg 4 metformin hcl tab sr 24hr osmotic 1000 mg (Fortamet) 2 PRECOSE – acarbose tab 50 mg 4 PRECOSE – acarbose tab 100 mg 4 metformin hcl tab sr 24hr osmotic 500 mg (Fortamet) 2 repaglinide tab 0.5 mg (Prandin) 2 1 repaglinide tab 1 mg (Prandin) 2 metformin hcl tab sr 24hr 500 mg (Glucophage xr) repaglinide tab 2 mg (Prandin) 2 metformin hcl tab sr 24hr 750 mg (Glucophage xr) 1 RIOMET – metformin hcl oral soln 500 mg/5ml 4 metformin hcl tab 1000 mg (Glucophage) 1 STARLIX – nateglinide tab 60 mg 4 STARLIX – nateglinide tab 120 mg 4 metformin hcl tab 500 mg (Glucophage) 1 TOLAZAMIDE – tolazamide tab 500 mg 1 metformin hcl tab 850 mg (Glucophage) 1 tolazamide tab 250 mg 1 2 TOLBUTAMIDE – tolbutamide tab 500 mg 1 nateglinide tab 120 mg (Starlix) nateglinide tab 60 mg (Starlix) 2 3 ONGLYZA – saxagliptin hcl tab 2.5 mg (base equiv) 3 VICTOZA – liraglutide soln peninjector 18 mg/3ml (6 mg/ml) 22 • • Rapid-Acting Insulins Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Drug Name Specialty Drug Tier 2015 NOVOLOG – insulin aspart inj 100 unit/ml 3 ARMOUR THYROID – thyroid tab 15 mg (1/4 grain) 4 NOVOLOG FLEXPEN – insulin aspart soln pen-injector 100 unit/ ml 3 ARMOUR THYROID – thyroid tab 30 mg (1/2 grain) 4 NOVOLOG PENFILL – insulin aspart soln cartridge 100 unit/ml ARMOUR THYROID – thyroid tab 60 mg (1 grain) 4 3 3 ARMOUR THYROID – thyroid tab 90 mg (1 1/2 grain) 4 NOVOLOG PENFILL – insulin aspart inj 100 unit/ml ARMOUR THYROID – thyroid tab 120 mg (2 grain) 4 Short-Acting Insulins NOVOLIN R – insulin regular (human) inj 100 unit/ml 3 ARMOUR THYROID – thyroid tab 180 mg (3 grain) 4 NOVOLIN R RELION – insulin regular (human) inj 100 unit/ml 3 ARMOUR THYROID – thyroid tab 240 mg (4 grain) 4 RELION R – insulin regular (human) inj 100 unit/ml 3 ARMOUR THYROID – thyroid tab 300 mg (5 grain) 4 4 Intermediate-Acting Insulins NOVOLIN N – insulin isophane (human) inj 100 unit/ml 3 CYTOMEL – liothyronine sodium tab 5 mcg 4 NOVOLIN N RELION – insulin isophane (human) inj 100 unit/ml 3 CYTOMEL – liothyronine sodium tab 25 mcg 4 NOVOLIN 70/30 – insulin isophane & regular (human) inj 100 unit/ml (70-30) 3 CYTOMEL – liothyronine sodium tab 50 mcg levothyroxine sodium tab 100 mcg (Synthroid) 1 NOVOLIN 70/30 RELION – insulin isophane & regular (human) inj 100 unit/ml (70-30) 3 levothyroxine sodium tab 112 mcg (Synthroid) 1 3 levothyroxine sodium tab 125 mcg (Synthroid) 1 NOVOLOG MIX 70/30 – insulin aspart prot & aspart (human) inj 100 unit/ml (70-30) levothyroxine sodium tab 137 mcg (Synthroid) 1 NOVOLOG MIX 70/30 PREFILL – insulin aspart prot & aspart sus pen-inj 100 unit/ml (70-30) 3 levothyroxine sodium tab 150 mcg (Synthroid) 1 levothyroxine sodium tab 175 mcg (Synthroid) 1 levothyroxine sodium tab 200 mcg (Synthroid) 1 levothyroxine sodium tab 25 mcg (Synthroid) 1 levothyroxine sodium tab 300 mcg (Synthroid) 1 Basal Insulins LANTUS – insulin glargine inj 100 unit/ml 3 LANTUS SOLOSTAR – insulin glargine soln pen-injector 100 unit/ml 3 THYROID AGENTS Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 23 levothyroxine sodium tab 50 mcg (Synthroid) 1 levothyroxine sodium tab 75 mcg (Synthroid) 1 NATURE-THROID NT-2.5 – thyroid 1 tab 162.5 mg (2 1/2 grain) 1 propylthiouracil tab 50 mg levothyroxine sodium tab 88 mcg (Synthroid) SYNTHROID – levothyroxine sodium tab 25 mcg 4 1 1 SYNTHROID – levothyroxine sodium tab 50 mcg 4 liothyronine sodium tab 25 mcg (Cytomel) 1 SYNTHROID – levothyroxine sodium tab 75 mcg 4 liothyronine sodium tab 5 mcg (Cytomel) liothyronine sodium tab 50 mcg (Cytomel) SYNTHROID – levothyroxine sodium tab 88 mcg 4 1 methimazole tab 10 mg (Tapazole) SYNTHROID – levothyroxine sodium tab 100 mcg 4 1 methimazole tab 5 mg (Tapazole) SYNTHROID – levothyroxine sodium tab 112 mcg 4 1 NATURE-THROID – thyroid tab 16.25 mg 1 SYNTHROID – levothyroxine sodium tab 125 mcg 4 NATURE-THROID – thyroid tab 32.5 mg 1 SYNTHROID – levothyroxine sodium tab 137 mcg 4 NATURE-THROID – thyroid tab 48.75 mg (3/4 grain) 1 SYNTHROID – levothyroxine sodium tab 150 mcg 4 NATURE-THROID – thyroid tab 65 mg 1 SYNTHROID – levothyroxine sodium tab 175 mcg 4 NATURE-THROID – thyroid tab 81.25 mg 1 SYNTHROID – levothyroxine sodium tab 200 mcg 4 NATURE-THROID – thyroid tab 97.5 mg 1 SYNTHROID – levothyroxine sodium tab 300 mcg 4 NATURE-THROID – thyroid tab 113.75 mg 1 TAPAZOLE – methimazole tab 5 mg 4 NATURE-THROID – thyroid tab 130 mg 1 TAPAZOLE – methimazole tab 10 mg 4 NATURE-THROID – thyroid tab 195 mg 1 thyroid tab 30 mg (1/2 grain) (Armour thyroid) 1 NATURE-THROID – thyroid tab 260 mg 1 thyroid tab 60 mg (1 grain) (Armour thyroid) 1 NATURE-THROID – thyroid tab 325 mg (5 grain) 1 thyroid tab 90 mg (1 1/2 grain) (Armour thyroid) 1 NATURE-THROID – thyroid tab 146.25 mg 1 TIROSINT – levothyroxine sodium cap 13 mcg 4 24 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Drug Name Specialty Drug Tier 2015 TIROSINT – levothyroxine sodium cap 25 mcg 4 TIROSINT – levothyroxine sodium cap 50 mcg 4 TIROSINT – levothyroxine sodium cap 75 mcg 4 TIROSINT – levothyroxine sodium cap 88 mcg 4 TIROSINT – levothyroxine sodium cap 100 mcg 4 TIROSINT – levothyroxine sodium cap 112 mcg 4 TIROSINT – levothyroxine sodium cap 125 mcg 4 TIROSINT – levothyroxine sodium cap 137 mcg 4 TIROSINT – levothyroxine sodium cap 150 mcg 4 WESTHROID – thyroid tab 16.25 mg 1 WESTHROID-P – thyroid tab 16.25 1 mg WESTHROID-P – thyroid tab 32.5 1 mg WESTHROID-P – thyroid tab 48.75 1 mg (3/4 grain) 1 WESTHROID-P – thyroid tab 65 mg WESTHROID-P – thyroid tab 97.5 1 mg 1 WESTHROID-P – thyroid tab 130 mg 1 WP THYROID – thyroid tab 16.25 mg 1 WP THYROID – thyroid tab 32.5 mg 1 WP THYROID – thyroid tab 48.75 mg (3/4 grain) WP THYROID – thyroid tab 65 mg 1 WESTHROID – thyroid tab 32.5 mg WP THYROID – thyroid tab 81.25 mg 1 1 WESTHROID – thyroid tab 48.75 mg (3/4 grain) WP THYROID – thyroid tab 97.5 mg 1 1 1 WESTHROID – thyroid tab 65 mg 1 WP THYROID – thyroid tab 113.75 mg WESTHROID – thyroid tab 81.25 mg 1 WP THYROID – thyroid tab 130 mg 1 WESTHROID – thyroid tab 97.5 mg 1 OXYTOCICS WESTHROID – thyroid tab 113.75 mg 1 methylergonovine maleate tab 0.2 mg WESTHROID – thyroid tab 130 mg 1 WESTHROID – thyroid tab 162.5 mg (2 1/2 grain) 1 WESTHROID – thyroid tab 195 mg 1 WESTHROID – thyroid tab 260 mg 1 WESTHROID – thyroid tab 325 mg (5 grain) 1 WESTHROID – thyroid tab 146.25 mg 1 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits 1 ENDOCRINE and METABOLIC AGENTS - MISC. 4 ACTONEL – risedronate sodium tab 150 mg 1 ALENDRONATE SODIUM – alendronate sodium tab 40 mg 4 • ALENDRONATE SODIUM – alendronate sodium oral soln 70 mg/75ml 1 alendronate sodium tab 10 mg alendronate sodium tab 35 mg Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 • 1 25 2 1 desmopressin acetate nasal soln 0.01% (refrigerated) (Ddavp) 2 BONIVA – ibandronate sodium tab 150 mg (base equivalent) 4 desmopressin acetate nasal spray soln 0.01% (Ddavp) 2 BRAVELLE – Benefit Limits may apply – urofollitropin purified for inj 75 unit 5 desmopressin acetate nasal spray soln 0.01% (refrigerated) desmopressin acetate tab 0.1 mg (Ddavp) 2 cabergoline tab 0.5 mg 2 2 calcitonin (salmon) nasal soln 200 unit/act (Miacalcin) 2 desmopressin acetate tab 0.2 mg (Ddavp) 2 calcitriol cap 0.25 mcg (Rocaltrol) 1 ETIDRONATE DISODIUM – etidronate disodium tab 400 mg calcitriol cap 0.5 mcg (Rocaltrol) 1 EVISTA – raloxifene hcl tab 60 mg 4 calcitriol oral soln 1 mcg/ml (Rocaltrol) 2 5 CARBAGLU – carglumic acid tab 200 mg 5 FOLLISTIM AQ – Benefit Limits may apply – follitropin beta inj 75 unit/0.5ml 5 CARNITOR – levocarnitine tab 330 mg 4 FOLLISTIM AQ – Benefit Limits may apply – follitropin beta inj 150 unit/0.5ml 4 FOLLISTIM AQ – Benefit Limits may apply – follitropin beta inj 300 unit/0.36ml 5 CARNITOR – levocarnitine oral soln 1 gm/10ml (10%) CARNITOR SF – levocarnitine oral soln 1 gm/10ml (10%) 4 5 CETROTIDE – Benefit Limits may apply – cetrorelix acetate for inj kit 0.25 mg 5 FOLLISTIM AQ – Benefit Limits may apply – follitropin beta inj 600 unit/0.72ml 5 chorionic gonadotropin for inj 10000 unit – Benefit Limits may apply 5 FOLLISTIM AQ – Benefit Limits may apply – follitropin beta inj 900 unit/1.08ml FORTEO – teriparatide (recombinant) inj 600 mcg/2.4ml 5 clomiphene citrate tab 50 mg – Benefit Limits may apply 1 FORTICAL – calcitonin (salmon) nasal soln 200 unit/act 2 DDAVP – desmopressin acetate tab 0.1 mg 4 FOSAMAX – alendronate sodium tab 70 mg 4 DDAVP – desmopressin acetate tab 0.2 mg 4 5 DDAVP – desmopressin acetate nasal soln 0.01% (refrigerated) 4 GANIRELIX ACETATE – Benefit Limits may apply – ganirelix acetate inj 250 mcg/0.5ml DDAVP – desmopressin acetate nasal spray soln 0.01% GONAL-F – Benefit Limits may apply – follitropin alfa for inj 450 unit 5 4 26 • • Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits alendronate sodium tab 70 mg (Fosamax) Restricted Access 1 Prior Review alendronate sodium tab 5 mg Specialty Drug Name Drug Tier 2015 GONAL-F RFF – Benefit Limits may apply – follitropin alfa for inj 75 unit 5 GONAL-F RFF PEN – Benefit Limits may apply – follitropin alfa inj 300 unit/0.5ml 5 GONAL-F RFF PEN – Benefit Limits may apply – follitropin alfa inj 450 unit/0.75ml 5 GONAL-F RFF PEN – Benefit Limits may apply – follitropin alfa inj 900 unit/1.5ml 5 GONAL-F RFF REDIJECT – Benefit Limits may apply – follitropin alfa inj 300 unit/0.5ml 5 GONAL-F RFF REDIJECT – Benefit Limits may apply – follitropin alfa inj 450 unit/0.75ml 5 GONAL-F RFF REDIJECT – Benefit Limits may apply – follitropin alfa inj 900 unit/1.5ml 5 ibandronate sodium tab 150 mg (base equivalent) (Boniva) 2 levocarnitine oral soln 1 gm/10ml (10%) (Carnitor) 2 levocarnitine tab 330 mg (Carnitor) 2 LUPRON DEPOT-PED – leuprolide 5 acetate for inj pediatric kit 7.5 mg LUPRON DEPOT-PED – leuprolide 5 acetate for inj pediatric kit 11.25 mg LUPRON DEPOT-PED – leuprolide 5 acetate for inj pediatric kit 15 mg LUPRON DEPOT-PED – leuprolide 5 acetate (3 month) for inj pediatric kit 11.25 mg • • • • paricalcitol cap 2 mcg (Zemplar) 2 paricalcitol cap 4 mcg (Zemplar) 2 raloxifene hcl tab 60 mg (Evista) 2 REPRONEX – Benefit Limits may apply – menotropins for inj 75 unit 5 risedronate sodium tab 150 mg (Actonel) 2 ROCALTROL – calcitriol cap 0.25 mcg 4 ROCALTROL – calcitriol cap 0.5 mcg 4 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits • Restricted Access LUPRON DEPOT-PED – leuprolide 5 acetate (3 month) for inj pediatric kit 30 mg 5 MENOPUR – Benefit Limits may apply – menotropins for subcutaneous inj 75 unit 4 MIACALCIN – calcitonin (salmon) nasal soln 200 unit/act octreotide acetate inj 100 mcg/ml 2 (0.1 mg/ml) (Sandostatin) 2 octreotide acetate inj 1000 mcg/ ml (1 mg/ml) (Sandostatin) octreotide acetate inj 200 mcg/ml 2 (0.2 mg/ml) (Sandostatin) 2 octreotide acetate inj 50 mcg/ml (0.05 mg/ml) (Sandostatin) octreotide acetate inj 500 mcg/ml 2 (0.5 mg/ml) (Sandostatin) 5 OMNITROPE – somatropin inj 5 mg/1.5ml 5 OMNITROPE – somatropin inj 10 mg/1.5ml 5 OMNITROPE – somatropin for inj 5.8 mg 5 OVIDREL – Benefit Limits may apply – choriogonadotropin alfa inj 250 mcg/0.5ml 2 paricalcitol cap 1 mcg (Zemplar) Drug Name Prior Review Quantity Limits Restricted Access Prior Review Specialty 5 Drug Tier GONAL-F – Benefit Limits may apply – follitropin alfa for inj 1050 unit Specialty Drug Name Drug Tier 2015 • • • • • • • • • • • 27 ROCALTROL – calcitriol oral soln 1 4 mcg/ml 5 SAMSCA – tolvaptan tab 15 mg • • • SAMSCA – tolvaptan tab 30 mg 5 SANDOSTATIN – octreotide acetate inj 50 mcg/ml (0.05 mg/ ml) 4 SANDOSTATIN – octreotide acetate inj 100 mcg/ml (0.1 mg/ ml) 4 SANDOSTATIN – octreotide acetate inj 200 mcg/ml (0.2 mg/ ml) 4 • SANDOSTATIN – octreotide acetate inj 500 mcg/ml (0.5 mg/ ml) 4 • SANDOSTATIN – octreotide acetate inj 1000 mcg/ml (1 mg/ ml) 4 • SENSIPAR – cinacalcet hcl tab 30 mg (base equiv) 4 • SENSIPAR – cinacalcet hcl tab 60 mg (base equiv) 4 • SENSIPAR – cinacalcet hcl tab 90 mg (base equiv) 4 • SIGNIFOR – pasireotide diaspartate inj 0.3 mg/ml (base equiv) 5 • SIGNIFOR – pasireotide diaspartate inj 0.6 mg/ml (base equiv) 5 • SIGNIFOR – pasireotide diaspartate inj 0.9 mg/ml (base equiv) 5 • sodium phenylbutyrate oral powder 3 gm/teaspoonful (Buphenyl) 2 • ZEMPLAR – paricalcitol cap 1 mcg 4 ZEMPLAR – paricalcitol cap 2 mcg 4 CARDIOVASCULAR AGENTS • digoxin tab 125 mcg (0.125 mg) (Lanoxin) 1 digoxin tab 250 mcg (0.25 mg) (Lanoxin) 1 LANOXIN – digoxin tab 62.5 mcg (0.0625 mg) 4 LANOXIN – digoxin tab 125 mcg (0.125 mg) 4 LANOXIN – digoxin tab 187.5 mcg (0.1875 mg) 4 LANOXIN – digoxin tab 250 mcg (0.25 mg) 4 ANTIANGINAL AGENTS ISORDIL TITRADOSE – isosorbide 4 dinitrate tab 5 mg ISORDIL TITRADOSE – isosorbide 4 dinitrate tab 40 mg 1 ISOSORBIDE DINITRATE – isosorbide dinitrate tab 30 mg isosorbide dinitrate tab cr 40 mg 1 isosorbide dinitrate tab 10 mg 1 isosorbide dinitrate tab 20 mg 1 isosorbide dinitrate tab 5 mg (Isordil titradose) 1 isosorbide mononitrate tab sr 24hr 120 mg (Imdur) 1 isosorbide mononitrate tab sr 24hr 30 mg (Imdur) 1 isosorbide mononitrate tab sr 24hr 60 mg (Imdur) 1 isosorbide mononitrate tab 10 mg 1 isosorbide mononitrate tab 20 mg 1 NITRO-BID – nitroglycerin oint 2% 1 NITRO-DUR – nitroglycerin td patch 24hr 0.1 mg/hr 4 NITRO-DUR – nitroglycerin td patch 24hr 0.2 mg/hr 4 CARDIOTONICS 28 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Drug Name Specialty Drug Tier 2015 NITRO-DUR – nitroglycerin td patch 24hr 0.3 mg/hr 4 BETAPACE – sotalol hcl tab 120 mg 4 NITRO-DUR – nitroglycerin td patch 24hr 0.4 mg/hr 4 BETAPACE – sotalol hcl tab 160 mg 4 NITRO-DUR – nitroglycerin td patch 24hr 0.6 mg/hr 4 BETAPACE AF – sotalol hcl (afib/ afl) tab 80 mg 4 NITRO-DUR – nitroglycerin td patch 24hr 0.8 mg/hr 4 BETAPACE AF – sotalol hcl (afib/ afl) tab 120 mg 4 nitroglycerin cap cr 2.5 mg 1 4 nitroglycerin cap cr 6.5 mg 1 BETAPACE AF – sotalol hcl (afib/ afl) tab 160 mg nitroglycerin cap cr 9 mg 1 betaxolol hcl tab 10 mg (Kerlone) 1 nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur) 1 betaxolol hcl tab 20 mg (Kerlone) 1 1 nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur) 1 bisoprolol fumarate tab 10 mg (Zebeta) 1 nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur) 1 bisoprolol fumarate tab 5 mg (Zebeta) carvedilol tab 12.5 mg (Coreg) 1 nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur) 1 carvedilol tab 25 mg (Coreg) 1 carvedilol tab 3.125 mg (Coreg) 1 NITROSTAT – nitroglycerin sl tab 0.3 mg 3 carvedilol tab 6.25 mg (Coreg) 1 3 COREG – carvedilol tab 3.125 mg 4 NITROSTAT – nitroglycerin sl tab 0.4 mg COREG – carvedilol tab 6.25 mg 4 NITROSTAT – nitroglycerin sl tab 0.6 mg 3 COREG – carvedilol tab 12.5 mg 4 COREG – carvedilol tab 25 mg 4 RANEXA – ranolazine tab sr 12hr 500 mg 4 CORGARD – nadolol tab 20 mg 4 CORGARD – nadolol tab 40 mg 4 RANEXA – ranolazine tab sr 12hr 1000 mg 4 CORGARD – nadolol tab 80 mg 4 INDERAL LA – propranolol hcl cap sr 24hr 60 mg 4 INDERAL LA – propranolol hcl cap sr 24hr 80 mg 4 INDERAL LA – propranolol hcl cap sr 24hr 120 mg 4 INDERAL LA – propranolol hcl cap sr 24hr 160 mg 4 KERLONE – betaxolol hcl tab 10 mg 4 BETA BLOCKERS acebutolol hcl cap 200 mg (Sectral) 1 acebutolol hcl cap 400 mg (Sectral) 1 atenolol tab 100 mg (Tenormin) 1 atenolol tab 25 mg (Tenormin) 1 atenolol tab 50 mg (Tenormin) 1 BETAPACE – sotalol hcl tab 80 mg 4 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 29 1 labetalol hcl tab 100 mg (Trandate) labetalol hcl tab 200 mg (Trandate) 1 labetalol hcl tab 300 mg (Trandate) 1 LOPRESSOR – metoprolol tartrate tab 50 mg 4 LOPRESSOR – metoprolol tartrate tab 100 mg 4 metoprolol succinate tab sr 24hr 100 mg (Toprol xl) 1 metoprolol succinate tab sr 24hr 200 mg (Toprol xl) 1 sotalol hcl tab 160 mg (Betapace) 1 1 sotalol hcl tab 240 mg metoprolol succinate tab sr 24hr 25 mg (Toprol xl) 1 sotalol hcl tab 80 mg (Betapace) 1 TENORMIN – atenolol tab 25 mg 4 metoprolol succinate tab sr 24hr 50 mg (Toprol xl) 1 TENORMIN – atenolol tab 50 mg 4 TENORMIN – atenolol tab 100 mg 4 metoprolol tartrate tab 100 mg (Lopressor) 1 4 metoprolol tartrate tab 25 mg 1 TOPROL XL – metoprolol succinate tab sr 24hr 25 mg metoprolol tartrate tab 50 mg (Lopressor) TOPROL XL – metoprolol succinate tab sr 24hr 50 mg 4 1 1 TOPROL XL – metoprolol succinate tab sr 24hr 100 mg 4 nadolol tab 20 mg (Corgard) nadolol tab 40 mg (Corgard) 1 4 nadolol tab 80 mg (Corgard) 1 TOPROL XL – metoprolol succinate tab sr 24hr 200 mg propranolol hcl cap sr 24hr 120 mg (Inderal la) 1 TRANDATE – labetalol hcl tab 100 mg 4 propranolol hcl cap sr 24hr 160 mg (Inderal la) 1 TRANDATE – labetalol hcl tab 200 mg 4 propranolol hcl cap sr 24hr 60 mg (Inderal la) 1 TRANDATE – labetalol hcl tab 300 mg 4 propranolol hcl cap sr 24hr 80 mg (Inderal la) 1 ZEBETA – bisoprolol fumarate tab 5 mg 4 propranolol hcl tab 10 mg 1 4 propranolol hcl tab 20 mg 1 ZEBETA – bisoprolol fumarate tab 10 mg propranolol hcl tab 40 mg 1 30 SECTRAL – acebutolol hcl cap 200 4 mg SECTRAL – acebutolol hcl cap 400 4 mg 1 sotalol hcl (afib/afl) tab 120 mg (Betapace af) 1 sotalol hcl (afib/afl) tab 160 mg (Betapace af) 1 sotalol hcl (afib/afl) tab 80 mg (Betapace af) sotalol hcl tab 120 mg (Betapace) 1 CALCIUM CHANNEL BLOCKERS Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits propranolol hcl tab 80 mg 1 Restricted Access 1 4 Prior Review propranolol hcl tab 60 mg KERLONE – betaxolol hcl tab 20 mg Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Drug Name Specialty Drug Tier 2015 ADALAT CC – nifedipine tab sr 24hr 30 mg 4 CARDIZEM LA – diltiazem hcl coated beads tab sr 24hr 120 mg 4 ADALAT CC – nifedipine tab sr 24hr 60 mg 4 CARDIZEM LA – diltiazem hcl coated beads tab sr 24hr 180 mg 4 ADALAT CC – nifedipine tab sr 24hr 90 mg 4 CARDIZEM LA – diltiazem hcl coated beads tab sr 24hr 240 mg 4 amlodipine besylate tab 10 mg (Norvasc) 1 CARDIZEM LA – diltiazem hcl coated beads tab sr 24hr 300 mg 4 amlodipine besylate tab 2.5 mg (Norvasc) 1 CARDIZEM LA – diltiazem hcl coated beads tab sr 24hr 360 mg 4 amlodipine besylate tab 5 mg (Norvasc) 1 CARDIZEM LA – diltiazem hcl coated beads tab sr 24hr 420 mg 4 CALAN – verapamil hcl tab 80 mg 4 diltiazem hcl cap sr 12hr 120 mg 1 diltiazem hcl cap sr 12hr 60 mg 1 diltiazem hcl cap sr 12hr 90 mg 1 diltiazem hcl cap sr 24hr 120 mg 1 diltiazem hcl cap sr 24hr 180 mg 1 diltiazem hcl cap sr 24hr 240 mg 1 diltiazem hcl coated beads cap sr 24hr 120 mg (Cardizem cd) 1 diltiazem hcl coated beads cap sr 24hr 180 mg (Cardizem cd) 1 diltiazem hcl coated beads cap sr 24hr 240 mg (Cardizem cd) 1 diltiazem hcl coated beads cap sr 24hr 300 mg (Cardizem cd) 1 diltiazem hcl coated beads cap sr 24hr 360 mg (Cardizem cd) 1 diltiazem hcl coated beads tab sr 24hr 180 mg (Cardizem la) 2 diltiazem hcl coated beads tab sr 24hr 240 mg (Cardizem la) 2 diltiazem hcl coated beads tab sr 24hr 300 mg (Cardizem la) 2 diltiazem hcl coated beads tab sr 24hr 360 mg (Cardizem la) 2 diltiazem hcl coated beads tab sr 24hr 420 mg (Cardizem la) 2 CALAN – verapamil hcl tab 120 mg 4 4 CALAN SR – verapamil hcl tab cr 120 mg 4 CALAN SR – verapamil hcl tab cr 180 mg 4 CALAN SR – verapamil hcl tab cr 240 mg 4 CARDIZEM – diltiazem hcl tab 30 mg 4 CARDIZEM – diltiazem hcl tab 60 mg CARDIZEM – diltiazem hcl tab 120 4 mg 4 CARDIZEM CD – diltiazem hcl coated beads cap sr 24hr 120 mg 4 CARDIZEM CD – diltiazem hcl coated beads cap sr 24hr 180 mg 4 CARDIZEM CD – diltiazem hcl coated beads cap sr 24hr 240 mg 4 CARDIZEM CD – diltiazem hcl coated beads cap sr 24hr 300 mg 4 CARDIZEM CD – diltiazem hcl coated beads cap sr 24hr 360 mg Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 31 diltiazem hcl extended release beads cap sr 24hr 120 mg (Tiazac) 1 diltiazem hcl extended release beads cap sr 24hr 180 mg (Tiazac) 1 diltiazem hcl extended release beads cap sr 24hr 240 mg (Tiazac) 1 diltiazem hcl extended release beads cap sr 24hr 300 mg (Tiazac) 1 diltiazem hcl extended release beads cap sr 24hr 360 mg (Tiazac) 1 diltiazem hcl extended release beads cap sr 24hr 420 mg (Tiazac) 1 diltiazem hcl tab 120 mg (Cardizem) nifedipine tab sr 24hr osmotic 60 mg (Procardia xl) 1 nifedipine tab sr 24hr osmotic 90 mg (Procardia xl) 1 nifedipine tab sr 24hr 30 mg (Adalat cc) 1 nifedipine tab sr 24hr 60 mg (Adalat cc) 1 nifedipine tab sr 24hr 90 mg (Adalat cc) 1 nimodipine cap 30 mg 2 NISOLDIPINE – nisoldipine tab sr 24hr 40 mg 2 nisoldipine tab sr 24hr 17 mg (Sular) 2 nisoldipine tab sr 24hr 34 mg (Sular) 2 1 nisoldipine tab sr 24hr 8.5 mg (Sular) 2 diltiazem hcl tab 30 mg (Cardizem) 1 NORVASC – amlodipine besylate tab 2.5 mg 4 diltiazem hcl tab 60 mg (Cardizem) 1 NORVASC – amlodipine besylate tab 5 mg 4 diltiazem hcl tab 90 mg 1 4 felodipine tab sr 24hr 10 mg 2 NORVASC – amlodipine besylate tab 10 mg felodipine tab sr 24hr 2.5 mg 2 5 felodipine tab sr 24hr 5 mg 2 NYMALIZE – nimodipine oral soln 60 mg/20ml 4 PROCARDIA – nifedipine cap 10 mg 4 ISOPTIN SR – verapamil hcl tab cr 120 mg ISOPTIN SR – verapamil hcl tab cr 180 mg 4 ISOPTIN SR – verapamil hcl tab cr 240 mg 4 nicardipine hcl cap 20 mg 1 nicardipine hcl cap 30 mg 1 nifedipine cap 10 mg (Procardia) 2 nifedipine cap 20 mg 2 nifedipine tab sr 24hr osmotic 30 mg (Procardia xl) 1 32 • • PROCARDIA XL – nifedipine tab sr 4 24hr osmotic 30 mg PROCARDIA XL – nifedipine tab sr 4 24hr osmotic 60 mg PROCARDIA XL – nifedipine tab sr 4 24hr osmotic 90 mg 4 SULAR – nisoldipine tab sr 24hr 8.5 mg SULAR – nisoldipine tab sr 24hr 17 4 mg Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Drug Name Specialty Drug Tier 2015 SULAR – nisoldipine tab sr 24hr 34 4 mg 4 TIAZAC – diltiazem hcl extended release beads cap sr 24hr 120 mg 4 TIAZAC – diltiazem hcl extended release beads cap sr 24hr 180 mg 4 TIAZAC – diltiazem hcl extended release beads cap sr 24hr 240 mg 4 TIAZAC – diltiazem hcl extended release beads cap sr 24hr 300 mg 4 TIAZAC – diltiazem hcl extended release beads cap sr 24hr 360 mg 4 TIAZAC – diltiazem hcl extended release beads cap sr 24hr 420 mg 1 VERAPAMIL HCL – verapamil hcl tab 40 mg 1 verapamil hcl cap sr 24hr 100 mg (Verelan pm) 1 verapamil hcl cap sr 24hr 120 mg (Verelan) 1 verapamil hcl cap sr 24hr 180 mg (Verelan) 1 verapamil hcl cap sr 24hr 200 mg (Verelan pm) 1 verapamil hcl cap sr 24hr 240 mg (Verelan) 1 verapamil hcl cap sr 24hr 300 mg (Verelan pm) 1 verapamil hcl cap sr 24hr 360 mg (Verelan) 1 verapamil hcl tab cr 120 mg (Calan sr) 1 verapamil hcl tab cr 180 mg (Calan sr) verapamil hcl tab cr 240 mg (Calan sr) 1 verapamil hcl tab 120 mg (Calan) 1 verapamil hcl tab 80 mg (Calan) 1 VERELAN – verapamil hcl cap sr 24hr 120 mg 4 VERELAN – verapamil hcl cap sr 24hr 180 mg 4 VERELAN – verapamil hcl cap sr 24hr 240 mg 4 VERELAN – verapamil hcl cap sr 24hr 360 mg 4 VERELAN PM – verapamil hcl cap sr 24hr 100 mg 4 VERELAN PM – verapamil hcl cap sr 24hr 200 mg 4 VERELAN PM – verapamil hcl cap sr 24hr 300 mg 4 Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 ANTIARRHYTHMICS amiodarone hcl tab 100 mg 2 amiodarone hcl tab 200 mg (Cordarone) 1 amiodarone hcl tab 400 mg 1 amiodarone hcl tab 400 mg 2 CORDARONE – amiodarone hcl tab 200 mg 4 disopyramide phosphate cap 100 mg (Norpace) 1 disopyramide phosphate cap 150 mg (Norpace) 1 flecainide acetate tab 100 mg 1 flecainide acetate tab 150 mg 1 flecainide acetate tab 50 mg 1 mexiletine hcl cap 150 mg 2 mexiletine hcl cap 200 mg 2 mexiletine hcl cap 250 mg 2 NORPACE – disopyramide phosphate cap 100 mg 4 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 33 NORPACE – disopyramide phosphate cap 150 mg 4 ACCUPRIL – quinapril hcl tab 40 mg 4 propafenone hcl cap sr 12hr 225 mg (Rythmol sr) 2 4 propafenone hcl cap sr 12hr 325 mg (Rythmol sr) 2 ACCURETIC – quinaprilhydrochlorothiazide tab 10-12.5 mg 4 propafenone hcl cap sr 12hr 425 mg (Rythmol sr) 2 ACCURETIC – quinaprilhydrochlorothiazide tab 20-12.5 mg propafenone hcl tab 150 mg (Rythmol) 1 ACCURETIC – quinaprilhydrochlorothiazide tab 20-25 mg 4 propafenone hcl tab 225 mg (Rythmol) 1 ACEON – perindopril erbumine tab 4 mg 4 propafenone hcl tab 300 mg 1 4 quinidine gluconate tab cr 324 mg 2 ACEON – perindopril erbumine tab 8 mg ALTACE – ramipril cap 1.25 mg 4 QUINIDINE SULFATE – quinidine sulfate tab 200 mg 2 ALTACE – ramipril cap 2.5 mg 4 ALTACE – ramipril cap 5 mg 4 quinidine sulfate tab 300 mg 2 ALTACE – ramipril cap 10 mg 4 RYTHMOL – propafenone hcl tab 150 mg 4 amlodipine besylate-benazepril hcl cap 10-20 mg (Lotrel) 2 RYTHMOL – propafenone hcl tab 225 mg 4 amlodipine besylate-benazepril hcl cap 10-40 mg (Lotrel) 2 RYTHMOL SR – propafenone hcl cap sr 12hr 225 mg 4 amlodipine besylate-benazepril hcl cap 2.5-10 mg (Lotrel) 2 RYTHMOL SR – propafenone hcl cap sr 12hr 325 mg 4 amlodipine besylate-benazepril hcl cap 5-10 mg (Lotrel) 2 RYTHMOL SR – propafenone hcl cap sr 12hr 425 mg 4 amlodipine besylate-benazepril hcl cap 5-20 mg (Lotrel) 2 TIKOSYN – dofetilide cap 125 mcg (0.125 mg) 4 amlodipine besylate-benazepril hcl cap 5-40 mg (Lotrel) 2 TIKOSYN – dofetilide cap 250 mcg (0.25 mg) 4 amlodipine besylate-valsartan tab 10-160 mg (Exforge) 2 TIKOSYN – dofetilide cap 500 mcg (0.5 mg) 4 amlodipine besylate-valsartan tab 10-320 mg (Exforge) 2 amlodipine besylate-valsartan tab 5-160 mg (Exforge) 2 amlodipine besylate-valsartan tab 5-320 mg (Exforge) 2 ANTIHYPERTENSIVES ACCUPRIL – quinapril hcl tab 5 mg 4 4 ACCUPRIL – quinapril hcl tab 10 mg 4 ACCUPRIL – quinapril hcl tab 20 mg 34 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Drug Name Specialty Drug Tier 2015 4 AVAPRO – irbesartan tab 300 mg 4 benazepril & hydrochlorothiazide tab 10-12.5 mg (Lotensin hct) 1 benazepril & hydrochlorothiazide tab 20-12.5 mg (Lotensin hct) 1 benazepril & hydrochlorothiazide tab 20-25 mg (Lotensin hct) 1 benazepril & hydrochlorothiazide tab 5-6.25 mg 1 benazepril hcl tab 10 mg (Lotensin) 1 benazepril hcl tab 20 mg (Lotensin) 1 benazepril hcl tab 40 mg (Lotensin) 1 benazepril hcl tab 5 mg 1 bisoprolol & hydrochlorothiazide tab 10-6.25 mg (Ziac) 1 bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg (Ziac) 1 bisoprolol & hydrochlorothiazide tab 5-6.25 mg (Ziac) 1 candesartan cilexetil tab 16 mg (Atacand) 2 amlodipine-valsartanhydrochlorothiazide tab 10-160-25 mg (Exforge hct) 2 amlodipine-valsartanhydrochlorothiazide tab 10-320-25 mg (Exforge hct) 2 amlodipine-valsartanhydrochlorothiazide tab 5-160-12.5 mg (Exforge hct) 2 amlodipine-valsartanhydrochlorothiazide tab 5-160-25 mg (Exforge hct) 2 ATACAND – candesartan cilexetil tab 4 mg 4 ATACAND – candesartan cilexetil tab 8 mg 4 ATACAND – candesartan cilexetil tab 16 mg 4 ATACAND – candesartan cilexetil tab 32 mg 4 ATACAND HCT – candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg 4 ATACAND HCT – candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg 4 ATACAND HCT – candesartan cilexetil-hydrochlorothiazide tab 32-25 mg 4 atenolol & chlorthalidone tab 100-25 mg (Tenoretic 100) candesartan cilexetil tab 32 mg (Atacand) 2 1 atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50) candesartan cilexetil tab 4 mg (Atacand) 2 1 4 candesartan cilexetil tab 8 mg (Atacand) 2 AVALIDE – irbesartanhydrochlorothiazide tab 150-12.5 mg 2 AVALIDE – irbesartanhydrochlorothiazide tab 300-12.5 mg 4 candesartan cilexetilhydrochlorothiazide tab 16-12.5 mg (Atacand hct) Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits AVAPRO – irbesartan tab 150 mg Restricted Access 4 2 Prior Review AVAPRO – irbesartan tab 75 mg amlodipine-valsartanhydrochlorothiazide tab 10-160-12.5 mg (Exforge hct) Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 35 candesartan cilexetilhydrochlorothiazide tab 32-12.5 mg (Atacand hct) 2 candesartan cilexetilhydrochlorothiazide tab 32-25 mg (Atacand hct) 2 captopril tab 100 mg 1 captopril tab 12.5 mg 1 captopril tab 25 mg 1 captopril tab 50 mg 1 CAPTOPRIL/ HYDROCHLOROTHIA – captopril & hydrochlorothiazide tab 25-15 mg 1 CAPTOPRIL/ HYDROCHLOROTHIA – captopril & hydrochlorothiazide tab 25-25 mg 1 CAPTOPRIL/ HYDROCHLOROTHIA – captopril & hydrochlorothiazide tab 50-15 mg 1 CAPTOPRIL/ HYDROCHLOROTHIA – captopril & hydrochlorothiazide tab 50-25 mg 1 CARDURA – doxazosin mesylate tab 1 mg CATAPRES-TTS-1 – clonidine hcl td patch weekly 0.1 mg/24hr 4 CATAPRES-TTS-2 – clonidine hcl td patch weekly 0.2 mg/24hr 4 CATAPRES-TTS-3 – clonidine hcl td patch weekly 0.3 mg/24hr 4 clonidine hcl tab 0.1 mg (Catapres) 1 clonidine hcl tab 0.2 mg (Catapres) 1 clonidine hcl tab 0.3 mg (Catapres) 1 clonidine hcl td patch weekly 0.1 mg/24hr (Catapres-tts-1) 2 clonidine hcl td patch weekly 0.2 mg/24hr (Catapres-tts-2) 2 clonidine hcl td patch weekly 0.3 mg/24hr (Catapres-tts-3) 2 CORZIDE – nadolol & bendroflumethiazide tab 40-5 mg 4 CORZIDE – nadolol & bendroflumethiazide tab 80-5 mg 4 COZAAR – losartan potassium tab 25 mg 4 4 4 COZAAR – losartan potassium tab 50 mg 4 CARDURA – doxazosin mesylate tab 2 mg 4 COZAAR – losartan potassium tab 100 mg DIOVAN – valsartan tab 40 mg 4 CARDURA – doxazosin mesylate tab 4 mg 4 DIOVAN – valsartan tab 80 mg 4 DIOVAN – valsartan tab 160 mg 4 CARDURA – doxazosin mesylate tab 8 mg 4 DIOVAN – valsartan tab 320 mg 4 4 CATAPRES – clonidine hcl tab 0.2 mg 4 DIOVAN HCT – valsartanhydrochlorothiazide tab 80-12.5 mg 4 CATAPRES – clonidine hcl tab 0.1 mg 4 CATAPRES – clonidine hcl tab 0.3 mg 4 DIOVAN HCT – valsartanhydrochlorothiazide tab 160-12.5 mg 36 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Drug Name Specialty Drug Tier 2015 4 DIOVAN HCT – valsartanhydrochlorothiazide tab 320-12.5 mg 4 DIOVAN HCT – valsartanhydrochlorothiazide tab 320-25 mg 4 doxazosin mesylate tab 1 mg (Cardura) 1 doxazosin mesylate tab 2 mg (Cardura) 1 doxazosin mesylate tab 4 mg (Cardura) 1 doxazosin mesylate tab 8 mg (Cardura) 1 DUTOPROL – metoprolol & hydrochlorothiazide tab sr 24hr 25-12.5 mg 3 DUTOPROL – metoprolol & hydrochlorothiazide tab sr 24hr 50-12.5 mg 3 DUTOPROL – metoprolol & hydrochlorothiazide tab sr 24hr 100-12.5 mg 3 enalapril maleate & hydrochlorothiazide tab 10-25 mg (Vaseretic) 1 enalapril maleate & hydrochlorothiazide tab 5-12.5 mg 1 enalapril maleate tab 10 mg (Vasotec) 1 enalapril maleate tab 2.5 mg (Vasotec) 1 enalapril maleate tab 20 mg (Vasotec) 1 enalapril maleate tab 5 mg (Vasotec) 1 eplerenone tab 25 mg (Inspra) 2 2 EXFORGE – amlodipine besylatevalsartan tab 5-160 mg 4 EXFORGE – amlodipine besylatevalsartan tab 5-320 mg 4 EXFORGE – amlodipine besylatevalsartan tab 10-160 mg 4 EXFORGE – amlodipine besylatevalsartan tab 10-320 mg 4 EXFORGE HCT – amlodipinevalsartan-hydrochlorothiazide tab 5-160-12.5 mg 4 EXFORGE HCT – amlodipinevalsartan-hydrochlorothiazide tab 5-160-25 mg 4 EXFORGE HCT – amlodipinevalsartan-hydrochlorothiazide tab 10-160-12.5 mg 4 EXFORGE HCT – amlodipinevalsartan-hydrochlorothiazide tab 10-160-25 mg 4 EXFORGE HCT – amlodipinevalsartan-hydrochlorothiazide tab 10-320-25 mg 4 fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg 1 fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg 1 fosinopril sodium tab 10 mg 1 fosinopril sodium tab 20 mg 1 fosinopril sodium tab 40 mg 1 guanfacine hcl tab 1 mg (Tenex) 1 guanfacine hcl tab 2 mg (Tenex) 1 hydralazine hcl tab 10 mg 1 hydralazine hcl tab 100 mg 1 hydralazine hcl tab 25 mg 1 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits eprosartan mesylate tab 600 mg (Teveten) Restricted Access 2 Prior Review eplerenone tab 50 mg (Inspra) Specialty Quantity Limits Restricted Access Prior Review Drug Name Drug Tier DIOVAN HCT – valsartanhydrochlorothiazide tab 160-25 mg Specialty Drug Name Drug Tier 2015 37 1 4 losartan potassium & hydrochlorothiazide tab 100-25 mg (Hyzaar) 1 HYZAAR – losartan potassium & hydrochlorothiazide tab 100-12.5 mg 4 losartan potassium & hydrochlorothiazide tab 50-12.5 mg (Hyzaar) 1 HYZAAR – losartan potassium & hydrochlorothiazide tab 100-25 mg 4 losartan potassium tab 100 mg (Cozaar) losartan potassium tab 25 mg (Cozaar) 1 INSPRA – eplerenone tab 25 mg 4 1 INSPRA – eplerenone tab 50 mg 4 losartan potassium tab 50 mg (Cozaar) irbesartan tab 150 mg (Avapro) 2 4 irbesartan tab 300 mg (Avapro) 2 LOTENSIN – benazepril hcl tab 10 mg 2 LOTENSIN – benazepril hcl tab 20 mg 4 irbesartan tab 75 mg (Avapro) irbesartan-hydrochlorothiazide tab 150-12.5 mg (Avalide) 2 LOTENSIN – benazepril hcl tab 40 mg 4 irbesartan-hydrochlorothiazide tab 300-12.5 mg (Avalide) 2 4 lisinopril & hydrochlorothiazide tab 10-12.5 mg (Zestoretic) 1 LOTENSIN HCT – benazepril & hydrochlorothiazide tab 10-12.5 mg lisinopril & hydrochlorothiazide tab 20-12.5 mg (Zestoretic) LOTENSIN HCT – benazepril & hydrochlorothiazide tab 20-12.5 mg 4 1 lisinopril & hydrochlorothiazide tab 20-25 mg (Zestoretic) 1 LOTENSIN HCT – benazepril & hydrochlorothiazide tab 20-25 mg 4 lisinopril tab 10 mg (Prinivil) 1 4 lisinopril tab 2.5 mg (Zestril) 1 LOTREL – amlodipine besylatebenazepril hcl cap 2.5-10 mg lisinopril tab 20 mg (Prinivil) 1 4 lisinopril tab 30 mg (Zestril) 1 LOTREL – amlodipine besylatebenazepril hcl cap 5-10 mg 1 LOTREL – amlodipine besylatebenazepril hcl cap 5-20 mg 4 lisinopril tab 40 mg (Zestril) lisinopril tab 5 mg (Prinivil) 1 4 LOPRESSOR HCT – metoprolol & hydrochlorothiazide tab 50-25 mg 4 LOTREL – amlodipine besylatebenazepril hcl cap 5-40 mg 4 LOPRESSOR HCT – metoprolol & hydrochlorothiazide tab 100-25 mg 4 LOTREL – amlodipine besylatebenazepril hcl cap 10-20 mg LOTREL – amlodipine besylatebenazepril hcl cap 10-40 mg 4 losartan potassium & hydrochlorothiazide tab 100-12.5 mg (Hyzaar) 1 MAVIK – trandolapril tab 1 mg 4 MAVIK – trandolapril tab 2 mg 4 38 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits HYZAAR – losartan potassium & hydrochlorothiazide tab 50-12.5 mg Restricted Access 1 Prior Review hydralazine hcl tab 50 mg Specialty Drug Name Drug Tier 2015 METHYLDOPA/ HYDROCHLOROTHI – methyldopa & hydrochlorothiazide tab 250-25 mg 1 metoprolol & hydrochlorothiazide tab 100-25 mg (Lopressor hct) 1 metoprolol & hydrochlorothiazide tab 100-50 mg 1 metoprolol & hydrochlorothiazide tab 50-25 mg (Lopressor hct) 1 MICARDIS – telmisartan tab 20 mg 4 MICARDIS – telmisartan tab 40 mg 4 MICARDIS – telmisartan tab 80 mg 4 4 MICARDIS HCT – telmisartanhydrochlorothiazide tab 40-12.5 mg 4 MICARDIS HCT – telmisartanhydrochlorothiazide tab 80-12.5 mg 4 MICARDIS HCT – telmisartanhydrochlorothiazide tab 80-25 mg 4 MINIPRESS – prazosin hcl cap 1 mg 4 MINIPRESS – prazosin hcl cap 2 mg 4 MINIPRESS – prazosin hcl cap 5 mg 1 minoxidil tab 10 mg minoxidil tab 2.5 mg Quantity Limits 1 Restricted Access METHYLDOPA/ HYDROCHLOROTHI – methyldopa & hydrochlorothiazide tab 250-15 mg Prior Review 1 Specialty methyldopa tab 500 mg Drug Name Drug Tier 1 Quantity Limits methyldopa tab 250 mg Restricted Access 4 Prior Review MAVIK – trandolapril tab 4 mg Specialty Drug Name Drug Tier 2015 moexipril hcl tab 15 mg (Univasc) 1 1 moexipril hcl tab 7.5 mg (Univasc) 1 moexipril-hydrochlorothiazide tab 15-12.5 mg (Uniretic) 1 moexipril-hydrochlorothiazide tab 15-25 mg 1 moexipril-hydrochlorothiazide tab 7.5-12.5 mg 2 nadolol & bendroflumethiazide tab 40-5 mg (Corzide) 2 nadolol & bendroflumethiazide tab 80-5 mg (Corzide) 1 perindopril erbumine tab 2 mg perindopril erbumine tab 4 mg (Aceon) 1 perindopril erbumine tab 8 mg (Aceon) 1 prazosin hcl cap 1 mg (Minipress) 1 prazosin hcl cap 2 mg (Minipress) 1 prazosin hcl cap 5 mg (Minipress) 1 4 PRINIVIL – lisinopril tab 5 mg PRINIVIL – lisinopril tab 10 mg 4 PRINIVIL – lisinopril tab 20 mg 4 PROPRANOLOL/ HYDROCHLOROTH – propranolol & hydrochlorothiazide tab 40-25 mg 1 PROPRANOLOL/ HYDROCHLOROTH – propranolol & hydrochlorothiazide tab 80-25 mg 1 quinapril hcl tab 10 mg (Accupril) 1 quinapril hcl tab 20 mg (Accupril) 1 quinapril hcl tab 40 mg (Accupril) 1 quinapril hcl tab 5 mg (Accupril) 1 quinapril-hydrochlorothiazide tab 10-12.5 mg (Accuretic) 1 1 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 39 1 trandolapril tab 2 mg (Mavik) 1 trandolapril tab 4 mg (Mavik) 1 TWYNSTA – telmisartanamlodipine tab 40-5 mg 4 TWYNSTA – telmisartanamlodipine tab 40-10 mg 4 quinapril-hydrochlorothiazide tab 20-25 mg (Accuretic) ramipril cap 1.25 mg (Altace) 1 ramipril cap 10 mg (Altace) 1 ramipril cap 2.5 mg (Altace) 1 ramipril cap 5 mg (Altace) 1 RESERPINE – reserpine tab 0.1 mg 3 TWYNSTA – telmisartanamlodipine tab 80-5 mg 4 RESERPINE – reserpine tab 0.25 mg 3 TWYNSTA – telmisartanamlodipine tab 80-10 mg 4 telmisartan tab 20 mg (Micardis) 2 valsartan tab 160 mg (Diovan) 2 telmisartan tab 40 mg (Micardis) 2 valsartan tab 320 mg (Diovan) 2 telmisartan tab 80 mg (Micardis) 2 valsartan tab 40 mg (Diovan) 2 telmisartan-amlodipine tab 40-10 mg (Twynsta) 2 valsartan tab 80 mg (Diovan) 2 telmisartan-amlodipine tab 40-5 mg (Twynsta) valsartan-hydrochlorothiazide tab 160-12.5 mg (Diovan hct) 2 2 telmisartan-amlodipine tab 80-10 mg (Twynsta) valsartan-hydrochlorothiazide tab 160-25 mg (Diovan hct) 2 2 telmisartan-amlodipine tab 80-5 mg (Twynsta) valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovan hct) 2 2 2 valsartan-hydrochlorothiazide tab 320-25 mg (Diovan hct) 2 telmisartan-hydrochlorothiazide tab 40-12.5 mg (Micardis hct) 2 valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan hct) 2 telmisartan-hydrochlorothiazide tab 80-12.5 mg (Micardis hct) telmisartan-hydrochlorothiazide tab 80-25 mg (Micardis hct) VASERETIC – enalapril maleate & hydrochlorothiazide tab 10-25 mg 4 2 TENEX – guanfacine hcl tab 1 mg VASOTEC – enalapril maleate tab 2.5 mg 4 4 TENEX – guanfacine hcl tab 2 mg 4 4 TENORETIC 100 – atenolol & chlorthalidone tab 100-25 mg 4 VASOTEC – enalapril maleate tab 5 mg 4 TENORETIC 50 – atenolol & chlorthalidone tab 50-25 mg 4 VASOTEC – enalapril maleate tab 10 mg 4 terazosin hcl cap 1 mg 1 VASOTEC – enalapril maleate tab 20 mg terazosin hcl cap 10 mg 1 4 terazosin hcl cap 2 mg 1 ZESTORETIC – lisinopril & hydrochlorothiazide tab 10-12.5 mg 40 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits trandolapril tab 1 mg (Mavik) 1 Restricted Access 1 1 Prior Review terazosin hcl cap 5 mg quinapril-hydrochlorothiazide tab 20-12.5 mg (Accuretic) Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Drug Name Specialty Drug Tier 2015 4 ZESTORETIC – lisinopril & hydrochlorothiazide tab 20-25 mg 4 ZESTRIL – lisinopril tab 2.5 mg 4 ZESTRIL – lisinopril tab 5 mg 4 ZESTRIL – lisinopril tab 10 mg 4 ZESTRIL – lisinopril tab 20 mg 4 ZESTRIL – lisinopril tab 30 mg 4 ZESTRIL – lisinopril tab 40 mg 4 ZIAC – bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg 4 ZIAC – bisoprolol & hydrochlorothiazide tab 5-6.25 mg 4 ZIAC – bisoprolol & hydrochlorothiazide tab 10-6.25 mg 4 DIURETICS ACETAZOLAMIDE – acetazolamide tab 125 mg 1 acetazolamide cap sr 12hr 500 mg (Diamox) 2 acetazolamide sodium for inj 500 mg 2 acetazolamide tab 250 mg 1 ALDACTAZIDE – spironolactone & hydrochlorothiazide tab 25-25 mg 4 ALDACTAZIDE – spironolactone & hydrochlorothiazide tab 50-50 mg 4 ALDACTONE – spironolactone tab 25 mg 1 bumetanide tab 1 mg 1 bumetanide tab 2 mg 1 CHLOROTHIAZIDE – chlorothiazide tab 250 mg 1 chlorothiazide tab 500 mg 1 CHLORTHALIDONE – chlorthalidone tab 25 mg 1 CHLORTHALIDONE – chlorthalidone tab 50 mg 1 CHLORTHALIDONE – chlorthalidone tab 100 mg 4 DEMADEX – torsemide tab 5 mg 4 DEMADEX – torsemide tab 10 mg 4 DEMADEX – torsemide tab 20 mg 4 Quantity Limits bumetanide tab 0.5 mg Restricted Access 1 Prior Review amiloride hcl tab 5 mg Specialty Quantity Limits Restricted Access Prior Review Drug Name Drug Tier ZESTORETIC – lisinopril & hydrochlorothiazide tab 20-12.5 mg Specialty Drug Name Drug Tier 2015 DEMADEX – torsemide tab 100 mg 4 4 DIAMOX – acetazolamide cap sr 12hr 500 mg 4 DYAZIDE – triamterene & hydrochlorothiazide cap 37.5-25 mg 4 DYRENIUM – triamterene cap 50 mg DYRENIUM – triamterene cap 100 4 mg 3 FUROSEMIDE – furosemide oral soln 8 mg/ml 1 furosemide oral soln 10 mg/ml furosemide tab 20 mg (Lasix) 1 furosemide tab 40 mg (Lasix) 1 4 furosemide tab 80 mg (Lasix) 1 4 hydrochlorothiazide cap 12.5 mg (Microzide) 1 ALDACTONE – spironolactone tab 50 mg hydrochlorothiazide tab 12.5 mg 2 ALDACTONE – spironolactone tab 100 mg 4 hydrochlorothiazide tab 25 mg 1 1 hydrochlorothiazide tab 50 mg 1 amiloride & hydrochlorothiazide tab 5-50 mg indapamide tab 1.25 mg 1 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 41 MAXZIDE – triamterene & hydrochlorothiazide tab 75-50 mg 4 MAXZIDE-25 – triamterene & hydrochlorothiazide tab 37.5-25 mg 4 methazolamide tab 25 mg (Neptazane) 2 methazolamide tab 50 mg (Neptazane) 2 metolazone tab 10 mg 1 metolazone tab 2.5 mg (Zaroxolyn) 1 metolazone tab 5 mg (Zaroxolyn) 1 MICROZIDE – hydrochlorothiazide cap 12.5 mg 4 NEPTAZANE – methazolamide tab 25 mg 4 NEPTAZANE – methazolamide tab 50 mg 4 spironolactone & hydrochlorothiazide tab 25-25 mg (Aldactazide) 1 spironolactone tab 100 mg (Aldactone) 1 spironolactone tab 25 mg (Aldactone) 1 spironolactone tab 50 mg (Aldactone) 1 torsemide tab 10 mg (Demadex) 1 torsemide tab 100 mg (Demadex) 1 torsemide tab 20 mg (Demadex) 1 torsemide tab 5 mg (Demadex) 1 triamterene & hydrochlorothiazide cap 37.5-25 mg (Dyazide) 1 42 triamterene & hydrochlorothiazide tab 75-50 mg (Maxzide) 1 VASOPRESSORS ADRENALIN – epinephrine inj 1 mg/ml (1:1000) 4 ADRENALIN – epinephrine inj 30 mg/30ml (1 mg/ml) (1:1000) 4 EPINEPHRINE – epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000) 4 EPINEPHRINE – epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) 4 EPIPEN 2-PAK – epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) 3 EPIPEN-JR 2-PAK – epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000) 3 midodrine hcl tab 10 mg 1 midodrine hcl tab 2.5 mg 1 midodrine hcl tab 5 mg 1 ANTIHYPERLIPIDEMICS ANTARA – fenofibrate micronized cap 30 mg 4 ANTARA – fenofibrate micronized cap 90 mg 4 atorvastatin calcium tab 10 mg (base equivalent) (Lipitor) 2 atorvastatin calcium tab 20 mg (base equivalent) (Lipitor) 2 atorvastatin calcium tab 40 mg (base equivalent) (Lipitor) 2 atorvastatin calcium tab 80 mg (base equivalent) (Lipitor) 2 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits 4 Restricted Access LASIX – furosemide tab 80 mg 1 Prior Review 4 triamterene & hydrochlorothiazide tab 37.5-25 mg (Maxzide-25) Specialty LASIX – furosemide tab 40 mg Drug Name Drug Tier 4 Quantity Limits LASIX – furosemide tab 20 mg Restricted Access 1 Prior Review indapamide tab 2.5 mg Specialty Drug Name Drug Tier 2015 cholestyramine light powder packets 4 gm 2 fenofibrate micronized cap 134 mg (Lofibra) 1 cholestyramine light powder 4 gm/dose (Questran light) 2 fenofibrate micronized cap 200 mg (Lofibra) 1 cholestyramine powder packets 4 gm (Questran) 2 fenofibrate micronized cap 43 mg 2 cholestyramine powder 4 gm/ dose (Questran) 2 fenofibrate micronized cap 67 mg (Lofibra) 1 choline fenofibrate cap dr 135 mg (fenofibric acid equiv) (Trilipix) 2 fenofibrate tab 145 mg (Tricor) 2 fenofibrate tab 160 mg (Lofibra) 1 2 fenofibrate tab 48 mg (Tricor) 2 choline fenofibrate cap dr 45 mg (fenofibric acid equiv) (Trilipix) fenofibrate tab 54 mg (Lofibra) 1 COLESTID – colestipol hcl tab 1 gm 4 fluvastatin sodium cap 20 mg (Lescol) 2 COLESTID – colestipol hcl granules 5 gm 4 fluvastatin sodium cap 40 mg (Lescol) 2 COLESTID – colestipol hcl granule packets 5 gm 4 gemfibrozil tab 600 mg (Lopid) 1 4 COLESTID FLAVORED – colestipol hcl granules 5 gm 4 LESCOL – fluvastatin sodium cap 20 mg 4 COLESTID FLAVORED – colestipol hcl granule packets 5 gm 4 LESCOL – fluvastatin sodium cap 40 mg LIPITOR – atorvastatin calcium tab 10 mg (base equivalent) 4 colestipol hcl granule packets 5 gm (Colestid flavored) 2 LIPITOR – atorvastatin calcium tab 20 mg (base equivalent) 4 colestipol hcl granules 5 gm (Colestid flavored) 2 LIPITOR – atorvastatin calcium tab 40 mg (base equivalent) 4 colestipol hcl tab 1 gm (Colestid) 2 4 CRESTOR – rosuvastatin calcium tab 5 mg 3 LIPITOR – atorvastatin calcium tab 80 mg (base equivalent) LOFIBRA – fenofibrate tab 54 mg 4 CRESTOR – rosuvastatin calcium tab 10 mg 3 LOFIBRA – fenofibrate tab 160 mg 4 CRESTOR – rosuvastatin calcium tab 20 mg LOFIBRA – fenofibrate micronized cap 67 mg 4 3 3 LOFIBRA – fenofibrate micronized cap 134 mg 4 CRESTOR – rosuvastatin calcium tab 40 mg 2 LOFIBRA – fenofibrate micronized cap 200 mg 4 fenofibrate micronized cap 130 mg LOPID – gemfibrozil tab 600 mg 4 lovastatin tab 10 mg 1 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 43 lovastatin tab 40 mg (Mevacor) 1 simvastatin tab 5 mg (Zocor) 1 MEVACOR – lovastatin tab 40 mg 4 simvastatin tab 80 mg (Zocor) 1 niacin tab cr 1000 mg (antihyperlipidemic) (Niaspan) 2 TRICOR – fenofibrate tab 48 mg 4 TRICOR – fenofibrate tab 145 mg 4 niacin tab cr 500 mg (antihyperlipidemic) (Niaspan) 2 TRILIPIX – choline fenofibrate cap dr 45 mg (fenofibric acid equiv) 4 niacin tab cr 750 mg (antihyperlipidemic) (Niaspan) 2 TRILIPIX – choline fenofibrate cap dr 135 mg (fenofibric acid equiv) 4 NIACOR – niacin (antihyperlipidemic) tab 500 mg 1 ZETIA – ezetimibe tab 10 mg 4 4 ZOCOR – simvastatin tab 5 mg 4 NIASPAN – niacin tab cr 500 mg (antihyperlipidemic) ZOCOR – simvastatin tab 10 mg 4 NIASPAN – niacin tab cr 750 mg (antihyperlipidemic) 4 ZOCOR – simvastatin tab 20 mg 4 ZOCOR – simvastatin tab 40 mg 4 NIASPAN – niacin tab cr 1000 mg (antihyperlipidemic) 4 ZOCOR – simvastatin tab 80 mg 4 PRAVACHOL – pravastatin sodium 4 tab 20 mg PRAVACHOL – pravastatin sodium 4 tab 40 mg PRAVACHOL – pravastatin sodium 4 tab 80 mg 1 pravastatin sodium tab 10 mg pravastatin sodium tab 20 mg (Pravachol) 1 pravastatin sodium tab 40 mg (Pravachol) 1 pravastatin sodium tab 80 mg (Pravachol) 1 QUESTRAN – cholestyramine powder 4 gm/dose 4 QUESTRAN – cholestyramine powder packets 4 gm 4 QUESTRAN LIGHT – cholestyramine light powder 4 gm/dose 4 simvastatin tab 10 mg (Zocor) 1 simvastatin tab 20 mg (Zocor) 1 44 CARDIOVASCULAR AGENTS - MISC. amlodipine besylate-atorvastatin 2 calcium tab 10-10 mg (Caduet) amlodipine besylate-atorvastatin 2 calcium tab 10-20 mg (Caduet) amlodipine besylate-atorvastatin 2 calcium tab 10-40 mg (Caduet) amlodipine besylate-atorvastatin 2 calcium tab 10-80 mg (Caduet) amlodipine besylate-atorvastatin 2 calcium tab 2.5-10 mg (Caduet) amlodipine besylate-atorvastatin 2 calcium tab 2.5-20 mg (Caduet) amlodipine besylate-atorvastatin 2 calcium tab 2.5-40 mg (Caduet) amlodipine besylate-atorvastatin 2 calcium tab 5-10 mg (Caduet) amlodipine besylate-atorvastatin 2 calcium tab 5-20 mg (Caduet) amlodipine besylate-atorvastatin 2 calcium tab 5-40 mg (Caduet) amlodipine besylate-atorvastatin 2 calcium tab 5-80 mg (Caduet) Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits 1 Restricted Access simvastatin tab 40 mg (Zocor) Prior Review 1 Specialty Drug Tier Quantity Limits Restricted Access lovastatin tab 20 mg (Mevacor) Prior Review Drug Name Specialty Drug Name Drug Tier 2015 BIDIL – isosorbide dinitratehydralazine hcl tab 20-37.5 mg 4 VIAGRA – Benefit Limits may apply – sildenafil citrate tab 25 mg 3 CADUET – amlodipine besylateatorvastatin calcium tab 2.5-10 mg 4 VIAGRA – Benefit Limits may apply – sildenafil citrate tab 50 mg 3 CADUET – amlodipine besylateatorvastatin calcium tab 2.5-20 mg VIAGRA – Benefit Limits may apply – sildenafil citrate tab 100 mg 3 4 CADUET – amlodipine besylateatorvastatin calcium tab 2.5-40 mg 4 CADUET – amlodipine besylateatorvastatin calcium tab 5-10 mg Quantity Limits Restricted Access Prior Review RESPIRATORY AGENTS ANTIHISTAMINES brompheniramine maleate tab sr 12hr 6 mg 1 4 carbinoxamine maleate soln 4 mg/5ml 1 CADUET – amlodipine besylateatorvastatin calcium tab 5-20 mg 4 carbinoxamine maleate tab 4 mg 1 4 CADUET – amlodipine besylateatorvastatin calcium tab 5-40 mg 4 CLARINEX – desloratadine tab 5 mg 4 CADUET – amlodipine besylateatorvastatin calcium tab 5-80 mg 4 CLARINEX REDITABS – desloratadine tab orally disintegrating 2.5 mg CADUET – amlodipine besylateatorvastatin calcium tab 10-10 mg 4 CLARINEX REDITABS – desloratadine tab orally disintegrating 5 mg 4 CADUET – amlodipine besylateatorvastatin calcium tab 10-20 mg 4 cyproheptadine hcl syrup 2 mg/5ml 1 cyproheptadine hcl tab 4 mg 1 CADUET – amlodipine besylateatorvastatin calcium tab 10-40 mg 4 desloratadine tab orally disintegrating 2.5 mg (Clarinex reditabs) 2 CADUET – amlodipine besylateatorvastatin calcium tab 10-80 mg 4 desloratadine tab orally disintegrating 5 mg (Clarinex reditabs) 2 OPSUMIT – macitentan tab 10 mg 4 desloratadine tab 5 mg (Clarinex) 2 REVATIO – sildenafil citrate tab 20 mg 5 • • • • 2 sildenafil citrate tab 20 mg (Revatio) 5 • • levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) (Xyzal) 2 TRACLEER – bosentan tab 62.5 mg 4 • • levocetirizine dihydrochloride tab 5 mg (Xyzal) 1 TRACLEER – bosentan tab 125 mg 4 • • promethazine hcl suppos 12.5 mg promethazine hcl suppos 25 mg 1 promethazine hcl suppos 50 mg 1 ERECTLIE DYSFUNCTION Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 45 promethazine hcl syrup 6.25 mg/5ml 1 OMNARIS – ciclesonide nasal susp 50 mcg/act 4 promethazine hcl tab 12.5 mg 1 4 promethazine hcl tab 25 mg 1 promethazine hcl tab 50 mg 1 QNASL – beclomethasone dipropionate nasal aerosol 80 mcg/act 4 QNASL CHILDRENS – beclomethasone dipropionate nasal aerosol 40 mcg/act 4 XYZAL – levocetirizine dihydrochloride tab 5 mg XYZAL – levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) 4 RHINOCORT AQUA – budesonide nasal susp 32 mcg/act 4 triamcinolone acetonide nasal aerosol suspension 55 mcg/act (Nasacort aq) 2 VERAMYST – fluticasone furoate nasal susp 27.5 mcg/spray 4 ZETONNA – ciclesonide nasal aerosol soln 37 mcg/act (50 mcg/ valve) 4 NASAL AGENTS - SYSTEMIC and TOPICAL ATROVENT – ipratropium bromide 4 nasal soln 0.03% (21 mcg/spray) ATROVENT – ipratropium bromide 4 nasal soln 0.06% (42 mcg/spray) 2 azelastine hcl nasal spray 137 mcg/spray (1 mg/ml) 2 budesonide nasal susp 32 mcg/ act (Rhinocort aqua) 4 DYMISTA – azelastine hclfluticasone prop nasal spray 137-50 mcg/act FLONASE – fluticasone propionate 4 nasal susp 50 mcg/act 4 FLUNISOLIDE – flunisolide nasal soln 25 mcg/act (0.025%) flunisolide nasal soln 25 mcg/act 2 (0.025%) (Flunisolide) 1 fluticasone propionate nasal susp 50 mcg/act (Flonase) 1 ipratropium bromide nasal soln 0.03% (21 mcg/spray) (Atrovent) 1 ipratropium bromide nasal soln 0.06% (42 mcg/spray) (Atrovent) 4 NASACORT AQ – triamcinolone acetonide nasal aerosol suspension 55 mcg/act NASONEX – mometasone furoate 3 nasal susp 50 mcg/act 46 COUGH/COLD/ALLERGY acetylcysteine inhal soln 10% 2 acetylcysteine inhal soln 20% 2 benzonatate cap 100 mg (Tessalon perles) 1 benzonatate cap 200 mg 1 2 hydrocod polst-chlorphen polst cr susp 10-8 mg/5ml (Tussionex pennkineti) 1 hydrocodone w/ homatropine syrup 5-1.5 mg/5ml 1 hydrocodone w/ homatropine tab 5-1.5 mg 4 HYPER-SAL – sodium chloride soln nebu 7% HYPERSAL – sodium chloride soln 4 nebu 7% 2 PROMETHAZINE VC PLAIN – promethazine & phenylephrine syrup 6.25-5 mg/5ml PROMETHAZINE VC/CODEINE – 2 phenylephrine-promethazine w/ codeine syrup 5-6.25-10 mg/5ml Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Drug Name Specialty Drug Tier 2015 promethazine w/ codeine syrup 6.25-10 mg/5ml 2 albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) 1 promethazine-dm syrup 6.25-15 mg/5ml 2 albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) 1 sodium chloride soln nebu 0.9% 1 albuterol sulfate syrup 2 mg/5ml 1 sodium chloride soln nebu 3% 1 1 sodium chloride soln nebu 7% (Hyper-sal) 1 albuterol sulfate tab sr 12hr 4 mg (Vospire er) 1 TESSALON PERLES – benzonatate cap 100 mg 4 albuterol sulfate tab sr 12hr 8 mg (Vospire er) albuterol sulfate tab 2 mg 1 TUSSIONEX PENNKINETIC EXT – hydrocod polst-chlorphen polst cr susp 10-8 mg/5ml 4 albuterol sulfate tab 4 mg 1 3 ZONATUSS – benzonatate cap 150 mg 4 ANORO ELLIPTA – umeclidiniumvilanterol aero powd ba 62.5-25 mcg/inh ASMANEX HFA – mometasone furoate inhal aerosol suspension 100 mcg/act 3 ASMANEX HFA – mometasone furoate inhal aerosol suspension 200 mcg/act 3 ASMANEX TWISTHALER 120 ME – mometasone furoate inhal powd 220 mcg/inh (breath activated) 3 ASMANEX TWISTHALER 14 MET – mometasone furoate inhal powd 220 mcg/inh (breath activated) 3 • • ANTIASTHMATIC and BRONCHODILATOR AGENTS ACCOLATE – zafirlukast tab 10 mg 4 ACCOLATE – zafirlukast tab 20 mg 4 3 ADVAIR DISKUS – fluticasonesalmeterol aer powder ba 100-50 mcg/dose 3 ADVAIR DISKUS – fluticasonesalmeterol aer powder ba 250-50 mcg/dose 3 ADVAIR DISKUS – fluticasonesalmeterol aer powder ba 500-50 mcg/dose 3 ADVAIR HFA – fluticasonesalmeterol inhal aerosol 45-21 mcg/act 3 ADVAIR HFA – fluticasonesalmeterol inhal aerosol 115-21 mcg/act 3 ADVAIR HFA – fluticasonesalmeterol inhal aerosol 230-21 mcg/act 1 albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) 1 albuterol sulfate soln nebu 0.5% (5 mg/ml) Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 ASMANEX TWISTHALER 30 ME – 3 mometasone furoate inhal powd 220 mcg/inh (breath activated) 3 ASMANEX TWISTHALER 30 MET – mometasone furoate inhal powd 110 mcg/inh (breath activated) 3 ASMANEX TWISTHALER 60 MET – mometasone furoate inhal powd 220 mcg/inh (breath activated) 3 ASMANEX TWISTHALER 7 METE – mometasone furoate Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 47 ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml 2 levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) (Xopenex concentrate) 1 levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv) (Xopenex) 2 BREO ELLIPTA – fluticasone furoate-vilanterol aero powd ba 100-25 mcg/inh 3 budesonide inhalation susp 0.25 mg/2ml (Pulmicort) 2 budesonide inhalation susp 0.5 mg/2ml (Pulmicort) 2 3 levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv) (Xopenex) 2 COMBIVENT RESPIMAT – ipratropium-albuterol inhal aerosol soln 20-100 mcg/act CROMOLYN SODIUM – cromolyn sodium soln nebu 20 mg/2ml levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) (Xopenex) 2 2 DALIRESP – roflumilast tab 500 mcg 4 METAPROTERENOL SULFATE – metaproterenol sulfate tab 10 mg 1 ELIXOPHYLLIN – theophylline elixir 80 mg/15ml 1 METAPROTERENOL SULFATE – metaproterenol sulfate tab 20 mg 1 FLOVENT DISKUS – fluticasone propionate aer pow ba 50 mcg/ blister 3 METAPROTERENOL SULFATE – metaproterenol sulfate syrup 10 mg/5ml 1 FLOVENT DISKUS – fluticasone propionate aer pow ba 100 mcg/ blister 3 montelukast sodium chew tab 4 mg (base equiv) (Singulair) 2 FLOVENT DISKUS – fluticasone propionate aer pow ba 250 mcg/ blister montelukast sodium chew tab 5 mg (base equiv) (Singulair) 2 3 montelukast sodium tab 10 mg (base equiv) (Singulair) 2 FLOVENT HFA – fluticasone propionate hfa inhal aero 44 mcg/act (50/valve) 3 PROAIR HFA – albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv) 3 FLOVENT HFA – fluticasone propionate hfa inhal aer 110 mcg/act (125/valve) 3 PULMICORT – budesonide inhalation susp 0.25 mg/2ml 4 3 PULMICORT – budesonide inhalation susp 0.5 mg/2ml 4 FLOVENT HFA – fluticasone propionate hfa inhal aer 220 mcg/act (250/valve) 3 FORADIL AEROLIZER – formoterol fumarate inhal cap 12 mcg 3 SEREVENT DISKUS – salmeterol xinafoate aer pow ba 50 mcg/ dose (base equiv) 4 ipratropium bromide inhal soln 0.02% 1 SINGULAIR – montelukast sodium tab 10 mg (base equiv) SINGULAIR – montelukast sodium chew tab 4 mg (base equiv) 4 48 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name inhal powd 110 mcg/inh (breath activated) Drug Tier 2015 SINGULAIR – montelukast sodium chew tab 5 mg (base equiv) 4 PULMOZYME – dornase alfa inhal soln 1 mg/ml SPIRIVA HANDIHALER – tiotropium bromide monohydrate inhal cap 18 mcg (base equiv) 3 GASTROINTESTINAL AGENTS SPIRIVA RESPIMAT – tiotropium bromide monohydrate inhal aerosol 2.5 mcg/act 3 SYMBICORT – budesonideformoterol fumarate dihyd aerosol 80-4.5 mcg/act 3 SYMBICORT – budesonideformoterol fumarate dihyd aerosol 160-4.5 mcg/act 3 terbutaline sulfate tab 2.5 mg 1 terbutaline sulfate tab 5 mg LAXATIVES COLYTE-FLAVOR PACKS – peg 3350-kcl-na bicarb-nacl-na sulfate for soln 227.1 gm 3 • • COLYTE-FLAVOR PACKS – peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm 4 • • GOLYTELY – peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm 4 3 1 GOLYTELY – peg 3350-kcl-na bicarb-nacl-na sulfate packet 227.1 gm theophylline soln 80 mg/15ml 1 lactulose solution 10 gm/15ml 1 theophylline tab sr 12hr 100 mg 1 4 theophylline tab sr 12hr 200 mg 1 theophylline tab sr 12hr 300 mg 1 NULYTELY/FLAVOR PACKS – peg 3350-kcl-sod bicarb-nacl for soln 420 gm 1 theophylline tab sr 24hr 400 mg 1 peg 3350-kcl-na bicarb-naclna sulfate for soln 236 gm (Golytely) 1 theophylline tab sr 12hr 450 mg theophylline tab sr 24hr 600 mg 1 1 VOSPIRE ER – albuterol sulfate tab sr 12hr 4 mg 4 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm (Colyteflavor packs) VOSPIRE ER – albuterol sulfate tab sr 12hr 8 mg 4 1 XOPENEX – levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv) 4 peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/flavor pack) 2 XOPENEX – levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv) 4 polyethylene glycol 3350 oral packet 2 XOPENEX – levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) 4 polyethylene glycol 3350 oral powder XOPENEX CONCENTRATE – levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) 4 diphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil) 1 1 zafirlukast tab 10 mg (Accolate) 2 zafirlukast tab 20 mg (Accolate) 2 DIPHENOXYLATE/ATROPINE – diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml LOMOTIL – diphenoxylate w/ atropine tab 2.5-0.025 mg 4 RESPIRATORY AGENTS - MISC. Quantity Limits • Restricted Access 5 Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 ANTIDIARRHEALS Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 49 ULCER DRUGS ACIPHEX – rabeprazole sodium ec 4 tab 20 mg 2 amoxicillin cap-clarithro tablansopraz cap dr therapy pack (Prevpac) 4 ANASPAZ – hyoscyamine sulfate tab disp 0.125 mg 4 AXID – nizatidine cap 300 mg AXID – nizatidine oral soln 15 mg/ ml 4 BENTYL – dicyclomine hcl cap 10 mg 4 BENTYL – dicyclomine hcl tab 20 mg 4 CARAFATE – sucralfate tab 1 gm 4 CARAFATE – sucralfate susp 1 gm/10ml 4 cimetidine hcl soln 300 mg/5ml 1 cimetidine tab 200 mg 1 cimetidine tab 300 mg 1 cimetidine tab 400 mg 1 cimetidine tab 800 mg 1 clidinium & chlordiazepoxide cap 2.5-5 mg (Librax) 2 CYTOTEC – misoprostol tab 100 mcg 4 CYTOTEC – misoprostol tab 200 mcg 4 dicyclomine hcl cap 10 mg (Bentyl) 1 dicyclomine hcl tab 20 mg (Bentyl) 1 DONNATAL – pb-hyoscyatrop-scopol tab 16.2-0.1037-0.0194-0.0065 mg 4 DONNATAL – pb-hyoscyatrop-scopol elix 4 50 famotidine for susp 40 mg/5ml (Pepcid) 2 famotidine tab 20 mg (Pepcid) 1 famotidine tab 40 mg (Pepcid) 1 GASTRINEX NF – hyoscyaminephenyltoloxamine cap 0.0625-15 mg 2 glycopyrrolate tab 1 mg (Robinul) 2 glycopyrrolate tab 2 mg (Robinul 2 forte) 1 hyoscyamine sulfate elixir 0.125 mg/5ml 1 hyoscyamine sulfate soln 0.125 mg/ml 1 hyoscyamine sulfate tab disp 0.125 mg (Anaspaz) 1 hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl) 2 hyoscyamine sulfate tab sr 12hr 0.375 mg (Levbid) 1 hyoscyamine sulfate tab 0.125 mg (Levsin) 2 lansoprazole cap delayed release 15 mg (Prevacid) 2 lansoprazole cap delayed release 30 mg (Prevacid) LEVBID – hyoscyamine sulfate tab 4 sr 12hr 0.375 mg LEVSIN – hyoscyamine sulfate tab 4 0.125 mg LEVSIN/SL – hyoscyamine sulfate 4 tab sl 0.125 mg 4 LIBRAX – clidinium & chlordiazepoxide cap 2.5-5 mg 2 methscopolamine bromide tab 2.5 mg (Pamine) 2 methscopolamine bromide tab 5 mg (Pamine forte) Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name 16.2-0.1037-0.0194-0.0065 mg/5ml Drug Tier Quantity Limits Restricted Access 1 Prior Review loperamide hcl cap 2 mg Specialty Drug Name Drug Tier 2015 misoprostol tab 100 mcg (Cytotec) 1 pantoprazole sodium ec tab 20 mg (base equiv) (Protonix) 1 misoprostol tab 200 mcg (Cytotec) 1 pantoprazole sodium ec tab 40 mg (base equiv) (Protonix) 1 NEXIUM – esomeprazole magnesium for delayed release susp pack 2.5 mg 3 PEPCID – famotidine tab 20 mg 4 PEPCID – famotidine tab 40 mg 4 3 PEPCID – famotidine for susp 40 mg/5ml 4 NEXIUM – esomeprazole magnesium for delayed release susp packet 5 mg 4 NEXIUM – esomeprazole magnesium for delayed release susp packet 10 mg 3 PREVACID – lansoprazole cap delayed release 15 mg PREVACID – lansoprazole cap delayed release 30 mg 4 NEXIUM – esomeprazole magnesium for delayed release susp packet 20 mg 3 PREVPAC – amoxicillin capclarithro tab-lansopraz cap dr therapy pack 4 NEXIUM – esomeprazole magnesium for delayed release susp packet 40 mg 3 PRILOSEC – omeprazole cap delayed release 10 mg 4 4 NEXIUM – esomeprazole magnesium cap delayed release 20 mg 3 PRILOSEC – omeprazole cap delayed release 20 mg PRILOSEC – omeprazole cap delayed release 40 mg 4 NEXIUM – esomeprazole magnesium cap delayed release 40 mg 3 nizatidine cap 150 mg 1 nizatidine cap 300 mg (Axid) 1 nizatidine oral soln 15 mg/ml (Axid) 2 omeprazole cap delayed release 10 mg (Prilosec) 1 ranitidine hcl cap 300 mg 1 omeprazole cap delayed release 20 mg (Prilosec) ranitidine hcl syrup 15 mg/ml (75 mg/5ml) 1 1 omeprazole cap delayed release 40 mg (Prilosec) 1 ranitidine hcl tab 150 mg (Zantac) 1 ranitidine hcl tab 300 mg (Zantac) 1 4 ROBINUL – glycopyrrolate tab 1 mg 4 PAMINE – methscopolamine bromide tab 2.5 mg 4 ROBINUL FORTE – glycopyrrolate tab 2 mg 4 PAMINE FORTE – methscopolamine bromide tab 5 mg sucralfate tab 1 gm (Carafate) 1 Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 PROTONIX – pantoprazole sodium 4 ec tab 20 mg (base equiv) PROTONIX – pantoprazole sodium 4 ec tab 40 mg (base equiv) 2 rabeprazole sodium ec tab 20 mg (Aciphex) 1 ranitidine hcl cap 150 mg Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 51 SYMAX DUOTAB – hyoscyamine sulfate tab cr 0.375 mg (0.125 mg ir/0.25 mg cr) 4 ZANTAC – ranitidine hcl tab 150 mg 4 ZANTAC – ranitidine hcl tab 300 mg 4 ANTIEMETICS TIGAN – trimethobenzamide hcl cap 300 mg 4 TRANSDERM-SCOP – scopolamine td patch 72hr 1.5 mg 4 trimethobenzamide hcl cap 300 mg (Tigan) 2 ZOFRAN – ondansetron hcl tab 4 mg 4 ZOFRAN – ondansetron hcl tab 8 mg 4 dronabinol cap 10 mg (Marinol) 2 dronabinol cap 2.5 mg (Marinol) 2 dronabinol cap 5 mg (Marinol) 2 5 ZOFRAN – ondansetron hcl oral soln 4 mg/5ml 4 EMEND – aprepitant capsule 40 mg 5 ZOFRAN ODT – ondansetron orally disintegrating tab 4 mg 4 EMEND – aprepitant capsule 80 mg 5 ZOFRAN ODT – ondansetron orally disintegrating tab 8 mg 4 EMEND – aprepitant capsule 125 mg EMEND – aprepitant capsule therapy pack 80 & 125 mg 5 MARINOL – dronabinol cap 2.5 mg 4 MARINOL – dronabinol cap 5 mg 4 MARINOL – dronabinol cap 10 mg 4 meclizine hcl tab 12.5 mg 1 meclizine hcl tab 25 mg 1 meclizine hcl tab 32 mg 2 ondansetron hcl oral soln 4 mg/5ml (Zofran) 2 ondansetron hcl tab 24 mg 1 ondansetron hcl tab 4 mg (Zofran) 1 ondansetron hcl tab 8 mg (Zofran) 1 ondansetron orally disintegrating tab 4 mg (Zofran odt) ondansetron orally disintegrating tab 8 mg (Zofran odt) 52 DIGESTIVE AIDS ZENPEP – pancrelipase (lip-protamyl) dr cap 3000-10000-16000 unit 3 ZENPEP – pancrelipase (lip-protamyl) dr cap 5000-17000-27000 unit 3 ZENPEP – pancrelipase (lip-protamyl) dr cap 10000-34000-55000 unit 3 ZENPEP – pancrelipase (lip-protamyl) dr cap 15000-51000-82000 unit 3 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 20000-68000-109000 unit 3 3 1 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 25000-85000-136000 unit 3 1 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 40000-136000-218000 unit GASTROINTESTINAL AGENTS- MISC. 4 ACTIGALL – ursodiol cap 300 mg Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Drug Name Specialty Drug Tier 2015 AZULFIDINE – sulfasalazine tab 500 mg 4 metoclopramide hcl inj 5 mg/ml 2 AZULFIDINE EN-TABS – sulfasalazine tab delayed release 500 mg metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) 1 4 metoclopramide hcl tab 10 mg (Reglan) 1 balsalazide disodium cap 750 mg (Colazal) 2 metoclopramide hcl tab 5 mg (Reglan) 1 calcium acetate (phosphate binder) cap 667 mg (169 mg ca) (Phoslo) 2 PENTASA – mesalamine cap cr 250 mg 4 2 PENTASA – mesalamine cap cr 500 mg 4 calcium acetate (phosphate binder) tab 667 mg (Eliphos) 4 PHOSLO – calcium acetate (phosphate binder) cap 667 mg (169 mg ca) 4 CANASA – mesalamine suppos 1000 mg COLAZAL – balsalazide disodium cap 750 mg 4 REGLAN – metoclopramide hcl tab 5 mg 4 cromolyn sodium oral conc 100 mg/5ml (Gastrocrom) 2 REGLAN – metoclopramide hcl tab 10 mg 4 DELZICOL – mesalamine cap dr 400 mg 3 DIPENTUM – olsalazine sodium cap 250 mg 5 ELIPHOS – calcium acetate (phosphate binder) tab 667 mg 4 ENTEREG – alvimopan cap 12 mg 5 GASTROCROM – cromolyn sodium oral conc 100 mg/5ml 4 lactulose (encephalopathy) solution 10 gm/15ml 1 LIALDA – mesalamine tab delayed release 1.2 gm 4 • • • • • LINZESS – linaclotide cap 145 mcg 3 LINZESS – linaclotide cap 290 mcg 3 LOTRONEX – alosetron hcl tab 0.5 5 mg (base equiv) 5 LOTRONEX – alosetron hcl tab 1 mg (base equiv) 2 mesalamine enema 4 gm mesalamine rectal enema 4 gm & cleanser wipe kit (Rowasa) 2 • • • • Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 RENAGEL – sevelamer hcl tab 400 4 mg RENAGEL – sevelamer hcl tab 800 4 mg RENVELA – sevelamer carbonate 4 tab 800 mg RENVELA – sevelamer carbonate 4 packet 0.8 gm RENVELA – sevelamer carbonate 4 packet 2.4 gm 4 ROWASA – mesalamine rectal enema 4 gm & cleanser wipe kit 1 sulfasalazine tab delayed release 500 mg (Azulfidine entabs) 1 sulfasalazine tab 500 mg (Azulfidine) 4 URSO FORTE – ursodiol tab 500 mg 4 URSO 250 – ursodiol tab 250 mg ursodiol cap 300 mg (Actigall) 2 ursodiol tab 250 mg (Urso 250) 2 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 53 GENITOURINARY AGENTS UREX – methenamine hippurate tab 1 gm URINARY ANTI-INFECTIVES URINARY ANTISPASMODICS 4 bethanechol chloride tab 10 mg (Urecholine) 1 HIPREX – methenamine hippurate tab 1 gm 4 bethanechol chloride tab 25 mg (Urecholine) 1 MACROBID – nitrofurantoin monohydrate macrocrystalline cap 100 mg 4 bethanechol chloride tab 5 mg (Urecholine) 1 1 MACRODANTIN – nitrofurantoin macrocrystalline cap 25 mg 4 bethanechol chloride tab 50 mg (Urecholine) 4 MACRODANTIN – nitrofurantoin macrocrystalline cap 50 mg 4 DETROL – tolterodine tartrate tab 1 mg 4 MACRODANTIN – nitrofurantoin macrocrystalline cap 100 mg 4 DETROL – tolterodine tartrate tab 2 mg 4 methenamine hippurate tab 1 gm (Hiprex) 2 DITROPAN XL – oxybutynin chloride tab sr 24hr 5 mg 4 METHENAMINE MANDELATE – methenamine mandelate tab 0.5 gm 3 DITROPAN XL – oxybutynin chloride tab sr 24hr 10 mg DITROPAN XL – oxybutynin chloride tab sr 24hr 15 mg 4 methenamine mandelate tab 1 gm 2 flavoxate hcl tab 100 mg 2 methenamine-hyos-meth bluesod phos-phen sal tab 81.6 mg oxybutynin chloride syrup 5 mg/5ml 1 2 2 oxybutynin chloride tab sr 24hr 10 mg (Ditropan xl) 2 methenamine-hyosc-meth bluebenz acid-phenyl sal tab 81.6mg (Prosed/ds) oxybutynin chloride tab sr 24hr 15 mg (Ditropan xl) 2 nitrofurantoin macrocrystalline cap 100 mg (Macrodantin) 1 oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl) 2 nitrofurantoin macrocrystalline cap 50 mg (Macrodantin) 1 oxybutynin chloride tab 5 mg 1 1 tolterodine tartrate tab 1 mg (Detrol) 2 nitrofurantoin monohydrate macrocrystalline cap 100 mg (Macrobid) 2 nitrofurantoin susp 25 mg/5ml (Furadantin) 2 tolterodine tartrate tab 2 mg (Detrol) 2 PROSED/DS – methenaminehyosc-meth blue-benz acidphenyl sal tab 81.6mg 4 trospium chloride cap sr 24hr 60 mg trospium chloride tab 20 mg 2 URECHOLINE – bethanechol chloride tab 5 mg 4 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review 4 FURADANTIN – nitrofurantoin susp 25 mg/5ml 54 Specialty Drug Name Drug Tier Quantity Limits Restricted Access 2 Prior Review ursodiol tab 500 mg (Urso forte) Specialty Drug Name Drug Tier 2015 URECHOLINE – bethanechol chloride tab 10 mg 4 alfuzosin hcl tab sr 24hr 10 mg (Uroxatral) 2 URECHOLINE – bethanechol chloride tab 25 mg 4 ELMIRON – pentosan polysulfate sodium caps 100 mg 4 URECHOLINE – bethanechol chloride tab 50 mg 4 finasteride tab 5 mg (Proscar) 1 FLOMAX – tamsulosin hcl cap 0.4 mg 4 phenazopyridine hcl tab 100 mg (Pyridium) 1 phenazopyridine hcl tab 200 mg (Pyridium) 1 potassium citrate & citric acid powder pack 3300-1002 mg 1 potassium citrate tab cr 10 meq (1080 mg) (Urocit-k 10) 2 potassium citrate tab cr 15 meq (1620 mg) (Urocit-k 15) 2 potassium citrate tab cr 5 meq (540 mg) (Urocit-k 5) 2 PROSCAR – finasteride tab 5 mg 4 PYRIDIUM – phenazopyridine hcl tab 100 mg 4 PYRIDIUM – phenazopyridine hcl tab 200 mg 4 SHOHLS SOLUTION MODIFIED – sodium citrate & citric acid soln 500-334 mg/5ml 4 sodium chloride irrigation soln 0.9% 1 VAGINAL PRODUCTS CLEOCIN – clindamycin phosphate 4 vaginal cream 2% 1 clindamycin phosphate vaginal cream 2% (Cleocin) 4 CRINONE – progesterone vaginal gel 4% 4 CRINONE – progesterone vaginal gel 8% 5 ENDOMETRIN – progesterone vaginal insert 100 mg 3 ESTRACE – estradiol vaginal cream 0.1 mg/gm ESTRING – estradiol vaginal ring 2 4 mg (7.5 mcg/24hrs) 4 METROGEL-VAGINAL – metronidazole vaginal gel 0.75% 1 metronidazole vaginal gel 0.75% (Metrogel-vaginal) 3 PREMARIN – estrogens, conjugated vaginal cream 0.625 mg/gm TERAZOL 3 – terconazole vaginal 4 cream 0.8% TERAZOL 7 – terconazole vaginal 4 cream 0.4% 1 terconazole vaginal cream 0.4% (Terazol 7) 1 terconazole vaginal cream 0.8% (Terazol 3) 1 terconazole vaginal suppos 80 mg GENITOURINARY AGENTS - MISC. • • Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 1 sodium citrate & citric acid soln 500-334 mg/5ml (Shohls solution modi) 1 tamsulosin hcl cap 0.4 mg (Flomax) 4 UROCIT-K 10 – potassium citrate tab cr 10 meq (1080 mg) 4 UROCIT-K 15 – potassium citrate tab cr 15 meq (1620 mg) 4 UROCIT-K 5 – potassium citrate tab cr 5 meq (540 mg) Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 55 UROXATRAL – alfuzosin hcl tab sr 24hr 10 mg 4 CENTRAL NERVOUS SYSTEM DRUGS ANTIANXIETY AGENTS alprazolam orally disintegrating tab 0.25 mg (Niravam) 2 alprazolam orally disintegrating tab 0.5 mg 2 alprazolam orally disintegrating tab 1 mg 2 alprazolam orally disintegrating tab 2 mg 2 alprazolam tab sr 24hr 0.5 mg (Xanax xr) 1 alprazolam tab sr 24hr 1 mg (Xanax xr) 1 alprazolam tab sr 24hr 2 mg (Xanax xr) 1 alprazolam tab sr 24hr 3 mg (Xanax xr) 1 alprazolam tab 0.25 mg (Xanax) 1 alprazolam tab 0.5 mg (Xanax) 1 alprazolam tab 1 mg (Xanax) 1 alprazolam tab 2 mg (Xanax) 1 ATIVAN – lorazepam tab 0.5 mg 4 ATIVAN – lorazepam tab 1 mg 4 ATIVAN – lorazepam tab 2 mg 4 buspirone hcl tab 10 mg 1 buspirone hcl tab 15 mg 1 buspirone hcl tab 30 mg 1 buspirone hcl tab 5 mg 1 buspirone hcl tab 7.5 mg 2 chlordiazepoxide hcl cap 10 mg 1 chlordiazepoxide hcl cap 25 mg 1 chlordiazepoxide hcl cap 5 mg 1 clorazepate dipotassium tab 15 mg (Tranxene t) 1 56 clorazepate dipotassium tab 3.75 mg (Tranxene t) 1 clorazepate dipotassium tab 7.5 mg (Tranxene t) 1 diazepam tab 10 mg (Valium) 1 diazepam tab 2 mg (Valium) 1 diazepam tab 5 mg (Valium) 1 hydroxyzine hcl syrup 10 mg/5ml 1 hydroxyzine hcl tab 10 mg 1 hydroxyzine hcl tab 25 mg 1 hydroxyzine hcl tab 50 mg 1 HYDROXYZINE PAMOATE – hydroxyzine pamoate cap 100 mg 1 hydroxyzine pamoate cap 25 mg (Vistaril) 1 hydroxyzine pamoate cap 50 mg (Vistaril) 1 LORAZEPAM INTENSOL – lorazepam conc 2 mg/ml 4 lorazepam tab 0.5 mg (Ativan) 1 lorazepam tab 1 mg (Ativan) 1 lorazepam tab 2 mg (Ativan) 1 meprobamate tab 200 mg 2 meprobamate tab 400 mg 2 NIRAVAM – alprazolam orally disintegrating tab 0.25 mg 4 oxazepam cap 10 mg 1 oxazepam cap 15 mg 1 oxazepam cap 30 mg 1 TRANXENE T – clorazepate dipotassium tab 3.75 mg 4 TRANXENE T – clorazepate dipotassium tab 7.5 mg 4 TRANXENE T – clorazepate dipotassium tab 15 mg 4 VALIUM – diazepam tab 2 mg 4 VALIUM – diazepam tab 5 mg 4 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Drug Name Specialty Drug Tier 2015 1 4 bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl) 1 VISTARIL – hydroxyzine pamoate cap 50 mg 4 bupropion hcl tab 100 mg (Wellbutrin) 1 XANAX – alprazolam tab 0.25 mg 4 bupropion hcl tab 75 mg (Wellbutrin) XANAX – alprazolam tab 0.5 mg 4 4 XANAX – alprazolam tab 1 mg 4 CELEXA – citalopram hydrobromide tab 10 mg (base equiv) XANAX – alprazolam tab 2 mg 4 XANAX XR – alprazolam tab sr 24hr 0.5 mg CELEXA – citalopram hydrobromide tab 20 mg (base equiv) 4 4 XANAX XR – alprazolam tab sr 24hr 1 mg 4 4 XANAX XR – alprazolam tab sr 24hr 2 mg 4 CELEXA – citalopram hydrobromide tab 40 mg (base equiv) 1 XANAX XR – alprazolam tab sr 24hr 3 mg 4 citalopram hydrobromide oral soln 10 mg/5ml citalopram hydrobromide tab 10 mg (base equiv) (Celexa) 1 citalopram hydrobromide tab 20 mg (base equiv) (Celexa) 1 citalopram hydrobromide tab 40 mg (base equiv) (Celexa) 1 clomipramine hcl cap 25 mg (Anafranil) 1 1 ANTIDEPRESSANTS amitriptyline hcl tab 10 mg 1 amitriptyline hcl tab 100 mg 1 amitriptyline hcl tab 150 mg 1 amitriptyline hcl tab 25 mg 1 amitriptyline hcl tab 50 mg 1 amitriptyline hcl tab 75 mg 1 ANAFRANIL – clomipramine hcl cap 25 mg 4 clomipramine hcl cap 50 mg (Anafranil) 1 ANAFRANIL – clomipramine hcl cap 50 mg 4 clomipramine hcl cap 75 mg (Anafranil) 4 ANAFRANIL – clomipramine hcl cap 75 mg 4 CYMBALTA – duloxetine hcl enteric coated pellets cap 20 mg 4 bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr) 1 CYMBALTA – duloxetine hcl enteric coated pellets cap 30 mg 4 bupropion hcl tab sr 12hr 150 mg (Wellbutrin sr) 1 CYMBALTA – duloxetine hcl enteric coated pellets cap 60 mg 2 bupropion hcl tab sr 12hr 200 mg (Wellbutrin sr) 1 desipramine hcl tab 10 mg (Norpramin) 2 bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl) 1 desipramine hcl tab 100 mg (Norpramin) desipramine hcl tab 150 mg (Norpramin) 2 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits VISTARIL – hydroxyzine pamoate cap 25 mg Restricted Access 4 Prior Review VALIUM – diazepam tab 10 mg Specialty Drug Name Drug Tier 2015 57 desipramine hcl tab 25 mg (Norpramin) 2 fluoxetine hcl cap delayed release 90 mg (Prozac weekly) desipramine hcl tab 50 mg (Norpramin) 2 fluoxetine hcl cap 10 mg (Prozac) 1 fluoxetine hcl cap 20 mg (Prozac) 1 desipramine hcl tab 75 mg (Norpramin) 2 DOXEPIN HCL – doxepin hcl cap 75 mg 1 doxepin hcl cap 10 mg 1 fluoxetine hcl cap 40 mg (Prozac) 1 1 fluoxetine hcl solution 20 mg/5ml 1 fluoxetine hcl tab 10 mg doxepin hcl cap 100 mg 1 doxepin hcl cap 150 mg 2 doxepin hcl cap 25 mg 1 doxepin hcl cap 50 mg 1 doxepin hcl conc 10 mg/ml 1 duloxetine hcl enteric coated pellets cap 20 mg (Cymbalta) 2 duloxetine hcl enteric coated pellets cap 30 mg (Cymbalta) 2 duloxetine hcl enteric coated pellets cap 60 mg (Cymbalta) 2 EFFEXOR XR – venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) 4 EFFEXOR XR – venlafaxine hcl cap sr 24hr 75 mg (base equivalent) 4 EFFEXOR XR – venlafaxine hcl cap sr 24hr 150 mg (base equivalent) 4 escitalopram oxalate soln 5 mg/5ml (base equiv) (Lexapro) 2 escitalopram oxalate tab 10 mg (base equiv) (Lexapro) 2 escitalopram oxalate tab 20 mg (base equiv) (Lexapro) 2 escitalopram oxalate tab 5 mg (base equiv) (Lexapro) 2 FLUOXETINE HCL – fluoxetine hcl tab 60 mg 4 58 2 fluoxetine hcl tab 20 mg 1 fluvoxamine maleate tab 100 mg 1 fluvoxamine maleate tab 25 mg 1 fluvoxamine maleate tab 50 mg 1 imipramine hcl tab 10 mg (Tofranil) 1 imipramine hcl tab 25 mg (Tofranil) 1 imipramine hcl tab 50 mg (Tofranil) 1 LEXAPRO – escitalopram oxalate tab 5 mg (base equiv) 4 LEXAPRO – escitalopram oxalate tab 10 mg (base equiv) 4 LEXAPRO – escitalopram oxalate tab 20 mg (base equiv) 4 LEXAPRO – escitalopram oxalate soln 5 mg/5ml (base equiv) 4 mirtazapine orally disintegrating tab 15 mg (Remeron soltab) 1 mirtazapine orally disintegrating tab 30 mg (Remeron soltab) 1 mirtazapine orally disintegrating tab 45 mg (Remeron soltab) 1 mirtazapine tab 15 mg (Remeron) 1 mirtazapine tab 30 mg (Remeron) 1 mirtazapine tab 45 mg (Remeron) 1 mirtazapine tab 7.5 mg 1 NARDIL – phenelzine sulfate tab 15 mg 4 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Drug Name Specialty Drug Tier 2015 4 NORPRAMIN – desipramine hcl tab 25 mg 4 NORPRAMIN – desipramine hcl tab 50 mg 4 NORPRAMIN – desipramine hcl tab 75 mg 4 NORPRAMIN – desipramine hcl tab 100 mg 4 NORPRAMIN – desipramine hcl tab 150 mg 4 nortriptyline hcl cap 10 mg (Pamelor) 1 nortriptyline hcl cap 25 mg (Pamelor) 1 nortriptyline hcl cap 50 mg (Pamelor) 1 nortriptyline hcl cap 75 mg (Pamelor) 1 PAMELOR – nortriptyline hcl cap 10 mg 4 PAMELOR – nortriptyline hcl cap 25 mg 4 PAMELOR – nortriptyline hcl cap 50 mg 4 PAMELOR – nortriptyline hcl cap 75 mg 4 PARNATE – tranylcypromine sulfate tab 10 mg 4 paroxetine hcl tab sr 24hr 12.5 mg (Paxil cr) 2 paroxetine hcl tab sr 24hr 25 mg (Paxil cr) 2 paroxetine hcl tab sr 24hr 37.5 mg (Paxil cr) 2 paroxetine hcl tab 10 mg (Paxil) 1 paroxetine hcl tab 20 mg (Paxil) 1 paroxetine hcl tab 30 mg (Paxil) 1 paroxetine hcl tab 40 mg (Paxil) 1 4 PAXIL – paroxetine hcl tab 30 mg 4 PAXIL – paroxetine hcl tab 40 mg 4 PAXIL CR – paroxetine hcl tab sr 24hr 12.5 mg 4 PAXIL CR – paroxetine hcl tab sr 24hr 25 mg 4 PAXIL CR – paroxetine hcl tab sr 24hr 37.5 mg 4 phenelzine sulfate tab 15 mg (Nardil) 2 protriptyline hcl tab 10 mg (Vivactil) 2 protriptyline hcl tab 5 mg (Vivactil) 2 PROZAC – fluoxetine hcl cap 10 mg 4 PROZAC – fluoxetine hcl cap 20 mg 4 PROZAC – fluoxetine hcl cap 40 mg 4 PROZAC WEEKLY – fluoxetine hcl cap delayed release 90 mg 4 REMERON – mirtazapine tab 15 mg 4 REMERON – mirtazapine tab 30 mg 4 REMERON – mirtazapine tab 45 mg 4 Quantity Limits PAXIL – paroxetine hcl tab 20 mg Restricted Access 4 Prior Review PAXIL – paroxetine hcl tab 10 mg Specialty Quantity Limits Restricted Access Prior Review Drug Name Drug Tier NORPRAMIN – desipramine hcl tab 10 mg Specialty Drug Name Drug Tier 2015 REMERON SOLTAB – mirtazapine 4 orally disintegrating tab 15 mg REMERON SOLTAB – mirtazapine 4 orally disintegrating tab 30 mg REMERON SOLTAB – mirtazapine 4 orally disintegrating tab 45 mg sertraline hcl oral conc 20 mg/ml 2 (Zoloft) sertraline hcl tab 100 mg (Zoloft) 1 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 59 TOFRANIL – imipramine hcl tab 50 mg 4 tranylcypromine sulfate tab 10 mg (Parnate) 2 trazodone hcl tab 100 mg 1 trazodone hcl tab 150 mg 1 trazodone hcl tab 300 mg 1 trazodone hcl tab 50 mg 1 venlafaxine hcl cap sr 24hr 150 mg (base equivalent) (Effexor xr) 1 venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) (Effexor xr) 1 venlafaxine hcl cap sr 24hr 75 mg (base equivalent) (Effexor xr) 1 VENLAFAXINE HCL ER – venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent) 4 VENLAFAXINE HCL ER – venlafaxine hcl tab sr 24hr 75 mg (base equivalent) 4 VENLAFAXINE HCL ER – venlafaxine hcl tab sr 24hr 150 mg (base equivalent) 4 VENLAFAXINE HCL ER – venlafaxine hcl tab sr 24hr 225 mg (base equivalent) 4 venlafaxine hcl tab sr 24hr 150 mg (base equivalent) (Venlafaxine hcl er) 2 venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent) (Venlafaxine hcl er) 2 60 1 venlafaxine hcl tab 25 mg 1 venlafaxine hcl tab 37.5 mg 1 venlafaxine hcl tab 50 mg 1 venlafaxine hcl tab 75 mg 1 WELLBUTRIN – bupropion hcl tab 75 mg 4 WELLBUTRIN – bupropion hcl tab 100 mg 4 WELLBUTRIN SR – bupropion hcl tab sr 12hr 100 mg 4 WELLBUTRIN SR – bupropion hcl tab sr 12hr 150 mg 4 WELLBUTRIN SR – bupropion hcl tab sr 12hr 200 mg 4 WELLBUTRIN XL – bupropion hcl tab sr 24hr 150 mg 4 WELLBUTRIN XL – bupropion hcl tab sr 24hr 300 mg 4 ZOLOFT – sertraline hcl tab 25 mg 4 ZOLOFT – sertraline hcl tab 50 mg 4 ZOLOFT – sertraline hcl tab 100 mg 4 ZOLOFT – sertraline hcl oral conc 20 mg/ml 4 ANTIPSYCHOTICS ABILIFY – aripiprazole tab 2 mg 4 ABILIFY – aripiprazole tab 5 mg 4 ABILIFY – aripiprazole tab 10 mg 4 ABILIFY – aripiprazole tab 15 mg 4 ABILIFY – aripiprazole tab 20 mg 4 ABILIFY – aripiprazole tab 30 mg 4 ABILIFY – aripiprazole oral solution 4 1 mg/ml 1 chlorpromazine hcl tab 10 mg Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits 4 venlafaxine hcl tab 100 mg Restricted Access TOFRANIL – imipramine hcl tab 25 mg 2 Prior Review 4 venlafaxine hcl tab sr 24hr 75 mg (base equivalent) (Venlafaxine hcl er) Specialty TOFRANIL – imipramine hcl tab 10 mg Drug Name Drug Tier 1 Quantity Limits sertraline hcl tab 50 mg (Zoloft) Restricted Access 1 Prior Review sertraline hcl tab 25 mg (Zoloft) Specialty Drug Name Drug Tier 2015 clozapine tab 100 mg (Clozaril) 2 clozapine tab 200 mg 2 clozapine tab 25 mg (Clozaril) 2 1 lithium carbonate cap 300 mg 1 lithium carbonate cap 600 mg (Lithium carbonate) 1 clozapine tab 50 mg lithium carbonate tab cr 300 mg (Lithobid) 1 2 CLOZARIL – clozapine tab 25 mg 4 lithium carbonate tab cr 450 mg 1 CLOZARIL – clozapine tab 100 mg 4 lithium carbonate tab 300 mg 1 fluphenazine hcl tab 1 mg 1 4 fluphenazine hcl tab 10 mg 1 LITHOBID – lithium carbonate tab cr 300 mg fluphenazine hcl tab 2.5 mg 1 loxapine succinate cap 10 mg 1 fluphenazine hcl tab 5 mg 1 loxapine succinate cap 25 mg 1 GEODON – ziprasidone hcl cap 20 mg 4 loxapine succinate cap 5 mg 1 loxapine succinate cap 50 mg 1 GEODON – ziprasidone hcl cap 40 mg 4 olanzapine orally disintegrating tab 10 mg (Zyprexa zydis) 2 GEODON – ziprasidone hcl cap 60 mg 4 olanzapine orally disintegrating tab 15 mg (Zyprexa zydis) 2 GEODON – ziprasidone hcl cap 80 mg 4 olanzapine orally disintegrating tab 20 mg (Zyprexa zydis) 2 haloperidol lactate oral conc 2 mg/ml 2 olanzapine orally disintegrating tab 5 mg (Zyprexa zydis) 2 haloperidol tab 0.5 mg 1 olanzapine tab 10 mg (Zyprexa) 2 haloperidol tab 1 mg 1 olanzapine tab 15 mg (Zyprexa) 2 haloperidol tab 10 mg 1 olanzapine tab 2.5 mg (Zyprexa) 2 haloperidol tab 2 mg 1 olanzapine tab 20 mg (Zyprexa) 2 haloperidol tab 20 mg 1 olanzapine tab 5 mg (Zyprexa) 2 haloperidol tab 5 mg 1 olanzapine tab 7.5 mg (Zyprexa) 2 LATUDA – lurasidone hcl tab 60 mg 4 perphenazine tab 16 mg 2 perphenazine tab 2 mg 2 LITHIUM – lithium oral solution 8 meq/5ml 3 perphenazine tab 4 mg 2 4 perphenazine tab 8 mg 2 LITHIUM CARBONATE – lithium carbonate cap 150 mg prochlorperazine maleate tab 10 mg (Compazine) 1 • • Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits 1 lithium carbonate cap 150 mg (Lithium carbonate) Restricted Access chlorpromazine hcl tab 50 mg 4 Prior Review 1 LITHIUM CARBONATE – lithium carbonate cap 600 mg Specialty chlorpromazine hcl tab 25 mg Drug Name Drug Tier 1 Quantity Limits chlorpromazine hcl tab 200 mg Restricted Access 1 Prior Review chlorpromazine hcl tab 100 mg Specialty Drug Name Drug Tier 2015 61 prochlorperazine maleate tab 5 mg (Compazine) 1 risperidone orally disintegrating tab 0.25 mg 2 prochlorperazine suppos 25 mg 1 2 quetiapine fumarate tab 100 mg (Seroquel) 2 risperidone orally disintegrating tab 0.5 mg (Risperdal m-tab) 2 quetiapine fumarate tab 200 mg (Seroquel) 2 risperidone orally disintegrating tab 1 mg (Risperdal m-tab) 2 quetiapine fumarate tab 25 mg (Seroquel) 2 risperidone orally disintegrating tab 2 mg (Risperdal m-tab) 2 quetiapine fumarate tab 300 mg (Seroquel) 2 risperidone orally disintegrating tab 3 mg (Risperdal m-tab) 2 quetiapine fumarate tab 400 mg (Seroquel) 2 risperidone orally disintegrating tab 4 mg (Risperdal m-tab) 2 quetiapine fumarate tab 50 mg (Seroquel) 2 risperidone soln 1 mg/ml (Risperdal) risperidone tab 0.25 mg (Risperdal) 1 risperidone tab 0.5 mg (Risperdal) 1 risperidone tab 1 mg (Risperdal) 1 risperidone tab 2 mg (Risperdal) 1 risperidone tab 3 mg (Risperdal) 1 risperidone tab 4 mg (Risperdal) 1 SEROQUEL – quetiapine fumarate tab 25 mg 4 SEROQUEL – quetiapine fumarate tab 50 mg 4 SEROQUEL – quetiapine fumarate tab 100 mg 4 SEROQUEL – quetiapine fumarate tab 200 mg 4 SEROQUEL – quetiapine fumarate tab 300 mg 4 SEROQUEL – quetiapine fumarate tab 400 mg 4 thioridazine hcl tab 10 mg 1 thioridazine hcl tab 100 mg 1 thioridazine hcl tab 25 mg 1 thioridazine hcl tab 50 mg 1 thiothixene cap 1 mg 1 RISPERDAL – risperidone tab 0.25 4 mg 4 RISPERDAL – risperidone tab 0.5 mg 4 RISPERDAL – risperidone tab 1 mg 4 RISPERDAL – risperidone tab 2 mg 4 RISPERDAL – risperidone tab 3 mg 4 RISPERDAL – risperidone tab 4 mg 4 RISPERDAL – risperidone soln 1 mg/ml RISPERDAL M-TAB – risperidone 4 orally disintegrating tab 0.5 mg RISPERDAL M-TAB – risperidone 4 orally disintegrating tab 1 mg RISPERDAL M-TAB – risperidone 4 orally disintegrating tab 2 mg RISPERDAL M-TAB – risperidone 4 orally disintegrating tab 3 mg RISPERDAL M-TAB – risperidone 4 orally disintegrating tab 4 mg 62 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Drug Name Specialty Drug Tier 2015 thiothixene cap 2 mg 1 eszopiclone tab 2 mg (Lunesta) 2 thiothixene cap 5 mg 1 eszopiclone tab 3 mg (Lunesta) 2 trifluoperazine hcl tab 1 mg 1 1 trifluoperazine hcl tab 10 mg 1 FLURAZEPAM HCL – flurazepam hcl cap 15 mg trifluoperazine hcl tab 2 mg 1 1 trifluoperazine hcl tab 5 mg 1 FLURAZEPAM HCL – flurazepam hcl cap 30 mg 2 HALCION – triazolam tab 0.25 mg 4 ziprasidone hcl cap 20 mg (Geodon) LUNESTA – eszopiclone tab 1 mg 4 ziprasidone hcl cap 40 mg (Geodon) 2 LUNESTA – eszopiclone tab 2 mg 4 LUNESTA – eszopiclone tab 3 mg 4 ziprasidone hcl cap 60 mg (Geodon) 2 midazolam hcl syrup 2 mg/ml (base equivalent) 1 ziprasidone hcl cap 80 mg (Geodon) 2 PHENOBARBITAL – phenobarbital tab 15 mg 1 ZYPREXA – olanzapine tab 2.5 mg 4 4 ZYPREXA – olanzapine tab 5 mg PHENOBARBITAL – phenobarbital tab 30 mg 1 ZYPREXA – olanzapine tab 7.5 mg 4 ZYPREXA – olanzapine tab 10 mg 4 PHENOBARBITAL – phenobarbital tab 60 mg 1 PHENOBARBITAL – phenobarbital tab 100 mg 1 phenobarbital elixir 20 mg/5ml 1 phenobarbital tab 16.2 mg 1 phenobarbital tab 32.4 mg 1 phenobarbital tab 64.8 mg 1 phenobarbital tab 97.2 mg 1 RESTORIL – temazepam cap 7.5 mg 4 ZYPREXA – olanzapine tab 15 mg 4 ZYPREXA – olanzapine tab 20 mg 4 ZYPREXA ZYDIS – olanzapine orally disintegrating tab 10 mg 4 ZYPREXA ZYDIS – olanzapine orally disintegrating tab 15 mg 4 ZYPREXA ZYDIS – olanzapine orally disintegrating tab 20 mg 4 HYPNOTICS AMBIEN – zolpidem tartrate tab 5 mg 4 RESTORIL – temazepam cap 15 mg 4 AMBIEN – zolpidem tartrate tab 10 mg 4 RESTORIL – temazepam cap 22.5 mg 4 AMBIEN CR – zolpidem tartrate tab cr 6.25 mg 4 RESTORIL – temazepam cap 30 mg 4 AMBIEN CR – zolpidem tartrate tab cr 12.5 mg 4 SONATA – zaleplon cap 5 mg 4 SONATA – zaleplon cap 10 mg 4 estazolam tab 1 mg 1 temazepam cap 15 mg (Restoril) 1 estazolam tab 2 mg 1 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits 2 Restricted Access eszopiclone tab 1 mg (Lunesta) Prior Review 1 Specialty Drug Tier Quantity Limits Restricted Access thiothixene cap 10 mg Prior Review Drug Name Specialty Drug Name Drug Tier 2015 63 temazepam cap 22.5 mg (Restoril) 2 temazepam cap 30 mg (Restoril) 1 temazepam cap 7.5 mg (Restoril) 2 triazolam tab 0.125 mg 1 triazolam tab 0.25 mg (Halcion) 1 zaleplon cap 10 mg (Sonata) 1 zaleplon cap 5 mg (Sonata) 1 zolpidem tartrate tab cr 12.5 mg (Ambien cr) 2 zolpidem tartrate tab cr 6.25 mg (Ambien cr) 2 zolpidem tartrate tab 10 mg (Ambien) 1 zolpidem tartrate tab 5 mg (Ambien) 1 ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ ANOREXIANTS 4 ADDERALL – amphetaminedextroamphetamine tab 5 mg 4 ADDERALL – amphetaminedextroamphetamine tab 7.5 mg 4 ADDERALL – amphetaminedextroamphetamine tab 10 mg 4 ADDERALL – amphetaminedextroamphetamine tab 12.5 mg 4 ADDERALL – amphetaminedextroamphetamine tab 15 mg 4 ADDERALL – amphetaminedextroamphetamine tab 20 mg 4 ADDERALL – amphetaminedextroamphetamine tab 30 mg 4 ADDERALL XR – amphetaminedextroamphetamine cap sr 24hr 5 mg 4 ADDERALL XR – amphetaminedextroamphetamine cap sr 24hr 10 mg 64 Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Drug Name Specialty Drug Tier 2015 ADDERALL XR – amphetaminedextroamphetamine cap sr 24hr 15 mg 4 • ADDERALL XR – amphetaminedextroamphetamine cap sr 24hr 20 mg 4 • ADDERALL XR – amphetaminedextroamphetamine cap sr 24hr 25 mg 4 • ADDERALL XR – amphetaminedextroamphetamine cap sr 24hr 30 mg 4 • amphetaminedextroamphetamine cap sr 24hr 10 mg (Adderall xr) 2 • amphetaminedextroamphetamine cap sr 24hr 15 mg (Adderall xr) 2 • amphetaminedextroamphetamine cap sr 24hr 20 mg (Adderall xr) 2 • amphetaminedextroamphetamine cap sr 24hr 25 mg (Adderall xr) 2 • amphetaminedextroamphetamine cap sr 24hr 30 mg (Adderall xr) 2 • amphetaminedextroamphetamine cap sr 24hr 5 mg (Adderall xr) 2 • amphetaminedextroamphetamine tab 10 mg (Adderall) 2 • 2 • • amphetaminedextroamphetamine tab 12.5 mg (Adderall) 2 • • amphetaminedextroamphetamine tab 15 mg (Adderall) amphetaminedextroamphetamine tab 20 mg (Adderall) 2 • • • • • • • • Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary • amphetaminedextroamphetamine tab 30 mg (Adderall) 2 amphetaminedextroamphetamine tab 5 mg (Adderall) 2 amphetaminedextroamphetamine tab 7.5 mg (Adderall) 2 • clonidine hcl tab sr 12hr 0.1 mg (Kapvay) 2 • CONCERTA – methylphenidate hcl 3 tab sa osm 18 mg CONCERTA – methylphenidate hcl 3 tab sa osm 27 mg CONCERTA – methylphenidate hcl 3 tab sa osm 36 mg CONCERTA – methylphenidate hcl 3 tab sa osm 54 mg 4 DEXEDRINE – dextroamphetamine sulfate cap sr 24hr 5 mg 4 DEXEDRINE – dextroamphetamine sulfate cap sr 24hr 10 mg 4 DEXEDRINE – dextroamphetamine sulfate cap sr 24hr 15 mg 1 dexmethylphenidate hcl tab 10 mg (Focalin) 1 dexmethylphenidate hcl tab 2.5 mg (Focalin) 1 dexmethylphenidate hcl tab 5 mg (Focalin) 2 dextroamphetamine sulfate cap sr 24hr 10 mg (Dexedrine) 2 dextroamphetamine sulfate cap sr 24hr 15 mg (Dexedrine) 2 dextroamphetamine sulfate cap sr 24hr 5 mg (Dexedrine) • • • • • • • • • • • • • • Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 dextroamphetamine sulfate tab 10 mg 1 • dextroamphetamine sulfate tab 5 mg 1 • FOCALIN – dexmethylphenidate hcl tab 2.5 mg 4 • FOCALIN – dexmethylphenidate hcl tab 5 mg 4 • FOCALIN – dexmethylphenidate hcl tab 10 mg 4 • KAPVAY – clonidine hcl tab sr 12hr 4 0.1 mg 4 METHYLIN – methylphenidate hcl soln 5 mg/5ml 4 METHYLIN – methylphenidate hcl soln 10 mg/5ml 2 methylphenidate hcl cap sr 24hr 20 mg (Ritalin la) 2 methylphenidate hcl cap sr 24hr 30 mg (Ritalin la) 2 methylphenidate hcl cap sr 24hr 40 mg (Ritalin la) 2 METHYLPHENIDATE HCL ER – methylphenidate hcl tab cr 10 mg 3 METHYLPHENIDATE HCL ER – methylphenidate hcl tab sa osm 18 mg 3 METHYLPHENIDATE HCL ER – methylphenidate hcl tab sa osm 27 mg 3 METHYLPHENIDATE HCL ER – methylphenidate hcl tab sa osm 36 mg 3 METHYLPHENIDATE HCL ER – methylphenidate hcl tab sa osm 54 mg 2 methylphenidate hcl soln 10 mg/5ml (Methylin) 2 methylphenidate hcl soln 5 mg/5ml (Methylin) • Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary • • • • • • • • • • • • 65 methylphenidate hcl tab cr 20 mg (Ritalin sr) 2 • methylphenidate hcl tab 10 mg (Ritalin) 1 • methylphenidate hcl tab 20 mg (Ritalin) 1 • methylphenidate hcl tab 5 mg (Ritalin) 1 • modafinil tab 100 mg (Provigil) 2 modafinil tab 200 mg (Provigil) 2 PROVIGIL – modafinil tab 100 mg 4 PROVIGIL – modafinil tab 200 mg 4 RITALIN – methylphenidate hcl tab 5 mg 4 • • • • • RITALIN – methylphenidate hcl tab 10 mg 4 • RITALIN – methylphenidate hcl tab 20 mg 4 • RITALIN LA – methylphenidate hcl cap sr 24hr 10 mg 4 • RITALIN LA – methylphenidate hcl cap sr 24hr 20 mg 4 • RITALIN LA – methylphenidate hcl cap sr 24hr 30 mg 4 • RITALIN LA – methylphenidate hcl cap sr 24hr 40 mg 4 • VYVANSE – lisdexamfetamine dimesylate cap 10 mg 4 • • • VYVANSE – lisdexamfetamine dimesylate cap 20 mg 4 • • • VYVANSE – lisdexamfetamine dimesylate cap 30 mg 4 • • • VYVANSE – lisdexamfetamine dimesylate cap 40 mg 4 • • • VYVANSE – lisdexamfetamine dimesylate cap 50 mg 4 • • • VYVANSE – lisdexamfetamine dimesylate cap 60 mg 4 • • • VYVANSE – lisdexamfetamine dimesylate cap 70 mg 4 • • • 66 • • • • PSYCHOTHERAPEUTIC and NEUROLOGICAL AGENTS - MISC. 2 acamprosate calcium tab delayed release 333 mg (Campral) 5 • • AMPYRA – dalfampridine tab sr 12hr 10 mg 4 ANTABUSE – disulfiram tab 250 mg 4 ANTABUSE – disulfiram tab 500 mg 4 ARICEPT – donepezil hydrochloride tab 5 mg 4 ARICEPT – donepezil hydrochloride tab 10 mg 4 ARICEPT – donepezil hydrochloride tab 23 mg 4 ARICEPT ODT – donepezil hydrochloride orally disintegrating tab 10 mg BETASERON – interferon beta-1b 5 • • for inj kit 0.3 mg 1 bupropion hcl (smoking deterrent) tab sr 12hr 150 mg (Zyban) CHANTIX – varenicline tartrate tab 3 0.5 mg (base equiv) CHANTIX – varenicline tartrate tab 3 1 mg (base equiv) 3 CHANTIX CONTINUING MONTH – varenicline tartrate tab 1 mg (base equiv) 3 CHANTIX STARTING MONTH PA – varenicline tartrate tab 0.5 mg x 11 & tab 1 mg x 42 pack 5 • • COPAXONE – glatiramer acetate soln prefilled syringe 40 mg/ml 5 • • COPAXONE – glatiramer acetate inj kit 20 mg/ml disulfiram tab 250 mg (Antabuse) 2 disulfiram tab 500 mg (Antabuse) 2 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Drug Name Specialty Drug Tier 2015 donepezil hydrochloride orally disintegrating tab 10 mg (Aricept odt) 2 NICOTROL NS – nicotine nasal spray 10 mg/ml (0.5 mg/spray) 4 donepezil hydrochloride orally disintegrating tab 5 mg olanzapine-fluoxetine hcl cap 12-25 mg (Symbyax) 2 2 donepezil hydrochloride tab 10 mg (Aricept) olanzapine-fluoxetine hcl cap 12-50 mg (Symbyax) 2 2 2 olanzapine-fluoxetine hcl cap 3-25 mg (Symbyax) 2 donepezil hydrochloride tab 23 mg (Aricept) donepezil hydrochloride tab 5 mg (Aricept) olanzapine-fluoxetine hcl cap 6-25 mg (Symbyax) 2 2 EXELON – rivastigmine tartrate cap 1.5 mg olanzapine-fluoxetine hcl cap 6-50 mg (Symbyax) 2 4 • • EXELON – rivastigmine tartrate cap 3 mg PLEGRIDY – peginterferon beta-1a soln pen-injector 125 mcg/0.5ml 5 4 EXELON – rivastigmine tartrate cap 4.5 mg 4 5 • • EXELON – rivastigmine tartrate cap 6 mg 4 PLEGRIDY – peginterferon beta-1a soln prefilled syringe 125 mcg/0.5ml 5 • • fluoxetine hcl (pmdd) cap 10 mg 1 fluoxetine hcl (pmdd) cap 20 mg 1 PLEGRIDY STARTER PACK – peginterferon beta-1a soln peninj 63 & 94 mcg/0.5ml pack 2 PLEGRIDY STARTER PACK – peginterferon beta-1a soln pref syr 63 & 94 mcg/0.5ml pack 5 GALANTAMINE HYDROBROMIDE – galantamine hydrobromide oral soln 4 mg/ml • • 2 RAZADYNE – galantamine hydrobromide tab 4 mg 4 galantamine hydrobromide cap sr 24hr 16 mg (Razadyne er) 2 RAZADYNE – galantamine hydrobromide tab 8 mg 4 galantamine hydrobromide cap sr 24hr 24 mg (Razadyne er) 2 RAZADYNE – galantamine hydrobromide tab 12 mg 4 galantamine hydrobromide cap sr 24hr 8 mg (Razadyne er) 2 RAZADYNE – galantamine hydrobromide oral soln 4 mg/ml 4 galantamine hydrobromide tab 12 mg (Razadyne) 2 RAZADYNE ER – galantamine hydrobromide cap sr 24hr 8 mg 4 galantamine hydrobromide tab 4 mg (Razadyne) 2 RAZADYNE ER – galantamine hydrobromide cap sr 24hr 16 mg 4 galantamine hydrobromide tab 8 mg (Razadyne) 4 RAZADYNE ER – galantamine hydrobromide cap sr 24hr 24 mg 4 NICOTROL INHALER – nicotine inhaler system 10 mg (4 mg delivered) REBIF – interferon beta-1a inj 22 mcg/0.5ml (12mu/ml) (44 mcg/ ml) 5 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 • • 67 REBIF REBIDOSE TITRATION – interferon beta-1a inj 6 x 8.8 mcg/0.2ml & 6 x 22 mcg/0.5ml 5 REBIF TITRATION PACK – interferon beta-1a inj 6 x 8.8 mcg/0.2ml & 6 x 22 mcg/0.5ml 5 rivastigmine tartrate cap 1.5 mg (Exelon) 2 rivastigmine tartrate cap 3 mg (Exelon) 2 rivastigmine tartrate cap 4.5 mg (Exelon) 2 rivastigmine tartrate cap 6 mg (Exelon) 2 SYMBYAX – olanzapine-fluoxetine hcl cap 3-25 mg 4 SYMBYAX – olanzapine-fluoxetine hcl cap 6-25 mg 4 SYMBYAX – olanzapine-fluoxetine hcl cap 6-50 mg 4 SYMBYAX – olanzapine-fluoxetine hcl cap 12-25 mg 4 SYMBYAX – olanzapine-fluoxetine hcl cap 12-50 mg 4 TECFIDERA – dimethyl fumarate capsule delayed release 120 mg 5 • • TECFIDERA – dimethyl fumarate capsule delayed release 240 mg 5 • • TECFIDERA STARTER PACK – dimethyl fumarate capsule dr starter pack 120 mg & 240 mg 5 • • 68 5 • • ZYBAN – bupropion hcl (smoking deterrent) tab sr 12hr 150 mg 4 Quantity Limits 5 XYREM – sodium oxybate oral solution 500 mg/ml Drug Name Restricted Access REBIF REBIDOSE – interferon beta-1a inj 44 mcg/0.5ml (24mu/ ml) (88 mcg/ml) • • Prior Review REBIF REBIDOSE – interferon beta-1a inj 22 mcg/0.5ml (12mu/ ml) (44 mcg/ml) 5 Specialty • • Drug Tier 5 Quantity Limits Specialty REBIF – interferon beta-1a inj 44 mcg/0.5ml (24mu/ml) (88 mcg/ ml) Drug Name Restricted Access Drug Tier Prior Review 2015 ANALGESICS AND ANESTHETICS • • ANALGESICS - NON-NARCOTIC butalbital-acetaminophen tab 50-325 mg 2 • • butalbital-acetaminophencaffeine cap 50-325-40 mg 2 2 • • butalbital-acetaminophencaffeine tab 50-325-40 mg (Esgic) butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal) 2 diflunisal tab 500 mg 1 ESGIC – butalbital-acetaminophen- 4 caffeine tab 50-325-40 mg 4 FIORICET – butalbitalacetaminophen-caffeine tab 50-325-40 mg 4 FIORINAL – butalbital-aspirincaffeine cap 50-325-40 mg 1 salsalate tab 500 mg salsalate tab 750 mg 1 ANALGESICS - NARCOTIC acetaminophen w/ codeine soln 120-12 mg/5ml 1 acetaminophen w/ codeine tab 300-15 mg (Tylenol/codeine) 1 acetaminophen w/ codeine tab 300-30 mg (Tylenol/codeine #3) 1 acetaminophen w/ codeine tab 300-60 mg (Tylenol/codeine #4) 1 ACTIQ – fentanyl citrate lollipop 200 mcg 5 • • ACTIQ – fentanyl citrate lollipop 400 mcg 5 • • ACTIQ – fentanyl citrate lollipop 600 mcg 5 • • Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 ACTIQ – fentanyl citrate lollipop 800 mcg 5 • • DILAUDID – hydromorphone hcl tab 4 mg 4 ACTIQ – fentanyl citrate lollipop 1200 mcg 5 • • DILAUDID – hydromorphone hcl tab 8 mg 4 ACTIQ – fentanyl citrate lollipop 1600 mcg 5 • • DOLOPHINE – methadone hcl tab 10 mg 4 buprenorphine hcl sl tab 2 mg (base equiv) 2 • • DOLOPHINE HCL – methadone hcl tab 5 mg 4 buprenorphine hcl sl tab 8 mg (base equiv) 2 • • DURAGESIC – fentanyl td patch 72hr 12 mcg/hr 4 buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv) 2 • • DURAGESIC – fentanyl td patch 72hr 25 mcg/hr 4 buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) 2 • • DURAGESIC – fentanyl td patch 72hr 50 mcg/hr 4 butalbital-acetaminophen-caff w/ cod cap 50-300-40-30 mg (Fioricet/codeine) 2 DURAGESIC – fentanyl td patch 72hr 75 mcg/hr 4 2 DURAGESIC – fentanyl td patch 72hr 100 mcg/hr 4 butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg • • butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg (Fiorinal/ codeine #3) fentanyl citrate lollipop 1200 mcg (Actiq) 5 2 fentanyl citrate lollipop 1600 mcg (Actiq) 5 • • butorphanol tartrate nasal soln 10 mg/ml 2 fentanyl citrate lollipop 200 mcg (Actiq) 5 • • CODEINE SULFATE – codeine sulfate tab 15 mg 1 fentanyl citrate lollipop 400 mcg (Actiq) 5 • • CODEINE SULFATE – codeine sulfate tab 30 mg 1 fentanyl citrate lollipop 600 mcg (Actiq) 5 • • CODEINE SULFATE – codeine sulfate tab 60 mg 1 fentanyl citrate lollipop 800 mcg (Actiq) 5 • • codeine sulfate tab 15 mg (Codeine sulfate) 1 fentanyl td patch 72hr 100 mcg/ hr (Duragesic) 2 codeine sulfate tab 30 mg 1 codeine sulfate tab 60 mg fentanyl td patch 72hr 12 mcg/hr (Duragesic) 2 1 fentanyl td patch 72hr 25 mcg/hr (Duragesic) 2 fentanyl td patch 72hr 50 mcg/hr (Duragesic) 2 fentanyl td patch 72hr 75 mcg/hr (Duragesic) 2 DEMEROL – meperidine hcl tab 50 4 mg 4 DEMEROL – meperidine hcl tab 100 mg 4 DILAUDID – hydromorphone hcl tab 2 mg Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 69 FIORICET/CODEINE – butalbitalacetaminophen-caff w/ cod cap 50-300-40-30 mg 4 FIORICET/CODEINE – butalbitalacetaminophen-caff w/ cod cap 50-325-40-30 mg 4 FIORINAL/CODEINE #3 – butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg 4 HYCET – hydrocodoneacetaminophen soln 7.5-325 mg/15ml 4 hydrocodone-acetaminophen soln 7.5-325 mg/15ml (Hycet) 2 hydrocodone-acetaminophen tab 10-300 mg (Xodol) 2 hydrocodone-acetaminophen tab 10-325 mg (Norco) 1 hydrocodone-acetaminophen tab 5-300 mg (Xodol) 2 hydrocodone-acetaminophen tab 5-325 mg (Norco) 1 hydrocodone-acetaminophen tab 7.5-300 mg (Xodol) 2 hydrocodone-acetaminophen tab 7.5-325 mg (Norco) 1 hydrocodone-ibuprofen tab 10-200 mg (Ibudone) 2 hydrocodone-ibuprofen tab 2.5-200 mg (Reprexain) 2 hydrocodone-ibuprofen tab 5-200 mg (Reprexain) 1 hydrocodone-ibuprofen tab 7.5-200 mg (Vicoprofen) 1 HYDROCODONE/ ACETAMINOPHEN – hydrocodone-acetaminophen soln 7.5-500 mg/15ml 2 HYDROMORPHONE HCL – hydromorphone hcl suppos 3 mg 3 70 hydromorphone hcl tab 2 mg (Dilaudid) 1 hydromorphone hcl tab 4 mg (Dilaudid) 1 hydromorphone hcl tab 8 mg (Dilaudid) 1 IBUDONE – hydrocodoneibuprofen tab 10-200 mg 4 KADIAN – morphine sulfate cap sr 24hr 10 mg 4 KADIAN – morphine sulfate cap sr 24hr 20 mg 4 KADIAN – morphine sulfate cap sr 24hr 30 mg 4 KADIAN – morphine sulfate cap sr 24hr 50 mg 4 KADIAN – morphine sulfate cap sr 24hr 60 mg 4 KADIAN – morphine sulfate cap sr 24hr 80 mg 4 KADIAN – morphine sulfate cap sr 24hr 100 mg 4 KADIAN – morphine sulfate cap sr 24hr 200 mg 4 meperidine hcl tab 100 mg (Demerol) 1 meperidine hcl tab 50 mg (Demerol) 1 METHADONE HCL – methadone hcl soln 5 mg/5ml 4 METHADONE HCL – methadone hcl soln 10 mg/5ml 4 methadone hcl conc 10 mg/ml (Methadose) 2 methadone hcl tab for oral susp 40 mg 2 methadone hcl tab 10 mg (Dolophine) 1 methadone hcl tab 5 mg (Dolophine hcl) 1 • • Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Drug Name Specialty Drug Tier 2015 METHADOSE – methadone hcl conc 10 mg/ml 4 morphine sulfate tab cr 200 mg (Ms contin) 1 METHADOSE SUGAR-FREE – methadone hcl conc 10 mg/ml 4 morphine sulfate tab cr 30 mg (Ms contin) 1 MORPHINE SULFATE – morphine sulfate tab 15 mg 1 morphine sulfate tab cr 60 mg (Ms contin) 1 MORPHINE SULFATE – morphine sulfate tab 30 mg 1 MS CONTIN – morphine sulfate tab cr 15 mg 4 MORPHINE SULFATE – morphine sulfate suppos 5 mg 4 MS CONTIN – morphine sulfate tab cr 30 mg 4 MORPHINE SULFATE – morphine sulfate suppos 10 mg 4 MS CONTIN – morphine sulfate tab cr 60 mg 4 MORPHINE SULFATE – morphine sulfate suppos 20 mg 4 MS CONTIN – morphine sulfate tab cr 100 mg 4 MORPHINE SULFATE – morphine sulfate suppos 30 mg 4 MS CONTIN – morphine sulfate tab cr 200 mg 4 morphine sulfate (concentrate) oral soln 20 mg/ml 1 NORCO – hydrocodoneacetaminophen tab 10-325 mg 4 morphine sulfate cap sr 24hr 10 mg (Kadian) 2 NORCO – hydrocodoneacetaminophen tab 5-325 mg 4 morphine sulfate cap sr 24hr 100 mg (Kadian) 2 NORCO – hydrocodoneacetaminophen tab 7.5-325 mg 4 morphine sulfate cap sr 24hr 20 mg (Kadian) 2 NUCYNTA – tapentadol hcl tab 50 mg 4 morphine sulfate cap sr 24hr 30 mg (Kadian) 2 NUCYNTA – tapentadol hcl tab 75 mg 4 morphine sulfate cap sr 24hr 50 mg (Kadian) 2 NUCYNTA – tapentadol hcl tab 100 mg 4 morphine sulfate cap sr 24hr 60 mg (Kadian) 2 NUCYNTA ER – tapentadol hcl tab sr 12hr 50 mg 4 morphine sulfate cap sr 24hr 80 mg (Kadian) 2 NUCYNTA ER – tapentadol hcl tab sr 12hr 100 mg 4 morphine sulfate oral soln 10 mg/5ml 1 NUCYNTA ER – tapentadol hcl tab sr 12hr 150 mg 4 morphine sulfate oral soln 20 mg/5ml 1 NUCYNTA ER – tapentadol hcl tab sr 12hr 200 mg 4 morphine sulfate tab cr 100 mg (Ms contin) 1 NUCYNTA ER – tapentadol hcl tab sr 12hr 250 mg 4 morphine sulfate tab cr 15 mg (Ms contin) 1 OPANA – oxymorphone hcl tab 5 mg 4 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 71 Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Drug Name Specialty Drug Tier 2015 OPANA – oxymorphone hcl tab 10 mg 4 oxycodone-aspirin tab 4.8355-325 mg (Percodan) 1 OXYCODONE HCL – oxycodone hcl conc 100 mg/5ml (20 mg/ml) 4 oxycodone-ibuprofen tab 5-400 mg 2 OXYCODONE HCL – oxycodone hcl soln 5 mg/5ml 4 OXYCONTIN – oxycodone hcl tab er 12hr deter 10 mg 4 • oxycodone hcl cap 5 mg 1 4 • oxycodone hcl conc 100 mg/5ml (20 mg/ml) (Oxycodone hcl) 2 OXYCONTIN – oxycodone hcl tab er 12hr deter 15 mg 4 • OXYCODONE HCL ER – oxycodone hcl tab er 12hr deter 10 mg 4 OXYCONTIN – oxycodone hcl tab er 12hr deter 20 mg OXYCONTIN – oxycodone hcl tab er 12hr deter 30 mg 4 • OXYCODONE HCL ER – oxycodone hcl tab er 12hr deter 20 mg 4 OXYCONTIN – oxycodone hcl tab er 12hr deter 40 mg 4 • 4 • OXYCODONE HCL ER – oxycodone hcl tab er 12hr deter 40 mg 4 OXYCONTIN – oxycodone hcl tab er 12hr deter 60 mg OXYCONTIN – oxycodone hcl tab er 12hr deter 80 mg 4 • OXYCODONE HCL ER – oxycodone hcl tab er 12hr deter 80 mg 4 oxymorphone hcl tab 10 mg (Opana) 2 2 oxymorphone hcl tab 5 mg (Opana) 2 oxycodone hcl soln 5 mg/5ml (Oxycodone hcl) 2 pentazocine w/ naloxone tab 50-0.5 mg 2 oxycodone hcl tab 10 mg oxycodone hcl tab 15 mg (Roxicodone) 1 PERCOCET – oxycodone w/ acetaminophen tab 2.5-325 mg 4 oxycodone hcl tab 20 mg 2 1 PERCOCET – oxycodone w/ acetaminophen tab 5-325 mg 4 oxycodone hcl tab 30 mg (Roxicodone) oxycodone hcl tab 5 mg (Roxicodone) PERCOCET – oxycodone w/ acetaminophen tab 7.5-325 mg 4 1 oxycodone w/ acetaminophen tab 10-325 mg (Percocet) PERCOCET – oxycodone w/ acetaminophen tab 10-325 mg 4 1 oxycodone w/ acetaminophen tab 2.5-325 mg (Percocet) PERCODAN – oxycodone-aspirin tab 4.8355-325 mg 4 1 1 REPREXAIN – hydrocodoneibuprofen tab 2.5-200 mg 4 oxycodone w/ acetaminophen tab 5-325 mg (Percocet) 1 REPREXAIN – hydrocodoneibuprofen tab 5-200 mg 4 oxycodone w/ acetaminophen tab 7.5-325 mg (Percocet) ROXICODONE – oxycodone hcl tab 5 mg 4 72 • • • • Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary ROXICODONE – oxycodone hcl tab 15 mg 4 ULTRAM ER – tramadol hcl tab sr 24hr 100 mg 4 ROXICODONE – oxycodone hcl tab 30 mg 4 ULTRAM ER – tramadol hcl tab sr 24hr 200 mg 4 SUBOXONE – buprenorphine hclnaloxone hcl sl film 2-0.5 mg (base equiv) 3 • • ULTRAM ER – tramadol hcl tab sr 24hr 300 mg 4 3 • • VICOPROFEN – hydrocodoneibuprofen tab 7.5-200 mg 4 SUBOXONE – buprenorphine hclnaloxone hcl sl film 4-1 mg (base equiv) 4 SUBOXONE – buprenorphine hclnaloxone hcl sl film 8-2 mg (base equiv) 3 • • XODOL – hydrocodoneacetaminophen tab 5-300 mg XODOL – hydrocodoneacetaminophen tab 7.5-300 mg 4 3 • • XODOL – hydrocodoneacetaminophen tab 10-300 mg 4 SUBOXONE – buprenorphine hclnaloxone hcl sl film 12-3 mg (base equiv) tramadol hcl tab sr 24hr biphasic release 200 mg 2 tramadol hcl tab sr 24hr biphasic release 300 mg 2 tramadol hcl tab sr 24hr 100 mg (Ultram er) 2 tramadol hcl tab sr 24hr 200 mg (Ultram er) 2 tramadol hcl tab sr 24hr 300 mg (Ultram er) 2 tramadol hcl tab 50 mg (Ultram) 1 tramadol-acetaminophen tab 37.5-325 mg (Ultracet) 1 TYLENOL/CODEINE – acetaminophen w/ codeine tab 300-15 mg 4 TYLENOL/CODEINE #3 – acetaminophen w/ codeine tab 300-30 mg 4 TYLENOL/CODEINE #4 – acetaminophen w/ codeine tab 300-60 mg 4 ULTRACET – tramadolacetaminophen tab 37.5-325 mg 4 ULTRAM – tramadol hcl tab 50 mg 4 Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 ANALGESICS - ANTI-INFLAMMATORY ANAPROX – naproxen sodium tab 4 275 mg ANAPROX DS – naproxen sodium 4 tab 550 mg 5 ARAVA – leflunomide tab 10 mg ARAVA – leflunomide tab 20 mg 5 ARTHROTEC 50 – diclofenac w/ misoprostol tab delayed release 50-0.2 mg 4 ARTHROTEC 75 – diclofenac w/ misoprostol tab delayed release 75-0.2 mg 4 CELEBREX – celecoxib cap 50 mg 4 CELEBREX – celecoxib cap 100 mg 4 • • CELEBREX – celecoxib cap 200 mg 4 • CELEBREX – celecoxib cap 400 mg 4 • celecoxib cap 100 mg (Celebrex) 2 celecoxib cap 200 mg (Celebrex) 2 celecoxib cap 400 mg (Celebrex) 2 celecoxib cap 50 mg (Celebrex) 2 • • • • DAYPRO – oxaprozin tab 600 mg 4 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 73 1 diclofenac sodium tab delayed release 25 mg 1 diclofenac sodium tab delayed release 50 mg 1 diclofenac sodium tab delayed release 75 mg 1 diclofenac sodium tab sr 24hr 100 mg (Voltaren-xr) 2 diclofenac w/ misoprostol tab delayed release 50-0.2 mg (Arthrotec 50) 2 diclofenac w/ misoprostol tab delayed release 75-0.2 mg (Arthrotec 75) 2 EC-NAPROSYN – naproxen tab ec 4 375 mg EC-NAPROSYN – naproxen tab ec 4 500 mg 5 ENBREL – etanercept subcutaneous soln prefilled syringe 25 mg/0.5ml 5 ENBREL – etanercept subcutaneous soln prefilled syringe 50 mg/ml 5 ENBREL – etanercept for subcutaneous inj kit 25 mg 5 ENBREL SURECLICK – etanercept subcutaneous solution auto-injector 50 mg/ml 1 etodolac cap 200 mg • • • • • • • • • • • Quantity Limits Restricted Access 1 flurbiprofen tab 50 mg 1 HUMIRA – adalimumab prefilled syringe kit 10 mg/0.2ml 5 • • • HUMIRA – adalimumab inj kit 20 mg/0.4ml 5 • • • HUMIRA – adalimumab inj kit 40 mg/0.8ml (50 mg/ml) 5 • • • HUMIRA PEDIATRIC CROHNS D – adalimumab inj kit 40 mg/0.8ml (50 mg/ml) 5 • • • HUMIRA PEN – adalimumab inj kit 40 mg/0.8ml (50 mg/ml) 5 • • • HUMIRA PEN-CROHNS DISEASE – adalimumab inj kit 40 mg/0.8ml (50 mg/ml) 5 • • • HUMIRA PEN-PSORIASIS STAR – adalimumab inj kit 40 mg/0.8ml (50 mg/ml) 5 • • • ibuprofen tab 400 mg 1 ibuprofen tab 600 mg 1 ibuprofen tab 800 mg 1 indomethacin cap cr 75 mg 2 indomethacin cap 25 mg 1 indomethacin cap 50 mg 1 ketoprofen cap 50 mg 1 ketoprofen cap 75 mg 1 ketorolac tromethamine im inj 60 mg/2ml (30 mg/ml) 1 1 etodolac cap 300 mg 1 ketorolac tromethamine tab 10 mg 1 leflunomide tab 10 mg (Arava) 1 etodolac tab sr 24hr 400 mg 1 leflunomide tab 20 mg (Arava) 1 etodolac tab sr 24hr 500 mg 1 etodolac tab 400 mg 1 MELOXICAM – meloxicam susp 7.5 mg/5ml 4 etodolac tab sr 24hr 600 mg meloxicam tab 15 mg (Mobic) 1 etodolac tab 500 mg 1 meloxicam tab 7.5 mg (Mobic) 1 FELDENE – piroxicam cap 10 mg 4 MOBIC – meloxicam tab 7.5 mg 4 FELDENE – piroxicam cap 20 mg 4 74 Prior Review flurbiprofen tab 100 mg Specialty Restricted Access Quantity Limits • Drug Name Drug Tier diclofenac potassium tab 50 mg (Cataflam) Prior Review Drug Name Specialty Drug Tier 2015 • • Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 5 • • 1 sulindac tab 150 mg 1 nabumetone tab 750 mg 1 sulindac tab 200 mg 1 NAPROSYN – naproxen tab 250 mg 4 tolmetin sodium cap 400 mg 2 4 NAPROSYN – naproxen tab 375 mg 4 VOLTAREN-XR – diclofenac sodium tab sr 24hr 100 mg 5 NAPROSYN – naproxen tab 500 mg 4 XELJANZ – tofacitinib citrate tab 5 mg (base equivalent) NAPROSYN – naproxen susp 125 mg/5ml 4 naproxen sodium tab 275 mg (Anaprox) • • Quantity Limits SIMPONI – golimumab subcutaneous soln prefilled syringe 100 mg/ml Drug Name Restricted Access Specialty nabumetone tab 500 mg Prior Review Drug Tier 4 Quantity Limits MOBIC – meloxicam susp 7.5 mg/5ml Restricted Access 4 Prior Review MOBIC – meloxicam tab 15 mg Specialty Drug Name Drug Tier 2015 • • • • • MIGRAINE PRODUCTS 2 1 acetaminophen-isometheptenecaffeine tab 325-65-20 mg (Prodrin) 2 naproxen sodium tab 550 mg (Anaprox ds) 1 acetaminophen-isometheptenedichloral cap 325-65-100 mg 4 • naproxen susp 125 mg/5ml (Naprosyn) 1 AMERGE – naratriptan hcl tab 1 mg (base equiv) 4 • naproxen tab ec 375 mg (Ecnaprosyn) 1 AMERGE – naratriptan hcl tab 2.5 mg (base equiv) 5 • naproxen tab ec 500 mg (Ecnaprosyn) 1 D.H.E. 45 – dihydroergotamine mesylate inj 1 mg/ml 2 • naproxen tab 250 mg (Naprosyn) 1 dihydroergotamine mesylate inj 1 mg/ml (D.h.e. 45) naproxen tab 375 mg (Naprosyn) 1 4 • naproxen tab 500 mg (Naprosyn) 1 IMITREX – sumatriptan nasal spray 5 mg/act 1 IMITREX – sumatriptan nasal spray 20 mg/act 4 oxaprozin tab 600 mg (Daypro) • piroxicam cap 10 mg (Feldene) 2 • piroxicam cap 20 mg (Feldene) IMITREX – sumatriptan succinate tab 25 mg 4 2 SIMPONI – golimumab subcutaneous soln auto-injector 50 mg/0.5ml 5 IMITREX – sumatriptan succinate tab 50 mg 4 • 4 • SIMPONI – golimumab subcutaneous soln auto-injector 100 mg/ml 5 IMITREX – sumatriptan succinate tab 100 mg IMITREX – sumatriptan succinate inj 6 mg/0.5ml 4 • SIMPONI – golimumab subcutaneous soln prefilled syringe 50 mg/0.5ml 5 IMITREX STATDOSE REFILL – sumatriptan succinate solution cartridge 4 mg/0.5ml 4 • • • • • • • • • • Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 75 Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Drug Name Specialty Drug Tier 2015 IMITREX STATDOSE REFILL – sumatriptan succinate solution cartridge 6 mg/0.5ml 4 • SUMATRIPTAN SUCCINATE – sumatriptan succinate solution prefilled syringe 6 mg/0.5ml 2 • IMITREX STATDOSE SYSTEM – sumatriptan succinate solution auto-injector 4 mg/0.5ml 4 • SUMATRIPTAN SUCCINATE – sumatriptan succinate inj 4 mg/0.5ml 2 • IMITREX STATDOSE SYSTEM – sumatriptan succinate solution auto-injector 6 mg/0.5ml 4 • sumatriptan succinate inj 6 mg/0.5ml (Imitrex) 2 • • • 4 sumatriptan succinate solution auto-injector 4 mg/0.5ml (Imitrex statdose sys) 2 MAXALT – rizatriptan benzoate tab 5 mg MAXALT – rizatriptan benzoate tab 10 mg 4 • 2 • MAXALT-MLT – rizatriptan benzoate orally disintegrating tab 5 mg 4 • sumatriptan succinate solution auto-injector 6 mg/0.5ml (Imitrex statdose sys) 2 • MAXALT-MLT – rizatriptan benzoate orally disintegrating tab 10 mg 4 • sumatriptan succinate solution cartridge 4 mg/0.5ml (Imitrex statdose ref) 2 • naratriptan hcl tab 1 mg (base equiv) (Amerge) 2 • sumatriptan succinate solution cartridge 6 mg/0.5ml (Imitrex statdose ref) 1 • naratriptan hcl tab 2.5 mg (base equiv) (Amerge) 2 • sumatriptan succinate tab 100 mg (Imitrex) 1 • PRODRIN – acetaminophenisometheptene-caffeine tab 325-65-20 mg 4 sumatriptan succinate tab 25 mg (Imitrex) sumatriptan succinate tab 50 mg (Imitrex) 1 • rizatriptan benzoate orally disintegrating tab 10 mg (Maxalt-mlt) 2 rizatriptan benzoate orally disintegrating tab 5 mg (Maxalt-mlt) 2 rizatriptan benzoate tab 10 mg (Maxalt) • GOUT AGENTS allopurinol tab 100 mg (Zyloprim) 1 • allopurinol tab 300 mg (Zyloprim) 1 COLCHICINE – colchicine tab 0.6 mg 3 2 • colchicine w/ probenecid tab 0.5-500 mg 1 rizatriptan benzoate tab 5 mg (Maxalt) 2 • COLCRYS – colchicine tab 0.6 mg 3 probenecid tab 500 mg 1 SUMATRIPTAN – sumatriptan nasal spray 5 mg/act 4 • ZYLOPRIM – allopurinol tab 100 mg 4 SUMATRIPTAN – sumatriptan nasal spray 20 mg/act 4 • ZYLOPRIM – allopurinol tab 300 mg 4 NEUROMUSCULAR DRUGS 76 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary ANTICONVULSANTS 4 carbamazepine cap sr 12hr 100 mg (Carbatrol) 2 DEPAKOTE – divalproex sodium tab delayed release 125 mg 4 carbamazepine cap sr 12hr 200 mg (Carbatrol) 2 DEPAKOTE – divalproex sodium tab delayed release 250 mg 4 carbamazepine cap sr 12hr 300 mg (Carbatrol) 2 DEPAKOTE – divalproex sodium tab delayed release 500 mg 4 carbamazepine chew tab 100 mg 1 DEPAKOTE ER – divalproex sodium tab sr 24 hr 250 mg carbamazepine susp 100 mg/5ml (Tegretol) 1 DEPAKOTE ER – divalproex sodium tab sr 24 hr 500 mg 4 carbamazepine tab sr 12hr 200 mg (Tegretol-xr) 2 4 carbamazepine tab sr 12hr 400 mg (Tegretol-xr) 2 DEPAKOTE SPRINKLES – divalproex sodium cap sprinkle 125 mg 4 carbamazepine tab 200 mg (Tegretol) 1 DIASTAT ACUDIAL – diazepam rectal gel delivery system 10 mg 4 CARBATROL – carbamazepine cap sr 12hr 100 mg 4 DIASTAT ACUDIAL – diazepam rectal gel delivery system 20 mg 4 CARBATROL – carbamazepine cap sr 12hr 200 mg 4 DIASTAT PEDIATRIC – diazepam rectal gel delivery system 2.5 mg 4 CARBATROL – carbamazepine cap sr 12hr 300 mg 4 DIAZEPAM – diazepam rectal gel delivery system 2.5 mg 4 clonazepam orally disintegrating tab 0.125 mg 2 DIAZEPAM – diazepam rectal gel delivery system 10 mg 4 clonazepam orally disintegrating tab 0.25 mg 2 DIAZEPAM – diazepam rectal gel delivery system 20 mg 4 clonazepam orally disintegrating tab 0.5 mg 2 DILANTIN – phenytoin susp 125 mg/5ml 4 clonazepam orally disintegrating tab 1 mg 2 DILANTIN – phenytoin sodium extended cap 30 mg 4 clonazepam orally disintegrating tab 2 mg 2 DILANTIN – phenytoin sodium extended cap 100 mg 4 clonazepam tab 0.5 mg (Klonopin) 1 DILANTIN INFATABS – phenytoin chew tab 50 mg 2 clonazepam tab 1 mg (Klonopin) 1 divalproex sodium cap sprinkle 125 mg (Depakote sprinkles) 1 divalproex sodium tab delayed release 125 mg (Depakote) 1 clonazepam tab 2 mg (Klonopin) DEPAKENE – valproate sodium syrup 250 mg/5ml (base equiv) 4 divalproex sodium tab delayed release 250 mg (Depakote) 1 DEPAKENE – valproic acid cap 250 mg 4 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 77 divalproex sodium tab delayed release 500 mg (Depakote) 1 KEPPRA – levetiracetam tab 1000 mg 4 divalproex sodium tab sr 24 hr 250 mg (Depakote er) 1 KEPPRA – levetiracetam oral soln 100 mg/ml 4 divalproex sodium tab sr 24 hr 500 mg (Depakote er) 1 KEPPRA XR – levetiracetam tab sr 24hr 500 mg 4 ethosuximide cap 250 mg (Zarontin) 1 KEPPRA XR – levetiracetam tab sr 24hr 750 mg 4 ethosuximide soln 250 mg/5ml (Zarontin) 1 KLONOPIN – clonazepam tab 0.5 mg 4 felbamate susp 600 mg/5ml (Felbatol) 2 KLONOPIN – clonazepam tab 1 mg 4 felbamate tab 400 mg (Felbatol) 2 4 felbamate tab 600 mg (Felbatol) 2 KLONOPIN – clonazepam tab 2 mg FELBATOL – felbamate tab 400 mg 4 FELBATOL – felbamate tab 600 mg 4 FELBATOL – felbamate susp 600 mg/5ml 4 gabapentin cap 100 mg (Neurontin) 1 gabapentin cap 300 mg (Neurontin) 1 gabapentin cap 400 mg (Neurontin) 1 gabapentin oral soln 250 mg/5ml (Neurontin) 2 gabapentin tab 600 mg (Neurontin) 1 gabapentin tab 800 mg (Neurontin) 1 GABITRIL – tiagabine hcl tab 2 mg 4 GABITRIL – tiagabine hcl tab 4 mg 4 KEPPRA – levetiracetam tab 250 mg 4 KEPPRA – levetiracetam tab 500 mg 4 KEPPRA – levetiracetam tab 750 mg 4 78 LAMICTAL – lamotrigine tab 25 mg 4 4 LAMICTAL – lamotrigine tab 100 mg 4 LAMICTAL – lamotrigine tab 150 mg 4 LAMICTAL – lamotrigine tab 200 mg LAMICTAL CHEWABLE DISPERS 4 – lamotrigine tab chewable dispersible 5 mg LAMICTAL CHEWABLE DISPERS 4 – lamotrigine tab chewable dispersible 25 mg 4 LAMICTAL ODT – lamotrigine orally disintegrating tab 25 mg 4 LAMICTAL ODT – lamotrigine orally disintegrating tab 50 mg 4 LAMICTAL ODT – lamotrigine orally disintegrating tab 100 mg 4 LAMICTAL ODT – lamotrigine orally disintegrating tab 200 mg LAMICTAL STARTER/NOT TAKI – 4 lamotrigine tab 25 mg (42) & 100 mg (7) starter kit LAMICTAL STARTER/TAKING C – 4 lamotrigine tab 25 mg (84) & 100 mg (14) starter kit Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Drug Name Specialty Drug Tier 2015 1 lamotrigine tab 200 mg (Lamictal) 1 lamotrigine tab 25 mg (Lamictal) 1 levetiracetam oral soln 100 mg/ ml (Keppra) 1 levetiracetam tab sr 24hr 500 mg (Keppra xr) 2 levetiracetam tab sr 24hr 750 mg (Keppra xr) 2 levetiracetam tab 1000 mg (Keppra) 1 levetiracetam tab 250 mg (Keppra) 1 levetiracetam tab 500 mg (Keppra) 1 levetiracetam tab 750 mg (Keppra) 1 LYRICA – pregabalin cap 25 mg 4 LYRICA – pregabalin cap 50 mg 4 LYRICA – pregabalin cap 75 mg 4 LYRICA – pregabalin cap 100 mg 4 LYRICA – pregabalin cap 150 mg 4 LYRICA – pregabalin cap 200 mg 4 LYRICA – pregabalin cap 225 mg 4 LYRICA – pregabalin cap 300 mg 4 LYRICA – pregabalin soln 20 mg/ ml 4 MYSOLINE – primidone tab 50 mg 4 MYSOLINE – primidone tab 250 mg 4 NEURONTIN – gabapentin cap 100 mg 4 NEURONTIN – gabapentin cap 300 mg 4 NEURONTIN – gabapentin cap 400 mg 4 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits lamotrigine tab 150 mg (Lamictal) Restricted Access 1 Prior Review lamotrigine tab 100 mg (Lamictal) Specialty Quantity Limits Restricted Access Prior Review Drug Name Drug Tier LAMICTAL STARTER/TAKING V – 4 lamotrigine tab 25 mg (35) starter kit LAMICTAL XR – lamotrigine tab sr 4 24hr 25 mg LAMICTAL XR – lamotrigine tab sr 4 24hr 50 mg LAMICTAL XR – lamotrigine tab sr 4 24hr 100 mg LAMICTAL XR – lamotrigine tab sr 4 24hr 200 mg LAMICTAL XR – lamotrigine tab sr 4 24hr 250 mg LAMICTAL XR – lamotrigine tab sr 4 24hr 300 mg 2 lamotrigine orally disintegrating tab 100 mg (Lamictal odt) 2 lamotrigine orally disintegrating tab 200 mg (Lamictal odt) 2 lamotrigine orally disintegrating tab 25 mg (Lamictal odt) 2 lamotrigine orally disintegrating tab 50 mg (Lamictal odt) 2 lamotrigine tab chewable dispersible 25 mg (Lamictal chewable di) 2 lamotrigine tab chewable dispersible 5 mg (Lamictal chewable di) 2 lamotrigine tab sr 24hr 100 mg (Lamictal xr) 2 lamotrigine tab sr 24hr 200 mg (Lamictal xr) 2 lamotrigine tab sr 24hr 25 mg (Lamictal xr) 2 lamotrigine tab sr 24hr 250 mg (Lamictal xr) 2 lamotrigine tab sr 24hr 300 mg (Lamictal xr) 2 lamotrigine tab sr 24hr 50 mg (Lamictal xr) Specialty Drug Name Drug Tier 2015 79 primidone tab 50 mg (Mysoline) 1 TEGRETOL – carbamazepine tab 200 mg 4 TEGRETOL – carbamazepine susp 4 100 mg/5ml 4 TEGRETOL-XR – carbamazepine tab sr 12hr 100 mg 4 TEGRETOL-XR – carbamazepine tab sr 12hr 200 mg 4 TEGRETOL-XR – carbamazepine tab sr 12hr 400 mg 2 tiagabine hcl tab 2 mg (Gabitril) tiagabine hcl tab 4 mg (Gabitril) 80 4 TOPAMAX – topiramate tab 100 mg 4 TOPAMAX – topiramate tab 200 mg 4 TOPAMAX SPRINKLE – topiramate sprinkle cap 15 mg 4 TOPAMAX SPRINKLE – topiramate sprinkle cap 25 mg 4 topiramate sprinkle cap 15 mg (Topamax sprinkle) 2 topiramate sprinkle cap 25 mg (Topamax sprinkle) 2 topiramate tab 100 mg (Topamax) 1 topiramate tab 200 mg (Topamax) 1 topiramate tab 25 mg (Topamax) 1 topiramate tab 50 mg (Topamax) 1 TRILEPTAL – oxcarbazepine tab 150 mg 4 TRILEPTAL – oxcarbazepine tab 300 mg 4 TRILEPTAL – oxcarbazepine tab 600 mg 4 valproate sodium syrup 250 mg/5ml (base equiv) (Depakene) 1 valproic acid cap 250 mg (Depakene) 1 ZARONTIN – ethosuximide cap 250 mg 4 ZARONTIN – ethosuximide soln 250 mg/5ml 4 ZONEGRAN – zonisamide cap 25 mg 4 ZONEGRAN – zonisamide cap 100 4 mg 1 zonisamide cap 100 mg (Zonegran) 2 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits TOPAMAX – topiramate tab 50 mg Restricted Access 4 Prior Review TOPAMAX – topiramate tab 25 mg Specialty Quantity Limits Restricted Access Drug Name Drug Tier NEURONTIN – gabapentin tab 600 4 mg NEURONTIN – gabapentin tab 800 4 mg 4 NEURONTIN – gabapentin oral soln 250 mg/5ml 1 oxcarbazepine tab 150 mg (Trileptal) 1 oxcarbazepine tab 300 mg (Trileptal) 1 oxcarbazepine tab 600 mg (Trileptal) 4 PHENYTEK – phenytoin sodium extended cap 200 mg 4 PHENYTEK – phenytoin sodium extended cap 300 mg 2 phenytoin chew tab 50 mg (Dilantin infatabs) 1 phenytoin sodium extended cap 100 mg (Dilantin) 1 phenytoin sodium extended cap 200 mg (Phenytek) 1 phenytoin sodium extended cap 300 mg (Phenytek) 2 phenytoin susp 125 mg/5ml (Dilantin) primidone tab 250 mg (Mysoline) 1 Prior Review Drug Name Specialty Drug Tier 2015 zonisamide cap 25 mg (Zonegran) 1 zonisamide cap 50 mg 1 ANTIPARKINSON AGENTS CARBIDOPA/LEVODOPA/ ENTACA – carbidopa-levodopaentacapone tabs 31.25-125-200 mg 3 CARBIDOPA/LEVODOPA/ ENTACA – carbidopa-levodopaentacapone tabs 37.5-150-200 mg 3 3 AMANTADINE HCL – amantadine hcl tab 100 mg 1 amantadine hcl cap 100 mg 1 amantadine hcl syrup 50 mg/5ml 1 AZILECT – rasagiline mesylate tab 0.5 mg (base equiv) 4 CARBIDOPA/LEVODOPA/ ENTACA – carbidopa-levodopaentacapone tabs 50-200-200 mg AZILECT – rasagiline mesylate tab 1 mg (base equiv) 4 COMTAN – entacapone tab 200 mg 4 benztropine mesylate tab 0.5 mg 1 4 benztropine mesylate tab 1 mg 1 ELDEPRYL – selegiline hcl cap 5 mg 1 entacapone tab 200 mg (Comtan) 2 benztropine mesylate tab 2 mg 2 LODOSYN – carbidopa tab 25 mg 4 bromocriptine mesylate cap 5 mg (Parlodel) 4 bromocriptine mesylate tab 2.5 mg 2 MIRAPEX – pramipexole dihydrochloride tab 0.125 mg 4 carbidopa & levodopa tab cr 25-100 mg (Sinemet cr) 1 MIRAPEX – pramipexole dihydrochloride tab 0.25 mg 4 carbidopa & levodopa tab cr 50-200 mg (Sinemet cr) 1 MIRAPEX – pramipexole dihydrochloride tab 0.5 mg 4 carbidopa & levodopa tab 10-100 mg (Sinemet) 1 MIRAPEX – pramipexole dihydrochloride tab 0.75 mg 4 carbidopa & levodopa tab 25-100 mg (Sinemet) 1 MIRAPEX – pramipexole dihydrochloride tab 1 mg 4 carbidopa & levodopa tab 25-250 mg (Sinemet) 1 MIRAPEX – pramipexole dihydrochloride tab 1.5 mg 4 carbidopa tab 25 mg (Lodosyn) 2 PARLODEL – bromocriptine mesylate cap 5 mg 3 pramipexole dihydrochloride tab 0.125 mg (Mirapex) 1 CARBIDOPA/LEVODOPA/ ENTACA – carbidopa-levodopaentacapone tabs 12.5-50-200 mg 1 CARBIDOPA/LEVODOPA/ ENTACA – carbidopa-levodopaentacapone tabs 18.75-75-200 mg 3 pramipexole dihydrochloride tab 0.25 mg (Mirapex) pramipexole dihydrochloride tab 0.5 mg (Mirapex) 1 1 CARBIDOPA/LEVODOPA/ ENTACA – carbidopa-levodopaentacapone tabs 25-100-200 mg 3 pramipexole dihydrochloride tab 0.75 mg (Mirapex) pramipexole dihydrochloride tab 1 mg (Mirapex) 1 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 81 pramipexole dihydrochloride tab 1.5 mg (Mirapex) 1 REQUIP – ropinirole hydrochloride tab 0.25 mg 4 REQUIP – ropinirole hydrochloride tab 0.5 mg ropinirole hydrochloride tab sr 24hr 6 mg (base equivalent) (Requip xl) 2 2 4 ropinirole hydrochloride tab sr 24hr 8 mg (base equivalent) (Requip xl) REQUIP – ropinirole hydrochloride tab 1 mg 4 ropinirole hydrochloride tab 0.25 mg (Requip) 1 REQUIP – ropinirole hydrochloride tab 2 mg 4 ropinirole hydrochloride tab 0.5 mg (Requip) 1 REQUIP – ropinirole hydrochloride tab 3 mg 4 ropinirole hydrochloride tab 1 mg (Requip) 1 REQUIP – ropinirole hydrochloride tab 4 mg 4 ropinirole hydrochloride tab 2 mg (Requip) 1 REQUIP – ropinirole hydrochloride tab 5 mg 4 ropinirole hydrochloride tab 3 mg (Requip) 1 REQUIP XL – ropinirole hydrochloride tab sr 24hr 2 mg (base equivalent) 4 ropinirole hydrochloride tab 4 mg (Requip) 1 1 REQUIP XL – ropinirole hydrochloride tab sr 24hr 4 mg (base equivalent) 4 ropinirole hydrochloride tab 5 mg (Requip) selegiline hcl cap 5 mg (Eldepryl) 2 selegiline hcl tab 5 mg 2 REQUIP XL – ropinirole hydrochloride tab sr 24hr 6 mg (base equivalent) 4 SINEMET – carbidopa & levodopa tab 10-100 mg 4 4 SINEMET – carbidopa & levodopa tab 25-100 mg 4 REQUIP XL – ropinirole hydrochloride tab sr 24hr 8 mg (base equivalent) 4 REQUIP XL – ropinirole hydrochloride tab sr 24hr 12 mg (base equivalent) 4 SINEMET – carbidopa & levodopa tab 25-250 mg SINEMET CR – carbidopa & levodopa tab cr 25-100 mg 4 ropinirole hydrochloride tab sr 24hr 12 mg (base equivalent) (Requip xl) 2 SINEMET CR – carbidopa & levodopa tab cr 50-200 mg 4 4 ropinirole hydrochloride tab sr 24hr 2 mg (base equivalent) (Requip xl) 2 STALEVO 100 – carbidopalevodopa-entacapone tabs 25-100-200 mg 4 ropinirole hydrochloride tab sr 24hr 4 mg (base equivalent) (Requip xl) 2 STALEVO 125 – carbidopalevodopa-entacapone tabs 31.25-125-200 mg STALEVO 150 – carbidopalevodopa-entacapone tabs 37.5-150-200 mg 4 82 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Drug Name Specialty Drug Tier 2015 STALEVO 200 – carbidopalevodopa-entacapone tabs 50-200-200 mg 4 STALEVO 50 – carbidopalevodopa-entacapone tabs 12.5-50-200 mg 4 STALEVO 75 – carbidopalevodopa-entacapone tabs 18.75-75-200 mg 4 trihexyphenidyl hcl elixir 0.4 mg/ ml 2 trihexyphenidyl hcl tab 2 mg 1 trihexyphenidyl hcl tab 5 mg 1 5 riluzole tab 50 mg (Rilutek) 5 • • MUSCULOSKELETAL THERAPY AGENTS 1 baclofen tab 10 mg Quantity Limits Restricted Access Prior Review Specialty Drug Tier Quantity Limits Restricted Access Drug Name FEXMID – cyclobenzaprine hcl tab 7.5 mg NEUROMUSCULAR AGENTS RILUTEK – riluzole tab 50 mg Prior Review Specialty Drug Name Drug Tier 2015 4 metaxalone tab 800 mg (Skelaxin) 2 1 methocarbamol tab 500 mg (Robaxin) 1 methocarbamol tab 750 mg (Robaxin-750) 1 orphenadrine citrate tab sr 12hr 100 mg 4 PARAFON FORTE DSC – chlorzoxazone tab 500 mg 4 ROBAXIN – methocarbamol tab 500 mg 4 ROBAXIN-750 – methocarbamol tab 750 mg 4 SKELAXIN – metaxalone tab 800 mg 4 SOMA – carisoprodol tab 350 mg tizanidine hcl cap 2 mg (Zanaflex) 2 tizanidine hcl cap 4 mg (Zanaflex) 2 baclofen tab 20 mg 1 carisoprodol tab 350 mg (Soma) 2 chlorzoxazone tab 500 mg (Parafon forte dsc) 1 tizanidine hcl cap 6 mg (Zanaflex) 2 1 tizanidine hcl tab 2 mg cyclobenzaprine hcl tab 10 mg 1 tizanidine hcl tab 4 mg (Zanaflex) 1 cyclobenzaprine hcl tab 5 mg 1 4 cyclobenzaprine hcl tab 7.5 mg (Fexmid) 1 ZANAFLEX – tizanidine hcl cap 2 mg 4 DANTRIUM – dantrolene sodium cap 25 mg 4 ZANAFLEX – tizanidine hcl cap 4 mg 4 DANTRIUM – dantrolene sodium cap 50 mg 4 ZANAFLEX – tizanidine hcl cap 6 mg 4 DANTRIUM – dantrolene sodium cap 100 mg 4 ZANAFLEX – tizanidine hcl tab 4 mg DANTROLENE SODIUM – dantrolene sodium cap 100 mg 2 MESTINON – pyridostigmine bromide tab 60 mg 4 dantrolene sodium cap 25 mg (Dantrium) 2 pyridostigmine bromide tab 60 mg (Mestinon) 1 dantrolene sodium cap 50 mg (Dantrium) 2 NUTRITIONAL PRODUCTS ANTIMYASTHENIC AGENTS VITAMINS Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 83 DRISDOL – ergocalciferol cap 50000 unit 4 ergocalciferol cap 50000 unit (Drisdol) 1 MEPHYTON – phytonadione tab 5 mg 4 MULTIVITAMINS CITRANATAL ASSURE – prenat w/o a w/fecbn-fegl-dss-fa tab & dha cap 300 mg pack 4 CITRANATAL B-CALM – prenat w/ o a w/fecbn-feglu-fa tab 20-1 mg & vit b6 tab pak 4 CITRANATAL DHA – prenat w/o a w/fecbn-fegl-dss-fa tab & dha cap 250 mg pack 4 CITRANATAL HARMONY – prenatal w/o a w/fe cbn-dss-fadha cap 29-1-265 mg 4 CITRANATAL HARMONY – prenatal w/o vit a w/ fe cbn-dssfa-dha cap 30-1-260 mg 4 CITRANATAL HARMONY – prenat w/o a w/fe fum-fe cbn-dss-fa-dha cap 27-1-260 mg 4 CITRANATAL RX – prenatal w/o a w/ fe carbonyl-fe gluc-dss-fa tab 27-1mg 4 ACTIVE OB – prenatal w/o a w/fe cbn-fa-dha cap 20-1-320 mg 4 ATABEX EC – prenatal vit w/ dssiron carbonyl-fa tab dr 29-1 mg 4 ATABEX PRENATAL – prenatal vit w/ iron carbonyl-fa tab 65-1 mg 4 b-complex w/ c & folic acid cap 1 mg (Nephrocaps) 1 b-complex w/ c & folic acid tab 1 mg (Nephro-vite rx) 1 b-complex w/ c & folic acid tab 1 B-NEXA – prenatal w/ calcium-vit b6-fa-ginger tab 1.22 mg 4 BAL-CARE DHA – prenat w/fe poly-na fered-fa tab 27-1 & omega cap dr 430mg 4 CITRANATAL 90 DHA – prenat w/ o a w/fecbn-fegl-dss-fa tab 90 &dha cap 300mg pak 4 BP FOLINATAL PLUS B – prenatal 4 w/ calcium carbonate-b6-b12-fa tab 1 mg BP MULTINATAL PLUS – prenatal 4 w/o a vit w/ fe fumarate-fa tab 30-1 mg BP MULTINATAL PLUS – prenatal 4 w/o a vit w/ fe fum-fa tab chew 40-1 mg 4 C-NATE DHA – prenatal vit w/ fe fum-fa-omega 3 cap 28-1-200 mg 4 CALCIUM PNV – prenatal w/o vit a w/ fe fum-fa-omega 3 cap 28-1-250 mg 4 CHOICE-OB+DHA – prenatal mv w/fe poly-fa chw 29-1 mg & dha cap 250 mg pak CO-NATAL FA – prenatal vit w/ fe fumarate-fa tab 29-1 mg 4 84 COMPLETE NATAL DHA – prenat- 4 fe bis-fe prot succ-fa-ca tab & omega 3 cap 250 pk COMPLETENATE – prenatal vit w/ 4 fe fumarate-fa chew tab 29-1 mg 4 CONCEPT DHA – prenatal w/fe fum-fe poly -fa-omega 3 cap 53.5-38-1 mg CONCEPT OB – prenatal w/o a w/ 4 fe fum-fe poly-fa cap 130-92.4-1 mg 4 DUET DHA – prenat w/fe poly-na fered-fa tab 25-1 & omega cap 400 mg Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Drug Name Specialty Drug Tier 2015 DUET DHA BALANCED – prenat w/fe poly-na fered-fa tab 25-1 & omega cap 267 mg 4 GESTICARE DHA – prenatal w/fe fum-fa tab dr 27-1 mg & dha cap 250 mg pack 4 DUET DHA BALANCED – prenat w/fe poly-na fered-fa tab 27-1 & omega cap dr 380mg 4 HEMENATAL OB – prenat vit-fe poly cmplx-fe heme poly-fa tab 28-6-1 mg 4 DUET DHA 400 – prenat w/fe polyna fered-fa tab 25-1 & omega cap 400 mg 4 HEMENATAL OB + DHA – prenatfe poly cmplx-fe heme poly-fa tab & omega 3 cap pck 4 ELITE-OB – prenatal vit w/ iron carbonyl-fa tab 50-1.25 mg 4 4 ESCAVITE LQ – pediatric multiple vitamins w/ fl-fe drops 0.25-6 mg/ ml 1 INATAL ADVANCE – prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg INATAL GT – prenatal vit w/ dssiron carbonyl-fa tab 90-1 mg 4 EXTRA-VIRT PLUS DHA – prenatal w/o vit a w/ fe fum-docfa-dha cap 29-1.25-350 mg 4 INATAL ULTRA – prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg 4 4 INFANATE BALANCE – prenatal w/o a w/fe cbn-dss-fa-dha cap 29-1-265 mg 4 FOCALGIN-B – prenatal w/ calcium-vit b6-fa-ginger tab 1.22 mg FOLBECAL – prenatal w/ calcium carbonate-b6-b12-fa tab 1 mg INFANATE PLUS – prenat w/o a w/fe fum-fe cbn-dss-fa-dha cap 27-1-260 mg 4 4 FOLCAL DHA – prenatal w/o vit a w/ fe fum-dss-fa-dha cap 27-1.25-300 mg 4 L-METHYLFOLATE PNV DHA – prenat w/fe fum-l methylfolate-fadha cap 27-1.13-0.4 mg 4 FOLCAPS OMEGA 3 – prenatal vit w/ fe cbn-fe asp glyc-fa-omega 3 cap 27-1mg 4 FOLET DHA – prenat w/fecbnbisg-methylf-dss tab dr & dha cap pak 4 FOLET ONE – prenat w/o a w/ fecbn-bisg-methylf-dss-dha cap 38-1-225 mg 4 FOLIVANE-OB – prenatal w/o a w/ fe fum-fe poly-fa cap 130-92.4-1 mg 4 FOLIVANE-PRX DHA NF – prenatal w/o vit a w/fe fum-dssfa-dha cap 30-1.24-265 mg 4 M-VIT – prenatal vit w/ fe fumarate- 1 fa tab 27-1 mg 4 MACNATAL CN DHA – prenatal w/o a w/fe cbn-dss-fa-dha cap 28-1-250 mg 4 MARNATAL-F – prenatal w/o vit a w/ fe polysac cmplx-fa cap 60-1 mg 4 MULTI PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-0.8 mg MYNATAL – prenatal multivitamins 4 & minerals w/ iron & fa cap 1 mg 4 MYNATAL ADVANCE – prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg 4 MYNATAL PLUS – prenatal vit w/ fe fumarate-fa tab 65-1 mg Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 85 MYNATAL ULTRACAPLET – prenatal vit w/ dss-iron carbonylfa tab 90-1 mg 4 NEXA PLUS – prenatal w/o vit a w/ fe fum-doc-fa-dha cap 29-1.25-350 mg 4 MYNATAL-Z – prenatal vit w/ fe fumarate-fa tab 65-1 mg 4 NUTRI-TAB OB – prenatal vit w/o vit a w/ fe bisglycinate-fa tab 32-1 mg 4 NUTRI-TAB OB + DHA – prenat w/ o a w/ fe bisglyc-fa tab 32-1 mg & omega cap pack 4 O-CAL FA – prenatal vit w/ fe fumarate-fa tab 27-1 mg 1 O-CAL PRENATAL – prenatal vit w/ fe fumarate-fa tab 15-1 mg 4 OB COMPLETE – prenatal vit w/ iron carbonyl-fa tab 50-1.25 mg 4 OB COMPLETE ONE – prenatal w/o a w/fecbn-fe asp glyc-fa-fish cap 50-1-476 mg 4 OB COMPLETE PETITE – prenat w/o a w/fecbn-feaspglyc-faomega cap 35-5-1-200 mg 4 OB COMPLETE PREMIER – prenatal vit w/ fe cbn-fe asp glycfa tab 30-20-1 mg 4 OB COMPLETE/DHA – prenat w/ iron cbn-fe asp glyc-fa-omega cap 30-10-1-200 mg 4 OB-NATAL ONE – prenatal vit w/ fe cbn-fe asp glyc-fa-omega 3 cap 27-1mg 4 OBSTETRIX DHA – prenat w/ fecbn-fa-dss tab 29-1 mg & omega 3 cap 387 mg pak 4 OBSTETRIX EC – prenatal vit w/ dss-iron carbonyl-fa tab 29-1 mg 4 PAIRE OB – prenat w/ fe poly cmplx-fe asp-fe gly-fa tab & dha cap pak 4 pediatric multiple vitamins w/ flfe drops 0.25-10 mg/ml 1 pediatric multiple vitamins w/ fluoride chew tab 0.25 mg 1 MYNATE 90 PLUS – prenatal vit w/ 4 dss-fe fumarate-fa tab cr 90-1 mg 4 NATACHEW – prenatal vit w/ fe fum-fe bisglycin-fa chew tab 28-1 mg NATAL-V RX – prenatal vit w/ iron 4 carbonyl-fa tab 29-1 mg 4 NATALVIRT CA – prenat w/o a w/ fecbn-fegl-dss-fa tab & dha cap 300 mg pack 4 NATALVIRT 90 DHA – prenat w/ o a w/fecbn-fegl-dss-fa tab 90 &dha cap 300mg pak 4 NATALVIT – prenatal vit w/ fe fumarate-fa tab 75-1 mg 4 NATELLE ONE – prenatal w/o vit a w/ fe fum-fa-omega 3 cap 28-1-250 mg 4 NEEVO DHA – prenat w/o a w/ fefum-methylfol-omegas cap 27-1.13 mg NEPHRO-VITE RX – b-complex w/ 4 c & folic acid tab 1 mg NEPHROCAPS – b-complex w/ c & 4 folic acid cap 1 mg 4 NESTABS – prenatal vit w/o vit a w/ fe bisglycinate-fa tab 32-1 mg NESTABS ABC – prenatal w/o vit a 4 w/fe polysac-fa-ca tab & omega 3 cap 4 NESTABS DHA – prenat w/o a w/ fe bisglyc-fa tab 32-1 mg & omega cap pack NEWGEN – prenatal vit w/o vit a w/ 4 fe bisglycinate-fa tab 32-1 mg 86 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Drug Name Specialty Drug Tier 2015 pediatric multiple vitamins w/ fluoride chew tab 1 mg 1 pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml 4 1 PNV-TOTAL – prenat w/ fe cbnfe bisglyc-fa-fish oil cap 35-5-1.2 mg 4 pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml 1 PNV-VP-U – prenatal w/o a vit w/ fe fumarate-fa cap 106.5-1 mg 4 pediatric vitamins acd w/ fluoride soln 0.25 mg/ml 1 PR NATAL 400 – prenat-fe bis-fe prot succ-fa-ca tab & omega 3 cap 400 pk pediatric vitamins acd w/ fluoride soln 0.5 mg/ml 1 4 PNV FERROUS FUMARATE/ DOCU – prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg 4 PR NATAL 400 EC – prenat-fe bisfe prot succ-fa-ca tab & omega cap dr 400 pk 4 PNV FOLIC ACID + IRON MUL – prenatal vit w/ fe fumarate-fa tab 27-1 mg 1 PR NATAL 430 – prenat-fe bis-fe prot succ-fa-ca tab & omega 3 cap 430 pk 4 PNV OB+DHA – prenat w/o a w/ fecbn-fegl-dss-fa tab & dha cap 250 mg pack 4 PR NATAL 430 EC – prenat-fe bisfe prot succ-fa-ca tab & omega cap dr 430 pk 4 PNV PRENATAL PLUS MULTIVI – prenatal vit w/ fe fumarate-fa tab 27-1 mg 1 PREFERA OB – prenat vit-fe poly cmplx-fe heme poly-fa tab 28-6-1 mg 4 PNV TABS 29-1 – prenatal vit w/ iron carbonyl-fa tab 29-1 mg 4 PREFERA OB + DHA – prenat-fe poly cmplx-fe heme poly-fa tab & omega 3 cap pck 4 PNV-DHA – prenat w/o a w/ fefum-methfol-fa-dha cap 27-0.6-0.4-300 mg 4 PREFERAOB ONE – prenat-fe poly cmplx-fe heme poly-fa-dha cap 22-6-1-200 mg 4 PNV-DHA+DOCUSATE – prenatal w/o vit a w/ fe fum-dss-fa-dha cap 27-1.25-300 mg 4 PREFOL-DHA – prenatal w/o vit a w/ fe fum-dss-fa-dha cap 26-1.2-300 mg 4 PNV-FIRST – prenatal mv w/ fe polysac cmplx-fa-dha cap 29-1-200 mg 4 PRENAISSANCE – prenatal w/o vit a w/ fe fum-dss-fa-dha cap 29-1.25-325 mg 4 PNV-OB/DHA – prenatal mv w/fe fum-fa tab 65-1 mg & dha cap 250 mg pack 4 PRENAISSANCE BALANCE – prenatal w/o vit a w/ fe cbn-dssfa-dha cap 30-1-260 mg 4 PNV-OMEGA – prenat w/o a w/ fe fumerate-methylfolate-fa-omega 3 cap 4 PRENAISSANCE DHA – prenat w/ o a w/fecbn-fegl-dss-fa tab & dha cap 250 mg pack 4 PNV-SELECT – prenatal vit w/ fe fum-methylfolate-fa tab 27-0.6-0.4 mg 4 PRENAISSANCE HARMONY DHA – prenat w/fe poly-na fered-fa tab 27-1 & omega cap dr 380mg Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 87 PRENAISSANCE NEXT – prenatal w/ calcium-vit b6-fa-ginger tab 1.2 mg 4 PRENATAL VITAMINS PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg 1 PRENAISSANCE NEXT-B – prenatal w/ calcium-vit b6-faginger tab 1.22 mg 4 PRENATAL 19 – prenatal vit w/ fe fumarate-fa chew tab 29-1 mg 4 4 PRENAISSANCE PLUS – prenatal w/o a w/fe cbn-dss-fa-dha cap 28-1-250 mg 4 PRENATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg PRENATAL-U – prenatal w/o a vit w/ fe fumarate-fa cap 106.5-1 mg 4 PRENAISSANCE PROMISE – prenat w/o a w/fecbn-fegl-dss-fa tab & dha cap 300 mg pack 4 PRENATE – prenat mv & min w/ lmethylfolate-fa chew tab 0.6-0.4 mg 4 PRENAISSANCE 90 DHA – prenat w/o a w/fecbn-fegl-dss-fa tab 90 &dha cap 300mg pak 4 PRENATE AM – prenatal w/ calcium-vit b6-vit b12-fa-ginger tab 1 mg 4 PRENAPLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg 1 4 PRENATABS FA – prenatal vit w/ fe fumarate-fa tab 29-1 mg 4 PRENATE DHA – prenat w/o a w/fefum-methfol-fa-dha cap 28-0.6-0.4-300 mg 4 PRENATE DHA – prenat w/o a w/feaspg-methfol-fa-dha cap 18-0.6-0.4-300 mg 4 PRENATABS RX – prenatal vit w/ iron carbonyl-fa tab 29-1 mg PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-0.8 mg 4 4 PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-1 mg 1 PRENATE ELITE – prenatal w/ fe asp gly-l methylfol-fa tab 20-0.6-0.4 mg 4 PRENATAL AD – prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg 4 PRENATE ELITE – prenatal vit w/ fe fum-methylfolate-fa tab 26-0.6-0.4 mg PRENATAL LOW IRON – prenatal vit w/ fe fumarate-fa tab 27-0.8 mg 4 PRENATE ENHANCE – prenat w/ o a w/fefum-methfol-fa-dha cap 28-0.6-0.4-400 mg 4 PRENATAL LOW IRON – prenatal vit w/ fe fumarate-fa tab 27-1 mg 1 PRENATE ESSENTIAL – prenat w/ 4 o a w/feasp-methylf-fa-omeg cap 29-0.6-0.4-340 mg PRENATE ESSENTIAL – prenat w/ 4 o a w/feaspg-methfol-fa-dha cap 18-0.6-0.4-300 mg 4 PRENATE MINI – prenat w/oa w/fecb-feasp-meth-fa-dha cap 18-0.6-0.4-350 mg 4 PRENATE PIXIE – prenat w/o a w/feaspg-methfol-fa-dha cap 10-0.6-0.4-200 mg PRENATAL ONE DAILY – prenatal 4 vit w/ fe fumarate-fa tab 27-0.8 mg PRENATAL PLUS – prenatal vit w/ 1 fe fumarate-fa tab 27-1 mg PRENATAL PLUS IRON – prenatal 4 vit w/ iron carbonyl-fa tab 29-1 mg 88 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Drug Name Specialty Drug Tier 2015 PRENATE RESTORE – prenat w/ o a w/fefum-methfol-fa-dha cap 27-0.6-0.4-400 mg 4 QUFLORA PEDIATRIC – pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml 1 PRENATE STAR – prenatal vit w/ fe asparto glycinate-fa tab 20-1 mg 4 R-NATAL OB – prenatal w/o a w/fe cbn-fa-dha cap 20-1-320 mg 4 4 PRENA1 CHEW – prenat w/ b2b6-b12-d3-folic acid chew tab 1.4 mg 4 REAPHIRM – prenatal mv w/ fe polysac cmplx-fa-dha cap 29-1-200 mg 4 RELNATE DHA – prenatal vit w/ fe fum-fa-omega 3 cap 28-1-200 mg 4 PRENA1 PEARL – prenat w/oa w/fefum-na fered-fa-dha cap cr 30-1.4-200 mg PRENA1 PLUS/QUATREFOLIC – prenat w/o a w/ fe chelate-l methylfol-fa tab & dha cap pk RIGHT STEP PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-0.8 mg 4 4 PRENA1/QUATREFOLIC – prenat w/o a w/fefum-methfol-fa-dha cap 30-0.6-0.4-200 mg SE-NATAL 19 – prenatal vit w/ fe fumarate-fa chew tab 29-1 mg 4 4 PRENEXA – prenatal w/o vit a w/ fe fum-dss-fa-dha cap 27-1.25-300 mg 4 PREPLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg 1 PREQUE 10 – prenatal mv w/ fe carbonyl-dss-fa-dha tab 15-25-0.5-50 mg 4 PRETAB – prenatal vit w/ fe fumarate-fa tab 29-1 mg 4 PROVIDA OB – prenatal w/o a w/fe 4 fum-fe poly-fa cap 20-20-1.25 mg 4 PUREFE OB PLUS – prenatal w/o a w/fe fum-fe poly-fa cap 162.115.2-1 mg QUFLORA PEDIATRIC – pediatric 1 multiple vitamins w/ fluoride chew tab 0.25 mg QUFLORA PEDIATRIC – pediatric 1 multiple vitamins w/ fluoride chew tab 1 mg QUFLORA PEDIATRIC – pediatric 1 multiple vitamins w/ fluoride soln 0.25 mg/ml Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 SE-NATAL 19 – prenatal vit w/ dss- 4 fe fumarate-fa tab 29-1 mg SE-TAN DHA – prenatal w/fe fum- 4 fe poly -fa-omega 3 cap 15-15-1 mg 4 SELECT-OB – prenatal vit w/ fe polysac cmplx-fa chew tab 29-1 mg 4 SELECT-OB – prenat w/ fepolycmplx-methylfol-fa chew tab 29-0.6-0.4 mg 4 SELECT-OB+DHA – prenatal mv w/fe poly-fa chw 29-1 mg & dha cap 250 mg pak 4 SETON ET-EC – prenat-fe bis-fe prot succ-fa-ca tab & omega cap dr 430 pk 4 SETONET – prenat-fe bis-fe prot succ-fa-ca tab & omega 3 cap 430 pk 4 STROVITE – b-complex w/ c & folic acid tab 4 TARON-BC – prenat w/o a w/ fe cbnyl-fa tab 20-1 mg & vit b6 tab pak Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 89 TARON-C DHA – prenatal w/fe fum-fe poly -fa-omega 3 cap 53.5-38-1 mg 4 TARON-DUO EC – prenat-fe bis-fe prot succ-fa-ca tab & omega cap dr 400 pk 4 TARON-PREX – prenatal w/o vit a w/ fe fum-dss-fa-dha cap 30-1.2-265 mg 4 THERANATAL CORE NUTRITION – prenatal vit w/ fe fumarate-fa tab 27-1 mg 1 TL FOLATE – prenatal vit w/ fe fum-methylfolate-fa tab 27-0.5-0.5 mg 4 TL-CARE DHA – prenatal w/fe fumarate-fa-dss-fish oil cap 27-1-500 mg 4 TL-SELECT – prenatal w/o vit a w/ fe fum-dss-fa-dha cap 29-1.25-325 mg 4 TL-SELECT DHA – prenatal w/o vit a w/ fe fum-doc-fa-dha cap 29-1.25-350 mg 4 TRI-TABS DHA – prenat w/o a w/ fe bisglyc-fa tab 32-1 mg & omega cap pack 4 TRIADVANCE – prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg 4 TRICARE – prenatal vit w/ fe fumarate-fa tab 27-1 mg 1 TRICARE PRENATAL COMPLEAT – prenat w/o a fefum-fa tab 27-1 mg & fish oil chew cap pak 4 TRICARE PRENATAL DHA ONE – prenatal w/fe fumarate-fa-dssfish oil cap 27-1-500 mg 4 TRINATAL GT – prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg 4 TRINATAL RX 1 – prenatal vit w/ fe 4 fumarate-fa tab 60-1 mg 90 TRINATAL ULTRA – prenatal vit w/ 4 dss-iron carbonyl-fa tab 90-1 mg 4 TRINATE – prenatal vit w/ fe fumarate-fa tab 28-1 mg 4 TRIVEEN-DUO DHA – prenatfe bis-fe prot succ-fa-ca tab & omega 3 cap 400 pk 4 TRIVEEN-PRX RNF – prenatal w/ o vit a w/ fe fum-dss-fa-dha cap 26-1.2-300 mg ULTIMATE OB DHA – prenat w/ fe 4 poly cmplx-fe asp-fe gly-fa tab & dha cap pak 4 ULTIMATECARE ONE – prenatal vit w/ fe cbn-fe asp glyc-faomega 3 cap 27-1mg 4 ULTIMATECARE ONE NF – prenatal w/fe cbnyl-fe asp glycfa-dss-omega cap 20-7-1 mg ULTRA TABS – prenatal vit w/ dss- 4 iron carbonyl-fa tab 90-1 mg V-NATAL – prenatal vit w/o vit a w/ 4 fe bisglycinate-fa tab 32-1 mg V-NATAL DHA – prenat w/o a w/ fe 4 bisglyc-fa tab 32-1 mg & omega cap pack 4 VEMAVITE-PRX 2 – prenatal w/ o vit a w/ fe fum-dss-fa-dha cap 27-1.25-300 mg 4 VENA-BAL DHA – prenat w/fe poly-na fered-fa tab 27-1 & omega cap dr 430mg 4 VENATAL-FA – prenatal vit w/ fe fumarate-fa tab 29-1 mg 4 VINACAL – prenatal w/o a w/ fe carbonyl-fe gluc-dss-fa tab 27-1mg 4 VINACAL B – prenat w/o a w/ fecbn-feglu-fa tab 20-1 mg & vit b6 tab pak Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Drug Name Specialty Drug Tier 2015 VINATE AZ EXTRA – prenatal vit w/ fe bisglycinate chelate-fa tab 29-1 mg 4 VINATE C – prenatal w/o a vit w/ fe 4 fumarate-fa tab 30-1 mg VINATE CALCIUM – prenatal vit w/ 4 iron carbonyl-fe gluc-fa tab 27-1 mg VINATE CARE – prenatal w/o a vit 4 w/ fe fum-fa tab chew 40-1 mg 4 VINATE DHA RF – prenat w/o a w/fefum-methylfol-omegas cap 27-1.13 mg 4 VINATE GT – prenatal vit w/ dssiron carbonyl-fa tab 90-1 mg 4 VINATE IC – prenatal w/o a w/fe fum-fe poly-fa cap 162.115.2-1 mg 4 VINATE II – prenatal vit w/ fe bisglycinate chelate-fa tab 29-1 mg 4 VINATE M – prenatal vit w/ sel-fe fumarate-fa tab 27-1 mg 4 VINATE ONE – prenatal vit w/ fe fumarate-fa tab 60-1 mg 4 VINATE ULTRA – prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg 4 VIRT NATE – prenatal vit w/ fe fumarate-fa tab 28-1 mg 4 VIRT-ADVANCE – prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg 4 VIRT-BAL DHA PLUS – prenat w/ fe poly-na fered-fa tab 27-1 & omega cap dr 380mg VIRT-C DHA – prenatal w/fe fum-fe 4 poly -fa-omega 3 cap 53.5-38-1 mg VIRT-CARE ONE – prenatal vit w/ 4 fe cbn-fe asp glyc-fa-omega 3 cap 27-1mg VIRT-PN – prenatal vit w/ fe fummethylfolate-fa tab 27-0.6-0.4 mg 4 VIRT-PN DHA – prenat w/o a w/fefum-methfol-fa-dha cap 27-0.6-0.4-300 mg 4 VIRT-PN PLUS – prenat w/o a w/ fe fumerate-methylfolate-faomega 3 cap 4 VIRT-SELECT – prenatal w/o vit a w/ fe fum-dss-fa-dha cap 29-1.25-325 mg 4 VIRT-VITE GT – prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg 4 VIRTPREX – prenatal w/o vit a w/ fe fum-dss-fa-dha cap 26-1.2-300 mg 4 VITA-PREN – prenatal vit w/ docusate-iron-fa tab 65-1 mg 4 VITAFOL ULTRA – prenat w/ fe poly-methylfol-fa-dha cap 29-0.6-0.4-200 mg 4 VITAFOL-NANO – prenatal w/ o a w/ fefum-l methylfol-fa tab 18-0.6-0.4 mg 4 VITAFOL-OB – prenatal vit w/ fe fumarate-fa tab 65-1 mg 4 VITAFOL-OB+DHA – prenatal mv w/fe fum-fa tab 65-1 mg & dha cap 250 mg pack 4 VITAFOL-ONE – prenatal mv w/ fe polysac cmplx-fa-dha cap 29-1-200 mg 4 VITAFOL-PN – prenatal vit w/ fe fumarate-fa tab 65-1 mg 4 VITAMEDMD ONE RX/ QUATREFO – prenat w/o a w/fefum-methfol-fa-dha cap 30-0.6-0.4-200 mg 4 VITAMEDMD PLUS RX/QUATRE – prenat w/o a w/ fe chelate-l methylfol-fa tab & dha cap pk 4 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 91 VITAMEDMD REDICHEW RX – prenat w/ b2-b6-b12-d3-folic acid chew tab 1.4 mg 4 ZATEAN-PN DHA – prenat w/o a w/fefum-methfol-fa-dha cap 27-0.6-0.4-300 mg 4 VITAPEARL – prenat w/oa w/ fefum-na fered-fa-dha cap cr 30-1.4-200 mg 4 ZATEAN-PN PLUS – prenat w/o a w/ fe fumerate-methylfolate-faomega 3 cap 4 VIVA DHA – prenatal vit w/ fe fumfa-omega 3 cap 28-1-200 mg 4 ZINGIBER – prenatal w/ calcium-vit 4 b6-fa-ginger tab 1.2 mg VOL-NATE – prenatal vit w/ fe fumarate-fa tab 28-1 mg 4 MINERALS and ELECTROLYTES VOL-PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg EFFER-K – potassium bicarbonate-citric acid effer tab 10 meq 4 1 VOL-TAB RX – prenatal vit w/ iron carbonyl-fa tab 29-1 mg 4 4 VP CH ULTRA – prenat w/o a w/ fe fum-fe cbn-dss-fa-dha cap 27-1-260 mg 4 EFFER-K – potassium bicarbonate-citric acid effer tab 20 meq 4 VP-CH PLUS – prenatal w/o a w/fe cbn-dss-fa-dha cap 29-1-265 mg 4 K-PHOS NEUTRAL – pot phos monobasic w/sod phos di & monobas tab 155-852-130mg 4 VP-CH-PNV – prenatal w/o vit a w/ fe cbn-dss-fa-dha cap 30-1-260 mg 4 K-TAB – potassium chloride tab cr 10 meq K-TAB – potassium chloride tab cr 20 meq (1500 mg) 4 VP-GGR-B6 PRENATAL – prenatal w/ calcium-vit b6-faginger tab 1.2 mg 4 LURIDE – sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) 4 VP-HEME OB – prenat vit-fe poly cmplx-fe heme poly-fa tab 28-6-1 mg LURIDE – sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) 4 4 LURIDE – sodium fluoride chew tab 1 mg f (from 2.2 mg naf) 4 VP-HEME OB + DHA – prenat-fe poly cmplx-fe heme poly-fa tab & omega 3 cap pck 4 LURIDE – sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) 4 VP-HEME ONE – prenat-fe poly cmplx-fe heme poly-fa-dha cap 22-6-1-200 mg 4 VP-PNV-DHA – prenatal vit w/ fe fum-fa-omega 3 cap 28-1-215.8 mg 4 ZATEAN-CH – prenatal w/o a w/fe cbn-dss-fa-dha cap 27-1-250 mg 4 ZATEAN-PN – prenatal vit w/ fe fum-methylfolate-fa tab 27-0.6-0.4 mg 4 92 MICRO-K – potassium chloride cap 4 cr 8 meq MICRO-K – potassium chloride cap 4 cr 10 meq 2 pot bicarbonate & chloride effer tab 25 meq 1 pot phos monobasic w/sod phos di & monobas tab 155-852-130mg (K-phos neutral) 1 potassium bicarbonate effer tab 25 meq Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Drug Name Specialty Drug Tier 2015 potassium chloride cap cr 10 meq (Micro-k) 1 ANIMI-3 – folic acid-vit b6-vit b12omega 3-phytosterols cap 1 mg 4 potassium chloride cap cr 8 meq (Micro-k) 1 5 • POTASSIUM CHLORIDE ER – potassium chloride tab cr 20 meq (1500 mg) 4 ARANESP ALBUMIN FREE – darbepoetin alfa-polysorbate 80 soln inj 25 mcg/ml 5 • potassium chloride microencapsulated crys cr tab 10 meq 1 ARANESP ALBUMIN FREE – darbepoetin alfa-polysorbate 80 soln inj 25 mcg/0.42ml 5 • potassium chloride microencapsulated crys cr tab 20 meq 1 ARANESP ALBUMIN FREE – darbepoetin alfa-polysorbate 80 soln inj 40 mcg/ml 5 • potassium chloride oral liq 10% (20 meq/15ml) 1 ARANESP ALBUMIN FREE – darbepoetin alfa-polysorbate 80 soln inj 40 mcg/0.4ml 5 • potassium chloride oral liq 20% (40 meq/15ml) 1 ARANESP ALBUMIN FREE – darbepoetin alfa-polysorbate 80 soln inj 60 mcg/ml potassium chloride powder packet 20 meq 1 5 • potassium chloride tab cr 10 meq (K-tab) 1 ARANESP ALBUMIN FREE – darbepoetin alfa-polysorbate 80 soln inj 60 mcg/0.3ml 5 • potassium chloride tab cr 8 meq (600 mg) 1 ARANESP ALBUMIN FREE – darbepoetin alfa-polysorbate 80 soln inj 100 mcg/ml 1 ARANESP ALBUMIN FREE – darbepoetin alfa-polysorbate 80 soln inj 100 mcg/0.5ml 5 SODIUM FLUORIDE – sodium fluoride tab 1 mg f (from 2.2 mg naf) • 1 ARANESP ALBUMIN FREE – darbepoetin alfa-polysorbate 80 soln inj 150 mcg/0.75ml 5 sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) (Luride) • 1 ARANESP ALBUMIN FREE – darbepoetin alfa-polysorbate 80 soln inj 150 mcg/0.3ml 5 sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) (Luride) • sodium fluoride chew tab 1 mg f (from 2.2 mg naf) (Luride) 1 5 • sodium fluoride soln 0.125 mg/ drop f (0.275 mg/drop naf) 2 ARANESP ALBUMIN FREE – darbepoetin alfa-polysorbate 80 soln inj 200 mcg/ml 5 • sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) (Luride) 1 ARANESP ALBUMIN FREE – darbepoetin alfa-polysorbate 80 soln inj 200 mcg/0.4ml zinc sulfate cap 220 mg (50 mg elemental zn) 1 ARANESP ALBUMIN FREE – darbepoetin alfa-polysorbate 80 soln inj 300 mcg/ml 5 • HEMATOLOGICAL AGENTS Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 HEMATOPOIETIC AGENTS Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 93 5 3 FOLTRATE – cobalamine combination tab 3 B-6 FOLIC ACID – cobalamine combination cap 2 GRANIX – tbo-filgrastim soln prefilled syringe 300 mcg/0.5ml 5 BP VIT 3 – folic acid-vit b6-vit b12omega 3-phytosterols cap 1 mg • 4 GRANIX – tbo-filgrastim soln prefilled syringe 480 mcg/0.8ml 5 CORVITE 150 – iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg • 4 cyanocobalamin inj 1000 mcg/ml 1 DROXIA – hydroxyurea cap 200 mg 3 • HEMATRON-AF – iron-docusateb12-folic acid-c-e-cu-biotin tab 150-1 mg 4 DROXIA – hydroxyurea cap 300 mg 3 • ICAR-C PLUS – iron-vit c-vit b12folic acid tab 100-250-0.025-1 mg 3 • iron-docusate-b12-folic acidc-e-cu-biotin tab 150-1 mg (Hematron-af) 1 DROXIA – hydroxyurea cap 400 mg EPOGEN – epoetin alfa inj 2000 unit/ml 5 • 1 EPOGEN – epoetin alfa inj 3000 unit/ml 5 • iron-folic acid-vit c-vit b6-vit b12zinc tab 150-1.25 mg (Corvite 150) EPOGEN – epoetin alfa inj 4000 unit/ml 5 EPOGEN – epoetin alfa inj 10000 unit/ml 5 EPOGEN – epoetin alfa inj 20000 unit/ml 5 fe fum-iron polysacch complexfa-b cmplx-c-zn-mn-cu cap (Tandem plus) 1 fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240 mg 1 fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1 mg 1 ferrous fumarate-folic acid tab 324-1 mg 1 FOLGARD RX – folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg 4 94 • • 1 folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg 1 folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg (Folgard rx) 1 1 iron-vit c-vit b12-folic acid tab 100-250-0.025-1 mg (Icar-c plus) 5 NEULASTA – pegfilgrastim inj 6 mg/0.6ml 5 NEULASTA DELIVERY KIT – pegfilgrastim inj 6 mg/0.6ml 5 NEUPOGEN – filgrastim inj 300 mcg/ml 5 NEUPOGEN – filgrastim inj 480 mcg/1.6ml (300 mcg/ml) 5 NEUPOGEN – filgrastim inj 300 mcg/0.5ml (600 mcg/ml) 5 NEUPOGEN – filgrastim inj 480 mcg/0.8ml (600 mcg/ml) 5 PROCRIT – epoetin alfa inj 2000 unit/ml 5 PROCRIT – epoetin alfa inj 3000 unit/ml • • • • • • • • Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits ARANESP ALBUMIN FREE – darbepoetin alfa-polysorbate 80 soln inj 500 mcg/ml • folic acid tab 1 mg Restricted Access • Prior Review 5 • Drug Name Specialty ARANESP ALBUMIN FREE – darbepoetin alfa-polysorbate 80 soln inj 300 mcg/0.6ml Drug Name Drug Tier Quantity Limits Specialty Restricted Access Drug Tier Prior Review 2015 2 PROCRIT – epoetin alfa inj 10000 unit/ml 5 • enoxaparin sodium inj 120 mg/0.8ml (Lovenox) 2 PROCRIT – epoetin alfa inj 20000 unit/ml 5 • enoxaparin sodium inj 150 mg/ ml (Lovenox) 2 PROCRIT – epoetin alfa inj 40000 unit/ml 5 • enoxaparin sodium inj 30 mg/0.3ml (Lovenox) 2 TANDEM PLUS – fe fum-iron polysacch complex-fa-b cmplx-czn-mn-cu cap 4 enoxaparin sodium inj 300 mg/3ml (Lovenox) 2 enoxaparin sodium inj 40 mg/0.4ml (Lovenox) 2 ANTICOAGULANTS ARIXTRA – fondaparinux sodium inj 2.5 mg/0.5ml 5 enoxaparin sodium inj 60 mg/0.6ml (Lovenox) 2 ARIXTRA – fondaparinux sodium inj 5 mg/0.4ml 5 enoxaparin sodium inj 80 mg/0.8ml (Lovenox) 2 ARIXTRA – fondaparinux sodium inj 7.5 mg/0.6ml 5 fondaparinux sodium inj 10 mg/0.8ml (Arixtra) 2 ARIXTRA – fondaparinux sodium inj 10 mg/0.8ml 5 fondaparinux sodium inj 2.5 mg/0.5ml (Arixtra) 2 COUMADIN – warfarin sodium tab 1 mg 4 fondaparinux sodium inj 5 mg/0.4ml (Arixtra) 2 COUMADIN – warfarin sodium tab 2 mg 4 fondaparinux sodium inj 7.5 mg/0.6ml (Arixtra) 2 COUMADIN – warfarin sodium tab 2.5 mg 4 HEPARIN SODIUM – heparin sodium (porcine) inj 2500 unit/ml 1 COUMADIN – warfarin sodium tab 3 mg 4 heparin sodium (porcine) inj 1000 unit/ml 1 COUMADIN – warfarin sodium tab 4 mg 4 heparin sodium (porcine) inj 10000 unit/ml 1 COUMADIN – warfarin sodium tab 5 mg 4 heparin sodium (porcine) inj 20000 unit/ml 1 COUMADIN – warfarin sodium tab 6 mg 4 heparin sodium (porcine) inj 5000 unit/ml 1 COUMADIN – warfarin sodium tab 7.5 mg 4 heparin sodium (porcine) pf inj 5000 unit/0.5ml 1 COUMADIN – warfarin sodium tab 10 mg 4 1 ELIQUIS – apixaban tab 2.5 mg 4 heparin sodium (porcine) 100 unit/ml in d5w (Heparin sodium/ d5w) ELIQUIS – apixaban tab 5 mg 4 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits enoxaparin sodium inj 100 mg/ ml (Lovenox) Restricted Access • Prior Review 5 Drug Name Specialty PROCRIT – epoetin alfa inj 4000 unit/ml Drug Name Drug Tier Quantity Limits Specialty Restricted Access Drug Tier Prior Review 2015 95 heparin sodium (porcine) 2 unit/ ml in sodium chloride 0.9% (Heparin sodium/sodiu) 1 warfarin sodium tab 10 mg (Coumadin) 1 heparin sodium (porcine) 40 unit/ml in d5w warfarin sodium tab 2 mg (Coumadin) 1 1 heparin sodium (porcine) 50 unit/ml in d5w (Heparin sodium/ d5w) warfarin sodium tab 2.5 mg (Coumadin) 1 1 warfarin sodium tab 3 mg (Coumadin) 1 warfarin sodium tab 4 mg (Coumadin) 1 warfarin sodium tab 5 mg (Coumadin) 1 warfarin sodium tab 6 mg (Coumadin) 1 warfarin sodium tab 7.5 mg (Coumadin) 1 HEPARIN SODIUM/D5W – heparin 4 sodium (porcine) 50 unit/ml in d5w HEPARIN SODIUM/D5W – heparin 4 sodium (porcine) 100 unit/ml in d5w 4 HEPARIN SODIUM/SODIUM CHL – heparin sodium (porcine) 2 unit/ml in sodium chloride 0.9% LOVENOX – enoxaparin sodium inj 4 30 mg/0.3ml LOVENOX – enoxaparin sodium inj 4 40 mg/0.4ml LOVENOX – enoxaparin sodium inj 4 60 mg/0.6ml LOVENOX – enoxaparin sodium inj 4 80 mg/0.8ml LOVENOX – enoxaparin sodium inj 4 100 mg/ml LOVENOX – enoxaparin sodium inj 4 120 mg/0.8ml LOVENOX – enoxaparin sodium inj 4 150 mg/ml LOVENOX – enoxaparin sodium inj 4 300 mg/3ml 4 PRADAXA – dabigatran etexilate mesylate cap 75 mg (etexilate base eq) 4 PRADAXA – dabigatran etexilate mesylate cap 150 mg (etexilate base eq) 1 warfarin sodium tab 1 mg (Coumadin) 96 XARELTO – rivaroxaban tab 10 mg 3 XARELTO – rivaroxaban tab 15 mg 3 XARELTO – rivaroxaban tab 20 mg 3 3 XARELTO STARTER PACK – rivaroxaban tab starter therapy pack 15 mg & 20 mg HEMOSTATICS AMICAR – aminocaproic acid tab 500 mg 4 AMICAR – aminocaproic acid tab 1000 mg 4 AMICAR – aminocaproic acid syrup 25% 4 AMINOCAPROIC ACID – aminocaproic acid tab 1000 mg 4 aminocaproic acid syrup 25% (Amicar) 2 aminocaproic acid tab 500 mg (Amicar) 2 tranexamic acid tab 650 mg (Lysteda) 2 HEMATOLOGICAL AGENTS - MISC. Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Drug Name Specialty Drug Tier 2015 4 AGRYLIN – anagrelide hcl cap 0.5 mg 4 anagrelide hcl cap 0.5 mg (Agrylin) 1 anagrelide hcl cap 1 mg 1 BRILINTA – ticagrelor tab 90 mg 4 cilostazol tab 100 mg (Pletal) 1 cilostazol tab 50 mg (Pletal) 1 clopidogrel bisulfate tab 300 mg (base equiv) (Plavix) 1 clopidogrel bisulfate tab 75 mg (base equiv) (Plavix) 1 dipyridamole tab 25 mg (Persantine) 1 dipyridamole tab 50 mg (Persantine) 1 dipyridamole tab 75 mg (Persantine) 1 EFFIENT – prasugrel hcl tab 5 mg (base equiv) 4 1 Quantity Limits ticlopidine hcl tab 250 mg Restricted Access 4 Prior Review PLETAL – cilostazol tab 100 mg Specialty Quantity Limits Restricted Access Prior Review Drug Name Drug Tier AGGRENOX – aspirindipyridamole cap sr 12hr 25-200 mg Specialty Drug Name Drug Tier 2015 TOPICAL PRODUCTS OPHTHALMIC AGENTS EFFIENT – prasugrel hcl tab 10 mg 4 (base equiv) FIRAZYR – icatibant acetate inj 30 5 mg/3ml (base equivalent) 1 pentoxifylline tab cr 400 mg • • ACULAR – ketorolac tromethamine 4 ophth soln 0.5% 4 ACULAR LS – ketorolac tromethamine ophth soln 0.4% ALCAINE – proparacaine hcl ophth 4 soln 0.5% 4 ALPHAGAN P – brimonidine tartrate ophth soln 0.1% 4 ALPHAGAN P – brimonidine tartrate ophth soln 0.15% 2 apraclonidine hcl ophth soln 0.5% (base equivalent) (Iopidine) 1 atropine sulfate ophth soln 1% (Isopto atropine) 2 azelastine hcl ophth soln 0.05% (Optivar) 1 BACITRACIN – bacitracin ophth oint 500 unit/gm 1 bacitracin-polymyxin b ophth oint 1 bacitracin-polymyxin-neomycinhc ophth oint 1% BETAGAN – levobunolol hcl ophth 4 soln 0.5% 1 betaxolol hcl ophth soln 0.5% PERSANTINE – dipyridamole tab 25 mg 4 PERSANTINE – dipyridamole tab 50 mg 4 BLEPH-10 – sulfacetamide sodium ophth soln 10% 4 PERSANTINE – dipyridamole tab 75 mg 4 brimonidine tartrate ophth soln 0.15% (Alphagan p) 2 PLAVIX – clopidogrel bisulfate tab 75 mg (base equiv) 4 brimonidine tartrate ophth soln 0.2% 1 PLAVIX – clopidogrel bisulfate tab 300 mg (base equiv) 4 carteolol hcl ophth soln 1% 1 PLETAL – cilostazol tab 50 mg CELLUGEL – hypromellose intraocular soln 2% 4 4 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 97 CILOXAN – ciprofloxacin hcl ophth soln 0.3% 4 FML LIQUIFILM – fluorometholone ophth susp 0.1% 4 ciprofloxacin hcl ophth soln 0.3% (Ciloxan) 1 GARAMYCIN – gentamicin sulfate ophth soln 0.3% 4 COMBIGAN – brimonidine tartratetimolol maleate ophth soln 0.2-0.5% 4 gatifloxacin ophth soln 0.5% (Zymaxid) 2 4 gentamicin sulfate ophth oint 0.3% 1 COSOPT – dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ ml gentamicin sulfate ophth soln 0.3% (Garamycin) 1 cromolyn sodium ophth soln 4% 1 CYCLOGYL – cyclopentolate hcl ophth soln 1% homatropine hbr ophth soln 5% (Isopto homatropine) 1 4 CYCLOGYL – cyclopentolate hcl ophth soln 2% hypromellose intraocular soln 2% (Cellugel) 1 4 4 cyclopentolate hcl ophth soln 1% (Cyclogyl) 1 IOPIDINE – apraclonidine hcl ophth soln 0.5% (base equivalent) cyclopentolate hcl ophth soln 2% (Cyclogyl) 2 ISOPTO ATROPINE – atropine sulfate ophth soln 1% 4 CYSTARAN – cysteamine hcl ophth soln 0.44% (base equivalent) 4 ISOPTO CARPINE – pilocarpine hcl ophth soln 1% 4 dexamethasone sodium phosphate ophth soln 0.1% ISOPTO CARPINE – pilocarpine hcl ophth soln 2% 4 1 diclofenac sodium ophth soln 0.1% ISOPTO CARPINE – pilocarpine hcl ophth soln 4% 4 1 1 ISOPTO HOMATROPINE – homatropine hbr ophth soln 5% 4 dorzolamide hcl ophth soln 2% (Trusopt) 1 ISOPTO HYOSCINE – scopolamine hbr ophth soln 0.25% 3 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml (Cosopt) ELESTAT – epinastine hcl ophth soln 0.05% ketorolac tromethamine ophth soln 0.4% (Acular ls) 1 4 epinastine hcl ophth soln 0.05% (Elestat) ketorolac tromethamine ophth soln 0.5% (Acular) 1 2 1 latanoprost ophth soln 0.005% (Xalatan) 1 erythromycin ophth oint 5 mg/ gm 1 LEVOBUNOLOL HCL – levobunolol hcl ophth soln 0.25% 1 fluorometholone ophth susp 0.1% (Fml liquifilm) flurbiprofen sodium ophth soln 0.03% (Ocufen) levobunolol hcl ophth soln 0.5% (Betagan) 1 1 98 • Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Drug Name Specialty Drug Tier 2015 MAXITROL – neomycin-polymyxin- 4 dexamethasone ophth susp 0.1% MAXITROL – neomycin-polymyxin- 4 dexamethasone ophth oint 0.1% 2 METIPRANOLOL – metipranolol ophth soln 0.3% 4 MYDRIACYL – tropicamide ophth soln 1% 1 NAPHAZOLINE HCL – naphazoline hcl ophth soln 0.1% 1 neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin 1 neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-untmg/ml (Neosporin) 1 neomycin-polymyxindexamethasone ophth oint 0.1% (Maxitrol) 1 neomycin-polymyxindexamethasone ophth susp 0.1% (Maxitrol) 1 NEOMYCIN/POLYMYXIN/ HYDROC – neomycin-polymyxinhc ophth susp 4 NEOSPORIN – neomycinpolymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml 4 OCUFEN – flurbiprofen sodium ophth soln 0.03% 4 OCUFLOX – ofloxacin ophth soln 0.3% 1 ofloxacin ophth soln 0.3% (Ocuflox) 4 OMNIPRED – prednisolone acetate ophth susp 1% 2 phenylephrine hcl ophth soln 10% • • phenylephrine hcl ophth soln 2.5% 2 pilocarpine hcl ophth soln 1% (Isopto carpine) 1 pilocarpine hcl ophth soln 2% (Isopto carpine) 1 pilocarpine hcl ophth soln 4% (Isopto carpine) 1 polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% (Polytrim) 1 POLYTRIM – polymyxin btrimethoprim ophth soln 10000 unit/ml-0.1% 4 PRED FORTE – prednisolone acetate ophth susp 1% 4 PRED MILD – prednisolone acetate ophth susp 0.12% 3 PRED-G – gentamicinprednisolone ace ophth susp 0.3-1% 2 prednisolone acetate ophth susp 1% (Pred forte) 1 PREDNISOLONE SODIUM PHOSP – prednisolone sodium phosphate ophth soln 1% 1 proparacaine hcl ophth soln 0.5% (Alcaine) 1 SIMBRINZA – brinzolamidebrimonidine tartrate ophth susp 1-0.2% 3 SULFACETAMIDE SODIUM – sulfacetamide sodium ophth oint 10% 2 sulfacetamide sodium ophth soln 10% (Bleph-10) 2 sulfacetamide sodiumprednisolone ophth soln 10-0.23(0.25)% 1 tetracaine hcl ophth soln 0.5% 1 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 3 Quantity Limits LOTEMAX – loteprednol etabonate ophth gel 0.5% Restricted Access 2 Prior Review levofloxacin ophth soln 0.5% Specialty Drug Name Drug Tier 2015 • • 99 timolol maleate ophth gel forming soln 0.25% (Timopticxe) 1 timolol maleate ophth gel forming soln 0.5% (Timoptic-xe) 1 timolol maleate ophth soln 0.25% (Timoptic) 1 timolol maleate ophth soln 0.5% (Timoptic) 1 TIMOPTIC – timolol maleate ophth soln 0.25% 4 TIMOPTIC – timolol maleate ophth soln 0.5% 4 TIMOPTIC-XE – timolol maleate ophth gel forming soln 0.25% 4 TIMOPTIC-XE – timolol maleate ophth gel forming soln 0.5% 4 TOBRADEX – tobramycindexamethasone ophth susp 0.3-0.1% tobramycin ophth soln 0.3% (Tobrex) 4 ZYMAXID – gatifloxacin ophth soln 0.5% 4 1 ACETIC ACID/ALUMINUM ACET – acetic acid 2% in aluminum acetate otic soln 2 antipyrine-benzocaine otic soln 54-14 mg/ml (5.4-1.4%) 1 antipyrine-benzocainepolycosanol otic sol 5.4-1.4-0.0097% (Treagan otic) 2 ANTIPYRINE/BENZOCAINE – antipyrine-benzocaine otic soln 55-14 mg/ml (5.5-1.4%) 2 4 AURALGAN – antipyrinebenzocaine otic soln 55-14 mg/ ml (5.5-1.4%) 4 1 CETRAXAL – ciprofloxacin hcl otic soln 0.2% (base equivalent) 4 CIPROFLOXACIN – ciprofloxacin hcl otic soln 0.2% (base equivalent) 4 CORTANE-B AQUEOUS – pramoxine-hc-chloroxylenol aqueous otic soln 10-10-1 mg/ml 4 CORTANE-B-OTIC – pramoxinehc-chloroxylenol otic soln 10-10-1 mg/ml 4 CORTISPORIN – neomycinpolymyxin-hc otic soln 1% 4 DERMOTIC – fluocinolone acetonide (otic) oil 0.01% 4 fluocinolone acetonide (otic) oil 0.01% (Dermotic) 1 neomycin-polymyxin-hc otic soln 1% (Cortisporin) 1 2 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Quantity Limits Restricted Access Drug Tier XALATAN – latanoprost ophth soln 0.005% acetic acid otic soln 2% TRUSOPT – dorzolamide hcl ophth 4 soln 2% VIGAMOX – moxifloxacin hcl ophth 4 soln 0.5% (base equiv) 4 VIROPTIC – trifluridine ophth soln 1% 100 Drug Name OTIC AGENTS 2 tobramycin-dexamethasone ophth susp 0.3-0.1% (Tobradex) 4 TOBREX – tobramycin sulfate ophth soln 0.3% TRAVOPROST – travoprost ophth 4 soln 0.004% 2 trifluridine ophth soln 1% (Viroptic) 2 tropicamide ophth soln 0.5% tropicamide ophth soln 1% (Mydriacyl) Prior Review Drug Name Specialty Drug Tier 2015 neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ ml-1% 1 ofloxacin otic soln 0.3% 1 OTICIN HC NR – pramoxine-hcchloroxylenol otic soln 10-10-1 mg/ml 4 PRAMOTIC – pramoxinechloroxylenol otic liquid 1-0.1% 4 pramoxine-chloroxylenol otic liquid 1-0.1% (Pramotic) PREVIDENT FLUORIDE – sodium fluoride gel 1.1% (0.5% f) 4 PREVIDENT 5000 BOOSTER – sodium fluoride paste 1.1% 4 PREVIDENT 5000 DRY MOUTH – sodium fluoride gel 1.1% (0.5% f) 4 PREVIDENT 5000 ENAMEL PRO – sodium fluoride-potassium nitrate paste 1.1-5% 4 2 PREVIDENT 5000 PLUS – sodium fluoride cream 1.1% 4 pramoxine-hc-chloroxylenol aqueous otic soln 10-10-1 mg/ ml (Cortane-b aqueous) 1 PREVIDENT 5000 SENSITIVE – sodium fluoride-potassium nitrate paste 1.1-5% 4 pramoxine-hc-chloroxylenol otic soln 10-10-1 mg/ml (Cortane-botic) 1 SALAGEN – pilocarpine hcl tab 5 mg 4 4 SALAGEN – pilocarpine hcl tab 7.5 mg 4 TREAGAN OTIC – antipyrinebenzocaine-polycosanol otic sol 5.4-1.4-0.0097% sodium fluoride cream 1.1% (Prevident 5000 plus) 1 sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride) 1 sodium fluoride paste 1.1% (Prevident 5000 boost) 1 MOUTH/THROAT/DENTAL AGENTS 1 chlorhexidine gluconate soln 0.12% (Peridex) 1 clotrimazole troche 10 mg GEL-KAM ORAL CARE RINSE – stannous fluoride conc 0.63% 4 sodium fluoride rinse 0.2% (Prevident) 1 lidocaine hcl laryngotracheal soln 4% (Lta 360 kit) 1 1 lidocaine hcl viscous soln 2% 1 sodium fluoride-potassium nitrate paste 1.1-5% (Prevident 5000 sensi) NUMOISYN – artificial saliva lozenge 4 stannous fluoride conc 0.63% (Gel-kam oral care ri) 1 nystatin susp 100000 unit/ml 1 4 PERIDEX – chlorhexidine gluconate soln 0.12% 4 THERA-FLUR-N – sodium fluoride gel 1.1% (0.5% f) 1 pilocarpine hcl tab 5 mg (Salagen) 2 triamcinolone acetonide dental paste 0.1% pilocarpine hcl tab 7.5 mg (Salagen) 2 PREVIDENT – sodium fluoride rinse 0.2% 4 Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 ANORECTAL AGENTS ANALPRAM E – hc-pramoxine emol cream 2.5-1% & pramoxine wipe 1% kit Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 4 101 ANALPRAM-HC – hydrocortisone acetate w/ pramoxine rectal cream 1-1% 4 ANALPRAM-HC – hydrocortisone acetate w/ pramoxine rectal cream 2.5-1% 4 ANALPRAM-HC SINGLES – hydrocortisone acetate w/ pramoxine rectal cream 1-1% 4 ANALPRAM-HC SINGLES – hydrocortisone acetate w/ pramoxine rectal cream 2.5-1% 4 ANUSOL-HC – hydrocortisone rectal cream 2.5% 4 ANUSOL-HC – hydrocortisone acetate suppos 25 mg 4 CORTENEMA – hydrocortisone enema 100 mg/60ml 4 CORTIFOAM – hydrocortisone acetate rectal foam 90 mg/dose 3 hc-pramoxine emol cream 2.5-1% & pramoxine wipe 1% kit (Analpram e) 2 hydrocortisone acetate suppos 25 mg (Anusol-hc) 1 hydrocortisone acetate suppos 30 mg (Proctocort) lidocaine-hydrocortisone acetate rectal cream kit 3-1% 2 lidocaine-hydrocortisone acetate rectal cream 3-0.5% 2 lidocaine-hydrocortisone acetate rectal gel kit 3-2.5% 2 PROCTOCORT – hydrocortisone rectal cream 1% 4 PROCTOCORT – hydrocortisone acetate suppos 30 mg 4 PROCTOFOAM HC – hydrocortisone acetate w/ pramoxine rectal foam 1-1% 3 2 acitretin cap 17.5 mg (Soriatane) 2 acitretin cap 25 mg (Soriatane) 2 ACLOVATE – alclometasone dipropionate cream 0.05% 4 acyclovir oint 5% (Zovirax) 2 ACZONE – dapsone gel 5% 4 adapalene cream 0.1% (Differin) 2 adapalene gel 0.1% (Differin) 2 1 adapalene gel 0.3% (Differin) 2 1 hydrocortisone acetate w/ pramoxine rectal cream 1-1% (Analpram-hc) 2 alclometasone dipropionate cream 0.05% (Aclovate) alclometasone dipropionate oint 0.05% 1 hydrocortisone acetate w/ pramoxine rectal cream 2.5-1% (Analpram-hc) 2 ALDARA – imiquimod cream 5% 4 1 hydrocortisone enema 100 mg/60ml (Cortenema) 2 aluminum chloride soln 20% (Drysol) ALUVEA – urea cream 39% 4 hydrocortisone rectal cream 1% (Proctocort) 1 hydrocortisone rectal cream 2.5% (Anusol-hc) 1 lidocaine-hydrocortisone acetate rectal cream kit 3-0.5% 2 • • AMCINONIDE – amcinonide cream 2 0.1% AMCINONIDE – amcinonide lotion 2 0.1% 2 AMCINONIDE – amcinonide oint 0.1% • • • • • • • Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review • • DERMATOLOGICALS acitretin cap 10 mg (Soriatane) 102 Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Drug Name Specialty Drug Tier 2015 ARZOL SILVER NITRATE APP – silver nitrate-potassium nitrate applicator 75-25% 4 BACTROBAN – mupirocin oint 2% 4 BACTROBAN – mupirocin calcium cream 2% 4 BENZAC AC WASH – benzoyl peroxide liq 5% betamethasone dipropionate augmented gel 0.05% 2 betamethasone dipropionate augmented lotion 0.05% (Diprolene) 2 2 4 betamethasone dipropionate augmented oint 0.05% (Diprolene) BENZAC W WASH – benzoyl peroxide liq 5% 4 betamethasone dipropionate cream 0.05% 2 BENZACLIN – clindamycin phosphate-benzoyl peroxide gel 1-5% 4 betamethasone dipropionate lotion 0.05% 2 2 BENZACLIN WITH PUMP – clindamycin phosphate-benzoyl peroxide gel 1-5% 4 betamethasone dipropionate oint 0.05% betamethasone valerate aerosol foam 0.12% (Luxiq) 2 BENZAMYCIN – benzoyl peroxideerythromycin gel 5-3% 4 betamethasone valerate cream 0.1% 1 BENZEFOAM – benzoyl peroxide foam 5.3% 4 betamethasone valerate lotion 0.1% 1 BENZEFOAMULTRA – benzoyl peroxide foam 9.8% 4 betamethasone valerate oint 0.1% 1 benzoyl peroxide creamy wash 4% & cleanser lotion kit 2 BPO 3% FOAMING CLOTHS – benzoyl peroxide cloth 3% 2 • • benzoyl peroxide creamy wash 8% & cleanser lotion kit 2 BPO 6% FOAMING CLOTHS – benzoyl peroxide cloth 6% 2 • • benzoyl peroxide foam 5.3% (Benzefoam) 2 BPO 9% FOAMING CLOTHS – benzoyl peroxide cloth 9% 2 • • benzoyl peroxide foam 9.8% (Benzefoamultra) 2 calcipotriene cream 0.005% (Dovonex) 2 benzoyl peroxide gel 10% 2 calcipotriene oint 0.005% 2 benzoyl peroxide liq 2.5% 2 2 benzoyl peroxide liq 7% 2 calcipotriene soln 0.005% (50 mcg/ml) benzoyl peroxide lotion 6% 2 2 benzoyl peroxideerythromycin gel 5-3% (Benzamycin) 2 calcipotriene-betamethasone dipropionate oint 0.005-0.064% (Taclonex) 4 betamethasone dipropionate augmented cream 0.05% (Diprolene af) 2 CALCITRIOL – calcitriol oint 3 mcg/gm CENTANY – mupirocin oint 2% 1 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 • • 103 CICLODAN SOLUTION KIT – ciclopirox solution kit 8% 4 clobetasol propionate cream 0.05% (Temovate) ciclopirox gel 0.77% 2 ciclopirox olamine cream 0.77% (base equiv) 2 ciclopirox olamine susp 0.77% (base equiv) 2 ciclopirox shampoo 1% (Loprox shampoo) 2 ciclopirox solution kit 8% (Ciclodan solution ki) 2 ciclopirox solution 8% (Penlac Nail Lacquer) 2 CLARAVIS – isotretinoin cap 30 mg 2 CLARIFOAM EF – sulfacetamide sodium w/ sulfur foam 10-5% 4 CLEOCIN-T – clindamycin phosphate soln 1% 4 CLEOCIN-T – clindamycin phosphate gel 1% 4 CLEOCIN-T – clindamycin phosphate lotion 1% 4 CLEOCIN-T – clindamycin phosphate swab 1% 4 clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% (Duac) 2 clindamycin phosphate foam 1% (Evoclin) 2 clindamycin phosphate gel 1% (Cleocin-t) 1 1 clobetasol propionate emollient base cream 0.05% (Temovate e) 2 clobetasol propionate emulsion foam 0.05% (Olux-e) 2 clobetasol propionate foam 0.05% (Olux) 1 clobetasol propionate gel 0.05% (Temovate) 2 clobetasol propionate lotion 0.05% (Clobex) clobetasol propionate oint 0.05% 1 (Temovate) 2 clobetasol propionate shampoo 0.05% (Clobex) 1 clobetasol propionate soln 0.05% (Temovate) 2 clobetasol propionate spray 0.05% (Clobex) 4 CLOBEX – clobetasol propionate spray 0.05% 4 CLOBEX – clobetasol propionate lotion 0.05% 4 CLOBEX – clobetasol propionate shampoo 0.05% 2 clotrimazole w/ betamethasone cream 1-0.05% (Lotrisone) 2 clotrimazole w/ betamethasone lotion 1-0.05% CONDYLOX – podofilox soln 0.5% 4 clindamycin phosphate lotion 1% (Cleocin-t) CUTIVATE – fluticasone propionate cream 0.05% 4 1 4 clindamycin phosphate soln 1% (Cleocin-t) 1 CUTIVATE – fluticasone propionate lotion 0.05% DENAVIR – penciclovir cream 1% 4 clindamycin phosphate swab 1% (Cleocin-t) 1 4 clindamycin phosphate-benzoyl peroxide gel 1-5% (Benzaclin) 2 DERMA-SMOOTHE/FS BODY – fluocinolone acetonide oil 0.01% (body oil) 104 1 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Drug Name Specialty Drug Tier 2015 DERMA-SMOOTHE/FS BODY OIL – fluocinolone acetonide oil 0.01% (body oil) 4 DIPROLENE – betamethasone dipropionate augmented oint 0.05% 4 DERMA-SMOOTHE/FS SCALP – fluocinolone acetonide oil 0.01% (scalp oil) 4 DIPROLENE AF – betamethasone dipropionate augmented cream 0.05% 4 DERMA-SMOOTHE/FS SCALP OI – fluocinolone acetonide oil 0.01% (scalp oil) 4 DOVONEX – calcipotriene cream 0.005% 4 4 DRYSOL – aluminum chloride soln 20% 4 DERMATOP – prednicarbate cream 0.1% DERMATOP – prednicarbate oint 0.1% DUAC – clindamycin phosphbenzoyl peroxide (refrig) gel 1.2 (1)-5% 4 4 desonide cream 0.05% (Desowen) 1 econazole nitrate cream 1% 1 EFUDEX – fluorouracil cream 5% 4 ELOCON – mometasone furoate solution 0.1% (lotion) 4 desonide lotion 0.05% (Desowen) 2 1 desonide oint 0.05% (Desowen) DESOWEN – desonide cream 0.05% 4 ELOCON – mometasone furoate cream 0.1% 4 DESOWEN – desonide lotion 0.05% 4 ELOCON – mometasone furoate oint 0.1% 4 DESOWEN – desonide oint 0.05% 4 erythromycin pads 2% 2 DESOXIMETASONE – desoximetasone cream 0.05% 2 erythromycin soln 2% 1 EURAX – crotamiton cream 10% 4 desoximetasone cream 0.25% (Topicort) 2 EURAX – crotamiton lotion 10% 4 desoximetasone gel 0.05% (Topicort) 2 desoximetasone oint 0.25% (Topicort) 2 DIFFERIN – adapalene cream 0.1% 4 DIFFERIN – adapalene gel 0.1% 4 DIFLORASONE DIACETATE – diflorasone diacetate cream 0.05% 2 diflorasone diacetate oint 0.05% 2 DIPROLENE – betamethasone dipropionate augmented lotion 0.05% 4 Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 EVOCLIN – clindamycin phosphate 4 foam 1% 4 EXTINA – ketoconazole foam 2% FINACEA – azelaic acid gel 15% 4 • • fluocinolone acetonide cream 0.01% 1 • • fluocinolone acetonide cream 0.025% (Synalar) 1 fluocinolone acetonide oil 0.01% (body oil) (Derma-smoothe/fs bod) 1 fluocinolone acetonide oil 0.01% (scalp oil) (Derma-smoothe/fs sca) 1 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary • • 105 fluocinolone acetonide oint 0.025% (Synalar) 1 hydrocortisone butyrate soln 0.1% (Locoid) 2 fluocinolone acetonide soln 0.01% (Synalar) 1 hydrocortisone cream 1% 1 hydrocortisone cream 2.5% 1 fluocinonide cream 0.05% 1 hydrocortisone lotion 2.5% 2 fluocinonide cream 0.1% (Vanos) 1 1 hydrocortisone valerate cream 0.2% 2 fluocinonide emulsified base cream 0.05% 1 hydrocortisone valerate oint 0.2% (Westcort) 2 fluocinonide gel 0.05% fluocinonide oint 0.05% 1 imiquimod cream 5% (Aldara) 2 fluocinonide soln 0.05% 1 iodoquinol-hc cream 1% 1 fluorouracil cream 5% (Efudex) 2 isotretinoin cap 10 mg 2 fluorouracil soln 2% 2 isotretinoin cap 20 mg 2 fluorouracil soln 5% 2 isotretinoin cap 40 mg 2 fluticasone propionate cream 0.05% (Cutivate) 1 KERALYT – salicylic acid gel 6% 4 ketoconazole cream 2% 1 fluticasone propionate lotion 0.05% (Cutivate) 1 ketoconazole foam 2% (Extina) 2 1 ketoconazole shampoo 2% (Nizoral) 1 fluticasone propionate oint 0.005% (Cutivate) 1 KLARON – sulfacetamide sodium lotion 10% (acne) 4 GENTAMICIN SULFATE – gentamicin sulfate cream 0.1% 1 LAC-HYDRIN – lactic acid (ammonium lactate) cream 12% 4 GENTAMICIN SULFATE – gentamicin sulfate oint 0.1% 4 LAC-HYDRIN – lactic acid (ammonium lactate) lotion 12% 4 GRANULEX – trypsin w/ castor oil & peruvian balsam spray 2 lactic acid (ammonium lactate) cream 12% (Lac-hydrin) 2 halobetasol prop oint 0.05% & ammonium lactate lot 12% kit 2 lactic acid (ammonium lactate) lotion 10% 2 halobetasol propionate cream 0.05% (Ultravate) 2 lactic acid (ammonium lactate) lotion 12% (Lac-hydrin) 2 halobetasol propionate oint 0.05% (Ultravate) 4 lactic acid w/ vitamin e cream 10%-3500 unit/30gm 2 HYDRO 35 – urea in lactic acid vehicle foam 35% 2 lidocaine hcl cream 3% 2 hydrocortisone butyrate cream 0.1% (Locoid) lidocaine hcl gel 2% 1 hydrocortisone butyrate oint 0.1% (Locoid) 2 lidocaine hcl soln 4% (Xylocaine) 1 lidocaine oint 5% 1 lidocaine patch 5% (Lidoderm) 2 106 • Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Drug Name Specialty Drug Tier 2015 • 4 LIDODERM – lidocaine patch 5% lindane lotion 1% 2 nystatin cream 100000 unit/gm 1 lindane shampoo 1% 2 nystatin oint 100000 unit/gm 1 LOCOID – hydrocortisone butyrate soln 0.1% 4 nystatin topical powder 1 4 nystatin-triamcinolone cream 100000-0.1 unit/gm-% 1 LOCOID – hydrocortisone butyrate cream 0.1% LOCOID – hydrocortisone butyrate oint 0.1% nystatin-triamcinolone oint 100000-0.1 unit/gm-% 1 4 LOPROX SHAMPOO – ciclopirox shampoo 1% OLUX – clobetasol propionate foam 0.05% 4 4 LOTRISONE – clotrimazole w/ betamethasone cream 1-0.05% OLUX-E – clobetasol propionate emulsion foam 0.05% 4 4 2 OVACE PLUS WASH – sulfacetamide sodium liquid 10% 4 mafenide acetate packet for topical soln 5% (50 gm) (Sulfamylon) OVACE WASH – sulfacetamide sodium liquid 10% 4 malathion lotion 0.5% (Ovide) 2 OVIDE – malathion lotion 0.5% 4 METROCREAM – metronidazole cream 0.75% 4 PENLAC NAIL LACQUER – ciclopirox solution 8% 4 METROGEL – metronidazole gel 1% 4 permethrin cream 5% (Elimite) 2 4 podofilox soln 0.5% (Condylox) 2 METROLOTION – metronidazole lotion 0.75% 4 metronidazole cream 0.75% (Metrocream) 2 PRAMOSONE – pramoxine-hc cream 1-1% 4 metronidazole gel 0.75% 2 PRAMOSONE – pramoxine-hc cream 1-2.5% 2 pramoxine-hc cream 1-2.5% (Pramosone) 2 metronidazole gel 1% (Metrogel) metronidazole lotion 0.75% (Metrolotion) 2 prednicarbate cream 0.1% (Dermatop) 1 mometasone furoate cream 0.1% (Elocon) 1 prednicarbate oint 0.1% (Dermatop) 1 mometasone furoate oint 0.1% (Elocon) 1 PROTOPIC – tacrolimus oint 0.03% 4 mometasone furoate solution 0.1% (lotion) (Elocon) 1 PROTOPIC – tacrolimus oint 0.1% 4 2 RETIN-A – tretinoin cream 0.025% 4 mupirocin calcium cream 2% (Bactroban) RETIN-A – tretinoin cream 0.05% 4 • • Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits NIZORAL – ketoconazole shampoo 2% 4 Restricted Access 1 1 Prior Review mupirocin oint 2% (Bactroban) lidocaine-prilocaine cream 2.5-2.5% (Emla) Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 • • • • 107 Quantity Limits Restricted Access SALEX – salicylic acid shampoo 6% Prior Review 4 Specialty RETIN-A – tretinoin gel 0.025% Drug Name Drug Tier 4 • • • • • • Quantity Limits RETIN-A – tretinoin gel 0.01% Restricted Access 4 Prior Review RETIN-A – tretinoin cream 0.1% Specialty Drug Name Drug Tier 2015 SORIATANE – acitretin cap 17.5 mg 4 SORIATANE – acitretin cap 25 mg 4 4 STELARA – ustekinumab soln prefilled syringe 45 mg/0.5ml 5 • • • SALEX CREAM – salicylic acid cream 6% & cleanser liqd kit 4 STELARA – ustekinumab soln prefilled syringe 90 mg/ml 5 • • • SALEX LOTION – salicylic acid lotion 6% & cleanser liqd kit 4 sulfacetamide sodium liquid 10% (Ovace wash) 2 SALICYLIC ACID – salicylic acid soln 26% 2 sulfacetamide sodium lotion 10% (acne) (Klaron) 2 salicylic acid cream 6% 2 2 salicylic acid cream 6% & cleanser liqd kit (Salex cream) 2 sulfacetamide sodium w/ sulfur cleansing pad 10-4% (Sumaxin) 2 salicylic acid film forming liquid 27.5% (Virasal) 2 sulfacetamide sodium w/ sulfur cream 10-5% 2 salicylic acid foam 6% (Salvax) 2 sulfacetamide sodium w/ sulfur emulsion 10-1% 2 sulfacetamide sodium w/ sulfur emulsion 10-5% 2 salicylic acid gel 6% (Keralyt) salicylic acid lotion 6% 2 salicylic acid lotion 6% & cleanser liqd kit (Salex lotion) sulfacetamide sodium w/ sulfur foam 10-5% (Clarifoam ef) 2 2 salicylic acid shampoo 6% (Salex) sulfacetamide sodium w/ sulfur lotion 10-5% 2 2 2 SALVAX – salicylic acid foam 6% 4 sulfacetamide sodium w/ sulfur susp 8-4% (Sumaxin ts) SELENIUM SULFIDE – selenium sulfide-pyrithione zinc in urea shampoo 2.25% 1 sulfacetamide sodium w/ sulfur wash 9-4.5% (Sumadan wash) 2 selenium sulfide lotion 2.5% sulfacetamide sodium w/ sulfur wash 9-4% (Sumaxin wash) 2 1 SILVADENE – silver sulfadiazine cream 1% 4 sulfacetamide sodium-sulfur in urea emulsion 10-4% 2 silver nitrate-potassium nitrate applicator 75-25% (Arzol silver nitrate) 2 sulfacetamide sodium-sulfur w/ sunscreens cream 10-5% 2 4 silver sulfadiazine cream 1% (Silvadene) 1 SULFAMYLON – mafenide acetate packet for topical soln 5% (50 gm) sodium thiosulfate-salicylic acid lotion 25-1% 2 SUMADAN WASH – sulfacetamide sodium w/ sulfur wash 9-4.5% 4 SORIATANE – acitretin cap 10 mg 4 SUMAXIN – sulfacetamide sodium w/ sulfur cleansing pad 10-4% 4 108 • • Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary SUMAXIN TS – sulfacetamide sodium w/ sulfur susp 8-4% 4 TOPICORT – desoximetasone oint 0.25% 4 SUMAXIN WASH – sulfacetamide sodium w/ sulfur wash 9-4% 4 tretinoin cream 0.025% (Retin-a) 2 tretinoin cream 0.05% (Retin-a) 2 SYNALAR – fluocinolone acetonide cream 0.025% 4 tretinoin cream 0.1% (Retin-a) 2 4 tretinoin gel 0.01% (Retin-a) 2 SYNALAR – fluocinolone acetonide oint 0.025% tretinoin gel 0.025% (Retin-a) 2 TACLONEX – calcipotrienebetamethasone dipropionate susp 0.005-0.064% 4 TRIAMCINOLONE ACETONIDE – triamcinolone acetonide oint 0.5% 1 TACLONEX – calcipotrienebetamethasone dipropionate oint 0.005-0.064% 4 triamcinolone acetonide cream 0.025% 1 1 tacrolimus oint 0.03% (Protopic) 2 triamcinolone acetonide cream 0.1% tacrolimus oint 0.1% (Protopic) 2 1 TARGRETIN – bexarotene gel 1% 5 4 triamcinolone acetonide lotion 0.025% 1 TAZORAC – tazarotene cream 0.05% • • • • triamcinolone acetonide cream 0.5% 4 • • triamcinolone acetonide lotion 0.1% 1 TAZORAC – tazarotene cream 0.1% 4 triamcinolone acetonide oint 0.025% TAZORAC – tazarotene gel 0.1% 4 • • • • 1 TAZORAC – tazarotene gel 0.05% TEMOVATE – clobetasol propionate soln 0.05% triamcinolone acetonide oint 0.1% 1 4 4 TRIANEX – triamcinolone acetonide oint 0.05% 4 TEMOVATE – clobetasol propionate cream 0.05% TEMOVATE – clobetasol propionate gel 0.05% trypsin w/ castor oil & peruvian balsam oint (Xenaderm) 1 4 TEMOVATE – clobetasol propionate oint 0.05% trypsin w/ castor oil & peruvian balsam spray (Granulex) 1 4 TEMOVATE E – clobetasol propionate emollient base cream 0.05% ULTRAVATE – halobetasol propionate cream 0.05% 4 4 ULTRAVATE – halobetasol propionate oint 0.05% 4 TOPICORT – desoximetasone cream 0.05% 2 URAMAXIN – urea cream 45% 4 4 URAMAXIN – urea gel 45% 4 TOPICORT – desoximetasone cream 0.25% URAMAXIN – urea lotion 45% 4 TOPICORT – desoximetasone gel 0.05% 4 urea cream 39% (Aluvea) 2 urea cream 40% 2 • • Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier Quantity Limits Restricted Access Prior Review Specialty Drug Name Drug Tier 2015 • • • • • 109 urea gel 45% (Uramaxin) 2 urea in lactic acid vehicle foam 35% (Hydro 35) 2 urea lotion 40% 2 urea lotion 45% (Uramaxin) 2 VECTICAL – calcitriol oint 3 mcg/ gm 4 VIRASAL – salicylic acid film forming liquid 27.5% 4 VOLTAREN – diclofenac sodium gel 1% 3 WESTCORT – hydrocortisone valerate oint 0.2% 4 ONETOUCH ULTRA TEST STRIP – glucose blood test strip XENADERM – trypsin w/ castor oil & peruvian balsam oint 4 ONETOUCH VERIO TEST STRIP – glucose blood test strip XYLOCAINE – lidocaine hcl soln 4% 4 SURESTEP PRO TEST STRIPS – glucose blood test strip ZOVIRAX – acyclovir oint 5% 4 MISCELLANEOUS PRODUCTS THYROGEN – thyrotropin alfa for inj 1.1 mg ANTISEPTICS & DISINFECTANTS MEDICAL DEVICES formaldehyde solution 10% ASCENSIA AUTODISC TEST ST – glucose blood test disk BAYER BREEZE 2 TEST DISC – glucose blood test disk BAYER CONTOUR BLOOD GLUCO – glucose blood test strip BAYER CONTOUR NEXT BLOOD – glucose blood test strip • • LANCETS – VARIOUS MANUFACTURERS • 1 ANTIDOTES EVZIO – naloxone hcl solution auto-injector 0.4 mg/0.4ml 4 EXJADE – deferasirox tab for oral susp 125 mg 5 • • EXJADE – deferasirox tab for oral susp 250 mg 5 • • EXJADE – deferasirox tab for oral susp 500 mg 5 naltrexone hcl tab 50 mg (Revia) 1 REVIA – naltrexone hcl tab 50 mg 5 • • DIAGNOSTIC PRODUCTS All Brand Diabetic Supplies 25% coinsurance 110 • GLUCOSE BLOOD TEST STRIPS – VARIOUS ONETOUCH ULTRA BLUE – glucose blood test strip 5 OMNIFLEX DIAPHRAGM – diaphragms 3 ORTHO DIAPHRAGM COIL SPRI – diaphragm coil spring kit 50 mm 3 ORTHO DIAPHRAGM COIL SPRI – diaphragm coil spring kit 100 mm 3 ORTHO DIAPHRAGM COIL SPRI – diaphragm coil spring kit 105 mm 3 ORTHO DIAPHRAGM FLAT SPRI – diaphragm flat spring kit 55 mm 3 ORTHO DIAPHRAGM FLAT SPRI – diaphragm flat spring kit 60 mm 3 ORTHO DIAPHRAGM FLAT SPRI – diaphragm flat spring kit 65 mm 3 • • Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits 2 Restricted Access urea gel 40% Prior Review urea cream 50% 2 Specialty 2 Drug Name Drug Tier Quantity Limits Restricted Access urea cream 45% (Uramaxin) Specialty Drug Name Drug Tier Prior Review 2015 • ORTHO DIAPHRAGM FLAT SPRI – diaphragm flat spring kit 75 mm 3 CELLCEPT – mycophenolate mofetil tab 500 mg 4 • ORTHO DIAPHRAGM FLAT SPRI – diaphragm flat spring kit 80 mm 3 CELLCEPT – mycophenolate mofetil for oral susp 200 mg/ml 4 • ORTHO DIAPHRAGM FLAT SPRI – diaphragm flat spring kit 85 mm 3 CUPRIMINE – penicillamine cap 250 mg 5 ORTHO DIAPHRAGM FLAT SPRI – diaphragm flat spring kit 90 mm 3 cyclosporine cap 100 mg (Sandimmune) 2 • ORTHO DIAPHRAGM FLAT SPRI – diaphragm flat spring kit 95 mm 3 cyclosporine cap 25 mg (Sandimmune) 2 • WIDE-SEAL SILICONE DIAPHR – diaphragm wide seal 60 mm 3 CYCLOSPORINE MODIFIED – cyclosporine modified cap 50 mg 2 • WIDE-SEAL SILICONE DIAPHR – diaphragm wide seal 65 mm 3 cyclosporine modified cap 100 mg (Neoral) 2 • WIDE-SEAL SILICONE DIAPHR – diaphragm wide seal 70 mm 3 cyclosporine modified cap 25 mg (Neoral) 2 • WIDE-SEAL SILICONE DIAPHR – diaphragm wide seal 75 mm 3 cyclosporine modified oral soln 100 mg/ml (Neoral) 2 • WIDE-SEAL SILICONE DIAPHR – diaphragm wide seal 80 mm 3 DEPEN TITRATABS – penicillamine tab 250 mg 4 WIDE-SEAL SILICONE DIAPHR – diaphragm wide seal 85 mm 3 IMURAN – azathioprine tab 50 mg 4 4 WIDE-SEAL SILICONE DIAPHR – diaphragm wide seal 90 mm 3 KAYEXALATE – sodium polystyrene sulfonate powder • 3 mycophenolate mofetil cap 250 mg (Cellcept) 2 WIDE-SEAL SILICONE DIAPHR – diaphragm wide seal 95 mm mycophenolate mofetil for oral susp 200 mg/ml (Cellcept) 2 • ASSORTED CLASSES ASTAGRAF XL – tacrolimus cap sr 24hr 0.5 mg 5 • mycophenolate mofetil tab 500 mg (Cellcept) 2 • ASTAGRAF XL – tacrolimus cap sr 24hr 1 mg 5 • NEORAL – cyclosporine modified cap 25 mg 4 • ASTAGRAF XL – tacrolimus cap sr 24hr 5 mg 5 • NEORAL – cyclosporine modified cap 100 mg 4 • AZASAN – azathioprine tab 75 mg 4 4 • AZASAN – azathioprine tab 100 mg 4 NEORAL – cyclosporine modified oral soln 100 mg/ml 4 • azathioprine tab 50 mg (Imuran) 1 PROGRAF – tacrolimus cap 0.5 mg PROGRAF – tacrolimus cap 1 mg 4 • Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits 4 Restricted Access Specialty CELLCEPT – mycophenolate mofetil cap 250 mg Drug Name Prior Review Drug Tier Quantity Limits Restricted Access Prior Review 3 Specialty ORTHO DIAPHRAGM FLAT SPRI – diaphragm flat spring kit 70 mm Drug Name Drug Tier 2015 111 RAPAMUNE – sirolimus tab 2 mg 4 RAPAMUNE – sirolimus oral soln 1 4 mg/ml REVLIMID – lenalidomide caps 2.5 5 mg 5 REVLIMID – lenalidomide cap 5 mg 5 REVLIMID – lenalidomide cap 10 mg 5 REVLIMID – lenalidomide cap 15 mg 5 REVLIMID – lenalidomide cap 20 mg 5 REVLIMID – lenalidomide cap 25 mg SANDIMMUNE – cyclosporine cap 4 25 mg SANDIMMUNE – cyclosporine cap 4 100 mg SANDIMMUNE – cyclosporine oral 4 soln 100 mg/ml sirolimus tab 0.5 mg (Rapamune) 2 • • THALOMID – thalidomide cap 200 mg 5 • • • • • • • • • • • • • • • • • • 2 sirolimus tab 2 mg (Rapamune) 2 sodium polystyrene sulfonate powder (Kayexalate) 2 SPS – sodium polystyrene sulfonate oral susp 15 gm/60ml 4 tacrolimus cap 0.5 mg (Prograf) 2 tacrolimus cap 1 mg (Prograf) 2 tacrolimus cap 5 mg (Prograf) 2 THALOMID – thalidomide cap 50 mg 5 • • • • • THALOMID – thalidomide cap 100 mg 5 • • Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary Quantity Limits 5 Restricted Access Prior Review THALOMID – thalidomide cap 150 mg Drug Name • • sirolimus tab 1 mg (Rapamune) 112 Specialty RAPAMUNE – sirolimus tab 0.5 mg 4 4 RAPAMUNE – sirolimus tab 1 mg Drug Tier • • • • • Quantity Limits 4 Restricted Access Specialty PROGRAF – tacrolimus cap 5 mg Prior Review Drug Name Drug Tier 2015 2015 INDEX A abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg (Trizivir).................................................6 abacavir sulfate tab 300 mg (base equiv) (Ziagen).........6 ABILIFY – aripiprazole oral solution 1 mg/ml.................... 60 ABILIFY – aripiprazole tab 10 mg.....................................60 ABILIFY – aripiprazole tab 15 mg.....................................60 ABILIFY – aripiprazole tab 20 mg.....................................60 ABILIFY – aripiprazole tab 2 mg.......................................60 ABILIFY – aripiprazole tab 30 mg.....................................60 ABILIFY – aripiprazole tab 5 mg.......................................60 acamprosate calcium tab delayed release 333 mg (Campral)........................................................................ 66 acarbose tab 100 mg (Precose)..................................... 20 acarbose tab 25 mg (Precose)....................................... 20 acarbose tab 50 mg (Precose)....................................... 20 ACCOLATE – zafirlukast tab 10 mg................................. 47 ACCOLATE – zafirlukast tab 20 mg................................. 47 ACCUPRIL – quinapril hcl tab 10 mg............................... 34 ACCUPRIL – quinapril hcl tab 20 mg............................... 34 ACCUPRIL – quinapril hcl tab 40 mg............................... 34 ACCUPRIL – quinapril hcl tab 5 mg................................. 34 ACCURETIC – quinapril-hydrochlorothiazide tab 10-12.5 mg.................................................................................... 34 ACCURETIC – quinapril-hydrochlorothiazide tab 20-12.5 mg.................................................................................... 34 ACCURETIC – quinapril-hydrochlorothiazide tab 20-25 mg.................................................................................... 34 acebutolol hcl cap 200 mg (Sectral)..............................29 acebutolol hcl cap 400 mg (Sectral)..............................29 ACEON – perindopril erbumine tab 4 mg......................... 34 ACEON – perindopril erbumine tab 8 mg......................... 34 acetaminophen-isometheptene-caffeine tab 325-65-20 mg (Prodrin)................................................................... 75 acetaminophen-isometheptene-dichloral cap 325-65-100 mg................................................................ 75 acetaminophen w/ codeine soln 120-12 mg/5ml...........68 acetaminophen w/ codeine tab 300-15 mg (Tylenol/ codeine).......................................................................... 68 acetaminophen w/ codeine tab 300-30 mg (Tylenol/ codeine #3).....................................................................68 acetaminophen w/ codeine tab 300-60 mg (Tylenol/ codeine #4).....................................................................68 ACETAZOLAMIDE – acetazolamide tab 125 mg.............. 41 acetazolamide cap sr 12hr 500 mg (Diamox)................41 acetazolamide sodium for inj 500 mg........................... 41 acetazolamide tab 250 mg..............................................41 ACETIC ACID/ALUMINUM ACET – acetic acid 2% in aluminum acetate otic soln............................................100 acetic acid otic soln 2%............................................... 100 acetylcysteine inhal soln 10%........................................46 acetylcysteine inhal soln 20%........................................46 ACIPHEX – rabeprazole sodium ec tab 20 mg................. 50 acitretin cap 10 mg (Soriatane)....................................102 acitretin cap 17.5 mg (Soriatane).................................102 acitretin cap 25 mg (Soriatane)....................................102 ACLOVATE – alclometasone dipropionate cream 0.05%.............................................................................102 ACTIGALL – ursodiol cap 300 mg.................................... 52 ACTIQ – fentanyl citrate lollipop 1200 mcg.......................69 ACTIQ – fentanyl citrate lollipop 1600 mcg.......................69 ACTIQ – fentanyl citrate lollipop 200 mcg.........................68 ACTIQ – fentanyl citrate lollipop 400 mcg.........................68 ACTIQ – fentanyl citrate lollipop 600 mcg.........................68 ACTIQ – fentanyl citrate lollipop 800 mcg.........................69 ACTIVELLA – estradiol & norethindrone acetate tab 0.5-0.1 mg....................................................................... 16 ACTIVELLA – estradiol & norethindrone acetate tab 1-0.5 mg.................................................................................... 16 ACTIVE OB – prenatal w/o a w/fe cbn-fa-dha cap 20-1-320 mg.................................................................... 84 ACTONEL – risedronate sodium tab 150 mg....................25 ACTOPLUS MET – pioglitazone hcl-metformin hcl tab 15-500 mg....................................................................... 20 ACTOPLUS MET – pioglitazone hcl-metformin hcl tab 15-850 mg....................................................................... 20 ACTOS – pioglitazone hcl tab 15 mg (base equiv)........... 20 ACTOS – pioglitazone hcl tab 30 mg (base equiv)........... 20 ACTOS – pioglitazone hcl tab 45 mg (base equiv)........... 20 ACULAR – ketorolac tromethamine ophth soln 0.5%........97 ACULAR LS – ketorolac tromethamine ophth soln 0.4%.................................................................................97 acyclovir cap 200 mg (Zovirax)........................................6 acyclovir oint 5% (Zovirax)...........................................102 acyclovir susp 200 mg/5ml (Zovirax).............................. 6 acyclovir tab 400 mg (Zovirax)........................................ 6 acyclovir tab 800 mg (Zovirax)........................................ 6 ACZONE – dapsone gel 5%........................................... 102 ADALAT CC – nifedipine tab sr 24hr 30 mg..................... 31 ADALAT CC – nifedipine tab sr 24hr 60 mg..................... 31 ADALAT CC – nifedipine tab sr 24hr 90 mg..................... 31 adapalene cream 0.1% (Differin).................................. 102 adapalene gel 0.1% (Differin)....................................... 102 adapalene gel 0.3% (Differin)....................................... 102 ADDERALL – amphetamine-dextroamphetamine tab 10 mg.................................................................................... 64 ADDERALL – amphetamine-dextroamphetamine tab 12.5 mg.................................................................................... 64 ADDERALL – amphetamine-dextroamphetamine tab 15 mg.................................................................................... 64 ADDERALL – amphetamine-dextroamphetamine tab 20 mg.................................................................................... 64 ADDERALL – amphetamine-dextroamphetamine tab 30 mg.................................................................................... 64 ADDERALL – amphetamine-dextroamphetamine tab 5 mg.................................................................................... 64 ADDERALL – amphetamine-dextroamphetamine tab 7.5 mg.................................................................................... 64 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 113 2015 ADDERALL XR – amphetamine-dextroamphetamine cap sr 24hr 10 mg..................................................................64 ADDERALL XR – amphetamine-dextroamphetamine cap sr 24hr 15 mg..................................................................64 ADDERALL XR – amphetamine-dextroamphetamine cap sr 24hr 20 mg..................................................................64 ADDERALL XR – amphetamine-dextroamphetamine cap sr 24hr 25 mg..................................................................64 ADDERALL XR – amphetamine-dextroamphetamine cap sr 24hr 30 mg..................................................................64 ADDERALL XR – amphetamine-dextroamphetamine cap sr 24hr 5 mg....................................................................64 adefovir dipivoxil tab 10 mg (Hepsera)........................... 6 ADRENALIN – epinephrine inj 1 mg/ml (1:1000).............. 42 ADRENALIN – epinephrine inj 30 mg/30ml (1 mg/ml) (1:1000)............................................................................42 ADVAIR DISKUS – fluticasone-salmeterol aer powder ba 100-50 mcg/dose............................................................. 47 ADVAIR DISKUS – fluticasone-salmeterol aer powder ba 250-50 mcg/dose............................................................. 47 ADVAIR DISKUS – fluticasone-salmeterol aer powder ba 500-50 mcg/dose............................................................. 47 ADVAIR HFA – fluticasone-salmeterol inhal aerosol 115-21 mcg/act................................................................ 47 ADVAIR HFA – fluticasone-salmeterol inhal aerosol 230-21 mcg/act................................................................ 47 ADVAIR HFA – fluticasone-salmeterol inhal aerosol 45-21 mcg/act............................................................................ 47 AFINITOR DISPERZ – everolimus tab for oral susp 2 mg.................................................................................... 11 AFINITOR DISPERZ – everolimus tab for oral susp 3 mg.................................................................................... 11 AFINITOR DISPERZ – everolimus tab for oral susp 5 mg.................................................................................... 11 AFINITOR – everolimus tab 10 mg...................................11 AFINITOR – everolimus tab 2.5 mg..................................11 AFINITOR – everolimus tab 5 mg.....................................11 AFINITOR – everolimus tab 7.5 mg..................................11 AGGRENOX – aspirin-dipyridamole cap sr 12hr 25-200 mg.................................................................................... 97 AGRYLIN – anagrelide hcl cap 0.5 mg............................. 97 ALBENZA – albendazole tab 200 mg............................... 10 albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)..........47 albuterol sulfate soln nebu 0.5% (5 mg/ml).................. 47 albuterol sulfate soln nebu 0.63 mg/3ml (base equiv).............................................................................. 47 albuterol sulfate soln nebu 1.25 mg/3ml (base equiv).............................................................................. 47 albuterol sulfate syrup 2 mg/5ml................................... 47 albuterol sulfate tab 2 mg.............................................. 47 albuterol sulfate tab 4 mg.............................................. 47 albuterol sulfate tab sr 12hr 4 mg (Vospire er).............47 albuterol sulfate tab sr 12hr 8 mg (Vospire er).............47 ALCAINE – proparacaine hcl ophth soln 0.5%..................97 alclometasone dipropionate cream 0.05% (Aclovate)......................................................................102 114 alclometasone dipropionate oint 0.05%...................... 102 ALDACTAZIDE – spironolactone & hydrochlorothiazide tab 25-25 mg................................................................... 41 ALDACTAZIDE – spironolactone & hydrochlorothiazide tab 50-50 mg................................................................... 41 ALDACTONE – spironolactone tab 100 mg...................... 41 ALDACTONE – spironolactone tab 25 mg........................41 ALDACTONE – spironolactone tab 50 mg........................41 ALDARA – imiquimod cream 5%.................................... 102 ALENDRONATE SODIUM – alendronate sodium oral soln 70 mg/75ml......................................................................25 ALENDRONATE SODIUM – alendronate sodium tab 40 mg.................................................................................... 25 alendronate sodium tab 10 mg...................................... 25 alendronate sodium tab 35 mg...................................... 25 alendronate sodium tab 5 mg........................................ 26 alendronate sodium tab 70 mg (Fosamax)................... 26 alfuzosin hcl tab sr 24hr 10 mg (Uroxatral).................. 55 ALKERAN – melphalan tab 2 mg..................................... 11 allopurinol tab 100 mg (Zyloprim)................................. 76 allopurinol tab 300 mg (Zyloprim)................................. 76 ALORA – estradiol td patch biweekly 0.025 mg/24hr........ 16 ALORA – estradiol td patch biweekly 0.05 mg/24hr.......... 16 ALORA – estradiol td patch biweekly 0.075 mg/24hr........ 16 ALORA – estradiol td patch biweekly 0.1 mg/24hr............ 16 ALPHAGAN P – brimonidine tartrate ophth soln 0.1%...... 97 ALPHAGAN P – brimonidine tartrate ophth soln 0.15%...............................................................................97 alprazolam orally disintegrating tab 0.25 mg (Niravam)........................................................................ 56 alprazolam orally disintegrating tab 0.5 mg................. 56 alprazolam orally disintegrating tab 1 mg.................... 56 alprazolam orally disintegrating tab 2 mg.................... 56 alprazolam tab 0.25 mg (Xanax).................................... 56 alprazolam tab 0.5 mg (Xanax)...................................... 56 alprazolam tab 1 mg (Xanax)......................................... 56 alprazolam tab 2 mg (Xanax)......................................... 56 alprazolam tab sr 24hr 0.5 mg (Xanax xr)..................... 56 alprazolam tab sr 24hr 1 mg (Xanax xr)........................ 56 alprazolam tab sr 24hr 2 mg (Xanax xr)........................ 56 alprazolam tab sr 24hr 3 mg (Xanax xr)........................ 56 ALTACE – ramipril cap 1.25 mg....................................... 34 ALTACE – ramipril cap 10 mg.......................................... 34 ALTACE – ramipril cap 2.5 mg......................................... 34 ALTACE – ramipril cap 5 mg............................................ 34 aluminum chloride soln 20% (Drysol)......................... 102 ALUVEA – urea cream 39%........................................... 102 AMANTADINE HCL – amantadine hcl tab 100 mg........... 81 amantadine hcl cap 100 mg........................................... 81 amantadine hcl syrup 50 mg/5ml...................................81 AMARYL – glimepiride tab 1 mg.......................................20 AMARYL – glimepiride tab 2 mg.......................................20 AMARYL – glimepiride tab 4 mg.......................................20 AMBIEN CR – zolpidem tartrate tab cr 12.5 mg............... 63 AMBIEN CR – zolpidem tartrate tab cr 6.25 mg............... 63 AMBIEN – zolpidem tartrate tab 10 mg............................ 63 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 2015 AMBIEN – zolpidem tartrate tab 5 mg.............................. 63 AMCINONIDE – amcinonide cream 0.1%.......................102 AMCINONIDE – amcinonide lotion 0.1%........................ 102 AMCINONIDE – amcinonide oint 0.1%........................... 102 AMERGE – naratriptan hcl tab 1 mg (base equiv)............ 75 AMERGE – naratriptan hcl tab 2.5 mg (base equiv)......... 75 AMICAR – aminocaproic acid syrup 25%......................... 96 AMICAR – aminocaproic acid tab 1000 mg...................... 96 AMICAR – aminocaproic acid tab 500 mg........................ 96 amiloride & hydrochlorothiazide tab 5-50 mg...............41 amiloride hcl tab 5 mg....................................................41 AMINOCAPROIC ACID – aminocaproic acid tab 1000 mg.................................................................................... 96 aminocaproic acid syrup 25% (Amicar)........................ 96 aminocaproic acid tab 500 mg (Amicar)....................... 96 amiodarone hcl tab 100 mg........................................... 33 amiodarone hcl tab 200 mg (Cordarone)...................... 33 amiodarone hcl tab 400 mg........................................... 33 amiodarone hcl tab 400 mg........................................... 33 amitriptyline hcl tab 100 mg...........................................57 amitriptyline hcl tab 10 mg............................................ 57 amitriptyline hcl tab 150 mg...........................................57 amitriptyline hcl tab 25 mg............................................ 57 amitriptyline hcl tab 50 mg............................................ 57 amitriptyline hcl tab 75 mg............................................ 57 amlodipine besylate-atorvastatin calcium tab 10-10 mg (Caduet).......................................................................... 44 amlodipine besylate-atorvastatin calcium tab 10-20 mg (Caduet).......................................................................... 44 amlodipine besylate-atorvastatin calcium tab 10-40 mg (Caduet).......................................................................... 44 amlodipine besylate-atorvastatin calcium tab 10-80 mg (Caduet).......................................................................... 44 amlodipine besylate-atorvastatin calcium tab 2.5-10 mg (Caduet)....................................................................44 amlodipine besylate-atorvastatin calcium tab 2.5-20 mg (Caduet)....................................................................44 amlodipine besylate-atorvastatin calcium tab 2.5-40 mg (Caduet)....................................................................44 amlodipine besylate-atorvastatin calcium tab 5-10 mg (Caduet).......................................................................... 44 amlodipine besylate-atorvastatin calcium tab 5-20 mg (Caduet).......................................................................... 44 amlodipine besylate-atorvastatin calcium tab 5-40 mg (Caduet).......................................................................... 44 amlodipine besylate-atorvastatin calcium tab 5-80 mg (Caduet).......................................................................... 44 amlodipine besylate-benazepril hcl cap 10-20 mg (Lotrel).............................................................................34 amlodipine besylate-benazepril hcl cap 10-40 mg (Lotrel).............................................................................34 amlodipine besylate-benazepril hcl cap 2.5-10 mg (Lotrel).............................................................................34 amlodipine besylate-benazepril hcl cap 5-10 mg (Lotrel).............................................................................34 amlodipine besylate-benazepril hcl cap 5-20 mg (Lotrel).............................................................................34 amlodipine besylate-benazepril hcl cap 5-40 mg (Lotrel).............................................................................34 amlodipine besylate tab 10 mg (Norvasc).....................31 amlodipine besylate tab 2.5 mg (Norvasc)....................31 amlodipine besylate tab 5 mg (Norvasc)...................... 31 amlodipine besylate-valsartan tab 10-160 mg (Exforge)......................................................................... 34 amlodipine besylate-valsartan tab 10-320 mg (Exforge)......................................................................... 34 amlodipine besylate-valsartan tab 5-160 mg (Exforge)......................................................................... 34 amlodipine besylate-valsartan tab 5-320 mg (Exforge)......................................................................... 34 amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5 mg (Exforge hct)....................................... 35 amlodipine-valsartan-hydrochlorothiazide tab 10-160-25 mg (Exforge hct).......................................... 35 amlodipine-valsartan-hydrochlorothiazide tab 10-320-25 mg (Exforge hct).......................................... 35 amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg (Exforge hct)......................................... 35 amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg (Exforge hct)............................................................35 amoxicillin (trihydrate) cap 250 mg................................. 1 amoxicillin (trihydrate) cap 500 mg................................. 1 amoxicillin (trihydrate) for susp 125 mg/5ml.................. 1 amoxicillin (trihydrate) for susp 200 mg/5ml.................. 1 amoxicillin (trihydrate) for susp 250 mg/5ml.................. 1 amoxicillin (trihydrate) for susp 400 mg/5ml.................. 1 amoxicillin (trihydrate) tab 500 mg..................................1 amoxicillin (trihydrate) tab 875 mg..................................1 amoxicillin & k clavulanate chew tab 200-28.5 mg.........1 amoxicillin & k clavulanate chew tab 400-57 mg............1 amoxicillin & k clavulanate for susp 200-28.5 mg/5ml.............................................................................. 1 amoxicillin & k clavulanate for susp 250-62.5 mg/5ml (Augmentin)......................................................................1 amoxicillin & k clavulanate for susp 400-57 mg/5ml...... 1 amoxicillin & k clavulanate for susp 600-42.9 mg/5ml (Augmentin es-600)......................................................... 1 amoxicillin & k clavulanate tab 250-125 mg................... 1 amoxicillin & k clavulanate tab 500-125 mg (Augmentin)......................................................................1 amoxicillin & k clavulanate tab 875-125 mg (Augmentin)......................................................................1 amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg (Augmentin xr)................................................................. 1 AMOXICILLIN – amoxicillin (trihydrate) chew tab 125 mg...................................................................................... 1 AMOXICILLIN – amoxicillin (trihydrate) chew tab 250 mg...................................................................................... 1 amoxicillin cap-clarithro tab-lansopraz cap dr therapy pack (Prevpac)............................................................... 50 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 115 2015 amphetamine-dextroamphetamine cap sr 24hr 10 mg (Adderall xr)................................................................... 64 amphetamine-dextroamphetamine cap sr 24hr 15 mg (Adderall xr)................................................................... 64 amphetamine-dextroamphetamine cap sr 24hr 20 mg (Adderall xr)................................................................... 64 amphetamine-dextroamphetamine cap sr 24hr 25 mg (Adderall xr)................................................................... 64 amphetamine-dextroamphetamine cap sr 24hr 30 mg (Adderall xr)................................................................... 64 amphetamine-dextroamphetamine cap sr 24hr 5 mg (Adderall xr)................................................................... 64 amphetamine-dextroamphetamine tab 10 mg (Adderall)........................................................................ 64 amphetamine-dextroamphetamine tab 12.5 mg (Adderall)........................................................................ 64 amphetamine-dextroamphetamine tab 15 mg (Adderall)........................................................................ 64 amphetamine-dextroamphetamine tab 20 mg (Adderall)........................................................................ 64 amphetamine-dextroamphetamine tab 30 mg (Adderall)........................................................................ 65 amphetamine-dextroamphetamine tab 5 mg (Adderall)........................................................................ 65 amphetamine-dextroamphetamine tab 7.5 mg (Adderall)........................................................................ 65 AMPICILLIN – ampicillin for susp 125 mg/5ml.................... 1 AMPICILLIN – ampicillin for susp 250 mg/5ml.................... 1 ampicillin cap 250 mg.......................................................1 ampicillin cap 500 mg.......................................................1 AMPYRA – dalfampridine tab sr 12hr 10 mg.................... 66 ANAFRANIL – clomipramine hcl cap 25 mg..................... 57 ANAFRANIL – clomipramine hcl cap 50 mg..................... 57 ANAFRANIL – clomipramine hcl cap 75 mg..................... 57 anagrelide hcl cap 0.5 mg (Agrylin).............................. 97 anagrelide hcl cap 1 mg................................................. 97 ANALPRAM E – hc-pramoxine emol cream 2.5-1% & pramoxine wipe 1% kit.................................................. 101 ANALPRAM-HC – hydrocortisone acetate w/ pramoxine rectal cream 1-1%......................................................... 102 ANALPRAM-HC – hydrocortisone acetate w/ pramoxine rectal cream 2.5-1%...................................................... 102 ANALPRAM-HC SINGLES – hydrocortisone acetate w/ pramoxine rectal cream 1-1%....................................... 102 ANALPRAM-HC SINGLES – hydrocortisone acetate w/ pramoxine rectal cream 2.5-1%.................................... 102 ANAPROX DS – naproxen sodium tab 550 mg................ 73 ANAPROX – naproxen sodium tab 275 mg...................... 73 ANASPAZ – hyoscyamine sulfate tab disp 0.125 mg........50 anastrozole tab 1 mg (Arimidex)................................... 11 ANCOBON – flucytosine cap 250 mg................................. 5 ANCOBON – flucytosine cap 500 mg................................. 5 ANDRODERM – testosterone td patch 24hr 2 mg/24hr............................................................................16 ANDRODERM – testosterone td patch 24hr 4 mg/24hr............................................................................16 116 ANDROGEL PUMP – testosterone td gel 12.5 mg/act (1%)................................................................................. 16 ANDROGEL PUMP – testosterone td gel 20.25 mg/act (1.62%)............................................................................ 16 ANDROGEL – testosterone td gel 20.25 mg/1.25gm (1.62%)............................................................................ 16 ANDROGEL – testosterone td gel 25 mg/2.5gm (1%)...... 16 ANDROGEL – testosterone td gel 40.5 mg/2.5gm (1.62%)............................................................................ 16 ANDROGEL – testosterone td gel 50 mg/5gm (1%)......... 16 ANDROID – methyltestosterone cap 10 mg......................16 ANIMI-3 – folic acid-vit b6-vit b12-omega 3-phytosterols cap 1 mg......................................................................... 93 ANORO ELLIPTA – umeclidinium-vilanterol aero powd ba 62.5-25 mcg/inh............................................................... 47 ANTABUSE – disulfiram tab 250 mg................................ 66 ANTABUSE – disulfiram tab 500 mg................................ 66 ANTARA – fenofibrate micronized cap 30 mg...................42 ANTARA – fenofibrate micronized cap 90 mg...................42 ANTIPYRINE/BENZOCAINE – antipyrine-benzocaine otic soln 55-14 mg/ml (5.5-1.4%)......................................... 100 antipyrine-benzocaine otic soln 54-14 mg/ml (5.4-1.4%)...................................................................... 100 antipyrine-benzocaine-polycosanol otic sol 5.4-1.4-0.0097% (Treagan otic)................................... 100 ANUSOL-HC – hydrocortisone acetate suppos 25 mg.................................................................................. 102 ANUSOL-HC – hydrocortisone rectal cream 2.5%..........102 apraclonidine hcl ophth soln 0.5% (base equivalent) (Iopidine).........................................................................97 APTIVUS – tipranavir cap 250 mg......................................6 APTIVUS – tipranavir oral soln 100 mg/ml......................... 6 ARALEN – chloroquine phosphate tab 500 mg.................10 ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 100 mcg/0.5ml............................ 93 ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 100 mcg/ml.................................93 ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 150 mcg/0.3ml............................ 93 ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 150 mcg/0.75ml.......................... 93 ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 200 mcg/0.4ml............................ 93 ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 200 mcg/ml.................................93 ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 25 mcg/0.42ml............................ 93 ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 25 mcg/ml...................................93 ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 300 mcg/0.6ml............................ 94 ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 300 mcg/ml.................................93 ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 40 mcg/0.4ml.............................. 93 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 2015 ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 40 mcg/ml...................................93 ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 500 mcg/ml.................................94 ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 60 mcg/0.3ml.............................. 93 ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 60 mcg/ml...................................93 ARAVA – leflunomide tab 10 mg...................................... 73 ARAVA – leflunomide tab 20 mg...................................... 73 ARICEPT – donepezil hydrochloride tab 10 mg................66 ARICEPT – donepezil hydrochloride tab 23 mg................66 ARICEPT – donepezil hydrochloride tab 5 mg..................66 ARICEPT ODT – donepezil hydrochloride orally disintegrating tab 10 mg..................................................66 ARIMIDEX – anastrozole tab 1 mg................................... 11 ARIXTRA – fondaparinux sodium inj 10 mg/0.8ml............ 95 ARIXTRA – fondaparinux sodium inj 2.5 mg/0.5ml........... 95 ARIXTRA – fondaparinux sodium inj 5 mg/0.4ml.............. 95 ARIXTRA – fondaparinux sodium inj 7.5 mg/0.6ml........... 95 ARMOUR THYROID – thyroid tab 120 mg (2 grain)......... 23 ARMOUR THYROID – thyroid tab 15 mg (1/4 grain)........ 23 ARMOUR THYROID – thyroid tab 180 mg (3 grain)......... 23 ARMOUR THYROID – thyroid tab 240 mg (4 grain)......... 23 ARMOUR THYROID – thyroid tab 300 mg (5 grain)......... 23 ARMOUR THYROID – thyroid tab 30 mg (1/2 grain)........ 23 ARMOUR THYROID – thyroid tab 60 mg (1 grain)........... 23 ARMOUR THYROID – thyroid tab 90 mg (1 1/2 grain)..... 23 AROMASIN – exemestane tab 25 mg.............................. 11 ARTHROTEC 50 – diclofenac w/ misoprostol tab delayed release 50-0.2 mg........................................................... 73 ARTHROTEC 75 – diclofenac w/ misoprostol tab delayed release 75-0.2 mg........................................................... 73 ARZOL SILVER NITRATE APP – silver nitrate-potassium nitrate applicator 75-25%...............................................103 ASCENSIA AUTODISC TEST ST – glucose blood test disk.................................................................................110 ASMANEX HFA – mometasone furoate inhal aerosol suspension 100 mcg/act..................................................47 ASMANEX HFA – mometasone furoate inhal aerosol suspension 200 mcg/act..................................................47 ASMANEX TWISTHALER 120 ME – mometasone furoate inhal powd 220 mcg/inh (breath activated)......................47 ASMANEX TWISTHALER 14 MET – mometasone furoate inhal powd 220 mcg/inh (breath activated)......................47 ASMANEX TWISTHALER 30 ME – mometasone furoate inhal powd 220 mcg/inh (breath activated)......................47 ASMANEX TWISTHALER 30 MET – mometasone furoate inhal powd 110 mcg/inh (breath activated)......................47 ASMANEX TWISTHALER 60 MET – mometasone furoate inhal powd 220 mcg/inh (breath activated)......................47 ASMANEX TWISTHALER 7 METE – mometasone furoate inhal powd 110 mcg/inh (breath activated)......................47 ASTAGRAF XL – tacrolimus cap sr 24hr 0.5 mg............ 111 ASTAGRAF XL – tacrolimus cap sr 24hr 1 mg............... 111 ASTAGRAF XL – tacrolimus cap sr 24hr 5 mg............... 111 ATABEX EC – prenatal vit w/ dss-iron carbonyl-fa tab dr 29-1 mg........................................................................... 84 ATABEX PRENATAL – prenatal vit w/ iron carbonyl-fa tab 65-1 mg........................................................................... 84 ATACAND – candesartan cilexetil tab 16 mg................... 35 ATACAND – candesartan cilexetil tab 32 mg................... 35 ATACAND – candesartan cilexetil tab 4 mg..................... 35 ATACAND – candesartan cilexetil tab 8 mg..................... 35 ATACAND HCT – candesartan cilexetilhydrochlorothiazide tab 16-12.5 mg................................ 35 ATACAND HCT – candesartan cilexetilhydrochlorothiazide tab 32-12.5 mg................................ 35 ATACAND HCT – candesartan cilexetilhydrochlorothiazide tab 32-25 mg................................... 35 atenolol & chlorthalidone tab 100-25 mg (Tenoretic 100)..................................................................................35 atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50)....................................................................................35 atenolol tab 100 mg (Tenormin).....................................29 atenolol tab 25 mg (Tenormin).......................................29 atenolol tab 50 mg (Tenormin).......................................29 ATIVAN – lorazepam tab 0.5 mg...................................... 56 ATIVAN – lorazepam tab 1 mg......................................... 56 ATIVAN – lorazepam tab 2 mg......................................... 56 atorvastatin calcium tab 10 mg (base equivalent) (Lipitor)........................................................................... 42 atorvastatin calcium tab 20 mg (base equivalent) (Lipitor)........................................................................... 42 atorvastatin calcium tab 40 mg (base equivalent) (Lipitor)........................................................................... 42 atorvastatin calcium tab 80 mg (base equivalent) (Lipitor)........................................................................... 42 atovaquone-proguanil hcl tab 250-100 mg (Malarone).......................................................................10 atovaquone-proguanil hcl tab 62.5-25 mg (Malarone).......................................................................10 ATRIPLA – efavirenz-emtricitabine-tenofovir df tab 600-200-300 mg................................................................ 6 atropine sulfate ophth soln 1% (Isopto atropine)......... 97 ATROVENT – ipratropium bromide nasal soln 0.03% (21 mcg/spray)....................................................................... 46 ATROVENT – ipratropium bromide nasal soln 0.06% (42 mcg/spray)....................................................................... 46 AUGMENTIN – amoxicillin & k clavulanate for susp 125-31.25 mg/5ml..............................................................1 AUGMENTIN – amoxicillin & k clavulanate for susp 250-62.5 mg/5ml................................................................1 AUGMENTIN – amoxicillin & k clavulanate tab 500-125 mg...................................................................................... 1 AUGMENTIN – amoxicillin & k clavulanate tab 875-125 mg...................................................................................... 1 AUGMENTIN XR – amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg.................................................................... 1 AURALGAN – antipyrine-benzocaine otic soln 55-14 mg/ ml (5.5-1.4%)................................................................. 100 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 117 2015 AVALIDE – irbesartan-hydrochlorothiazide tab 150-12.5 mg.................................................................................... 35 AVALIDE – irbesartan-hydrochlorothiazide tab 300-12.5 mg.................................................................................... 35 AVAPRO – irbesartan tab 150 mg.................................... 35 AVAPRO – irbesartan tab 300 mg.................................... 35 AVAPRO – irbesartan tab 75 mg......................................35 AXID – nizatidine cap 300 mg.......................................... 50 AXID – nizatidine oral soln 15 mg/ml................................50 AYGESTIN – norethindrone acetate tab 5 mg.................. 20 azacitidine for inj 100 mg (Vidaza)................................ 11 AZASAN – azathioprine tab 100 mg............................... 111 AZASAN – azathioprine tab 75 mg................................. 111 azathioprine tab 50 mg (Imuran)..................................111 azelastine hcl nasal spray 137 mcg/spray (1 mg/ ml)....................................................................................46 azelastine hcl ophth soln 0.05% (Optivar).................... 97 AZILECT – rasagiline mesylate tab 0.5 mg (base equiv)............................................................................... 81 AZILECT – rasagiline mesylate tab 1 mg (base equiv)..... 81 AZITHROMYCIN – azithromycin powd pack for susp 1 gm...................................................................................... 2 azithromycin for susp 100 mg/5ml (Zithromax)..............2 azithromycin for susp 200 mg/5ml (Zithromax)..............2 azithromycin tab 250 mg (Zithromax)............................. 2 azithromycin tab 500 mg (Zithromax)............................. 2 azithromycin tab 600 mg (Zithromax)............................. 2 AZULFIDINE EN-TABS – sulfasalazine tab delayed release 500 mg................................................................53 AZULFIDINE – sulfasalazine tab 500 mg......................... 53 B B-6 FOLIC ACID – cobalamine combination cap.............. 94 BACITRACIN – bacitracin ophth oint 500 unit/gm.............97 bacitracin-polymyxin b ophth oint.................................97 bacitracin-polymyxin-neomycin-hc ophth oint 1%.......97 baclofen tab 10 mg......................................................... 83 baclofen tab 20 mg......................................................... 83 BACTRIM DS – sulfamethoxazole-trimethoprim tab 800-160 mg..................................................................... 10 BACTRIM – sulfamethoxazole-trimethoprim tab 400-80 mg.................................................................................... 10 BACTROBAN – mupirocin calcium cream 2%................ 103 BACTROBAN – mupirocin oint 2%................................. 103 BAL-CARE DHA – prenat w/fe poly-na fered-fa tab 27-1 & omega cap dr 430mg...................................................... 84 balsalazide disodium cap 750 mg (Colazal)..................53 BARACLUDE – entecavir oral soln 0.05 mg/ml.................. 6 BARACLUDE – entecavir tab 0.5 mg................................. 6 BARACLUDE – entecavir tab 1 mg.................................... 6 BAYER BREEZE 2 TEST DISC – glucose blood test disk.................................................................................110 BAYER CONTOUR BLOOD GLUCO – glucose blood test strip................................................................................ 110 BAYER CONTOUR NEXT BLOOD – glucose blood test strip................................................................................ 110 118 b-complex w/ c & folic acid cap 1 mg (Nephrocaps)..................................................................84 b-complex w/ c & folic acid tab..................................... 84 b-complex w/ c & folic acid tab 1 mg (Nephro-vite rx).................................................................................... 84 benazepril & hydrochlorothiazide tab 10-12.5 mg (Lotensin hct)................................................................. 35 benazepril & hydrochlorothiazide tab 20-12.5 mg (Lotensin hct)................................................................. 35 benazepril & hydrochlorothiazide tab 20-25 mg (Lotensin hct)................................................................. 35 benazepril & hydrochlorothiazide tab 5-6.25 mg..........35 benazepril hcl tab 10 mg (Lotensin).............................. 35 benazepril hcl tab 20 mg (Lotensin).............................. 35 benazepril hcl tab 40 mg (Lotensin).............................. 35 benazepril hcl tab 5 mg.................................................. 35 BENTYL – dicyclomine hcl cap 10 mg..............................50 BENTYL – dicyclomine hcl tab 20 mg.............................. 50 BENZAC AC WASH – benzoyl peroxide liq 5%.............. 103 BENZACLIN – clindamycin phosphate-benzoyl peroxide gel 1-5%........................................................................ 103 BENZACLIN WITH PUMP – clindamycin phosphatebenzoyl peroxide gel 1-5%............................................ 103 BENZAC W WASH – benzoyl peroxide liq 5%................103 BENZAMYCIN – benzoyl peroxide-erythromycin gel 5-3%...............................................................................103 BENZEFOAM – benzoyl peroxide foam 5.3%.................103 BENZEFOAMULTRA – benzoyl peroxide foam 9.8%..... 103 benzonatate cap 100 mg (Tessalon perles).................. 46 benzonatate cap 200 mg................................................ 46 benzoyl peroxide creamy wash 4% & cleanser lotion kit...................................................................................103 benzoyl peroxide creamy wash 8% & cleanser lotion kit...................................................................................103 benzoyl peroxide-erythromycin gel 5-3% (Benzamycin)................................................................103 benzoyl peroxide foam 5.3% (Benzefoam)..................103 benzoyl peroxide foam 9.8% (Benzefoamultra).......... 103 benzoyl peroxide gel 10%............................................ 103 benzoyl peroxide liq 2.5%............................................ 103 benzoyl peroxide liq 7%............................................... 103 benzoyl peroxide lotion 6%..........................................103 benztropine mesylate tab 0.5 mg...................................81 benztropine mesylate tab 1 mg..................................... 81 benztropine mesylate tab 2 mg..................................... 81 BETAGAN – levobunolol hcl ophth soln 0.5%...................97 betamethasone dipropionate augmented cream 0.05% (Diprolene af)............................................................... 103 betamethasone dipropionate augmented gel 0.05%.............................................................................103 betamethasone dipropionate augmented lotion 0.05% (Diprolene).................................................................... 103 betamethasone dipropionate augmented oint 0.05% (Diprolene).................................................................... 103 betamethasone dipropionate cream 0.05%.................103 betamethasone dipropionate lotion 0.05%................. 103 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 2015 betamethasone dipropionate oint 0.05%.....................103 betamethasone valerate aerosol foam 0.12% (Luxiq)........................................................................... 103 betamethasone valerate cream 0.1%...........................103 betamethasone valerate lotion 0.1%........................... 103 betamethasone valerate oint 0.1%...............................103 BETAPACE AF – sotalol hcl (afib/afl) tab 120 mg.............29 BETAPACE AF – sotalol hcl (afib/afl) tab 160 mg.............29 BETAPACE AF – sotalol hcl (afib/afl) tab 80 mg...............29 BETAPACE – sotalol hcl tab 120 mg................................29 BETAPACE – sotalol hcl tab 160 mg................................29 BETAPACE – sotalol hcl tab 80 mg..................................29 BETASERON – interferon beta-1b for inj kit 0.3 mg..........66 betaxolol hcl ophth soln 0.5%....................................... 97 betaxolol hcl tab 10 mg (Kerlone)................................. 29 betaxolol hcl tab 20 mg (Kerlone)................................. 29 bethanechol chloride tab 10 mg (Urecholine)...............54 bethanechol chloride tab 25 mg (Urecholine)...............54 bethanechol chloride tab 50 mg (Urecholine)...............54 bethanechol chloride tab 5 mg (Urecholine)................ 54 BETHKIS – tobramycin nebu soln 300 mg/4ml................... 4 BIAXIN – clarithromycin for susp 250 mg/5ml.....................2 BIAXIN – clarithromycin tab 250 mg................................... 2 BIAXIN – clarithromycin tab 500 mg................................... 2 BIAXIN XL – clarithromycin tab sr 24hr 500 mg..................2 BIAXIN XL PAC – clarithromycin tab sr 24hr 500 mg..........2 bicalutamide tab 50 mg (Casodex)................................ 11 BIDIL – isosorbide dinitrate-hydralazine hcl tab 20-37.5 mg.................................................................................... 45 bisoprolol & hydrochlorothiazide tab 10-6.25 mg (Ziac)............................................................................... 35 bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg (Ziac)............................................................................... 35 bisoprolol & hydrochlorothiazide tab 5-6.25 mg (Ziac)............................................................................... 35 bisoprolol fumarate tab 10 mg (Zebeta)........................29 bisoprolol fumarate tab 5 mg (Zebeta)..........................29 BLEPH-10 – sulfacetamide sodium ophth soln 10%......... 97 B-NEXA – prenatal w/ calcium-vit b6-fa-ginger tab 1.22 mg.................................................................................... 84 BONIVA – ibandronate sodium tab 150 mg (base equivalent)....................................................................... 26 BP FOLINATAL PLUS B – prenatal w/ calcium carbonateb6-b12-fa tab 1 mg..........................................................84 BP MULTINATAL PLUS – prenatal w/o a vit w/ fe fumarate-fa tab 30-1 mg..................................................84 BP MULTINATAL PLUS – prenatal w/o a vit w/ fe fum-fa tab chew 40-1 mg........................................................... 84 BPO 3% FOAMING CLOTHS – benzoyl peroxide cloth 3%..................................................................................103 BPO 6% FOAMING CLOTHS – benzoyl peroxide cloth 6%..................................................................................103 BPO 9% FOAMING CLOTHS – benzoyl peroxide cloth 9%..................................................................................103 BP VIT 3 – folic acid-vit b6-vit b12-omega 3-phytosterols cap 1 mg......................................................................... 94 BRAVELLE – Benefit Limits may apply – urofollitropin purified for inj 75 unit...................................................... 26 BREO ELLIPTA – fluticasone furoate-vilanterol aero powd ba 100-25 mcg/inh...........................................................48 BREVICON-28 – norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg.......................................................................18 BRILINTA – ticagrelor tab 90 mg......................................97 brimonidine tartrate ophth soln 0.15% (Alphagan p)......................................................................................97 brimonidine tartrate ophth soln 0.2%............................97 bromocriptine mesylate cap 5 mg (Parlodel)................81 bromocriptine mesylate tab 2.5 mg...............................81 brompheniramine maleate tab sr 12hr 6 mg.................45 budesonide cap sr 24hr 3 mg (Entocort ec)................. 14 budesonide inhalation susp 0.25 mg/2ml (Pulmicort)...................................................................... 48 budesonide inhalation susp 0.5 mg/2ml (Pulmicort)...................................................................... 48 budesonide nasal susp 32 mcg/act (Rhinocort aqua)............................................................................... 46 bumetanide tab 0.5 mg................................................... 41 bumetanide tab 1 mg...................................................... 41 bumetanide tab 2 mg...................................................... 41 buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv).............................................................................. 69 buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv).............................................................................. 69 buprenorphine hcl sl tab 2 mg (base equiv)................. 69 buprenorphine hcl sl tab 8 mg (base equiv)................. 69 bupropion hcl (smoking deterrent) tab sr 12hr 150 mg (Zyban)............................................................................ 66 bupropion hcl tab 100 mg (Wellbutrin)......................... 57 bupropion hcl tab 75 mg (Wellbutrin)........................... 57 bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr)........ 57 bupropion hcl tab sr 12hr 150 mg (Wellbutrin sr)........ 57 bupropion hcl tab sr 12hr 200 mg (Wellbutrin sr)........ 57 bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl).........57 bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl).........57 buspirone hcl tab 10 mg................................................ 56 buspirone hcl tab 15 mg................................................ 56 buspirone hcl tab 30 mg................................................ 56 buspirone hcl tab 5 mg.................................................. 56 buspirone hcl tab 7.5 mg............................................... 56 butalbital-acetaminophen-caffeine cap 50-325-40 mg....................................................................................68 butalbital-acetaminophen-caffeine tab 50-325-40 mg (Esgic)............................................................................. 68 butalbital-acetaminophen-caff w/ cod cap 50-300-40-30 mg (Fioricet/codeine).................................................... 69 butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg....................................................................................69 butalbital-acetaminophen tab 50-325 mg...................... 68 butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal)..........................................................................68 butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg (Fiorinal/codeine #3)......................................................69 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 119 2015 butorphanol tartrate nasal soln 10 mg/ml.....................69 C cabergoline tab 0.5 mg................................................... 26 CADUET – amlodipine besylate-atorvastatin calcium tab 10-10 mg......................................................................... 45 CADUET – amlodipine besylate-atorvastatin calcium tab 10-20 mg......................................................................... 45 CADUET – amlodipine besylate-atorvastatin calcium tab 10-40 mg......................................................................... 45 CADUET – amlodipine besylate-atorvastatin calcium tab 10-80 mg......................................................................... 45 CADUET – amlodipine besylate-atorvastatin calcium tab 2.5-10 mg........................................................................ 45 CADUET – amlodipine besylate-atorvastatin calcium tab 2.5-20 mg........................................................................ 45 CADUET – amlodipine besylate-atorvastatin calcium tab 2.5-40 mg........................................................................ 45 CADUET – amlodipine besylate-atorvastatin calcium tab 5-10 mg........................................................................... 45 CADUET – amlodipine besylate-atorvastatin calcium tab 5-20 mg........................................................................... 45 CADUET – amlodipine besylate-atorvastatin calcium tab 5-40 mg........................................................................... 45 CADUET – amlodipine besylate-atorvastatin calcium tab 5-80 mg........................................................................... 45 CALAN SR – verapamil hcl tab cr 120 mg........................31 CALAN SR – verapamil hcl tab cr 180 mg........................31 CALAN SR – verapamil hcl tab cr 240 mg........................31 CALAN – verapamil hcl tab 120 mg..................................31 CALAN – verapamil hcl tab 80 mg....................................31 calcipotriene-betamethasone dipropionate oint 0.005-0.064% (Taclonex)............................................. 103 calcipotriene cream 0.005% (Dovonex)....................... 103 calcipotriene oint 0.005%............................................. 103 calcipotriene soln 0.005% (50 mcg/ml)........................103 calcitonin (salmon) nasal soln 200 unit/act (Miacalcin)...................................................................... 26 CALCITRIOL – calcitriol oint 3 mcg/gm.......................... 103 calcitriol cap 0.25 mcg (Rocaltrol).................................26 calcitriol cap 0.5 mcg (Rocaltrol)...................................26 calcitriol oral soln 1 mcg/ml (Rocaltrol)........................26 calcium acetate (phosphate binder) cap 667 mg (169 mg ca) (Phoslo)............................................................. 53 calcium acetate (phosphate binder) tab 667 mg (Eliphos)..........................................................................53 CALCIUM PNV – prenatal w/o vit a w/ fe fum-fa-omega 3 cap 28-1-250 mg............................................................. 84 CANASA – mesalamine suppos 1000 mg........................ 53 candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg (Atacand hct)........................................................... 35 candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg (Atacand hct)........................................................... 36 candesartan cilexetil-hydrochlorothiazide tab 32-25 mg (Atacand hct)........................................................... 36 candesartan cilexetil tab 16 mg (Atacand)....................35 120 candesartan cilexetil tab 32 mg (Atacand)....................35 candesartan cilexetil tab 4 mg (Atacand)......................35 candesartan cilexetil tab 8 mg (Atacand)......................35 capecitabine tab 150 mg (Xeloda)................................. 11 capecitabine tab 500 mg (Xeloda)................................. 11 CAPRELSA – vandetanib tab 100 mg.............................. 12 CAPRELSA – vandetanib tab 300 mg.............................. 12 CAPTOPRIL/HYDROCHLOROTHIA – captopril & hydrochlorothiazide tab 25-15 mg................................... 36 CAPTOPRIL/HYDROCHLOROTHIA – captopril & hydrochlorothiazide tab 25-25 mg................................... 36 CAPTOPRIL/HYDROCHLOROTHIA – captopril & hydrochlorothiazide tab 50-15 mg................................... 36 CAPTOPRIL/HYDROCHLOROTHIA – captopril & hydrochlorothiazide tab 50-25 mg................................... 36 captopril tab 100 mg....................................................... 36 captopril tab 12.5 mg...................................................... 36 captopril tab 25 mg......................................................... 36 captopril tab 50 mg......................................................... 36 CARAFATE – sucralfate susp 1 gm/10ml......................... 50 CARAFATE – sucralfate tab 1 gm.................................... 50 CARBAGLU – carglumic acid tab 200 mg........................ 26 carbamazepine cap sr 12hr 100 mg (Carbatrol)............77 carbamazepine cap sr 12hr 200 mg (Carbatrol)............77 carbamazepine cap sr 12hr 300 mg (Carbatrol)............77 carbamazepine chew tab 100 mg.................................. 77 carbamazepine susp 100 mg/5ml (Tegretol)................. 77 carbamazepine tab 200 mg (Tegretol)........................... 77 carbamazepine tab sr 12hr 200 mg (Tegretol-xr)..........77 carbamazepine tab sr 12hr 400 mg (Tegretol-xr)..........77 CARBATROL – carbamazepine cap sr 12hr 100 mg........ 77 CARBATROL – carbamazepine cap sr 12hr 200 mg........ 77 CARBATROL – carbamazepine cap sr 12hr 300 mg........ 77 CARBIDOPA/LEVODOPA/ENTACA – carbidopalevodopa-entacapone tabs 12.5-50-200 mg.................... 81 CARBIDOPA/LEVODOPA/ENTACA – carbidopalevodopa-entacapone tabs 18.75-75-200 mg.................. 81 CARBIDOPA/LEVODOPA/ENTACA – carbidopalevodopa-entacapone tabs 25-100-200 mg..................... 81 CARBIDOPA/LEVODOPA/ENTACA – carbidopalevodopa-entacapone tabs 31.25-125-200 mg................ 81 CARBIDOPA/LEVODOPA/ENTACA – carbidopalevodopa-entacapone tabs 37.5-150-200 mg.................. 81 CARBIDOPA/LEVODOPA/ENTACA – carbidopalevodopa-entacapone tabs 50-200-200 mg..................... 81 carbidopa & levodopa tab 10-100 mg (Sinemet)...........81 carbidopa & levodopa tab 25-100 mg (Sinemet)...........81 carbidopa & levodopa tab 25-250 mg (Sinemet)...........81 carbidopa & levodopa tab cr 25-100 mg (Sinemet cr).................................................................................... 81 carbidopa & levodopa tab cr 50-200 mg (Sinemet cr).................................................................................... 81 carbidopa tab 25 mg (Lodosyn).....................................81 carbinoxamine maleate soln 4 mg/5ml..........................45 carbinoxamine maleate tab 4 mg...................................45 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 2015 CARDIZEM CD – diltiazem hcl coated beads cap sr 24hr 120 mg.............................................................................31 CARDIZEM CD – diltiazem hcl coated beads cap sr 24hr 180 mg.............................................................................31 CARDIZEM CD – diltiazem hcl coated beads cap sr 24hr 240 mg.............................................................................31 CARDIZEM CD – diltiazem hcl coated beads cap sr 24hr 300 mg.............................................................................31 CARDIZEM CD – diltiazem hcl coated beads cap sr 24hr 360 mg.............................................................................31 CARDIZEM – diltiazem hcl tab 120 mg............................ 31 CARDIZEM – diltiazem hcl tab 30 mg.............................. 31 CARDIZEM – diltiazem hcl tab 60 mg.............................. 31 CARDIZEM LA – diltiazem hcl coated beads tab sr 24hr 120 mg.............................................................................31 CARDIZEM LA – diltiazem hcl coated beads tab sr 24hr 180 mg.............................................................................31 CARDIZEM LA – diltiazem hcl coated beads tab sr 24hr 240 mg.............................................................................31 CARDIZEM LA – diltiazem hcl coated beads tab sr 24hr 300 mg.............................................................................31 CARDIZEM LA – diltiazem hcl coated beads tab sr 24hr 360 mg.............................................................................31 CARDIZEM LA – diltiazem hcl coated beads tab sr 24hr 420 mg.............................................................................31 CARDURA – doxazosin mesylate tab 1 mg......................36 CARDURA – doxazosin mesylate tab 2 mg......................36 CARDURA – doxazosin mesylate tab 4 mg......................36 CARDURA – doxazosin mesylate tab 8 mg......................36 carisoprodol tab 350 mg (Soma)................................... 83 CARNITOR – levocarnitine oral soln 1 gm/10ml (10%).....26 CARNITOR – levocarnitine tab 330 mg............................ 26 CARNITOR SF – levocarnitine oral soln 1 gm/10ml (10%)............................................................................... 26 carteolol hcl ophth soln 1%........................................... 97 carvedilol tab 12.5 mg (Coreg).......................................29 carvedilol tab 25 mg (Coreg)..........................................29 carvedilol tab 3.125 mg (Coreg).....................................29 carvedilol tab 6.25 mg (Coreg).......................................29 CASODEX – bicalutamide tab 50 mg............................... 12 CATAPRES – clonidine hcl tab 0.1 mg.............................36 CATAPRES – clonidine hcl tab 0.2 mg.............................36 CATAPRES – clonidine hcl tab 0.3 mg.............................36 CATAPRES-TTS-1 – clonidine hcl td patch weekly 0.1 mg/24hr............................................................................36 CATAPRES-TTS-2 – clonidine hcl td patch weekly 0.2 mg/24hr............................................................................36 CATAPRES-TTS-3 – clonidine hcl td patch weekly 0.3 mg/24hr............................................................................36 CAYSTON – aztreonam lysine for inhal soln 75 mg (base equivalent)....................................................................... 10 cefaclor cap 250 mg......................................................... 2 cefaclor cap 500 mg......................................................... 2 CEFACLOR – cefaclor for susp 125 mg/5ml...................... 1 CEFACLOR – cefaclor for susp 250 mg/5ml...................... 1 CEFACLOR – cefaclor for susp 375 mg/5ml...................... 2 cefadroxil cap 500 mg...................................................... 2 cefadroxil for susp 250 mg/5ml....................................... 2 cefadroxil for susp 500 mg/5ml....................................... 2 cefadroxil tab 1 gm........................................................... 2 cefdinir cap 300 mg.......................................................... 2 cefdinir for susp 125 mg/5ml........................................... 2 cefdinir for susp 250 mg/5ml........................................... 2 cefpodoxime proxetil for susp 100 mg/5ml.................... 2 cefpodoxime proxetil for susp 50 mg/5ml...................... 2 cefpodoxime proxetil tab 100 mg.................................... 2 cefpodoxime proxetil tab 200 mg.................................... 2 cefprozil for susp 125 mg/5ml......................................... 2 cefprozil for susp 250 mg/5ml......................................... 2 cefprozil tab 250 mg......................................................... 2 cefprozil tab 500 mg......................................................... 2 CEFTIBUTEN – ceftibuten cap 400 mg.............................. 2 CEFTIBUTEN – ceftibuten for susp 180 mg/5ml.................2 CEFTIN – cefuroxime axetil for susp 125 mg/5ml...............2 CEFTIN – cefuroxime axetil for susp 250 mg/5ml...............2 CEFTIN – cefuroxime axetil tab 250 mg............................. 2 CEFTIN – cefuroxime axetil tab 500 mg............................. 2 cefuroxime axetil for susp 125 mg/5ml (Ceftin)..............2 cefuroxime axetil tab 250 mg (Ceftin)............................. 2 cefuroxime axetil tab 500 mg (Ceftin)............................. 2 CELEBREX – celecoxib cap 100 mg................................ 73 CELEBREX – celecoxib cap 200 mg................................ 73 CELEBREX – celecoxib cap 400 mg................................ 73 CELEBREX – celecoxib cap 50 mg.................................. 73 celecoxib cap 100 mg (Celebrex).................................. 73 celecoxib cap 200 mg (Celebrex).................................. 73 celecoxib cap 400 mg (Celebrex).................................. 73 celecoxib cap 50 mg (Celebrex).................................... 73 CELEXA – citalopram hydrobromide tab 10 mg (base equiv)............................................................................... 57 CELEXA – citalopram hydrobromide tab 20 mg (base equiv)............................................................................... 57 CELEXA – citalopram hydrobromide tab 40 mg (base equiv)............................................................................... 57 CELLCEPT – mycophenolate mofetil cap 250 mg.......... 111 CELLCEPT – mycophenolate mofetil for oral susp 200 mg/ ml................................................................................... 111 CELLCEPT – mycophenolate mofetil tab 500 mg........... 111 CELLUGEL – hypromellose intraocular soln 2%...............97 CENTANY – mupirocin oint 2%...................................... 103 cephalexin cap 250 mg (Keflex).......................................2 cephalexin cap 500 mg (Keflex).......................................2 cephalexin cap 750 mg (Keflex).......................................2 cephalexin for susp 125 mg/5ml......................................2 cephalexin for susp 250 mg/5ml......................................2 CETRAXAL – ciprofloxacin hcl otic soln 0.2% (base equivalent)..................................................................... 100 CETROTIDE – Benefit Limits may apply – cetrorelix acetate for inj kit 0.25 mg................................................26 CHANTIX CONTINUING MONTH – varenicline tartrate tab 1 mg (base equiv)........................................................... 66 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 121 2015 CHANTIX STARTING MONTH PA – varenicline tartrate tab 0.5 mg x 11 & tab 1 mg x 42 pack............................ 66 CHANTIX – varenicline tartrate tab 0.5 mg (base equiv)............................................................................... 66 CHANTIX – varenicline tartrate tab 1 mg (base equiv)......66 chlordiazepoxide hcl cap 10 mg.................................... 56 chlordiazepoxide hcl cap 25 mg.................................... 56 chlordiazepoxide hcl cap 5 mg......................................56 chlorhexidine gluconate soln 0.12% (Peridex)........... 101 chloroquine phosphate tab 250 mg...............................10 chloroquine phosphate tab 500 mg (Aralen)................ 10 CHLOROTHIAZIDE – chlorothiazide tab 250 mg..............41 chlorothiazide tab 500 mg.............................................. 41 chlorpromazine hcl tab 100 mg..................................... 61 chlorpromazine hcl tab 10 mg....................................... 60 chlorpromazine hcl tab 200 mg..................................... 61 chlorpromazine hcl tab 25 mg....................................... 61 chlorpromazine hcl tab 50 mg....................................... 61 CHLORTHALIDONE – chlorthalidone tab 100 mg............ 41 CHLORTHALIDONE – chlorthalidone tab 25 mg.............. 41 CHLORTHALIDONE – chlorthalidone tab 50 mg.............. 41 chlorzoxazone tab 500 mg (Parafon forte dsc).............83 CHOICE-OB+DHA – prenatal mv w/fe poly-fa chw 29-1 mg & dha cap 250 mg pak ............................................ 84 cholestyramine light powder 4 gm/dose (Questran light)................................................................................ 43 cholestyramine light powder packets 4 gm..................43 cholestyramine powder 4 gm/dose (Questran)............ 43 cholestyramine powder packets 4 gm (Questran)........43 choline fenofibrate cap dr 135 mg (fenofibric acid equiv) (Trilipix)............................................................... 43 choline fenofibrate cap dr 45 mg (fenofibric acid equiv) (Trilipix)............................................................... 43 chorionic gonadotropin for inj 10000 unit – Benefit Limits may apply........................................................... 26 CICLODAN SOLUTION KIT – ciclopirox solution kit 8%..................................................................................104 ciclopirox gel 0.77%......................................................104 ciclopirox olamine cream 0.77% (base equiv)............ 104 ciclopirox olamine susp 0.77% (base equiv).............. 104 ciclopirox shampoo 1% (Loprox shampoo)................104 ciclopirox solution 8% (Penlac Nail Lacquer).............104 ciclopirox solution kit 8% (Ciclodan solution ki)........104 cilostazol tab 100 mg (Pletal).........................................97 cilostazol tab 50 mg (Pletal)...........................................97 CILOXAN – ciprofloxacin hcl ophth soln 0.3%.................. 98 cimetidine hcl soln 300 mg/5ml..................................... 50 cimetidine tab 200 mg.................................................... 50 cimetidine tab 300 mg.................................................... 50 cimetidine tab 400 mg.................................................... 50 cimetidine tab 800 mg.................................................... 50 CIPRO – ciprofloxacin hcl tab 250 mg (base equiv)............4 CIPRO – ciprofloxacin hcl tab 500 mg (base equiv)............4 CIPROFLOXACIN – ciprofloxacin hcl otic soln 0.2% (base equivalent)..................................................................... 100 122 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq) (Cipro xr)....................................................4 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq) (Cipro xr)......................................................... 4 CIPROFLOXACIN HCL – ciprofloxacin hcl tab 100 mg (base equiv).......................................................................4 ciprofloxacin hcl ophth soln 0.3% (Ciloxan).................98 ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)......... 4 ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)......... 4 ciprofloxacin hcl tab 750 mg (base equiv)......................4 CIPRO XR – ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq)............................................................. 4 CIPRO XR – ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq)..................................................................... 4 citalopram hydrobromide oral soln 10 mg/5ml.............57 citalopram hydrobromide tab 10 mg (base equiv) (Celexa)........................................................................... 57 citalopram hydrobromide tab 20 mg (base equiv) (Celexa)........................................................................... 57 citalopram hydrobromide tab 40 mg (base equiv) (Celexa)........................................................................... 57 CITRANATAL 90 DHA – prenat w/o a w/fecbn-fegl-dss-fa tab 90 &dha cap 300mg pak........................................... 84 CITRANATAL ASSURE – prenat w/o a w/fecbn-fegl-dss-fa tab & dha cap 300 mg pack............................................84 CITRANATAL B-CALM – prenat w/o a w/fecbn-feglu-fa tab 20-1 mg & vit b6 tab pak.................................................84 CITRANATAL DHA – prenat w/o a w/fecbn-fegl-dss-fa tab & dha cap 250 mg pack.................................................. 84 CITRANATAL HARMONY – prenatal w/o a w/fe cbn-dssfa-dha cap 29-1-265 mg..................................................84 CITRANATAL HARMONY – prenatal w/o vit a w/ fe cbndss-fa-dha cap 30-1-260 mg........................................... 84 CITRANATAL HARMONY – prenat w/o a w/fe fum-fe cbndss-fa-dha cap 27-1-260 mg........................................... 84 CITRANATAL RX – prenatal w/o a w/ fe carbonyl-fe glucdss-fa tab 27-1mg........................................................... 84 CLARAVIS – isotretinoin cap 30 mg............................... 104 CLARIFOAM EF – sulfacetamide sodium w/ sulfur foam 10-5%.............................................................................104 CLARINEX – desloratadine tab 5 mg............................... 45 CLARINEX REDITABS – desloratadine tab orally disintegrating 2.5 mg....................................................... 45 CLARINEX REDITABS – desloratadine tab orally disintegrating 5 mg.......................................................... 45 clarithromycin for susp 125 mg/5ml................................3 clarithromycin for susp 250 mg/5ml (Biaxin)..................3 clarithromycin tab 250 mg (Biaxin)................................. 3 clarithromycin tab 500 mg (Biaxin)................................. 3 clarithromycin tab sr 24hr 500 mg (Biaxin xl pac)..........3 CLEOCIN – clindamycin hcl cap 150 mg..........................11 CLEOCIN – clindamycin hcl cap 300 mg..........................11 CLEOCIN – clindamycin hcl cap 75 mg............................11 CLEOCIN – clindamycin phosphate vaginal cream 2%.....55 CLEOCIN PEDIATRIC GRANULE – clindamycin palmitate hcl for soln 75 mg/5ml (base equiv)................................ 11 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 2015 CLEOCIN-T – clindamycin phosphate gel 1%................ 104 CLEOCIN-T – clindamycin phosphate lotion 1%.............104 CLEOCIN-T – clindamycin phosphate soln 1%...............104 CLEOCIN-T – clindamycin phosphate swab 1%............. 104 clidinium & chlordiazepoxide cap 2.5-5 mg (Librax)............................................................................50 CLIMARA – estradiol td patch weekly 0.025 mg/24hr....... 16 CLIMARA – estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr)............................................................... 16 CLIMARA – estradiol td patch weekly 0.05 mg/24hr......... 16 CLIMARA – estradiol td patch weekly 0.06 mg/24hr......... 16 CLIMARA – estradiol td patch weekly 0.075 mg/24hr....... 16 CLIMARA – estradiol td patch weekly 0.1 mg/24hr........... 16 clindamycin hcl cap 150 mg (Cleocin).......................... 11 clindamycin hcl cap 300 mg (Cleocin).......................... 11 clindamycin hcl cap 75 mg (Cleocin)............................ 11 clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) (Cleocin pediatric gr).........................................11 clindamycin phosphate-benzoyl peroxide gel 1-5% (Benzaclin)....................................................................104 clindamycin phosphate foam 1% (Evoclin).................104 clindamycin phosphate gel 1% (Cleocin-t)................. 104 clindamycin phosphate lotion 1% (Cleocin-t).............104 clindamycin phosphate soln 1% (Cleocin-t)............... 104 clindamycin phosphate swab 1% (Cleocin-t)..............104 clindamycin phosphate vaginal cream 2% (Cleocin)..........................................................................55 clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% (Duac)................................................................104 clobetasol propionate cream 0.05% (Temovate)........ 104 clobetasol propionate emollient base cream 0.05% (Temovate e)................................................................ 104 clobetasol propionate emulsion foam 0.05% (Oluxe)....................................................................................104 clobetasol propionate foam 0.05% (Olux)................... 104 clobetasol propionate gel 0.05% (Temovate)..............104 clobetasol propionate lotion 0.05% (Clobex)..............104 clobetasol propionate oint 0.05% (Temovate)............ 104 clobetasol propionate shampoo 0.05% (Clobex)........104 clobetasol propionate soln 0.05% (Temovate)........... 104 clobetasol propionate spray 0.05% (Clobex).............. 104 CLOBEX – clobetasol propionate lotion 0.05%............... 104 CLOBEX – clobetasol propionate shampoo 0.05%.........104 CLOBEX – clobetasol propionate spray 0.05%...............104 clomiphene citrate tab 50 mg – Benefit Limits may apply................................................................................26 clomipramine hcl cap 25 mg (Anafranil)....................... 57 clomipramine hcl cap 50 mg (Anafranil)....................... 57 clomipramine hcl cap 75 mg (Anafranil)....................... 57 clonazepam orally disintegrating tab 0.125 mg............77 clonazepam orally disintegrating tab 0.25 mg..............77 clonazepam orally disintegrating tab 0.5 mg................77 clonazepam orally disintegrating tab 1 mg...................77 clonazepam orally disintegrating tab 2 mg...................77 clonazepam tab 0.5 mg (Klonopin)................................77 clonazepam tab 1 mg (Klonopin)...................................77 clonazepam tab 2 mg (Klonopin)...................................77 clonidine hcl tab 0.1 mg (Catapres).............................. 36 clonidine hcl tab 0.2 mg (Catapres).............................. 36 clonidine hcl tab 0.3 mg (Catapres).............................. 36 clonidine hcl tab sr 12hr 0.1 mg (Kapvay).................... 65 clonidine hcl td patch weekly 0.1 mg/24hr (Cataprestts-1)................................................................................ 36 clonidine hcl td patch weekly 0.2 mg/24hr (Cataprestts-2)................................................................................ 36 clonidine hcl td patch weekly 0.3 mg/24hr (Cataprestts-3)................................................................................ 36 clopidogrel bisulfate tab 300 mg (base equiv) (Plavix)............................................................................ 97 clopidogrel bisulfate tab 75 mg (base equiv) (Plavix)............................................................................ 97 clorazepate dipotassium tab 15 mg (Tranxene t)......... 56 clorazepate dipotassium tab 3.75 mg (Tranxene t)...... 56 clorazepate dipotassium tab 7.5 mg (Tranxene t)........ 56 clotrimazole troche 10 mg............................................101 clotrimazole w/ betamethasone cream 1-0.05% (Lotrisone).................................................................... 104 clotrimazole w/ betamethasone lotion 1-0.05%.......... 104 clozapine tab 100 mg (Clozaril)..................................... 61 clozapine tab 200 mg......................................................61 clozapine tab 25 mg (Clozaril)....................................... 61 clozapine tab 50 mg........................................................61 CLOZARIL – clozapine tab 100 mg.................................. 61 CLOZARIL – clozapine tab 25 mg.................................... 61 C-NATE DHA – prenatal vit w/ fe fum-fa-omega 3 cap 28-1-200 mg.................................................................... 84 COARTEM – artemether-lumefantrine tab 20-120 mg...... 10 CODEINE SULFATE – codeine sulfate tab 15 mg............69 CODEINE SULFATE – codeine sulfate tab 30 mg............69 CODEINE SULFATE – codeine sulfate tab 60 mg............69 codeine sulfate tab 15 mg (Codeine sulfate)................ 69 codeine sulfate tab 30 mg..............................................69 codeine sulfate tab 60 mg..............................................69 COLAZAL – balsalazide disodium cap 750 mg.................53 COLCHICINE – colchicine tab 0.6 mg.............................. 76 colchicine w/ probenecid tab 0.5-500 mg......................76 COLCRYS – colchicine tab 0.6 mg...................................76 COLESTID – colestipol hcl granule packets 5 gm............ 43 COLESTID – colestipol hcl granules 5 gm........................43 COLESTID – colestipol hcl tab 1 gm................................ 43 COLESTID FLAVORED – colestipol hcl granule packets 5 gm.................................................................................... 43 COLESTID FLAVORED – colestipol hcl granules 5 gm.................................................................................... 43 colestipol hcl granule packets 5 gm (Colestid flavored)..........................................................................43 colestipol hcl granules 5 gm (Colestid flavored)..........43 colestipol hcl tab 1 gm (Colestid)..................................43 COLYTE-FLAVOR PACKS – peg 3350-kcl-na bicarb-naclna sulfate for soln 227.1 gm............................................49 COLYTE-FLAVOR PACKS – peg 3350-kcl-na bicarb-naclna sulfate for soln 240 gm.............................................. 49 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 123 2015 COMBIGAN – brimonidine tartrate-timolol maleate ophth soln 0.2-0.5%...................................................................98 COMBIVENT RESPIMAT – ipratropium-albuterol inhal aerosol soln 20-100 mcg/act........................................... 48 COMBIVIR – lamivudine-zidovudine tab 150-300 mg......... 6 COMETRIQ – cabozantinib s-malate cap 3 x 20 mg (60 mg dose) kit.....................................................................12 COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 1 x 20 mg (100 dose) kit............................................................ 12 COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 3 x 20 mg (140 dose) kit............................................................ 12 COMPLERA – emtricitabine-rilpivirine-tenofovir df tab 200-25-300 mg.................................................................. 6 COMPLETE NATAL DHA – prenat-fe bis-fe prot succ-faca tab & omega 3 cap 250 pk.........................................84 COMPLETENATE – prenatal vit w/ fe fumarate-fa chew tab 29-1 mg..................................................................... 84 COMTAN – entacapone tab 200 mg.................................81 CO-NATAL FA – prenatal vit w/ fe fumarate-fa tab 29-1 mg.................................................................................... 84 CONCEPT DHA – prenatal w/fe fum-fe poly -fa-omega 3 cap 53.5-38-1 mg............................................................ 84 CONCEPT OB – prenatal w/o a w/fe fum-fe poly-fa cap 130-92.4-1 mg................................................................. 84 CONCERTA – methylphenidate hcl tab sa osm 18 mg..... 65 CONCERTA – methylphenidate hcl tab sa osm 27 mg..... 65 CONCERTA – methylphenidate hcl tab sa osm 36 mg..... 65 CONCERTA – methylphenidate hcl tab sa osm 54 mg..... 65 CONDYLOX – podofilox soln 0.5%.................................104 COPAXONE – glatiramer acetate inj kit 20 mg/ml............ 66 COPAXONE – glatiramer acetate soln prefilled syringe 40 mg/ml............................................................................... 66 COPEGUS – ribavirin tab 200 mg...................................... 6 CORDARONE – amiodarone hcl tab 200 mg................... 33 COREG – carvedilol tab 12.5 mg..................................... 29 COREG – carvedilol tab 25 mg........................................ 29 COREG – carvedilol tab 3.125 mg................................... 29 COREG – carvedilol tab 6.25 mg..................................... 29 CORGARD – nadolol tab 20 mg.......................................29 CORGARD – nadolol tab 40 mg.......................................29 CORGARD – nadolol tab 80 mg.......................................29 CORTANE-B AQUEOUS – pramoxine-hc-chloroxylenol aqueous otic soln 10-10-1 mg/ml.................................. 100 CORTANE-B-OTIC – pramoxine-hc-chloroxylenol otic soln 10-10-1 mg/ml............................................................... 100 CORTEF – hydrocortisone tab 10 mg...............................14 CORTEF – hydrocortisone tab 20 mg...............................14 CORTEF – hydrocortisone tab 5 mg.................................14 CORTENEMA – hydrocortisone enema 100 mg/60ml......................................................................... 102 CORTIFOAM – hydrocortisone acetate rectal foam 90 mg/ dose............................................................................... 102 CORTISONE ACETATE – cortisone acetate tab 25 mg.................................................................................... 14 CORTISPORIN – neomycin-polymyxin-hc otic soln 1%..................................................................................100 124 CORVITE 150 – iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg.................................................................... 94 CORZIDE – nadolol & bendroflumethiazide tab 40-5 mg.................................................................................... 36 CORZIDE – nadolol & bendroflumethiazide tab 80-5 mg.................................................................................... 36 COSOPT – dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml.................................................................98 COUMADIN – warfarin sodium tab 10 mg........................ 95 COUMADIN – warfarin sodium tab 1 mg.......................... 95 COUMADIN – warfarin sodium tab 2.5 mg....................... 95 COUMADIN – warfarin sodium tab 2 mg.......................... 95 COUMADIN – warfarin sodium tab 3 mg.......................... 95 COUMADIN – warfarin sodium tab 4 mg.......................... 95 COUMADIN – warfarin sodium tab 5 mg.......................... 95 COUMADIN – warfarin sodium tab 6 mg.......................... 95 COUMADIN – warfarin sodium tab 7.5 mg....................... 95 COZAAR – losartan potassium tab 100 mg...................... 36 COZAAR – losartan potassium tab 25 mg........................ 36 COZAAR – losartan potassium tab 50 mg........................ 36 CRESTOR – rosuvastatin calcium tab 10 mg................... 43 CRESTOR – rosuvastatin calcium tab 20 mg................... 43 CRESTOR – rosuvastatin calcium tab 40 mg................... 43 CRESTOR – rosuvastatin calcium tab 5 mg..................... 43 CRINONE – progesterone vaginal gel 4%........................ 55 CRINONE – progesterone vaginal gel 8%........................ 55 CRIXIVAN – indinavir sulfate cap 200 mg.......................... 6 CRIXIVAN – indinavir sulfate cap 400 mg.......................... 6 CROMOLYN SODIUM – cromolyn sodium soln nebu 20 mg/2ml............................................................................. 48 cromolyn sodium ophth soln 4%...................................98 cromolyn sodium oral conc 100 mg/5ml (Gastrocrom).................................................................. 53 CUPRIMINE – penicillamine cap 250 mg....................... 111 CUTIVATE – fluticasone propionate cream 0.05%......... 104 CUTIVATE – fluticasone propionate lotion 0.05%...........104 cyanocobalamin inj 1000 mcg/ml.................................. 94 CYCLESSA – desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg-mg........................ 18 cyclobenzaprine hcl tab 10 mg......................................83 cyclobenzaprine hcl tab 5 mg........................................83 cyclobenzaprine hcl tab 7.5 mg (Fexmid)..................... 83 CYCLOGYL – cyclopentolate hcl ophth soln 1%.............. 98 CYCLOGYL – cyclopentolate hcl ophth soln 2%.............. 98 cyclopentolate hcl ophth soln 1% (Cyclogyl)............... 98 cyclopentolate hcl ophth soln 2% (Cyclogyl)............... 98 CYCLOPHOSPHAMIDE – cyclophosphamide cap 25 mg.................................................................................... 12 CYCLOPHOSPHAMIDE – cyclophosphamide cap 50 mg.................................................................................... 12 cyclosporine cap 100 mg (Sandimmune)....................111 cyclosporine cap 25 mg (Sandimmune)......................111 cyclosporine modified cap 100 mg (Neoral)............... 111 cyclosporine modified cap 25 mg (Neoral)................. 111 CYCLOSPORINE MODIFIED – cyclosporine modified cap 50 mg.............................................................................111 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 2015 cyclosporine modified oral soln 100 mg/ml (Neoral)......................................................................... 111 CYMBALTA – duloxetine hcl enteric coated pellets cap 20 mg.................................................................................... 57 CYMBALTA – duloxetine hcl enteric coated pellets cap 30 mg.................................................................................... 57 CYMBALTA – duloxetine hcl enteric coated pellets cap 60 mg.................................................................................... 57 cyproheptadine hcl syrup 2 mg/5ml..............................45 cyproheptadine hcl tab 4 mg......................................... 45 CYSTARAN – cysteamine hcl ophth soln 0.44% (base equivalent)....................................................................... 98 CYTOMEL – liothyronine sodium tab 25 mcg................... 23 CYTOMEL – liothyronine sodium tab 50 mcg................... 23 CYTOMEL – liothyronine sodium tab 5 mcg..................... 23 CYTOTEC – misoprostol tab 100 mcg..............................50 CYTOTEC – misoprostol tab 200 mcg..............................50 D D.H.E. 45 – dihydroergotamine mesylate inj 1 mg/ml....... 75 DALIRESP – roflumilast tab 500 mcg............................... 48 danazol cap 100 mg........................................................ 16 danazol cap 200 mg........................................................ 16 danazol cap 50 mg..........................................................16 DANTRIUM – dantrolene sodium cap 100 mg.................. 83 DANTRIUM – dantrolene sodium cap 25 mg.................... 83 DANTRIUM – dantrolene sodium cap 50 mg.................... 83 dantrolene sodium cap 25 mg (Dantrium).................... 83 dantrolene sodium cap 50 mg (Dantrium).................... 83 DANTROLENE SODIUM – dantrolene sodium cap 100 mg.................................................................................... 83 DAPSONE – dapsone tab 100 mg................................... 11 DAPSONE – dapsone tab 25 mg..................................... 11 DARAPRIM – pyrimethamine tab 25 mg...........................10 DAYPRO – oxaprozin tab 600 mg.................................... 73 DDAVP – desmopressin acetate nasal soln 0.01% (refrigerated).................................................................... 26 DDAVP – desmopressin acetate nasal spray soln 0.01%...............................................................................26 DDAVP – desmopressin acetate tab 0.1 mg.....................26 DDAVP – desmopressin acetate tab 0.2 mg.....................26 DELESTROGEN – estradiol valerate im in oil 10 mg/ ml..................................................................................... 17 DELESTROGEN – estradiol valerate im in oil 20 mg/ ml..................................................................................... 17 DELESTROGEN – estradiol valerate im in oil 40 mg/ ml..................................................................................... 17 DELZICOL – mesalamine cap dr 400 mg......................... 53 DEMADEX – torsemide tab 100 mg................................. 41 DEMADEX – torsemide tab 10 mg................................... 41 DEMADEX – torsemide tab 20 mg................................... 41 DEMADEX – torsemide tab 5 mg..................................... 41 demeclocycline hcl tab 150 mg....................................... 3 demeclocycline hcl tab 300 mg....................................... 3 DEMEROL – meperidine hcl tab 100 mg..........................69 DEMEROL – meperidine hcl tab 50 mg............................69 DENAVIR – penciclovir cream 1%.................................. 104 DEPAKENE – valproate sodium syrup 250 mg/5ml (base equiv)............................................................................... 77 DEPAKENE – valproic acid cap 250 mg...........................77 DEPAKOTE – divalproex sodium tab delayed release 125 mg.................................................................................... 77 DEPAKOTE – divalproex sodium tab delayed release 250 mg.................................................................................... 77 DEPAKOTE – divalproex sodium tab delayed release 500 mg.................................................................................... 77 DEPAKOTE ER – divalproex sodium tab sr 24 hr 250 mg.................................................................................... 77 DEPAKOTE ER – divalproex sodium tab sr 24 hr 500 mg.................................................................................... 77 DEPAKOTE SPRINKLES – divalproex sodium cap sprinkle 125 mg............................................................... 77 DEPEN TITRATABS – penicillamine tab 250 mg............111 DEPO-PROVERA CONTRACEPTIV – medroxyprogesterone acetate im susp 150 mg/ml.......... 18 DEPO-TESTOSTERONE – testosterone cypionate im inj in oil 100 mg/ml...............................................................16 DEPO-TESTOSTERONE – testosterone cypionate im inj in oil 200 mg/ml...............................................................16 DERMA-SMOOTHE/FS BODY – fluocinolone acetonide oil 0.01% (body oil)........................................................104 DERMA-SMOOTHE/FS BODY OIL – fluocinolone acetonide oil 0.01% (body oil)....................................... 105 DERMA-SMOOTHE/FS SCALP – fluocinolone acetonide oil 0.01% (scalp oil)....................................................... 105 DERMA-SMOOTHE/FS SCALP OI – fluocinolone acetonide oil 0.01% (scalp oil)...................................... 105 DERMATOP – prednicarbate cream 0.1%......................105 DERMATOP – prednicarbate oint 0.1%.......................... 105 DERMOTIC – fluocinolone acetonide (otic) oil 0.01%..... 100 desipramine hcl tab 100 mg (Norpramin)......................57 desipramine hcl tab 10 mg (Norpramin)....................... 57 desipramine hcl tab 150 mg (Norpramin)......................57 desipramine hcl tab 25 mg (Norpramin)....................... 58 desipramine hcl tab 50 mg (Norpramin)....................... 58 desipramine hcl tab 75 mg (Norpramin)....................... 58 desloratadine tab 5 mg (Clarinex)................................. 45 desloratadine tab orally disintegrating 2.5 mg (Clarinex reditabs)......................................................... 45 desloratadine tab orally disintegrating 5 mg (Clarinex reditabs)..........................................................................45 desmopressin acetate nasal soln 0.01% (refrigerated) (Ddavp)............................................................................26 desmopressin acetate nasal spray soln 0.01% (Ddavp)............................................................................26 desmopressin acetate nasal spray soln 0.01% (refrigerated)...................................................................26 desmopressin acetate tab 0.1 mg (Ddavp)................... 26 desmopressin acetate tab 0.2 mg (Ddavp)................... 26 DESOGEN – desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg.......................................................................18 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 125 2015 desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5) (Mircette).........................................................18 desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg-mg (Cyclessa)....................................................................... 18 desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg (Desogen)....................................................................... 18 desonide cream 0.05% (Desowen)...............................105 desonide lotion 0.05% (Desowen)............................... 105 desonide oint 0.05% (Desowen).................................. 105 DESOWEN – desonide cream 0.05%.............................105 DESOWEN – desonide lotion 0.05%.............................. 105 DESOWEN – desonide oint 0.05%................................. 105 desoximetasone cream 0.25% (Topicort)....................105 DESOXIMETASONE – desoximetasone cream 0.05%.............................................................................105 desoximetasone gel 0.05% (Topicort)......................... 105 desoximetasone oint 0.25% (Topicort)........................105 DETROL – tolterodine tartrate tab 1 mg........................... 54 DETROL – tolterodine tartrate tab 2 mg........................... 54 DEX4 GLUCOSE – glucose oral liquid 15 gm/59ml.......... 20 DEXAMETHASONE – dexamethasone soln 0.5 mg/5ml............................................................................. 14 DEXAMETHASONE – dexamethasone tab 1 mg............. 14 DEXAMETHASONE – dexamethasone tab 2 mg............. 14 dexamethasone elixir 0.5 mg/5ml.................................. 15 DEXAMETHASONE INTENSOL – dexamethasone conc 1 mg/ml............................................................................... 15 dexamethasone sodium phosphate ophth soln 0.1%.................................................................................98 dexamethasone tab 0.5 mg............................................ 15 dexamethasone tab 0.75 mg.......................................... 15 dexamethasone tab 1.5 mg............................................ 15 dexamethasone tab 4 mg............................................... 15 dexamethasone tab 6 mg............................................... 15 DEXEDRINE – dextroamphetamine sulfate cap sr 24hr 10 mg.................................................................................... 65 DEXEDRINE – dextroamphetamine sulfate cap sr 24hr 15 mg.................................................................................... 65 DEXEDRINE – dextroamphetamine sulfate cap sr 24hr 5 mg.................................................................................... 65 dexmethylphenidate hcl tab 10 mg (Focalin)................65 dexmethylphenidate hcl tab 2.5 mg (Focalin)...............65 dexmethylphenidate hcl tab 5 mg (Focalin)..................65 DEXPAK 10 DAY – dexamethasone tab 1.5 mg taper pack................................................................................. 15 DEXPAK 13 DAY – dexamethasone tab 1.5 mg taper pack................................................................................. 15 DEXPAK 6 DAY – dexamethasone tab 1.5 mg taper pack................................................................................. 15 dextroamphetamine sulfate cap sr 24hr 10 mg (Dexedrine)..................................................................... 65 dextroamphetamine sulfate cap sr 24hr 15 mg (Dexedrine)..................................................................... 65 dextroamphetamine sulfate cap sr 24hr 5 mg (Dexedrine)..................................................................... 65 126 dextroamphetamine sulfate tab 10 mg..........................65 dextroamphetamine sulfate tab 5 mg............................65 DIAMOX – acetazolamide cap sr 12hr 500 mg................. 41 DIASTAT ACUDIAL – diazepam rectal gel delivery system 10 mg...............................................................................77 DIASTAT ACUDIAL – diazepam rectal gel delivery system 20 mg...............................................................................77 DIASTAT PEDIATRIC – diazepam rectal gel delivery system 2.5 mg................................................................. 77 DIAZEPAM – diazepam rectal gel delivery system 10 mg.................................................................................... 77 DIAZEPAM – diazepam rectal gel delivery system 2.5 mg.................................................................................... 77 DIAZEPAM – diazepam rectal gel delivery system 20 mg.................................................................................... 77 diazepam tab 10 mg (Valium).........................................56 diazepam tab 2 mg (Valium)...........................................56 diazepam tab 5 mg (Valium)...........................................56 diclofenac potassium tab 50 mg (Cataflam)................. 74 diclofenac sodium ophth soln 0.1%.............................. 98 diclofenac sodium tab delayed release 25 mg............. 74 diclofenac sodium tab delayed release 50 mg............. 74 diclofenac sodium tab delayed release 75 mg............. 74 diclofenac sodium tab sr 24hr 100 mg (Voltarenxr).................................................................................... 74 diclofenac w/ misoprostol tab delayed release 50-0.2 mg (Arthrotec 50).......................................................... 74 diclofenac w/ misoprostol tab delayed release 75-0.2 mg (Arthrotec 75).......................................................... 74 dicloxacillin sodium cap 250 mg..................................... 1 dicloxacillin sodium cap 500 mg..................................... 1 dicyclomine hcl cap 10 mg (Bentyl).............................. 50 dicyclomine hcl tab 20 mg (Bentyl)...............................50 didanosine delayed release capsule 125 mg (Videx ec)......................................................................................6 didanosine delayed release capsule 200 mg (Videx ec)......................................................................................6 didanosine delayed release capsule 250 mg (Videx ec)......................................................................................6 didanosine delayed release capsule 400 mg (Videx ec)......................................................................................6 DIFFERIN – adapalene cream 0.1%...............................105 DIFFERIN – adapalene gel 0.1%....................................105 DIFICID – fidaxomicin tab 200 mg......................................3 DIFLORASONE DIACETATE – diflorasone diacetate cream 0.05%................................................................. 105 diflorasone diacetate oint 0.05%................................. 105 DIFLUCAN – fluconazole for susp 10 mg/ml...................... 5 DIFLUCAN – fluconazole for susp 40 mg/ml...................... 5 DIFLUCAN – fluconazole tab 100 mg.................................5 DIFLUCAN – fluconazole tab 150 mg.................................5 DIFLUCAN – fluconazole tab 200 mg.................................5 DIFLUCAN – fluconazole tab 50 mg...................................5 diflunisal tab 500 mg...................................................... 68 digoxin tab 125 mcg (0.125 mg) (Lanoxin)....................28 digoxin tab 250 mcg (0.25 mg) (Lanoxin)......................28 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 2015 dihydroergotamine mesylate inj 1 mg/ml (D.h.e. 45)....................................................................................75 DILANTIN INFATABS – phenytoin chew tab 50 mg..........77 DILANTIN – phenytoin sodium extended cap 100 mg.......77 DILANTIN – phenytoin sodium extended cap 30 mg........ 77 DILANTIN – phenytoin susp 125 mg/5ml..........................77 DILAUDID – hydromorphone hcl tab 2 mg........................69 DILAUDID – hydromorphone hcl tab 4 mg........................69 DILAUDID – hydromorphone hcl tab 8 mg........................69 diltiazem hcl cap sr 12hr 120 mg...................................31 diltiazem hcl cap sr 12hr 60 mg.................................... 31 diltiazem hcl cap sr 12hr 90 mg.................................... 31 diltiazem hcl cap sr 24hr 120 mg...................................31 diltiazem hcl cap sr 24hr 180 mg...................................31 diltiazem hcl cap sr 24hr 240 mg...................................31 diltiazem hcl coated beads cap sr 24hr 120 mg (Cardizem cd)................................................................. 31 diltiazem hcl coated beads cap sr 24hr 180 mg (Cardizem cd)................................................................. 31 diltiazem hcl coated beads cap sr 24hr 240 mg (Cardizem cd)................................................................. 31 diltiazem hcl coated beads cap sr 24hr 300 mg (Cardizem cd)................................................................. 31 diltiazem hcl coated beads cap sr 24hr 360 mg (Cardizem cd)................................................................. 31 diltiazem hcl coated beads tab sr 24hr 180 mg (Cardizem la).................................................................. 31 diltiazem hcl coated beads tab sr 24hr 240 mg (Cardizem la).................................................................. 31 diltiazem hcl coated beads tab sr 24hr 300 mg (Cardizem la).................................................................. 31 diltiazem hcl coated beads tab sr 24hr 360 mg (Cardizem la).................................................................. 31 diltiazem hcl coated beads tab sr 24hr 420 mg (Cardizem la).................................................................. 31 diltiazem hcl extended release beads cap sr 24hr 120 mg (Tiazac).....................................................................32 diltiazem hcl extended release beads cap sr 24hr 180 mg (Tiazac).....................................................................32 diltiazem hcl extended release beads cap sr 24hr 240 mg (Tiazac).....................................................................32 diltiazem hcl extended release beads cap sr 24hr 300 mg (Tiazac).....................................................................32 diltiazem hcl extended release beads cap sr 24hr 360 mg (Tiazac).....................................................................32 diltiazem hcl extended release beads cap sr 24hr 420 mg (Tiazac).....................................................................32 diltiazem hcl tab 120 mg (Cardizem)............................. 32 diltiazem hcl tab 30 mg (Cardizem)............................... 32 diltiazem hcl tab 60 mg (Cardizem)............................... 32 diltiazem hcl tab 90 mg.................................................. 32 DIOVAN HCT – valsartan-hydrochlorothiazide tab 160-12.5 mg.................................................................... 36 DIOVAN HCT – valsartan-hydrochlorothiazide tab 160-25 mg.................................................................................... 37 DIOVAN HCT – valsartan-hydrochlorothiazide tab 320-12.5 mg.................................................................... 37 DIOVAN HCT – valsartan-hydrochlorothiazide tab 320-25 mg.................................................................................... 37 DIOVAN HCT – valsartan-hydrochlorothiazide tab 80-12.5 mg.................................................................................... 36 DIOVAN – valsartan tab 160 mg...................................... 36 DIOVAN – valsartan tab 320 mg...................................... 36 DIOVAN – valsartan tab 40 mg........................................ 36 DIOVAN – valsartan tab 80 mg........................................ 36 DIPENTUM – olsalazine sodium cap 250 mg................... 53 DIPHENOXYLATE/ATROPINE – diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml..........................................49 diphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil)..........................................................................49 DIPROLENE AF – betamethasone dipropionate augmented cream 0.05%.............................................. 105 DIPROLENE – betamethasone dipropionate augmented lotion 0.05%...................................................................105 DIPROLENE – betamethasone dipropionate augmented oint 0.05%......................................................................105 dipyridamole tab 25 mg (Persantine)............................ 97 dipyridamole tab 50 mg (Persantine)............................ 97 dipyridamole tab 75 mg (Persantine)............................ 97 disopyramide phosphate cap 100 mg (Norpace)..........33 disopyramide phosphate cap 150 mg (Norpace)..........33 disulfiram tab 250 mg (Antabuse)................................. 66 disulfiram tab 500 mg (Antabuse)................................. 66 DITROPAN XL – oxybutynin chloride tab sr 24hr 10 mg.................................................................................... 54 DITROPAN XL – oxybutynin chloride tab sr 24hr 15 mg.................................................................................... 54 DITROPAN XL – oxybutynin chloride tab sr 24hr 5 mg.....54 divalproex sodium cap sprinkle 125 mg (Depakote sprinkles)........................................................................ 77 divalproex sodium tab delayed release 125 mg (Depakote)...................................................................... 77 divalproex sodium tab delayed release 250 mg (Depakote)...................................................................... 77 divalproex sodium tab delayed release 500 mg (Depakote)...................................................................... 78 divalproex sodium tab sr 24 hr 250 mg (Depakote er).................................................................................... 78 divalproex sodium tab sr 24 hr 500 mg (Depakote er).................................................................................... 78 DIVIGEL – estradiol td gel 0.25 mg/0.25gm (0.1%).......... 17 DIVIGEL – estradiol td gel 0.5 mg/0.5gm (0.1%).............. 17 DIVIGEL – estradiol td gel 1 mg/gm (0.1%)...................... 17 DOLOPHINE HCL – methadone hcl tab 5 mg.................. 69 DOLOPHINE – methadone hcl tab 10 mg........................ 69 donepezil hydrochloride orally disintegrating tab 10 mg (Aricept odt).............................................................67 donepezil hydrochloride orally disintegrating tab 5 mg....................................................................................67 donepezil hydrochloride tab 10 mg (Aricept)............... 67 donepezil hydrochloride tab 23 mg (Aricept)............... 67 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 127 2015 donepezil hydrochloride tab 5 mg (Aricept)................. 67 DONNATAL – pb-hyoscy-atrop-scopol elix 16.2-0.1037-0.0194-0.0065 mg/5ml................................ 50 DONNATAL – pb-hyoscy-atrop-scopol tab 16.2-0.1037-0.0194-0.0065 mg....................................... 50 dorzolamide hcl ophth soln 2% (Trusopt).....................98 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml (Cosopt).............................................................. 98 DOVONEX – calcipotriene cream 0.005%...................... 105 doxazosin mesylate tab 1 mg (Cardura)....................... 37 doxazosin mesylate tab 2 mg (Cardura)....................... 37 doxazosin mesylate tab 4 mg (Cardura)....................... 37 doxazosin mesylate tab 8 mg (Cardura)....................... 37 doxepin hcl cap 100 mg................................................. 58 doxepin hcl cap 10 mg................................................... 58 doxepin hcl cap 150 mg................................................. 58 doxepin hcl cap 25 mg................................................... 58 doxepin hcl cap 50 mg................................................... 58 doxepin hcl conc 10 mg/ml............................................ 58 DOXEPIN HCL – doxepin hcl cap 75 mg..........................58 doxycycline hyclate cap 100 mg (Vibramycin)............... 3 doxycycline hyclate cap 50 mg....................................... 3 doxycycline hyclate tab 100 mg...................................... 3 doxycycline hyclate tab 20 mg........................................ 3 doxycycline hyclate tab delayed release 100 mg........... 3 doxycycline hyclate tab delayed release 150 mg (Doryx).............................................................................. 3 doxycycline hyclate tab delayed release 75 mg............. 3 doxycycline monohydrate cap 100 mg (Monodox)........ 3 doxycycline monohydrate cap 150 mg (Adoxa)............. 3 doxycycline monohydrate cap 50 mg............................. 3 doxycycline monohydrate cap 75 mg (Monodox).......... 3 doxycycline monohydrate for susp 25 mg/5ml (Vibramycin)..................................................................... 3 doxycycline monohydrate tab 100 mg (Adoxa pak 1/100).................................................................................3 doxycycline monohydrate tab 150 mg (Adoxa pak 1/150).................................................................................3 doxycycline monohydrate tab 50 mg (Adoxa)................ 3 doxycycline monohydrate tab 75 mg (Adoxa)................ 4 DRISDOL – ergocalciferol cap 50000 unit........................ 84 dronabinol cap 10 mg (Marinol).....................................52 dronabinol cap 2.5 mg (Marinol)....................................52 dronabinol cap 5 mg (Marinol).......................................52 drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz)..... 18 drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin 28)....................................................................................18 DROXIA – hydroxyurea cap 200 mg.................................94 DROXIA – hydroxyurea cap 300 mg.................................94 DROXIA – hydroxyurea cap 400 mg.................................94 DRYSOL – aluminum chloride soln 20%........................ 105 DUAC – clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5%......................................................................105 DUETACT – pioglitazone hcl-glimepiride tab 30-2 mg...... 20 DUETACT – pioglitazone hcl-glimepiride tab 30-4 mg...... 20 128 DUET DHA 400 – prenat w/fe poly-na fered-fa tab 25-1 & omega cap 400 mg......................................................... 85 DUET DHA BALANCED – prenat w/fe poly-na fered-fa tab 25-1 & omega cap 267 mg............................................. 85 DUET DHA BALANCED – prenat w/fe poly-na fered-fa tab 27-1 & omega cap dr 380mg.......................................... 85 DUET DHA – prenat w/fe poly-na fered-fa tab 25-1 & omega cap 400 mg......................................................... 84 duloxetine hcl enteric coated pellets cap 20 mg (Cymbalta)...................................................................... 58 duloxetine hcl enteric coated pellets cap 30 mg (Cymbalta)...................................................................... 58 duloxetine hcl enteric coated pellets cap 60 mg (Cymbalta)...................................................................... 58 DURAGESIC – fentanyl td patch 72hr 100 mcg/hr............69 DURAGESIC – fentanyl td patch 72hr 12 mcg/hr............. 69 DURAGESIC – fentanyl td patch 72hr 25 mcg/hr............. 69 DURAGESIC – fentanyl td patch 72hr 50 mcg/hr............. 69 DURAGESIC – fentanyl td patch 72hr 75 mcg/hr............. 69 DUTOPROL – metoprolol & hydrochlorothiazide tab sr 24hr 100-12.5 mg............................................................ 37 DUTOPROL – metoprolol & hydrochlorothiazide tab sr 24hr 25-12.5 mg.............................................................. 37 DUTOPROL – metoprolol & hydrochlorothiazide tab sr 24hr 50-12.5 mg.............................................................. 37 DYAZIDE – triamterene & hydrochlorothiazide cap 37.5-25 mg.................................................................................... 41 DYMISTA – azelastine hcl-fluticasone prop nasal spray 137-50 mcg/act................................................................ 46 DYRENIUM – triamterene cap 100 mg............................. 41 DYRENIUM – triamterene cap 50 mg...............................41 E E.E.S. 400 – erythromycin ethylsuccinate tab 400 mg........ 3 EC-NAPROSYN – naproxen tab ec 375 mg..................... 74 EC-NAPROSYN – naproxen tab ec 500 mg..................... 74 econazole nitrate cream 1%......................................... 105 EDURANT – rilpivirine hcl tab 25 mg (base equivalent)...... 6 EFFER-K – potassium bicarbonate-citric acid effer tab 10 meq.................................................................................. 92 EFFER-K – potassium bicarbonate-citric acid effer tab 20 meq.................................................................................. 92 EFFEXOR XR – venlafaxine hcl cap sr 24hr 150 mg (base equivalent)....................................................................... 58 EFFEXOR XR – venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent)............................................................. 58 EFFEXOR XR – venlafaxine hcl cap sr 24hr 75 mg (base equivalent)....................................................................... 58 EFFIENT – prasugrel hcl tab 10 mg (base equiv)............. 97 EFFIENT – prasugrel hcl tab 5 mg (base equiv)............... 97 EFUDEX – fluorouracil cream 5%...................................105 ELDEPRYL – selegiline hcl cap 5 mg...............................81 ELESTAT – epinastine hcl ophth soln 0.05%................... 98 ELIGARD – leuprolide acetate (3 month) for subcutaneous inj kit 22.5mg................................................................... 12 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 2015 ELIGARD – leuprolide acetate (4 month) for subcutaneous inj kit 30 mg.....................................................................12 ELIGARD – leuprolide acetate (6 month) for subcutaneous inj kit 45 mg.....................................................................12 ELIGARD – leuprolide acetate for subcutaneous inj kit 7.5 mg.................................................................................... 12 ELIPHOS – calcium acetate (phosphate binder) tab 667 mg.................................................................................... 53 ELIQUIS – apixaban tab 2.5 mg....................................... 95 ELIQUIS – apixaban tab 5 mg.......................................... 95 ELITE-OB – prenatal vit w/ iron carbonyl-fa tab 50-1.25 mg.................................................................................... 85 ELIXOPHYLLIN – theophylline elixir 80 mg/15ml..............48 ELLA – ulipristal acetate tab 30 mg.................................. 18 ELMIRON – pentosan polysulfate sodium caps 100 mg.................................................................................... 55 ELOCON – mometasone furoate cream 0.1%................ 105 ELOCON – mometasone furoate oint 0.1%.................... 105 ELOCON – mometasone furoate solution 0.1% (lotion)............................................................................ 105 EMCYT – estramustine phosphate sodium cap 140 mg.................................................................................... 12 EMEND – aprepitant capsule 125 mg...............................52 EMEND – aprepitant capsule 40 mg.................................52 EMEND – aprepitant capsule 80 mg.................................52 EMEND – aprepitant capsule therapy pack 80 & 125 mg.................................................................................... 52 EMTRIVA – emtricitabine caps 200 mg.............................. 6 EMTRIVA – emtricitabine soln 10 mg/ml............................ 6 enalapril maleate & hydrochlorothiazide tab 10-25 mg (Vaseretic).......................................................................37 enalapril maleate & hydrochlorothiazide tab 5-12.5 mg....................................................................................37 enalapril maleate tab 10 mg (Vasotec).......................... 37 enalapril maleate tab 2.5 mg (Vasotec)......................... 37 enalapril maleate tab 20 mg (Vasotec).......................... 37 enalapril maleate tab 5 mg (Vasotec)............................ 37 ENBREL – etanercept for subcutaneous inj kit 25 mg...... 74 ENBREL – etanercept subcutaneous soln prefilled syringe 25 mg/0.5ml.....................................................................74 ENBREL – etanercept subcutaneous soln prefilled syringe 50 mg/ml..........................................................................74 ENBREL SURECLICK – etanercept subcutaneous solution auto-injector 50 mg/ml....................................... 74 ENDOMETRIN – progesterone vaginal insert 100 mg...... 55 enoxaparin sodium inj 100 mg/ml (Lovenox)............... 95 enoxaparin sodium inj 120 mg/0.8ml (Lovenox)...........95 enoxaparin sodium inj 150 mg/ml (Lovenox)............... 95 enoxaparin sodium inj 300 mg/3ml (Lovenox)..............95 enoxaparin sodium inj 30 mg/0.3ml (Lovenox).............95 enoxaparin sodium inj 40 mg/0.4ml (Lovenox).............95 enoxaparin sodium inj 60 mg/0.6ml (Lovenox).............95 enoxaparin sodium inj 80 mg/0.8ml (Lovenox).............95 entacapone tab 200 mg (Comtan)..................................81 entecavir tab 0.5 mg (Baraclude).....................................6 entecavir tab 1 mg (Baraclude)........................................6 ENTEREG – alvimopan cap 12 mg.................................. 53 ENTOCORT EC – budesonide cap sr 24hr 3 mg..............15 epinastine hcl ophth soln 0.05% (Elestat).....................98 EPINEPHRINE – epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000)..........................................................42 EPINEPHRINE – epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)............................................................42 EPIPEN 2-PAK – epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)............................................................42 EPIPEN-JR 2-PAK – epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000)................................................... 42 EPIVIR HBV – lamivudine oral soln 5 mg/ml...................... 6 EPIVIR HBV – lamivudine tab 100 mg............................... 6 EPIVIR – lamivudine oral soln 10 mg/ml.............................6 EPIVIR – lamivudine tab 150 mg........................................6 EPIVIR – lamivudine tab 300 mg........................................6 eplerenone tab 25 mg (Inspra).......................................37 eplerenone tab 50 mg (Inspra).......................................37 EPOGEN – epoetin alfa inj 10000 unit/ml......................... 94 EPOGEN – epoetin alfa inj 20000 unit/ml......................... 94 EPOGEN – epoetin alfa inj 2000 unit/ml...........................94 EPOGEN – epoetin alfa inj 3000 unit/ml...........................94 EPOGEN – epoetin alfa inj 4000 unit/ml...........................94 eprosartan mesylate tab 600 mg (Teveten)...................37 EPZICOM – abacavir sulfate-lamivudine tab 600-300 mg...................................................................................... 6 ergocalciferol cap 50000 unit (Drisdol)......................... 84 ERIVEDGE – vismodegib cap 150 mg............................. 12 ERY-TAB – erythromycin tab delayed release 250 mg....... 3 ERY-TAB – erythromycin tab delayed release 333 mg....... 3 ERY-TAB – erythromycin tab delayed release 500 mg....... 3 ERYTHROCIN STEARATE – erythromycin stearate tab 250 mg...............................................................................3 ERYTHROMYCIN BASE – erythromycin tab 250 mg......... 3 ERYTHROMYCIN BASE – erythromycin tab 500 mg......... 3 ERYTHROMYCIN ETHYLSUCCINA – erythromycin ethylsuccinate tab 400 mg................................................ 3 erythromycin ophth oint 5 mg/gm................................. 98 erythromycin pads 2%.................................................. 105 erythromycin soln 2%...................................................105 erythromycin w/ delayed release particles cap 250 mg......................................................................................3 ESCAVITE LQ – pediatric multiple vitamins w/ fl-fe drops 0.25-6 mg/ml....................................................................85 escitalopram oxalate soln 5 mg/5ml (base equiv) (Lexapro).........................................................................58 escitalopram oxalate tab 10 mg (base equiv) (Lexapro).........................................................................58 escitalopram oxalate tab 20 mg (base equiv) (Lexapro).........................................................................58 escitalopram oxalate tab 5 mg (base equiv) (Lexapro).........................................................................58 ESGIC – butalbital-acetaminophen-caffeine tab 50-325-40 mg.................................................................................... 68 estazolam tab 1 mg.........................................................63 estazolam tab 2 mg.........................................................63 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 129 2015 esterified estrogens & methyltestosterone tab 0.625-1.25 mg................................................................. 17 esterified estrogens & methyltestosterone tab 1.25-2.5 mg....................................................................................17 ESTRACE – estradiol tab 0.5 mg..................................... 17 ESTRACE – estradiol tab 1 mg........................................ 17 ESTRACE – estradiol tab 2 mg........................................ 17 ESTRACE – estradiol vaginal cream 0.1 mg/gm.............. 55 estradiol & norethindrone acetate tab 0.5-0.1 mg (Activella)........................................................................17 estradiol & norethindrone acetate tab 1-0.5 mg (Activella)........................................................................17 estradiol tab 0.5 mg (Estrace)........................................17 estradiol tab 1 mg (Estrace)...........................................17 estradiol tab 2 mg (Estrace)...........................................17 estradiol td patch twice weekly 0.025 mg/24hr (Vivelledot).................................................................................. 17 estradiol td patch twice weekly 0.0375 mg/24hr (Vivelle-dot).................................................................... 17 estradiol td patch twice weekly 0.05 mg/24hr (Vivelledot).................................................................................. 17 estradiol td patch twice weekly 0.075 mg/24hr (Vivelledot).................................................................................. 17 estradiol td patch twice weekly 0.1 mg/24hr (Vivelledot).................................................................................. 17 estradiol td patch weekly 0.025 mg/24hr (Climara)...... 17 estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) (Climara)....................................................... 17 estradiol td patch weekly 0.05 mg/24hr (Climara)........ 17 estradiol td patch weekly 0.06 mg/24hr (Climara)........ 17 estradiol td patch weekly 0.075 mg/24hr (Climara)...... 17 estradiol td patch weekly 0.1 mg/24hr (Climara).......... 17 estradiol valerate im in oil 20 mg/ml (Delestrogen)......17 estradiol valerate im in oil 40 mg/ml (Delestrogen)......17 ESTRING – estradiol vaginal ring 2 mg (7.5 mcg/24hrs)....................................................................... 55 ESTROPIPATE – estropipate tab 3 mg............................ 17 estropipate tab 0.75 mg..................................................17 estropipate tab 1.5 mg....................................................17 ESTROSTEP FE – norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg................................................... 18 eszopiclone tab 1 mg (Lunesta).................................... 63 eszopiclone tab 2 mg (Lunesta).................................... 63 eszopiclone tab 3 mg (Lunesta).................................... 63 ethambutol hcl tab 100 mg (Myambutol)........................ 5 ethambutol hcl tab 400 mg (Myambutol)........................ 5 ethosuximide cap 250 mg (Zarontin).............................78 ethosuximide soln 250 mg/5ml (Zarontin).................... 78 ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg..................................................................................18 ETIDRONATE DISODIUM – etidronate disodium tab 400 mg.................................................................................... 26 etodolac cap 200 mg.......................................................74 etodolac cap 300 mg.......................................................74 etodolac tab 400 mg....................................................... 74 etodolac tab 500 mg....................................................... 74 130 etodolac tab sr 24hr 400 mg.......................................... 74 etodolac tab sr 24hr 500 mg.......................................... 74 etodolac tab sr 24hr 600 mg.......................................... 74 ETOPOSIDE – etoposide cap 50 mg................................12 EURAX – crotamiton cream 10%....................................105 EURAX – crotamiton lotion 10%..................................... 105 EVISTA – raloxifene hcl tab 60 mg...................................26 EVOCLIN – clindamycin phosphate foam 1%.................105 EVZIO – naloxone hcl solution auto-injector 0.4 mg/0.4ml........................................................................ 110 EXELON – rivastigmine tartrate cap 1.5 mg..................... 67 EXELON – rivastigmine tartrate cap 3 mg........................ 67 EXELON – rivastigmine tartrate cap 4.5 mg..................... 67 EXELON – rivastigmine tartrate cap 6 mg........................ 67 exemestane tab 25 mg (Aromasin)................................12 EXFORGE – amlodipine besylate-valsartan tab 10-160 mg.................................................................................... 37 EXFORGE – amlodipine besylate-valsartan tab 10-320 mg.................................................................................... 37 EXFORGE – amlodipine besylate-valsartan tab 5-160 mg.................................................................................... 37 EXFORGE – amlodipine besylate-valsartan tab 5-320 mg.................................................................................... 37 EXFORGE HCT – amlodipine-valsartanhydrochlorothiazide tab 10-160-12.5 mg......................... 37 EXFORGE HCT – amlodipine-valsartanhydrochlorothiazide tab 10-160-25 mg............................ 37 EXFORGE HCT – amlodipine-valsartanhydrochlorothiazide tab 10-320-25 mg............................ 37 EXFORGE HCT – amlodipine-valsartanhydrochlorothiazide tab 5-160-12.5 mg........................... 37 EXFORGE HCT – amlodipine-valsartanhydrochlorothiazide tab 5-160-25 mg.............................. 37 EXJADE – deferasirox tab for oral susp 125 mg.............110 EXJADE – deferasirox tab for oral susp 250 mg.............110 EXJADE – deferasirox tab for oral susp 500 mg.............110 EXTINA – ketoconazole foam 2%...................................105 EXTRA-VIRT PLUS DHA – prenatal w/o vit a w/ fe fumdoc-fa-dha cap 29-1.25-350 mg...................................... 85 F famciclovir tab 125 mg (Famvir)...................................... 6 famciclovir tab 250 mg (Famvir)...................................... 7 famciclovir tab 500 mg (Famvir)...................................... 7 famotidine for susp 40 mg/5ml (Pepcid)....................... 50 famotidine tab 20 mg (Pepcid).......................................50 famotidine tab 40 mg (Pepcid).......................................50 FAMVIR – famciclovir tab 125 mg...................................... 7 FAMVIR – famciclovir tab 250 mg...................................... 7 FAMVIR – famciclovir tab 500 mg...................................... 7 FARESTON – toremifene citrate tab 60 mg (base equivalent)....................................................................... 12 FASLODEX – fulvestrant inj 250 mg/5ml.......................... 12 fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1 mg....................................................................................94 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 2015 fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240 mg....................................................................................94 fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu cap (Tandem plus).........................................................94 felbamate susp 600 mg/5ml (Felbatol).......................... 78 felbamate tab 400 mg (Felbatol).................................... 78 felbamate tab 600 mg (Felbatol).................................... 78 FELBATOL – felbamate susp 600 mg/5ml........................78 FELBATOL – felbamate tab 400 mg.................................78 FELBATOL – felbamate tab 600 mg.................................78 FELDENE – piroxicam cap 10 mg.................................... 74 FELDENE – piroxicam cap 20 mg.................................... 74 felodipine tab sr 24hr 10 mg.......................................... 32 felodipine tab sr 24hr 2.5 mg......................................... 32 felodipine tab sr 24hr 5 mg............................................32 FEMARA – letrozole tab 2.5 mg....................................... 12 FEMCON FE – norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg.......................................................... 18 FEMHRT LOW DOSE – norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg...........................................17 fenofibrate micronized cap 130 mg............................... 43 fenofibrate micronized cap 134 mg (Lofibra)................43 fenofibrate micronized cap 200 mg (Lofibra)................43 fenofibrate micronized cap 43 mg................................. 43 fenofibrate micronized cap 67 mg (Lofibra)..................43 fenofibrate tab 145 mg (Tricor)...................................... 43 fenofibrate tab 160 mg (Lofibra).................................... 43 fenofibrate tab 48 mg (Tricor)........................................ 43 fenofibrate tab 54 mg (Lofibra)...................................... 43 fentanyl citrate lollipop 1200 mcg (Actiq)..................... 69 fentanyl citrate lollipop 1600 mcg (Actiq)..................... 69 fentanyl citrate lollipop 200 mcg (Actiq)....................... 69 fentanyl citrate lollipop 400 mcg (Actiq)....................... 69 fentanyl citrate lollipop 600 mcg (Actiq)....................... 69 fentanyl citrate lollipop 800 mcg (Actiq)....................... 69 fentanyl td patch 72hr 100 mcg/hr (Duragesic)............ 69 fentanyl td patch 72hr 12 mcg/hr (Duragesic).............. 69 fentanyl td patch 72hr 25 mcg/hr (Duragesic).............. 69 fentanyl td patch 72hr 50 mcg/hr (Duragesic).............. 69 fentanyl td patch 72hr 75 mcg/hr (Duragesic).............. 69 ferrous fumarate-folic acid tab 324-1 mg...................... 94 FEXMID – cyclobenzaprine hcl tab 7.5 mg....................... 83 FINACEA – azelaic acid gel 15%................................... 105 finasteride tab 5 mg (Proscar)....................................... 55 FIORICET/CODEINE – butalbital-acetaminophen-caff w/ cod cap 50-300-40-30 mg............................................... 70 FIORICET/CODEINE – butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg............................................... 70 FIORICET – butalbital-acetaminophen-caffeine tab 50-325-40 mg.................................................................. 68 FIORINAL/CODEINE #3 – butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg........................................ 70 FIORINAL – butalbital-aspirin-caffeine cap 50-325-40 mg.................................................................................... 68 FIRAZYR – icatibant acetate inj 30 mg/3ml (base equivalent)....................................................................... 97 FLAGYL – metronidazole cap 375 mg..............................11 FLAGYL – metronidazole tab 250 mg...............................11 FLAGYL – metronidazole tab 500 mg...............................11 flavoxate hcl tab 100 mg................................................ 54 flecainide acetate tab 100 mg........................................ 33 flecainide acetate tab 150 mg........................................ 33 flecainide acetate tab 50 mg.......................................... 33 FLOMAX – tamsulosin hcl cap 0.4 mg..............................55 FLONASE – fluticasone propionate nasal susp 50 mcg/ act.................................................................................... 46 FLOVENT DISKUS – fluticasone propionate aer pow ba 100 mcg/blister................................................................ 48 FLOVENT DISKUS – fluticasone propionate aer pow ba 250 mcg/blister................................................................ 48 FLOVENT DISKUS – fluticasone propionate aer pow ba 50 mcg/blister.................................................................. 48 FLOVENT HFA – fluticasone propionate hfa inhal aer 110 mcg/act (125/valve)......................................................... 48 FLOVENT HFA – fluticasone propionate hfa inhal aer 220 mcg/act (250/valve)......................................................... 48 FLOVENT HFA – fluticasone propionate hfa inhal aero 44 mcg/act (50/valve)........................................................... 48 fluconazole for susp 10 mg/ml (Diflucan)....................... 5 fluconazole for susp 40 mg/ml (Diflucan)....................... 5 fluconazole tab 100 mg (Diflucan)................................... 5 fluconazole tab 150 mg (Diflucan)................................... 5 fluconazole tab 200 mg (Diflucan)................................... 5 fluconazole tab 50 mg (Diflucan).....................................5 flucytosine cap 250 mg (Ancobon)..................................5 flucytosine cap 500 mg (Ancobon)..................................5 fludrocortisone acetate tab 0.1 mg................................15 FLUMADINE – rimantadine hydrochloride tab 100 mg....... 7 FLUNISOLIDE – flunisolide nasal soln 25 mcg/act (0.025%).......................................................................... 46 flunisolide nasal soln 25 mcg/act (0.025%) (Flunisolide)....................................................................46 fluocinolone acetonide (otic) oil 0.01% (Dermotic)..................................................................... 100 fluocinolone acetonide cream 0.01%.......................... 105 fluocinolone acetonide cream 0.025% (Synalar)........ 105 fluocinolone acetonide oil 0.01% (body oil) (Dermasmoothe/fs bod)...........................................................105 fluocinolone acetonide oil 0.01% (scalp oil) (Dermasmoothe/fs sca)........................................................... 105 fluocinolone acetonide oint 0.025% (Synalar)............ 106 fluocinolone acetonide soln 0.01% (Synalar)............. 106 fluocinonide cream 0.05%............................................ 106 fluocinonide cream 0.1% (Vanos)................................ 106 fluocinonide emulsified base cream 0.05%................ 106 fluocinonide gel 0.05%................................................. 106 fluocinonide oint 0.05%................................................ 106 fluocinonide soln 0.05%............................................... 106 fluorometholone ophth susp 0.1% (Fml liquifilm)........ 98 fluorouracil cream 5% (Efudex)................................... 106 fluorouracil soln 2%......................................................106 fluorouracil soln 5%......................................................106 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 131 2015 fluoxetine hcl (pmdd) cap 10 mg................................... 67 fluoxetine hcl (pmdd) cap 20 mg................................... 67 fluoxetine hcl cap 10 mg (Prozac)................................. 58 fluoxetine hcl cap 20 mg (Prozac)................................. 58 fluoxetine hcl cap 40 mg (Prozac)................................. 58 fluoxetine hcl cap delayed release 90 mg (Prozac weekly)............................................................................ 58 FLUOXETINE HCL – fluoxetine hcl tab 60 mg................. 58 fluoxetine hcl solution 20 mg/5ml................................. 58 fluoxetine hcl tab 10 mg.................................................58 fluoxetine hcl tab 20 mg.................................................58 fluphenazine hcl tab 10 mg............................................ 61 fluphenazine hcl tab 1 mg..............................................61 fluphenazine hcl tab 2.5 mg........................................... 61 fluphenazine hcl tab 5 mg..............................................61 FLURAZEPAM HCL – flurazepam hcl cap 15 mg............. 63 FLURAZEPAM HCL – flurazepam hcl cap 30 mg............. 63 flurbiprofen sodium ophth soln 0.03% (Ocufen).......... 98 flurbiprofen tab 100 mg.................................................. 74 flurbiprofen tab 50 mg.................................................... 74 flutamide cap 125 mg..................................................... 12 fluticasone propionate cream 0.05% (Cutivate)..........106 fluticasone propionate lotion 0.05% (Cutivate).......... 106 fluticasone propionate nasal susp 50 mcg/act (Flonase)......................................................................... 46 fluticasone propionate oint 0.005% (Cutivate)............106 fluvastatin sodium cap 20 mg (Lescol)......................... 43 fluvastatin sodium cap 40 mg (Lescol)......................... 43 fluvoxamine maleate tab 100 mg................................... 58 fluvoxamine maleate tab 25 mg.....................................58 fluvoxamine maleate tab 50 mg.....................................58 FML LIQUIFILM – fluorometholone ophth susp 0.1%....... 98 FOCALGIN-B – prenatal w/ calcium-vit b6-fa-ginger tab 1.22 mg............................................................................85 FOCALIN – dexmethylphenidate hcl tab 10 mg................ 65 FOCALIN – dexmethylphenidate hcl tab 2.5 mg............... 65 FOCALIN – dexmethylphenidate hcl tab 5 mg.................. 65 FOLBECAL – prenatal w/ calcium carbonate-b6-b12-fa tab 1 mg.................................................................................85 FOLCAL DHA – prenatal w/o vit a w/ fe fum-dss-fa-dha cap 27-1.25-300 mg........................................................ 85 FOLCAPS OMEGA 3 – prenatal vit w/ fe cbn-fe asp glycfa-omega 3 cap 27-1mg.................................................. 85 FOLET DHA – prenat w/fecbn-bisg-methylf-dss tab dr & dha cap pak.....................................................................85 FOLET ONE – prenat w/o a w/fecbn-bisg-methylf-dss-dha cap 38-1-225 mg............................................................. 85 FOLGARD RX – folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg..................................................................... 94 folic acid tab 1 mg.......................................................... 94 folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg..... 94 folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg (Folgard rx).....................................................................94 FOLIVANE-OB – prenatal w/o a w/fe fum-fe poly-fa cap 130-92.4-1 mg................................................................. 85 132 FOLIVANE-PRX DHA NF – prenatal w/o vit a w/fe fumdss-fa-dha cap 30-1.24-265 mg...................................... 85 FOLLISTIM AQ – Benefit Limits may apply – follitropin beta inj 150 unit/0.5ml..................................................... 26 FOLLISTIM AQ – Benefit Limits may apply – follitropin beta inj 300 unit/0.36ml................................................... 26 FOLLISTIM AQ – Benefit Limits may apply – follitropin beta inj 600 unit/0.72ml................................................... 26 FOLLISTIM AQ – Benefit Limits may apply – follitropin beta inj 75 unit/0.5ml....................................................... 26 FOLLISTIM AQ – Benefit Limits may apply – follitropin beta inj 900 unit/1.08ml................................................... 26 FOLTRATE – cobalamine combination tab.......................94 fondaparinux sodium inj 10 mg/0.8ml (Arixtra)............ 95 fondaparinux sodium inj 2.5 mg/0.5ml (Arixtra)........... 95 fondaparinux sodium inj 5 mg/0.4ml (Arixtra).............. 95 fondaparinux sodium inj 7.5 mg/0.6ml (Arixtra)........... 95 FORADIL AEROLIZER – formoterol fumarate inhal cap 12 mcg.................................................................................. 48 formaldehyde solution 10%..........................................110 FORTAMET – metformin hcl tab sr 24hr osmotic 1000 mg.................................................................................... 20 FORTAMET – metformin hcl tab sr 24hr osmotic 500 mg.................................................................................... 20 FORTEO – teriparatide (recombinant) inj 600 mcg/2.4ml........................................................................ 26 FORTICAL – calcitonin (salmon) nasal soln 200 unit/ act.................................................................................... 26 FOSAMAX – alendronate sodium tab 70 mg.................... 26 fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg....................................................................................37 fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg....................................................................................37 fosinopril sodium tab 10 mg.......................................... 37 fosinopril sodium tab 20 mg.......................................... 37 fosinopril sodium tab 40 mg.......................................... 37 FURADANTIN – nitrofurantoin susp 25 mg/5ml................ 54 FUROSEMIDE – furosemide oral soln 8 mg/ml................ 41 furosemide oral soln 10 mg/ml...................................... 41 furosemide tab 20 mg (Lasix)........................................ 41 furosemide tab 40 mg (Lasix)........................................ 41 furosemide tab 80 mg (Lasix)........................................ 41 FUZEON – enfuvirtide for inj 90 mg....................................7 G gabapentin cap 100 mg (Neurontin).............................. 78 gabapentin cap 300 mg (Neurontin).............................. 78 gabapentin cap 400 mg (Neurontin).............................. 78 gabapentin oral soln 250 mg/5ml (Neurontin).............. 78 gabapentin tab 600 mg (Neurontin)...............................78 gabapentin tab 800 mg (Neurontin)...............................78 GABITRIL – tiagabine hcl tab 2 mg.................................. 78 GABITRIL – tiagabine hcl tab 4 mg.................................. 78 galantamine hydrobromide cap sr 24hr 16 mg (Razadyne er)................................................................. 67 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 2015 galantamine hydrobromide cap sr 24hr 24 mg (Razadyne er)................................................................. 67 galantamine hydrobromide cap sr 24hr 8 mg (Razadyne er)................................................................. 67 GALANTAMINE HYDROBROMIDE – galantamine hydrobromide oral soln 4 mg/ml...................................... 67 galantamine hydrobromide tab 12 mg (Razadyne).......67 galantamine hydrobromide tab 4 mg (Razadyne)........ 67 galantamine hydrobromide tab 8 mg (Razadyne)........ 67 GANIRELIX ACETATE – Benefit Limits may apply – ganirelix acetate inj 250 mcg/0.5ml................................. 26 GARAMYCIN – gentamicin sulfate ophth soln 0.3%......... 98 GASTRINEX NF – hyoscyamine-phenyltoloxamine cap 0.0625-15 mg.................................................................. 50 GASTROCROM – cromolyn sodium oral conc 100 mg/5ml............................................................................. 53 gatifloxacin ophth soln 0.5% (Zymaxid)........................98 GEL-KAM ORAL CARE RINSE – stannous fluoride conc 0.63%.............................................................................101 gemfibrozil tab 600 mg (Lopid)......................................43 GENTAMICIN SULFATE – gentamicin sulfate cream 0.1%...............................................................................106 GENTAMICIN SULFATE – gentamicin sulfate oint 0.1%...............................................................................106 gentamicin sulfate ophth oint 0.3%...............................98 gentamicin sulfate ophth soln 0.3% (Garamycin)........ 98 GEODON – ziprasidone hcl cap 20 mg............................ 61 GEODON – ziprasidone hcl cap 40 mg............................ 61 GEODON – ziprasidone hcl cap 60 mg............................ 61 GEODON – ziprasidone hcl cap 80 mg............................ 61 GESTICARE DHA – prenatal w/fe fum-fa tab dr 27-1 mg & dha cap 250 mg pack .................................................... 85 GILOTRIF – afatinib dimaleate tab 20 mg (base equivalent)....................................................................... 12 GILOTRIF – afatinib dimaleate tab 30 mg (base equivalent)....................................................................... 12 GILOTRIF – afatinib dimaleate tab 40 mg (base equivalent)....................................................................... 12 GLEEVEC – imatinib mesylate tab 100 mg (base equivalent)....................................................................... 12 GLEEVEC – imatinib mesylate tab 400 mg (base equivalent)....................................................................... 12 glimepiride tab 1 mg (Amaryl)....................................... 21 glimepiride tab 2 mg (Amaryl)....................................... 21 glimepiride tab 4 mg (Amaryl)....................................... 21 glipizide-metformin hcl tab 2.5-250 mg......................... 21 glipizide-metformin hcl tab 2.5-500 mg......................... 21 glipizide-metformin hcl tab 5-500 mg............................ 21 glipizide tab 10 mg (Glucotrol)...................................... 21 glipizide tab 5 mg (Glucotrol)........................................ 21 glipizide tab sr 24hr 10 mg (Glucotrol xl)......................21 glipizide tab sr 24hr 2.5 mg (Glucotrol xl).....................21 glipizide tab sr 24hr 5 mg (Glucotrol xl)....................... 21 GLUCAGEN – glucagon hcl (rdna) for inj 1 mg (base equiv)............................................................................... 21 GLUCAGEN HYPOKIT – glucagon hcl (rdna) for inj 1 mg (base equiv).....................................................................21 GLUCAGON EMERGENCY KIT – glucagon (rdna) for inj kit 1 mg............................................................................21 GLUCOPHAGE – metformin hcl tab 1000 mg.................. 21 GLUCOPHAGE – metformin hcl tab 500 mg.................... 21 GLUCOPHAGE – metformin hcl tab 850 mg.................... 21 GLUCOPHAGE XR – metformin hcl tab sr 24hr 500 mg.................................................................................... 21 GLUCOPHAGE XR – metformin hcl tab sr 24hr 750 mg.................................................................................... 21 GLUCOSE BLOOD TEST STRIPS – VARIOUS............. 110 glucose gel 40%.............................................................. 21 glucose oral liquid 15 gm/59ml......................................21 GLUCOTROL – glipizide tab 10 mg..................................21 GLUCOTROL – glipizide tab 5 mg....................................21 GLUCOTROL XL – glipizide tab sr 24hr 10 mg................ 21 GLUCOTROL XL – glipizide tab sr 24hr 2.5 mg............... 21 GLUCOTROL XL – glipizide tab sr 24hr 5 mg.................. 21 GLUCOVANCE – glyburide-metformin tab 1.25-250 mg.................................................................................... 21 GLUCOVANCE – glyburide-metformin tab 2.5-500 mg.....21 GLUCOVANCE – glyburide-metformin tab 5-500 mg........21 GLYBURIDE – glyburide tab 1.25 mg...............................21 GLYBURIDE – glyburide tab 2.5 mg.................................21 GLYBURIDE – glyburide tab 5 mg................................... 21 glyburide-metformin tab 1.25-250 mg (Glucovance).................................................................. 21 glyburide-metformin tab 2.5-500 mg (Glucovance)...... 21 glyburide-metformin tab 5-500 mg (Glucovance)......... 21 glyburide micronized tab 1.5 mg (Glynase).................. 21 glyburide micronized tab 3 mg (Glynase)..................... 21 glyburide micronized tab 6 mg (Glynase)..................... 21 glyburide tab 1.25 mg..................................................... 21 glyburide tab 2.5 mg....................................................... 21 glyburide tab 5 mg..........................................................21 glycopyrrolate tab 1 mg (Robinul).................................50 glycopyrrolate tab 2 mg (Robinul forte)........................50 GLYNASE – glyburide micronized tab 1.5 mg.................. 21 GLYNASE – glyburide micronized tab 3 mg..................... 21 GLYNASE – glyburide micronized tab 6 mg..................... 21 GOLYTELY – peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm.....................................................................49 GOLYTELY – peg 3350-kcl-na bicarb-nacl-na sulfate packet 227.1 gm..............................................................49 GONAL-F – Benefit Limits may apply – follitropin alfa for inj 1050 unit..................................................................... 27 GONAL-F – Benefit Limits may apply – follitropin alfa for inj 450 unit.......................................................................26 GONAL-F RFF – Benefit Limits may apply – follitropin alfa for inj 75 unit................................................................... 27 GONAL-F RFF PEN – Benefit Limits may apply – follitropin alfa inj 300 unit/0.5ml.......................................27 GONAL-F RFF PEN – Benefit Limits may apply – follitropin alfa inj 450 unit/0.75ml..................................... 27 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 133 2015 GONAL-F RFF PEN – Benefit Limits may apply – follitropin alfa inj 900 unit/1.5ml.......................................27 GONAL-F RFF REDIJECT – Benefit Limits may apply – follitropin alfa inj 300 unit/0.5ml.......................................27 GONAL-F RFF REDIJECT – Benefit Limits may apply – follitropin alfa inj 450 unit/0.75ml..................................... 27 GONAL-F RFF REDIJECT – Benefit Limits may apply – follitropin alfa inj 900 unit/1.5ml.......................................27 GRANIX – tbo-filgrastim soln prefilled syringe 300 mcg/0.5ml........................................................................ 94 GRANIX – tbo-filgrastim soln prefilled syringe 480 mcg/0.8ml........................................................................ 94 GRANULEX – trypsin w/ castor oil & peruvian balsam spray.............................................................................. 106 GRIFULVIN V – griseofulvin microsize tab 500 mg............ 5 griseofulvin microsize susp 125 mg/5ml........................ 5 griseofulvin microsize tab 500 mg (Grifulvin v)............. 5 griseofulvin ultramicrosize tab 125 mg (Gris-peg)......... 5 griseofulvin ultramicrosize tab 250 mg (Gris-peg)......... 5 GRIS-PEG – griseofulvin ultramicrosize tab 125 mg...........5 GRIS-PEG – griseofulvin ultramicrosize tab 250 mg...........5 guanfacine hcl tab 1 mg (Tenex)................................... 37 guanfacine hcl tab 2 mg (Tenex)................................... 37 H HALCION – triazolam tab 0.25 mg................................... 63 halobetasol propionate cream 0.05% (Ultravate)........106 halobetasol propionate oint 0.05% (Ultravate)........... 106 halobetasol prop oint 0.05% & ammonium lactate lot 12% kit.......................................................................... 106 haloperidol lactate oral conc 2 mg/ml...........................61 haloperidol tab 0.5 mg....................................................61 haloperidol tab 10 mg.....................................................61 haloperidol tab 1 mg.......................................................61 haloperidol tab 20 mg.....................................................61 haloperidol tab 2 mg.......................................................61 haloperidol tab 5 mg.......................................................61 HARVONI – ledipasvir-sofosbuvir tab 90-400 mg............... 7 hc-pramoxine emol cream 2.5-1% & pramoxine wipe 1% kit (Analpram e).....................................................102 HEMATRON-AF – iron-docusate-b12-folic acid-c-e-cubiotin tab 150-1 mg......................................................... 94 HEMENATAL OB + DHA – prenat-fe poly cmplx-fe heme poly-fa tab & omega 3 cap pck....................................... 85 HEMENATAL OB – prenat vit-fe poly cmplx-fe heme polyfa tab 28-6-1 mg..............................................................85 HEPARIN SODIUM/D5W – heparin sodium (porcine) 100 unit/ml in d5w.................................................................. 96 HEPARIN SODIUM/D5W – heparin sodium (porcine) 50 unit/ml in d5w.................................................................. 96 HEPARIN SODIUM/SODIUM CHL – heparin sodium (porcine) 2 unit/ml in sodium chloride 0.9%.................... 96 heparin sodium (porcine) 100 unit/ml in d5w (Heparin sodium/d5w)................................................................... 95 heparin sodium (porcine) 2 unit/ml in sodium chloride 0.9% (Heparin sodium/sodiu)....................................... 96 134 heparin sodium (porcine) 40 unit/ml in d5w................. 96 heparin sodium (porcine) 50 unit/ml in d5w (Heparin sodium/d5w)................................................................... 96 heparin sodium (porcine) inj 10000 unit/ml.................. 95 heparin sodium (porcine) inj 1000 unit/ml.................... 95 heparin sodium (porcine) inj 20000 unit/ml.................. 95 heparin sodium (porcine) inj 5000 unit/ml.................... 95 heparin sodium (porcine) pf inj 5000 unit/0.5ml........... 95 HEPARIN SODIUM – heparin sodium (porcine) inj 2500 unit/ml.............................................................................. 95 HEPSERA – adefovir dipivoxil tab 10 mg........................... 7 HEXALEN – altretamine cap 50 mg..................................12 HIPREX – methenamine hippurate tab 1 gm.................... 54 homatropine hbr ophth soln 5% (Isopto homatropine).................................................................. 98 HUMIRA – adalimumab inj kit 20 mg/0.4ml...................... 74 HUMIRA – adalimumab inj kit 40 mg/0.8ml (50 mg/ml).....74 HUMIRA – adalimumab prefilled syringe kit 10 mg/0.2ml.......................................................................... 74 HUMIRA PEDIATRIC CROHNS D – adalimumab inj kit 40 mg/0.8ml (50 mg/ml)....................................................... 74 HUMIRA PEN – adalimumab inj kit 40 mg/0.8ml (50 mg/ ml).................................................................................... 74 HUMIRA PEN-CROHNS DISEASE – adalimumab inj kit 40 mg/0.8ml (50 mg/ml).................................................. 74 HUMIRA PEN-PSORIASIS STAR – adalimumab inj kit 40 mg/0.8ml (50 mg/ml)....................................................... 74 HYCAMTIN – topotecan hcl cap 0.25 mg (base equiv)..... 12 HYCAMTIN – topotecan hcl cap 1 mg (base equiv)..........12 HYCET – hydrocodone-acetaminophen soln 7.5-325 mg/15ml........................................................................... 70 hydralazine hcl tab 100 mg............................................ 37 hydralazine hcl tab 10 mg.............................................. 37 hydralazine hcl tab 25 mg.............................................. 37 hydralazine hcl tab 50 mg.............................................. 38 HYDREA – hydroxyurea cap 500 mg............................... 12 HYDRO 35 – urea in lactic acid vehicle foam 35%......... 106 hydrochlorothiazide cap 12.5 mg (Microzide)...............41 hydrochlorothiazide tab 12.5 mg................................... 41 hydrochlorothiazide tab 25 mg...................................... 41 hydrochlorothiazide tab 50 mg...................................... 41 HYDROCODONE/ACETAMINOPHEN – hydrocodoneacetaminophen soln 7.5-500 mg/15ml............................ 70 hydrocodone-acetaminophen soln 7.5-325 mg/15ml (Hycet).............................................................................70 hydrocodone-acetaminophen tab 10-300 mg (Xodol).............................................................................70 hydrocodone-acetaminophen tab 10-325 mg (Norco)............................................................................ 70 hydrocodone-acetaminophen tab 5-300 mg (Xodol).............................................................................70 hydrocodone-acetaminophen tab 5-325 mg (Norco)............................................................................ 70 hydrocodone-acetaminophen tab 7.5-300 mg (Xodol).............................................................................70 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 2015 hydrocodone-acetaminophen tab 7.5-325 mg (Norco)............................................................................ 70 hydrocodone-ibuprofen tab 10-200 mg (Ibudone)........70 hydrocodone-ibuprofen tab 2.5-200 mg (Reprexain)..................................................................... 70 hydrocodone-ibuprofen tab 5-200 mg (Reprexain)...... 70 hydrocodone-ibuprofen tab 7.5-200 mg (Vicoprofen)....................................................................70 hydrocodone w/ homatropine syrup 5-1.5 mg/5ml.......46 hydrocodone w/ homatropine tab 5-1.5 mg.................. 46 hydrocod polst-chlorphen polst cr susp 10-8 mg/5ml (Tussionex pennkineti)..................................................46 hydrocortisone acetate suppos 25 mg (Anusolhc)..................................................................................102 hydrocortisone acetate suppos 30 mg (Proctocort).................................................................. 102 hydrocortisone acetate w/ pramoxine rectal cream 1-1% (Analpram-hc)..................................................... 102 hydrocortisone acetate w/ pramoxine rectal cream 2.5-1% (Analpram-hc).................................................. 102 hydrocortisone butyrate cream 0.1% (Locoid)........... 106 hydrocortisone butyrate oint 0.1% (Locoid)............... 106 hydrocortisone butyrate soln 0.1% (Locoid).............. 106 hydrocortisone cream 1%............................................ 106 hydrocortisone cream 2.5%......................................... 106 hydrocortisone enema 100 mg/60ml (Cortenema)..... 102 hydrocortisone lotion 2.5%.......................................... 106 hydrocortisone rectal cream 1% (Proctocort)............ 102 hydrocortisone rectal cream 2.5% (Anusol-hc).......... 102 hydrocortisone tab 10 mg (Cortef)................................ 15 hydrocortisone tab 20 mg (Cortef)................................ 15 hydrocortisone tab 5 mg (Cortef).................................. 15 hydrocortisone valerate cream 0.2%...........................106 hydrocortisone valerate oint 0.2% (Westcort)............ 106 HYDROMORPHONE HCL – hydromorphone hcl suppos 3 mg.................................................................................... 70 hydromorphone hcl tab 2 mg (Dilaudid)....................... 70 hydromorphone hcl tab 4 mg (Dilaudid)....................... 70 hydromorphone hcl tab 8 mg (Dilaudid)....................... 70 hydroxychloroquine sulfate tab 200 mg (Plaquenil).......................................................................10 hydroxyurea cap 500 mg (Hydrea)................................ 12 hydroxyzine hcl syrup 10 mg/5ml..................................56 hydroxyzine hcl tab 10 mg.............................................56 hydroxyzine hcl tab 25 mg............................................. 56 hydroxyzine hcl tab 50 mg.............................................56 hydroxyzine pamoate cap 25 mg (Vistaril)....................56 hydroxyzine pamoate cap 50 mg (Vistaril)....................56 HYDROXYZINE PAMOATE – hydroxyzine pamoate cap 100 mg.............................................................................56 hyoscyamine sulfate elixir 0.125 mg/5ml...................... 50 hyoscyamine sulfate soln 0.125 mg/ml......................... 50 hyoscyamine sulfate tab 0.125 mg (Levsin)................. 50 hyoscyamine sulfate tab disp 0.125 mg (Anaspaz)...... 50 hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl)..........50 hyoscyamine sulfate tab sr 12hr 0.375 mg (Levbid).....50 HYPERSAL – sodium chloride soln nebu 7%................... 46 HYPER-SAL – sodium chloride soln nebu 7%.................. 46 hypromellose intraocular soln 2% (Cellugel)................98 HYZAAR – losartan potassium & hydrochlorothiazide tab 100-12.5 mg.................................................................... 38 HYZAAR – losartan potassium & hydrochlorothiazide tab 100-25 mg....................................................................... 38 HYZAAR – losartan potassium & hydrochlorothiazide tab 50-12.5 mg...................................................................... 38 I ibandronate sodium tab 150 mg (base equivalent) (Boniva)...........................................................................27 IBUDONE – hydrocodone-ibuprofen tab 10-200 mg......... 70 ibuprofen tab 400 mg......................................................74 ibuprofen tab 600 mg......................................................74 ibuprofen tab 800 mg......................................................74 ICAR-C PLUS – iron-vit c-vit b12-folic acid tab 100-250-0.025-1 mg........................................................ 94 ICLUSIG – ponatinib hcl tab 15 mg (base equiv).............. 12 ICLUSIG – ponatinib hcl tab 45 mg (base equiv).............. 12 imipramine hcl tab 10 mg (Tofranil).............................. 58 imipramine hcl tab 25 mg (Tofranil).............................. 58 imipramine hcl tab 50 mg (Tofranil).............................. 58 imiquimod cream 5% (Aldara)......................................106 IMITREX STATDOSE REFILL – sumatriptan succinate solution cartridge 4 mg/0.5ml.......................................... 75 IMITREX STATDOSE REFILL – sumatriptan succinate solution cartridge 6 mg/0.5ml.......................................... 76 IMITREX STATDOSE SYSTEM – sumatriptan succinate solution auto-injector 4 mg/0.5ml.................................... 76 IMITREX STATDOSE SYSTEM – sumatriptan succinate solution auto-injector 6 mg/0.5ml.................................... 76 IMITREX – sumatriptan nasal spray 20 mg/act.................75 IMITREX – sumatriptan nasal spray 5 mg/act...................75 IMITREX – sumatriptan succinate inj 6 mg/0.5ml............. 75 IMITREX – sumatriptan succinate tab 100 mg..................75 IMITREX – sumatriptan succinate tab 25 mg....................75 IMITREX – sumatriptan succinate tab 50 mg....................75 IMURAN – azathioprine tab 50 mg................................. 111 INATAL ADVANCE – prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg..................................................................... 85 INATAL GT – prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg.................................................................................... 85 INATAL ULTRA – prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg........................................................................... 85 indapamide tab 1.25 mg................................................. 41 indapamide tab 2.5 mg................................................... 42 INDERAL LA – propranolol hcl cap sr 24hr 120 mg.......... 29 INDERAL LA – propranolol hcl cap sr 24hr 160 mg.......... 29 INDERAL LA – propranolol hcl cap sr 24hr 60 mg............29 INDERAL LA – propranolol hcl cap sr 24hr 80 mg............29 indomethacin cap 25 mg................................................ 74 indomethacin cap 50 mg................................................ 74 indomethacin cap cr 75 mg........................................... 74 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 135 2015 INFANATE BALANCE – prenatal w/o a w/fe cbn-dss-fadha cap 29-1-265 mg...................................................... 85 INFANATE PLUS – prenat w/o a w/fe fum-fe cbn-dss-fadha cap 27-1-260 mg...................................................... 85 INLYTA – axitinib tab 1 mg...............................................12 INLYTA – axitinib tab 5 mg...............................................12 INSPRA – eplerenone tab 25 mg..................................... 38 INSPRA – eplerenone tab 50 mg..................................... 38 INSTA-GLUCOSE – glucose gel 77.4%........................... 21 INTELENCE – etravirine tab 100 mg.................................. 7 INTELENCE – etravirine tab 200 mg.................................. 7 INTELENCE – etravirine tab 25 mg.................................... 7 INVIRASE – saquinavir mesylate cap 200 mg.................... 7 INVIRASE – saquinavir mesylate tab 500 mg.....................7 INVOKAMET – canagliflozin-metformin hcl tab 150-1000 mg.................................................................................... 22 INVOKAMET – canagliflozin-metformin hcl tab 150-500 mg.................................................................................... 22 INVOKAMET – canagliflozin-metformin hcl tab 50-1000 mg.................................................................................... 22 INVOKAMET – canagliflozin-metformin hcl tab 50-500 mg.................................................................................... 22 INVOKANA – canagliflozin tab 100 mg.............................22 INVOKANA – canagliflozin tab 300 mg.............................22 iodoquinol-hc cream 1%...............................................106 IOPIDINE – apraclonidine hcl ophth soln 0.5% (base equivalent)....................................................................... 98 ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml...... 48 ipratropium bromide inhal soln 0.02%.......................... 48 ipratropium bromide nasal soln 0.03% (21 mcg/spray) (Atrovent)........................................................................46 ipratropium bromide nasal soln 0.06% (42 mcg/spray) (Atrovent)........................................................................46 irbesartan-hydrochlorothiazide tab 150-12.5 mg (Avalide)..........................................................................38 irbesartan-hydrochlorothiazide tab 300-12.5 mg (Avalide)..........................................................................38 irbesartan tab 150 mg (Avapro)..................................... 38 irbesartan tab 300 mg (Avapro)..................................... 38 irbesartan tab 75 mg (Avapro)....................................... 38 iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1 mg (Hematron-af)...........................................................94 iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg (Corvite 150)...................................................................94 iron-vit c-vit b12-folic acid tab 100-250-0.025-1 mg (Icar-c plus).................................................................... 94 ISENTRESS – raltegravir potassium chew tab 100 mg (base equiv).......................................................................7 ISENTRESS – raltegravir potassium chew tab 25 mg (base equiv).......................................................................7 ISENTRESS – raltegravir potassium packet for susp 100 mg (base equiv).................................................................7 ISENTRESS – raltegravir potassium tab 400 mg (base equiv)................................................................................. 7 isoniazid tab 100 mg.........................................................5 isoniazid tab 300 mg.........................................................5 136 ISOPTIN SR – verapamil hcl tab cr 120 mg..................... 32 ISOPTIN SR – verapamil hcl tab cr 180 mg..................... 32 ISOPTIN SR – verapamil hcl tab cr 240 mg..................... 32 ISOPTO ATROPINE – atropine sulfate ophth soln 1%..... 98 ISOPTO CARPINE – pilocarpine hcl ophth soln 1%......... 98 ISOPTO CARPINE – pilocarpine hcl ophth soln 2%......... 98 ISOPTO CARPINE – pilocarpine hcl ophth soln 4%......... 98 ISOPTO HOMATROPINE – homatropine hbr ophth soln 5%....................................................................................98 ISOPTO HYOSCINE – scopolamine hbr ophth soln 0.25%...............................................................................98 ISORDIL TITRADOSE – isosorbide dinitrate tab 40 mg.................................................................................... 28 ISORDIL TITRADOSE – isosorbide dinitrate tab 5 mg......28 ISOSORBIDE DINITRATE – isosorbide dinitrate tab 30 mg.................................................................................... 28 isosorbide dinitrate tab 10 mg.......................................28 isosorbide dinitrate tab 20 mg.......................................28 isosorbide dinitrate tab 5 mg (Isordil titradose)........... 28 isosorbide dinitrate tab cr 40 mg.................................. 28 isosorbide mononitrate tab 10 mg................................ 28 isosorbide mononitrate tab 20 mg................................ 28 isosorbide mononitrate tab sr 24hr 120 mg (Imdur).....28 isosorbide mononitrate tab sr 24hr 30 mg (Imdur).......28 isosorbide mononitrate tab sr 24hr 60 mg (Imdur).......28 isotretinoin cap 10 mg..................................................106 isotretinoin cap 20 mg..................................................106 isotretinoin cap 40 mg..................................................106 itraconazole cap 100 mg (Sporanox)...............................5 ivermectin tab 3 mg (Stromectol).................................. 10 J JAKAFI – ruxolitinib phosphate tab 10 mg (base equivalent)....................................................................... 12 JAKAFI – ruxolitinib phosphate tab 15 mg (base equivalent)....................................................................... 12 JAKAFI – ruxolitinib phosphate tab 20 mg (base equivalent)....................................................................... 12 JAKAFI – ruxolitinib phosphate tab 25 mg (base equivalent)....................................................................... 12 JAKAFI – ruxolitinib phosphate tab 5 mg (base equivalent)....................................................................... 12 JINTELI – norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg.........................................................................17 K KADIAN – morphine sulfate cap sr 24hr 100 mg.............. 70 KADIAN – morphine sulfate cap sr 24hr 10 mg................ 70 KADIAN – morphine sulfate cap sr 24hr 200 mg.............. 70 KADIAN – morphine sulfate cap sr 24hr 20 mg................ 70 KADIAN – morphine sulfate cap sr 24hr 30 mg................ 70 KADIAN – morphine sulfate cap sr 24hr 50 mg................ 70 KADIAN – morphine sulfate cap sr 24hr 60 mg................ 70 KADIAN – morphine sulfate cap sr 24hr 80 mg................ 70 KALETRA – lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml).................................................................... 7 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 2015 KALETRA – lopinavir-ritonavir tab 100-25 mg.................... 7 KALETRA – lopinavir-ritonavir tab 200-50 mg.................... 7 KAPVAY – clonidine hcl tab sr 12hr 0.1 mg......................65 KAYEXALATE – sodium polystyrene sulfonate powder........................................................................... 111 KEFLEX – cephalexin cap 250 mg..................................... 2 KEFLEX – cephalexin cap 500 mg..................................... 2 KEPPRA – levetiracetam oral soln 100 mg/ml.................. 78 KEPPRA – levetiracetam tab 1000 mg............................. 78 KEPPRA – levetiracetam tab 250 mg............................... 78 KEPPRA – levetiracetam tab 500 mg............................... 78 KEPPRA – levetiracetam tab 750 mg............................... 78 KEPPRA XR – levetiracetam tab sr 24hr 500 mg............. 78 KEPPRA XR – levetiracetam tab sr 24hr 750 mg............. 78 KERALYT – salicylic acid gel 6%....................................106 KERLONE – betaxolol hcl tab 10 mg................................29 KERLONE – betaxolol hcl tab 20 mg................................30 ketoconazole cream 2%................................................106 ketoconazole foam 2% (Extina)................................... 106 ketoconazole shampoo 2% (Nizoral)........................... 106 ketoconazole tab 200 mg................................................. 5 ketoprofen cap 50 mg.....................................................74 ketoprofen cap 75 mg.....................................................74 ketorolac tromethamine im inj 60 mg/2ml (30 mg/ ml)....................................................................................74 ketorolac tromethamine ophth soln 0.4% (Acular ls).....................................................................................98 ketorolac tromethamine ophth soln 0.5% (Acular).......98 ketorolac tromethamine tab 10 mg................................74 KITABIS PAK – tobramycin nebu soln 300 mg/5ml............ 4 KLARON – sulfacetamide sodium lotion 10% (acne)...... 106 KLONOPIN – clonazepam tab 0.5 mg.............................. 78 KLONOPIN – clonazepam tab 1 mg................................. 78 KLONOPIN – clonazepam tab 2 mg................................. 78 KOMBIGLYZE XR – saxagliptin-metformin hcl tab sr 24hr 2.5-1000 mg.................................................................... 22 KOMBIGLYZE XR – saxagliptin-metformin hcl tab sr 24hr 5-1000 mg....................................................................... 22 KOMBIGLYZE XR – saxagliptin-metformin hcl tab sr 24hr 5-500 mg......................................................................... 22 K-PHOS NEUTRAL – pot phos monobasic w/sod phos di & monobas tab 155-852-130mg......................................92 K-TAB – potassium chloride tab cr 10 meq...................... 92 K-TAB – potassium chloride tab cr 20 meq (1500 mg)......92 L labetalol hcl tab 100 mg (Trandate)...............................30 labetalol hcl tab 200 mg (Trandate)...............................30 labetalol hcl tab 300 mg (Trandate)...............................30 LAC-HYDRIN – lactic acid (ammonium lactate) cream 12%................................................................................106 LAC-HYDRIN – lactic acid (ammonium lactate) lotion 12%................................................................................106 lactic acid (ammonium lactate) cream 12% (Lachydrin)...........................................................................106 lactic acid (ammonium lactate) lotion 10%................. 106 lactic acid (ammonium lactate) lotion 12% (Lachydrin)...........................................................................106 lactic acid w/ vitamin e cream 10%-3500 unit/30gm...................................................................... 106 lactulose (encephalopathy) solution 10 gm/15ml.........53 lactulose solution 10 gm/15ml....................................... 49 LAMICTAL CHEWABLE DISPERS – lamotrigine tab chewable dispersible 25 mg............................................ 78 LAMICTAL CHEWABLE DISPERS – lamotrigine tab chewable dispersible 5 mg.............................................. 78 LAMICTAL – lamotrigine tab 100 mg................................78 LAMICTAL – lamotrigine tab 150 mg................................78 LAMICTAL – lamotrigine tab 200 mg................................78 LAMICTAL – lamotrigine tab 25 mg..................................78 LAMICTAL ODT – lamotrigine orally disintegrating tab 100 mg.................................................................................... 78 LAMICTAL ODT – lamotrigine orally disintegrating tab 200 mg.................................................................................... 78 LAMICTAL ODT – lamotrigine orally disintegrating tab 25 mg.................................................................................... 78 LAMICTAL ODT – lamotrigine orally disintegrating tab 50 mg.................................................................................... 78 LAMICTAL STARTER/NOT TAKI – lamotrigine tab 25 mg (42) & 100 mg (7) starter kit............................................78 LAMICTAL STARTER/TAKING C – lamotrigine tab 25 mg (84) & 100 mg (14) starter kit..........................................78 LAMICTAL STARTER/TAKING V – lamotrigine tab 25 mg (35) starter kit.................................................................. 79 LAMICTAL XR – lamotrigine tab sr 24hr 100 mg.............. 79 LAMICTAL XR – lamotrigine tab sr 24hr 200 mg.............. 79 LAMICTAL XR – lamotrigine tab sr 24hr 250 mg.............. 79 LAMICTAL XR – lamotrigine tab sr 24hr 25 mg................ 79 LAMICTAL XR – lamotrigine tab sr 24hr 300 mg.............. 79 LAMICTAL XR – lamotrigine tab sr 24hr 50 mg................ 79 LAMISIL – terbinafine hcl tab 250 mg.................................5 lamivudine oral soln 10 mg/ml (Epivir)........................... 7 lamivudine tab 100 mg (Epivir hbv).................................7 lamivudine tab 150 mg (Epivir)........................................ 7 lamivudine tab 300 mg (Epivir)........................................ 7 lamivudine-zidovudine tab 150-300 mg (Combivir)........ 7 lamotrigine orally disintegrating tab 100 mg (Lamictal odt).................................................................................. 79 lamotrigine orally disintegrating tab 200 mg (Lamictal odt).................................................................................. 79 lamotrigine orally disintegrating tab 25 mg (Lamictal odt).................................................................................. 79 lamotrigine orally disintegrating tab 50 mg (Lamictal odt).................................................................................. 79 lamotrigine tab 100 mg (Lamictal)................................. 79 lamotrigine tab 150 mg (Lamictal)................................. 79 lamotrigine tab 200 mg (Lamictal)................................. 79 lamotrigine tab 25 mg (Lamictal)................................... 79 lamotrigine tab chewable dispersible 25 mg (Lamictal chewable di)................................................................... 79 lamotrigine tab chewable dispersible 5 mg (Lamictal chewable di)................................................................... 79 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 137 2015 lamotrigine tab sr 24hr 100 mg (Lamictal xr)................79 lamotrigine tab sr 24hr 200 mg (Lamictal xr)................79 lamotrigine tab sr 24hr 250 mg (Lamictal xr)................79 lamotrigine tab sr 24hr 25 mg (Lamictal xr)..................79 lamotrigine tab sr 24hr 300 mg (Lamictal xr)................79 lamotrigine tab sr 24hr 50 mg (Lamictal xr)..................79 LANCETS – VARIOUS MANUFACTURERS.................. 110 LANOXIN – digoxin tab 125 mcg (0.125 mg)....................28 LANOXIN – digoxin tab 187.5 mcg (0.1875 mg)............... 28 LANOXIN – digoxin tab 250 mcg (0.25 mg)......................28 LANOXIN – digoxin tab 62.5 mcg (0.0625 mg)................. 28 lansoprazole cap delayed release 15 mg (Prevacid)........................................................................50 lansoprazole cap delayed release 30 mg (Prevacid)........................................................................50 LANTUS – insulin glargine inj 100 unit/ml.........................23 LANTUS SOLOSTAR – insulin glargine soln pen-injector 100 unit/ml....................................................................... 23 LASIX – furosemide tab 20 mg.........................................42 LASIX – furosemide tab 40 mg.........................................42 LASIX – furosemide tab 80 mg.........................................42 latanoprost ophth soln 0.005% (Xalatan)...................... 98 LATUDA – lurasidone hcl tab 60 mg................................ 61 leflunomide tab 10 mg (Arava).......................................74 leflunomide tab 20 mg (Arava).......................................74 LESCOL – fluvastatin sodium cap 20 mg......................... 43 LESCOL – fluvastatin sodium cap 40 mg......................... 43 letrozole tab 2.5 mg (Femara)........................................ 13 LEUCOVORIN CALCIUM – leucovorin calcium tab 10 mg.................................................................................... 13 LEUCOVORIN CALCIUM – leucovorin calcium tab 15 mg.................................................................................... 13 leucovorin calcium tab 25 mg........................................13 leucovorin calcium tab 5 mg..........................................13 LEUKERAN – chlorambucil tab 2 mg............................... 13 leuprolide acetate inj kit 5 mg/ml.................................. 13 levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv) (Xopenex)........................................................................48 levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv) (Xopenex)........................................................................48 levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) (Xopenex)........................................................................48 levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) (Xopenex concentrate)...................................... 48 LEVAQUIN – levofloxacin oral soln 25 mg/ml.....................4 LEVAQUIN – levofloxacin tab 250 mg................................ 4 LEVAQUIN – levofloxacin tab 500 mg................................ 4 LEVAQUIN – levofloxacin tab 750 mg................................ 4 LEVBID – hyoscyamine sulfate tab sr 12hr 0.375 mg....... 50 levetiracetam oral soln 100 mg/ml (Keppra)................. 79 levetiracetam tab 1000 mg (Keppra)..............................79 levetiracetam tab 250 mg (Keppra)................................79 levetiracetam tab 500 mg (Keppra)................................79 levetiracetam tab 750 mg (Keppra)................................79 levetiracetam tab sr 24hr 500 mg (Keppra xr).............. 79 levetiracetam tab sr 24hr 750 mg (Keppra xr).............. 79 138 LEVOBUNOLOL HCL – levobunolol hcl ophth soln 0.25%...............................................................................98 levobunolol hcl ophth soln 0.5% (Betagan)..................98 levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)...... 27 levocarnitine tab 330 mg (Carnitor)...............................27 levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) (Xyzal)................................................................ 45 levocetirizine dihydrochloride tab 5 mg (Xyzal)........... 45 levofloxacin ophth soln 0.5%.........................................99 levofloxacin oral soln 25 mg/ml (Levaquin)....................4 levofloxacin tab 250 mg (Levaquin)................................ 4 levofloxacin tab 500 mg (Levaquin)................................ 4 levofloxacin tab 750 mg (Levaquin)................................ 4 levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg................................................................... 18 levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg..................................................................................18 levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg..................................................................................18 levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg................................ 18 levonorgestrel tab 0.75 mg (Plan b).............................. 18 levonorgestrel tab 1.5 mg (Plan b one-step).................18 levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) (Loseasonique)............................................ 18 levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) (Seasonique)................................................ 18 levothyroxine sodium tab 100 mcg (Synthroid)........... 23 levothyroxine sodium tab 112 mcg (Synthroid)........... 23 levothyroxine sodium tab 125 mcg (Synthroid)........... 23 levothyroxine sodium tab 137 mcg (Synthroid)........... 23 levothyroxine sodium tab 150 mcg (Synthroid)........... 23 levothyroxine sodium tab 175 mcg (Synthroid)........... 23 levothyroxine sodium tab 200 mcg (Synthroid)........... 23 levothyroxine sodium tab 25 mcg (Synthroid)............. 23 levothyroxine sodium tab 300 mcg (Synthroid)........... 23 levothyroxine sodium tab 50 mcg (Synthroid)............. 24 levothyroxine sodium tab 75 mcg (Synthroid)............. 24 levothyroxine sodium tab 88 mcg (Synthroid)............. 24 LEVSIN/SL – hyoscyamine sulfate tab sl 0.125 mg.......... 50 LEVSIN – hyoscyamine sulfate tab 0.125 mg................... 50 LEXAPRO – escitalopram oxalate soln 5 mg/5ml (base equiv)............................................................................... 58 LEXAPRO – escitalopram oxalate tab 10 mg (base equiv)............................................................................... 58 LEXAPRO – escitalopram oxalate tab 20 mg (base equiv)............................................................................... 58 LEXAPRO – escitalopram oxalate tab 5 mg (base equiv)............................................................................... 58 LEXIVA – fosamprenavir calcium susp 50 mg/ml (base equiv)................................................................................. 7 LEXIVA – fosamprenavir calcium tab 700 mg (base equiv)................................................................................. 7 LIALDA – mesalamine tab delayed release 1.2 gm.......... 53 LIBRAX – clidinium & chlordiazepoxide cap 2.5-5 mg.......50 lidocaine hcl cream 3%................................................ 106 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 2015 lidocaine hcl gel 2%......................................................106 lidocaine hcl laryngotracheal soln 4% (Lta 360 kit)..................................................................................101 lidocaine hcl soln 4% (Xylocaine)................................106 lidocaine hcl viscous soln 2%..................................... 101 lidocaine-hydrocortisone acetate rectal cream 3-0.5%............................................................................102 lidocaine-hydrocortisone acetate rectal cream kit 3-0.5%............................................................................102 lidocaine-hydrocortisone acetate rectal cream kit 3-1%...............................................................................102 lidocaine-hydrocortisone acetate rectal gel kit 3-2.5%............................................................................102 lidocaine oint 5%...........................................................106 lidocaine patch 5% (Lidoderm).................................... 106 lidocaine-prilocaine cream 2.5-2.5% (Emla)................107 LIDODERM – lidocaine patch 5%................................... 107 lindane lotion 1%...........................................................107 lindane shampoo 1%.................................................... 107 LINZESS – linaclotide cap 145 mcg................................. 53 LINZESS – linaclotide cap 290 mcg................................. 53 liothyronine sodium tab 25 mcg (Cytomel)...................24 liothyronine sodium tab 50 mcg (Cytomel)...................24 liothyronine sodium tab 5 mcg (Cytomel).....................24 LIPITOR – atorvastatin calcium tab 10 mg (base equivalent)....................................................................... 43 LIPITOR – atorvastatin calcium tab 20 mg (base equivalent)....................................................................... 43 LIPITOR – atorvastatin calcium tab 40 mg (base equivalent)....................................................................... 43 LIPITOR – atorvastatin calcium tab 80 mg (base equivalent)....................................................................... 43 lisinopril & hydrochlorothiazide tab 10-12.5 mg (Zestoretic)..................................................................... 38 lisinopril & hydrochlorothiazide tab 20-12.5 mg (Zestoretic)..................................................................... 38 lisinopril & hydrochlorothiazide tab 20-25 mg (Zestoretic)..................................................................... 38 lisinopril tab 10 mg (Prinivil)..........................................38 lisinopril tab 2.5 mg (Zestril).......................................... 38 lisinopril tab 20 mg (Prinivil)..........................................38 lisinopril tab 30 mg (Zestril)........................................... 38 lisinopril tab 40 mg (Zestril)........................................... 38 lisinopril tab 5 mg (Prinivil)............................................38 lithium carbonate cap 150 mg (Lithium carbonate)......61 lithium carbonate cap 300 mg....................................... 61 lithium carbonate cap 600 mg (Lithium carbonate)......61 LITHIUM CARBONATE – lithium carbonate cap 150 mg.................................................................................... 61 LITHIUM CARBONATE – lithium carbonate cap 600 mg.................................................................................... 61 lithium carbonate tab 300 mg........................................ 61 lithium carbonate tab cr 300 mg (Lithobid)...................61 lithium carbonate tab cr 450 mg....................................61 LITHIUM – lithium oral solution 8 meq/5ml....................... 61 LITHOBID – lithium carbonate tab cr 300 mg................... 61 L-METHYLFOLATE PNV DHA – prenat w/fe fum-l methylfolate-fa-dha cap 27-1.13-0.4 mg..........................85 LOCOID – hydrocortisone butyrate cream 0.1%............. 107 LOCOID – hydrocortisone butyrate oint 0.1%................. 107 LOCOID – hydrocortisone butyrate soln 0.1%................ 107 LODOSYN – carbidopa tab 25 mg................................... 81 LOESTRIN 1/20-21 – norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg.............................................. 19 LOESTRIN 1.5/30-21 – norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg............................................19 LOESTRIN FE 1/20 – norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg.......................................... 18 LOESTRIN FE 1.5/30 – norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg....................................... 18 LOFIBRA – fenofibrate micronized cap 134 mg................43 LOFIBRA – fenofibrate micronized cap 200 mg................43 LOFIBRA – fenofibrate micronized cap 67 mg..................43 LOFIBRA – fenofibrate tab 160 mg...................................43 LOFIBRA – fenofibrate tab 54 mg.................................... 43 LOMOTIL – diphenoxylate w/ atropine tab 2.5-0.025 mg.................................................................................... 49 LOMUSTINE – lomustine cap 100 mg..............................13 LOMUSTINE – lomustine cap 10 mg................................13 LOMUSTINE – lomustine cap 40 mg................................13 loperamide hcl cap 2 mg................................................50 LOPID – gemfibrozil tab 600 mg.......................................43 LOPRESSOR HCT – metoprolol & hydrochlorothiazide tab 100-25 mg....................................................................... 38 LOPRESSOR HCT – metoprolol & hydrochlorothiazide tab 50-25 mg......................................................................... 38 LOPRESSOR – metoprolol tartrate tab 100 mg................30 LOPRESSOR – metoprolol tartrate tab 50 mg..................30 LOPROX SHAMPOO – ciclopirox shampoo 1%............. 107 LORAZEPAM INTENSOL – lorazepam conc 2 mg/ml...... 56 lorazepam tab 0.5 mg (Ativan)....................................... 56 lorazepam tab 1 mg (Ativan).......................................... 56 lorazepam tab 2 mg (Ativan).......................................... 56 losartan potassium & hydrochlorothiazide tab 100-12.5 mg (Hyzaar).....................................................38 losartan potassium & hydrochlorothiazide tab 100-25 mg (Hyzaar).................................................................... 38 losartan potassium & hydrochlorothiazide tab 50-12.5 mg (Hyzaar).................................................................... 38 losartan potassium tab 100 mg (Cozaar)...................... 38 losartan potassium tab 25 mg (Cozaar)........................ 38 losartan potassium tab 50 mg (Cozaar)........................ 38 LOSEASONIQUE – levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7)...................................................... 19 LOTEMAX – loteprednol etabonate ophth gel 0.5%..........99 LOTENSIN – benazepril hcl tab 10 mg.............................38 LOTENSIN – benazepril hcl tab 20 mg.............................38 LOTENSIN – benazepril hcl tab 40 mg.............................38 LOTENSIN HCT – benazepril & hydrochlorothiazide tab 10-12.5 mg...................................................................... 38 LOTENSIN HCT – benazepril & hydrochlorothiazide tab 20-12.5 mg...................................................................... 38 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 139 2015 LOTENSIN HCT – benazepril & hydrochlorothiazide tab 20-25 mg......................................................................... 38 LOTREL – amlodipine besylate-benazepril hcl cap 10-20 mg.................................................................................... 38 LOTREL – amlodipine besylate-benazepril hcl cap 10-40 mg.................................................................................... 38 LOTREL – amlodipine besylate-benazepril hcl cap 2.5-10 mg.................................................................................... 38 LOTREL – amlodipine besylate-benazepril hcl cap 5-10 mg.................................................................................... 38 LOTREL – amlodipine besylate-benazepril hcl cap 5-20 mg.................................................................................... 38 LOTREL – amlodipine besylate-benazepril hcl cap 5-40 mg.................................................................................... 38 LOTRISONE – clotrimazole w/ betamethasone cream 1-0.05%..........................................................................107 LOTRONEX – alosetron hcl tab 0.5 mg (base equiv)........53 LOTRONEX – alosetron hcl tab 1 mg (base equiv)...........53 lovastatin tab 10 mg....................................................... 43 lovastatin tab 20 mg (Mevacor)..................................... 44 lovastatin tab 40 mg (Mevacor)..................................... 44 LOVENOX – enoxaparin sodium inj 100 mg/ml................ 96 LOVENOX – enoxaparin sodium inj 120 mg/0.8ml........... 96 LOVENOX – enoxaparin sodium inj 150 mg/ml................ 96 LOVENOX – enoxaparin sodium inj 300 mg/3ml.............. 96 LOVENOX – enoxaparin sodium inj 30 mg/0.3ml............. 96 LOVENOX – enoxaparin sodium inj 40 mg/0.4ml............. 96 LOVENOX – enoxaparin sodium inj 60 mg/0.6ml............. 96 LOVENOX – enoxaparin sodium inj 80 mg/0.8ml............. 96 loxapine succinate cap 10 mg....................................... 61 loxapine succinate cap 25 mg....................................... 61 loxapine succinate cap 50 mg....................................... 61 loxapine succinate cap 5 mg......................................... 61 LUNESTA – eszopiclone tab 1 mg................................... 63 LUNESTA – eszopiclone tab 2 mg................................... 63 LUNESTA – eszopiclone tab 3 mg................................... 63 LUPRON DEPOT – leuprolide acetate (3 month) for inj kit 11.25 mg..........................................................................13 LUPRON DEPOT – leuprolide acetate (3 month) for inj kit 22.5 mg............................................................................13 LUPRON DEPOT – leuprolide acetate (4 month) for inj kit 30 mg...............................................................................13 LUPRON DEPOT – leuprolide acetate (6 month) for inj kit 45 mg...............................................................................13 LUPRON DEPOT – leuprolide acetate for inj kit 3.75 mg.................................................................................... 13 LUPRON DEPOT – leuprolide acetate for inj kit 7.5 mg.................................................................................... 13 LUPRON DEPOT-PED – leuprolide acetate (3 month) for inj pediatric kit 11.25 mg................................................. 27 LUPRON DEPOT-PED – leuprolide acetate (3 month) for inj pediatric kit 30 mg...................................................... 27 LUPRON DEPOT-PED – leuprolide acetate for inj pediatric kit 11.25 mg...................................................... 27 LUPRON DEPOT-PED – leuprolide acetate for inj pediatric kit 15 mg........................................................... 27 140 LUPRON DEPOT-PED – leuprolide acetate for inj pediatric kit 7.5 mg.......................................................... 27 LURIDE – sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf)............................................................................ 92 LURIDE – sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)...................................................................................92 LURIDE – sodium fluoride chew tab 1 mg f (from 2.2 mg naf)...................................................................................92 LURIDE – sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ ml naf)..............................................................................92 LYRICA – pregabalin cap 100 mg.................................... 79 LYRICA – pregabalin cap 150 mg.................................... 79 LYRICA – pregabalin cap 200 mg.................................... 79 LYRICA – pregabalin cap 225 mg.................................... 79 LYRICA – pregabalin cap 25 mg...................................... 79 LYRICA – pregabalin cap 300 mg.................................... 79 LYRICA – pregabalin cap 50 mg...................................... 79 LYRICA – pregabalin cap 75 mg...................................... 79 LYRICA – pregabalin soln 20 mg/ml.................................79 LYSODREN – mitotane tab 500 mg................................. 13 M MACNATAL CN DHA – prenatal w/o a w/fe cbn-dss-fadha cap 28-1-250 mg...................................................... 85 MACROBID – nitrofurantoin monohydrate macrocrystalline cap 100 mg..................................................................... 54 MACRODANTIN – nitrofurantoin macrocrystalline cap 100 mg.................................................................................... 54 MACRODANTIN – nitrofurantoin macrocrystalline cap 25 mg.................................................................................... 54 MACRODANTIN – nitrofurantoin macrocrystalline cap 50 mg.................................................................................... 54 mafenide acetate packet for topical soln 5% (50 gm) (Sulfamylon)................................................................. 107 MALARONE – atovaquone-proguanil hcl tab 250-100 mg.................................................................................... 10 MALARONE – atovaquone-proguanil hcl tab 62.5-25 mg.................................................................................... 10 malathion lotion 0.5% (Ovide)......................................107 MARINOL – dronabinol cap 10 mg................................... 52 MARINOL – dronabinol cap 2.5 mg.................................. 52 MARINOL – dronabinol cap 5 mg.....................................52 MARNATAL-F – prenatal w/o vit a w/ fe polysac cmplx-fa cap 60-1 mg.................................................................... 85 MATULANE – procarbazine hcl cap 50 mg...................... 13 MAVIK – trandolapril tab 1 mg..........................................38 MAVIK – trandolapril tab 2 mg..........................................38 MAVIK – trandolapril tab 4 mg..........................................39 MAXALT-MLT – rizatriptan benzoate orally disintegrating tab 10 mg........................................................................ 76 MAXALT-MLT – rizatriptan benzoate orally disintegrating tab 5 mg.......................................................................... 76 MAXALT – rizatriptan benzoate tab 10 mg....................... 76 MAXALT – rizatriptan benzoate tab 5 mg......................... 76 MAXITROL – neomycin-polymyxin-dexamethasone ophth oint 0.1%..........................................................................99 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 2015 MAXITROL – neomycin-polymyxin-dexamethasone ophth susp 0.1%........................................................................99 MAXZIDE-25 – triamterene & hydrochlorothiazide tab 37.5-25 mg...................................................................... 42 MAXZIDE – triamterene & hydrochlorothiazide tab 75-50 mg.................................................................................... 42 meclizine hcl tab 12.5 mg...............................................52 meclizine hcl tab 25 mg..................................................52 meclizine hcl tab 32 mg..................................................52 MEDROL DOSEPAK – methylprednisolone tab 4 mg dose pack................................................................................. 15 MEDROL – methylprednisolone tab 16 mg.......................15 MEDROL – methylprednisolone tab 2 mg.........................15 MEDROL – methylprednisolone tab 32 mg.......................15 MEDROL – methylprednisolone tab 4 mg.........................15 MEDROL – methylprednisolone tab 8 mg.........................15 medroxyprogesterone acetate im susp 150 mg/ml (Depo-provera contrac)................................................. 19 medroxyprogesterone acetate tab 10 mg (Provera).....20 medroxyprogesterone acetate tab 2.5 mg (Provera)......................................................................... 20 medroxyprogesterone acetate tab 5 mg (Provera).......20 mefloquine hcl tab 250 mg.............................................10 MEGACE ORAL – megestrol acetate susp 40 mg/ml....... 13 megestrol acetate susp 40 mg/ml (Megace oral)..........13 megestrol acetate tab 20 mg..........................................13 megestrol acetate tab 40 mg..........................................13 MELOXICAM – meloxicam susp 7.5 mg/5ml.................... 74 meloxicam tab 15 mg (Mobic)........................................74 meloxicam tab 7.5 mg (Mobic).......................................74 MENOPUR – Benefit Limits may apply – menotropins for subcutaneous inj 75 unit................................................. 27 meperidine hcl tab 100 mg (Demerol)........................... 70 meperidine hcl tab 50 mg (Demerol)............................. 70 MEPHYTON – phytonadione tab 5 mg............................. 84 meprobamate tab 200 mg...............................................56 meprobamate tab 400 mg...............................................56 mercaptopurine tab 50 mg (Purinethol)........................ 13 mesalamine enema 4 gm................................................53 mesalamine rectal enema 4 gm & cleanser wipe kit (Rowasa)......................................................................... 53 MESNEX – mesna tab 400 mg.........................................13 MESTINON – pyridostigmine bromide tab 60 mg............. 83 METAPROTERENOL SULFATE – metaproterenol sulfate syrup 10 mg/5ml..............................................................48 METAPROTERENOL SULFATE – metaproterenol sulfate tab 10 mg........................................................................ 48 METAPROTERENOL SULFATE – metaproterenol sulfate tab 20 mg........................................................................ 48 metaxalone tab 800 mg (Skelaxin).................................83 metformin hcl tab 1000 mg (Glucophage).....................22 metformin hcl tab 500 mg (Glucophage)...................... 22 metformin hcl tab 850 mg (Glucophage)...................... 22 metformin hcl tab sr 24hr 500 mg (Glucophage xr)......22 metformin hcl tab sr 24hr 750 mg (Glucophage xr)......22 metformin hcl tab sr 24hr osmotic 1000 mg (Fortamet)....................................................................... 22 metformin hcl tab sr 24hr osmotic 500 mg (Fortamet)....................................................................... 22 methadone hcl conc 10 mg/ml (Methadose).................70 METHADONE HCL – methadone hcl soln 10 mg/5ml.......70 METHADONE HCL – methadone hcl soln 5 mg/5ml........ 70 methadone hcl tab 10 mg (Dolophine).......................... 70 methadone hcl tab 5 mg (Dolophine hcl)......................70 methadone hcl tab for oral susp 40 mg........................ 70 METHADOSE – methadone hcl conc 10 mg/ml................71 METHADOSE SUGAR-FREE – methadone hcl conc 10 mg/ml............................................................................... 71 methazolamide tab 25 mg (Neptazane)......................... 42 methazolamide tab 50 mg (Neptazane)......................... 42 methenamine hippurate tab 1 gm (Hiprex)................... 54 methenamine-hyosc-meth blue-benz acid-phenyl sal tab 81.6mg (Prosed/ds)................................................. 54 methenamine-hyos-meth blue-sod phos-phen sal tab 81.6 mg ..........................................................................54 METHENAMINE MANDELATE – methenamine mandelate tab 0.5 gm....................................................................... 54 methenamine mandelate tab 1 gm................................ 54 methimazole tab 10 mg (Tapazole)................................24 methimazole tab 5 mg (Tapazole)..................................24 methocarbamol tab 500 mg (Robaxin).......................... 83 methocarbamol tab 750 mg (Robaxin-750)................... 83 methotrexate sodium inj 25 mg/ml................................ 13 methotrexate sodium inj pf 25 mg/ml............................13 methotrexate sodium tab 2.5 mg (base equiv)............. 13 methscopolamine bromide tab 2.5 mg (Pamine)..........50 methscopolamine bromide tab 5 mg (Pamine forte)................................................................................50 METHYLDOPA/HYDROCHLOROTHI – methyldopa & hydrochlorothiazide tab 250-15 mg................................. 39 METHYLDOPA/HYDROCHLOROTHI – methyldopa & hydrochlorothiazide tab 250-25 mg................................. 39 methyldopa tab 250 mg.................................................. 39 methyldopa tab 500 mg.................................................. 39 methylergonovine maleate tab 0.2 mg.......................... 25 METHYLIN – methylphenidate hcl soln 10 mg/5ml........... 65 METHYLIN – methylphenidate hcl soln 5 mg/5ml............. 65 methylphenidate hcl cap sr 24hr 20 mg (Ritalin la)...... 65 methylphenidate hcl cap sr 24hr 30 mg (Ritalin la)...... 65 methylphenidate hcl cap sr 24hr 40 mg (Ritalin la)...... 65 METHYLPHENIDATE HCL ER – methylphenidate hcl tab cr 10 mg.......................................................................... 65 METHYLPHENIDATE HCL ER – methylphenidate hcl tab sa osm 18 mg................................................................. 65 METHYLPHENIDATE HCL ER – methylphenidate hcl tab sa osm 27 mg................................................................. 65 METHYLPHENIDATE HCL ER – methylphenidate hcl tab sa osm 36 mg................................................................. 65 METHYLPHENIDATE HCL ER – methylphenidate hcl tab sa osm 54 mg................................................................. 65 methylphenidate hcl soln 10 mg/5ml (Methylin)...........65 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 141 2015 methylphenidate hcl soln 5 mg/5ml (Methylin).............65 methylphenidate hcl tab 10 mg (Ritalin)....................... 66 methylphenidate hcl tab 20 mg (Ritalin)....................... 66 methylphenidate hcl tab 5 mg (Ritalin)......................... 66 methylphenidate hcl tab cr 20 mg (Ritalin sr)...............66 methylprednisolone tab 16 mg (Medrol)....................... 15 methylprednisolone tab 32 mg (Medrol)....................... 15 methylprednisolone tab 4 mg (Medrol)......................... 15 methylprednisolone tab 4 mg dose pack (Medrol dosepak)......................................................................... 15 methylprednisolone tab 8 mg (Medrol)......................... 15 METIPRANOLOL – metipranolol ophth soln 0.3%............ 99 metoclopramide hcl inj 5 mg/ml.................................... 53 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml).........53 metoclopramide hcl tab 10 mg (Reglan)....................... 53 metoclopramide hcl tab 5 mg (Reglan)......................... 53 metolazone tab 10 mg.................................................... 42 metolazone tab 2.5 mg (Zaroxolyn)............................... 42 metolazone tab 5 mg (Zaroxolyn).................................. 42 metoprolol & hydrochlorothiazide tab 100-25 mg (Lopressor hct).............................................................. 39 metoprolol & hydrochlorothiazide tab 100-50 mg........ 39 metoprolol & hydrochlorothiazide tab 50-25 mg (Lopressor hct).............................................................. 39 metoprolol succinate tab sr 24hr 100 mg (Toprol xl).....................................................................................30 metoprolol succinate tab sr 24hr 200 mg (Toprol xl).....................................................................................30 metoprolol succinate tab sr 24hr 25 mg (Toprol xl)..... 30 metoprolol succinate tab sr 24hr 50 mg (Toprol xl)..... 30 metoprolol tartrate tab 100 mg (Lopressor)..................30 metoprolol tartrate tab 25 mg........................................ 30 metoprolol tartrate tab 50 mg (Lopressor)....................30 METROCREAM – metronidazole cream 0.75%..............107 METROGEL – metronidazole gel 1%............................. 107 METROGEL-VAGINAL – metronidazole vaginal gel 0.75%...............................................................................55 METROLOTION – metronidazole lotion 0.75%...............107 metronidazole cap 375 mg (Flagyl)............................... 11 metronidazole cream 0.75% (Metrocream)..................107 metronidazole gel 0.75%...............................................107 metronidazole gel 1% (Metrogel)................................. 107 metronidazole lotion 0.75% (Metrolotion)................... 107 metronidazole tab 250 mg (Flagyl)................................ 11 metronidazole tab 500 mg (Flagyl)................................ 11 metronidazole vaginal gel 0.75% (Metrogelvaginal)........................................................................... 55 MEVACOR – lovastatin tab 40 mg................................... 44 mexiletine hcl cap 150 mg............................................. 33 mexiletine hcl cap 200 mg............................................. 33 mexiletine hcl cap 250 mg............................................. 33 MIACALCIN – calcitonin (salmon) nasal soln 200 unit/ act.................................................................................... 27 MICARDIS HCT – telmisartan-hydrochlorothiazide tab 40-12.5 mg...................................................................... 39 142 MICARDIS HCT – telmisartan-hydrochlorothiazide tab 80-12.5 mg...................................................................... 39 MICARDIS HCT – telmisartan-hydrochlorothiazide tab 80-25 mg......................................................................... 39 MICARDIS – telmisartan tab 20 mg..................................39 MICARDIS – telmisartan tab 40 mg..................................39 MICARDIS – telmisartan tab 80 mg..................................39 MICRO-K – potassium chloride cap cr 10 meq................. 92 MICRO-K – potassium chloride cap cr 8 meq...................92 MICROZIDE – hydrochlorothiazide cap 12.5 mg.............. 42 midazolam hcl syrup 2 mg/ml (base equivalent).......... 63 midodrine hcl tab 10 mg................................................ 42 midodrine hcl tab 2.5 mg............................................... 42 midodrine hcl tab 5 mg.................................................. 42 MILLIPRED DP – prednisolone tab 5 mg dose pack.........15 MILLIPRED – prednisolone sod phosphate oral soln 10 mg/5ml (base equiv)........................................................15 MILLIPRED – prednisolone tab 5 mg............................... 15 MINIPRESS – prazosin hcl cap 1 mg............................... 39 MINIPRESS – prazosin hcl cap 2 mg............................... 39 MINIPRESS – prazosin hcl cap 5 mg............................... 39 MINOCIN – minocycline hcl cap 100 mg............................ 4 MINOCIN – minocycline hcl cap 50 mg.............................. 4 MINOCIN – minocycline hcl cap 75 mg.............................. 4 minocycline hcl cap 100 mg (Minocin)............................4 minocycline hcl cap 50 mg (Minocin)............................. 4 minocycline hcl cap 75 mg (Minocin)............................. 4 minocycline hcl tab 100 mg............................................. 4 minocycline hcl tab 50 mg............................................... 4 minocycline hcl tab 75 mg............................................... 4 minocycline hcl tab sr 24hr 135 mg................................ 4 minocycline hcl tab sr 24hr 45 mg.................................. 4 minocycline hcl tab sr 24hr 90 mg.................................. 4 minoxidil tab 10 mg........................................................ 39 minoxidil tab 2.5 mg....................................................... 39 MIRAPEX – pramipexole dihydrochloride tab 0.125 mg.................................................................................... 81 MIRAPEX – pramipexole dihydrochloride tab 0.25 mg......81 MIRAPEX – pramipexole dihydrochloride tab 0.5 mg....... 81 MIRAPEX – pramipexole dihydrochloride tab 0.75 mg......81 MIRAPEX – pramipexole dihydrochloride tab 1.5 mg....... 81 MIRAPEX – pramipexole dihydrochloride tab 1 mg.......... 81 MIRCETTE – desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5).................................................. 19 mirtazapine orally disintegrating tab 15 mg (Remeron soltab)............................................................................. 58 mirtazapine orally disintegrating tab 30 mg (Remeron soltab)............................................................................. 58 mirtazapine orally disintegrating tab 45 mg (Remeron soltab)............................................................................. 58 mirtazapine tab 15 mg (Remeron)................................. 58 mirtazapine tab 30 mg (Remeron)................................. 58 mirtazapine tab 45 mg (Remeron)................................. 58 mirtazapine tab 7.5 mg................................................... 58 misoprostol tab 100 mcg (Cytotec)............................... 51 misoprostol tab 200 mcg (Cytotec)............................... 51 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 2015 MOBIC – meloxicam susp 7.5 mg/5ml..............................75 MOBIC – meloxicam tab 15 mg........................................75 MOBIC – meloxicam tab 7.5 mg.......................................74 modafinil tab 100 mg (Provigil)......................................66 modafinil tab 200 mg (Provigil)......................................66 MODERIBA 1200 DOSE PACK – ribavirin tab 600 mg....... 7 MODERIBA 800 DOSE PACK – ribavirin tab 400 mg.........7 MODERIBA – ribavirin tab 400 mg & ribavirin tab 600 mg dose pack.......................................................................... 7 MODICON – norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg.......................................................................19 moexipril hcl tab 15 mg (Univasc).................................39 moexipril hcl tab 7.5 mg (Univasc)................................39 moexipril-hydrochlorothiazide tab 15-12.5 mg (Uniretic)......................................................................... 39 moexipril-hydrochlorothiazide tab 15-25 mg................ 39 moexipril-hydrochlorothiazide tab 7.5-12.5 mg............ 39 mometasone furoate cream 0.1% (Elocon)................. 107 mometasone furoate oint 0.1% (Elocon).....................107 mometasone furoate solution 0.1% (lotion) (Elocon).........................................................................107 montelukast sodium chew tab 4 mg (base equiv) (Singulair)....................................................................... 48 montelukast sodium chew tab 5 mg (base equiv) (Singulair)....................................................................... 48 montelukast sodium tab 10 mg (base equiv) (Singulair)....................................................................... 48 morphine sulfate (concentrate) oral soln 20 mg/ml..... 71 morphine sulfate cap sr 24hr 100 mg (Kadian)............ 71 morphine sulfate cap sr 24hr 10 mg (Kadian).............. 71 morphine sulfate cap sr 24hr 20 mg (Kadian).............. 71 morphine sulfate cap sr 24hr 30 mg (Kadian).............. 71 morphine sulfate cap sr 24hr 50 mg (Kadian).............. 71 morphine sulfate cap sr 24hr 60 mg (Kadian).............. 71 morphine sulfate cap sr 24hr 80 mg (Kadian).............. 71 MORPHINE SULFATE – morphine sulfate suppos 10 mg.................................................................................... 71 MORPHINE SULFATE – morphine sulfate suppos 20 mg.................................................................................... 71 MORPHINE SULFATE – morphine sulfate suppos 30 mg.................................................................................... 71 MORPHINE SULFATE – morphine sulfate suppos 5 mg.................................................................................... 71 MORPHINE SULFATE – morphine sulfate tab 15 mg.......71 MORPHINE SULFATE – morphine sulfate tab 30 mg.......71 morphine sulfate oral soln 10 mg/5ml...........................71 morphine sulfate oral soln 20 mg/5ml...........................71 morphine sulfate tab cr 100 mg (Ms contin)................. 71 morphine sulfate tab cr 15 mg (Ms contin)...................71 morphine sulfate tab cr 200 mg (Ms contin)................. 71 morphine sulfate tab cr 30 mg (Ms contin)...................71 morphine sulfate tab cr 60 mg (Ms contin)...................71 MS CONTIN – morphine sulfate tab cr 100 mg................ 71 MS CONTIN – morphine sulfate tab cr 15 mg.................. 71 MS CONTIN – morphine sulfate tab cr 200 mg................ 71 MS CONTIN – morphine sulfate tab cr 30 mg.................. 71 MS CONTIN – morphine sulfate tab cr 60 mg.................. 71 MULTI PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-0.8 mg........................................................................ 85 mupirocin calcium cream 2% (Bactroban)..................107 mupirocin oint 2% (Bactroban).................................... 107 M-VIT – prenatal vit w/ fe fumarate-fa tab 27-1 mg........... 85 MYAMBUTOL – ethambutol hcl tab 100 mg....................... 5 MYAMBUTOL – ethambutol hcl tab 400 mg....................... 5 mycophenolate mofetil cap 250 mg (Cellcept)........... 111 mycophenolate mofetil for oral susp 200 mg/ml (Cellcept).......................................................................111 mycophenolate mofetil tab 500 mg (Cellcept)............ 111 MYDRIACYL – tropicamide ophth soln 1%....................... 99 MYLERAN – busulfan tab 2 mg........................................13 MYNATAL ADVANCE – prenatal vit w/ dss-iron carbonylfa tab 90-1 mg.................................................................85 MYNATAL PLUS – prenatal vit w/ fe fumarate-fa tab 65-1 mg.................................................................................... 85 MYNATAL – prenatal multivitamins & minerals w/ iron & fa cap 1 mg......................................................................... 85 MYNATAL ULTRACAPLET – prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg.................................................. 86 MYNATAL-Z – prenatal vit w/ fe fumarate-fa tab 65-1 mg.................................................................................... 86 MYNATE 90 PLUS – prenatal vit w/ dss-fe fumarate-fa tab cr 90-1 mg....................................................................... 86 MYSOLINE – primidone tab 250 mg.................................79 MYSOLINE – primidone tab 50 mg...................................79 N nabumetone tab 500 mg.................................................75 nabumetone tab 750 mg.................................................75 nadolol & bendroflumethiazide tab 40-5 mg (Corzide)......................................................................... 39 nadolol & bendroflumethiazide tab 80-5 mg (Corzide)......................................................................... 39 nadolol tab 20 mg (Corgard).......................................... 30 nadolol tab 40 mg (Corgard).......................................... 30 nadolol tab 80 mg (Corgard).......................................... 30 naltrexone hcl tab 50 mg (Revia).................................110 NAPHAZOLINE HCL – naphazoline hcl ophth soln 0.1%.................................................................................99 NAPROSYN – naproxen susp 125 mg/5ml.......................75 NAPROSYN – naproxen tab 250 mg................................75 NAPROSYN – naproxen tab 375 mg................................75 NAPROSYN – naproxen tab 500 mg................................75 naproxen sodium tab 275 mg (Anaprox)...................... 75 naproxen sodium tab 550 mg (Anaprox ds)................. 75 naproxen susp 125 mg/5ml (Naprosyn)........................ 75 naproxen tab 250 mg (Naprosyn).................................. 75 naproxen tab 375 mg (Naprosyn).................................. 75 naproxen tab 500 mg (Naprosyn).................................. 75 naproxen tab ec 375 mg (Ec-naprosyn)........................ 75 naproxen tab ec 500 mg (Ec-naprosyn)........................ 75 naratriptan hcl tab 1 mg (base equiv) (Amerge)........... 76 naratriptan hcl tab 2.5 mg (base equiv) (Amerge)........ 76 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 143 2015 NARDIL – phenelzine sulfate tab 15 mg...........................58 NASACORT AQ – triamcinolone acetonide nasal aerosol suspension 55 mcg/act....................................................46 NASONEX – mometasone furoate nasal susp 50 mcg/ act.................................................................................... 46 NATACHEW – prenatal vit w/ fe fum-fe bisglycin-fa chew tab 28-1 mg..................................................................... 86 NATALVIRT 90 DHA – prenat w/o a w/fecbn-fegl-dss-fa tab 90 &dha cap 300mg pak........................................... 86 NATALVIRT CA – prenat w/o a w/fecbn-fegl-dss-fa tab & dha cap 300 mg pack..................................................... 86 NATALVIT – prenatal vit w/ fe fumarate-fa tab 75-1 mg.................................................................................... 86 NATAL-V RX – prenatal vit w/ iron carbonyl-fa tab 29-1 mg.................................................................................... 86 nateglinide tab 120 mg (Starlix).....................................22 nateglinide tab 60 mg (Starlix).......................................22 NATELLE ONE – prenatal w/o vit a w/ fe fum-fa-omega 3 cap 28-1-250 mg............................................................. 86 NATURE-THROID NT-2.5 – thyroid tab 162.5 mg (2 1/2 grain)................................................................................24 NATURE-THROID – thyroid tab 113.75 mg......................24 NATURE-THROID – thyroid tab 130 mg...........................24 NATURE-THROID – thyroid tab 146.25 mg......................24 NATURE-THROID – thyroid tab 16.25 mg........................24 NATURE-THROID – thyroid tab 195 mg...........................24 NATURE-THROID – thyroid tab 260 mg...........................24 NATURE-THROID – thyroid tab 32.5 mg..........................24 NATURE-THROID – thyroid tab 325 mg (5 grain)............ 24 NATURE-THROID – thyroid tab 48.75 mg (3/4 grain).......24 NATURE-THROID – thyroid tab 65 mg.............................24 NATURE-THROID – thyroid tab 81.25 mg........................24 NATURE-THROID – thyroid tab 97.5 mg..........................24 NEEVO DHA – prenat w/o a w/fefum-methylfol-omegas cap 27-1.13 mg............................................................... 86 NEOMYCIN/POLYMYXIN/HYDROC – neomycinpolymyxin-hc ophth susp................................................. 99 neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin.................................99 neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml (Neosporin)............... 99 neomycin-polymyxin-dexamethasone ophth oint 0.1% (Maxitrol).........................................................................99 neomycin-polymyxin-dexamethasone ophth susp 0.1% (Maxitrol)............................................................... 99 neomycin-polymyxin-hc otic soln 1% (Cortisporin)................................................................. 100 neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%.....................................................................101 neomycin sulfate tab 500 mg...........................................4 NEORAL – cyclosporine modified cap 100 mg............... 111 NEORAL – cyclosporine modified cap 25 mg................. 111 NEORAL – cyclosporine modified oral soln 100 mg/ ml................................................................................... 111 NEOSPORIN – neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml...................................... 99 144 NEPHROCAPS – b-complex w/ c & folic acid cap 1 mg.................................................................................... 86 NEPHRO-VITE RX – b-complex w/ c & folic acid tab 1 mg.................................................................................... 86 NEPTAZANE – methazolamide tab 25 mg....................... 42 NEPTAZANE – methazolamide tab 50 mg....................... 42 NESTABS ABC – prenatal w/o vit a w/fe polysac-fa-ca tab & omega 3 cap................................................................86 NESTABS DHA – prenat w/o a w/ fe bisglyc-fa tab 32-1 mg & omega cap pack.................................................... 86 NESTABS – prenatal vit w/o vit a w/ fe bisglycinate-fa tab 32-1 mg........................................................................... 86 NEULASTA DELIVERY KIT – pegfilgrastim inj 6 mg/0.6ml.......................................................................... 94 NEULASTA – pegfilgrastim inj 6 mg/0.6ml....................... 94 NEUPOGEN – filgrastim inj 300 mcg/0.5ml (600 mcg/ ml).................................................................................... 94 NEUPOGEN – filgrastim inj 300 mcg/ml........................... 94 NEUPOGEN – filgrastim inj 480 mcg/0.8ml (600 mcg/ ml).................................................................................... 94 NEUPOGEN – filgrastim inj 480 mcg/1.6ml (300 mcg/ ml).................................................................................... 94 NEURONTIN – gabapentin cap 100 mg........................... 79 NEURONTIN – gabapentin cap 300 mg........................... 79 NEURONTIN – gabapentin cap 400 mg........................... 79 NEURONTIN – gabapentin oral soln 250 mg/5ml............. 80 NEURONTIN – gabapentin tab 600 mg............................ 80 NEURONTIN – gabapentin tab 800 mg............................ 80 NEVIRAPINE – nevirapine susp 50 mg/5ml....................... 7 nevirapine tab 200 mg (Viramune)...................................7 nevirapine tab sr 24hr 400 mg (Viramune xr)................. 7 NEWGEN – prenatal vit w/o vit a w/ fe bisglycinate-fa tab 32-1 mg........................................................................... 86 NEXA PLUS – prenatal w/o vit a w/ fe fum-doc-fa-dha cap 29-1.25-350 mg............................................................... 86 NEXAVAR – sorafenib tosylate tab 200 mg (base equivalent)....................................................................... 13 NEXIUM – esomeprazole magnesium cap delayed release 20 mg...............................................................................51 NEXIUM – esomeprazole magnesium cap delayed release 40 mg...............................................................................51 NEXIUM – esomeprazole magnesium for delayed release susp pack 2.5 mg............................................................51 NEXIUM – esomeprazole magnesium for delayed release susp packet 10 mg.......................................................... 51 NEXIUM – esomeprazole magnesium for delayed release susp packet 20 mg.......................................................... 51 NEXIUM – esomeprazole magnesium for delayed release susp packet 40 mg.......................................................... 51 NEXIUM – esomeprazole magnesium for delayed release susp packet 5 mg............................................................51 niacin tab cr 1000 mg (antihyperlipidemic) (Niaspan).........................................................................44 niacin tab cr 500 mg (antihyperlipidemic) (Niaspan).........................................................................44 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 2015 niacin tab cr 750 mg (antihyperlipidemic) (Niaspan).........................................................................44 NIACOR – niacin (antihyperlipidemic) tab 500 mg............ 44 NIASPAN – niacin tab cr 1000 mg (antihyperlipidemic)..........................................................44 NIASPAN – niacin tab cr 500 mg (antihyperlipidemic)...... 44 NIASPAN – niacin tab cr 750 mg (antihyperlipidemic)...... 44 nicardipine hcl cap 20 mg..............................................32 nicardipine hcl cap 30 mg..............................................32 NICOTROL INHALER – nicotine inhaler system 10 mg (4 mg delivered)...................................................................67 NICOTROL NS – nicotine nasal spray 10 mg/ml (0.5 mg/ spray)............................................................................... 67 nifedipine cap 10 mg (Procardia)...................................32 nifedipine cap 20 mg...................................................... 32 nifedipine tab sr 24hr 30 mg (Adalat cc).......................32 nifedipine tab sr 24hr 60 mg (Adalat cc).......................32 nifedipine tab sr 24hr 90 mg (Adalat cc).......................32 nifedipine tab sr 24hr osmotic 30 mg (Procardia xl).....................................................................................32 nifedipine tab sr 24hr osmotic 60 mg (Procardia xl).....................................................................................32 nifedipine tab sr 24hr osmotic 90 mg (Procardia xl).....................................................................................32 NILANDRON – nilutamide tab 150 mg............................. 13 nimodipine cap 30 mg.................................................... 32 NIRAVAM – alprazolam orally disintegrating tab 0.25 mg.................................................................................... 56 NISOLDIPINE – nisoldipine tab sr 24hr 40 mg................. 32 nisoldipine tab sr 24hr 17 mg (Sular)............................32 nisoldipine tab sr 24hr 34 mg (Sular)............................32 nisoldipine tab sr 24hr 8.5 mg (Sular)...........................32 NITRO-BID – nitroglycerin oint 2%................................... 28 NITRO-DUR – nitroglycerin td patch 24hr 0.1 mg/hr.........28 NITRO-DUR – nitroglycerin td patch 24hr 0.2 mg/hr.........28 NITRO-DUR – nitroglycerin td patch 24hr 0.3 mg/hr.........29 NITRO-DUR – nitroglycerin td patch 24hr 0.4 mg/hr.........29 NITRO-DUR – nitroglycerin td patch 24hr 0.6 mg/hr.........29 NITRO-DUR – nitroglycerin td patch 24hr 0.8 mg/hr.........29 nitrofurantoin macrocrystalline cap 100 mg (Macrodantin)................................................................. 54 nitrofurantoin macrocrystalline cap 50 mg (Macrodantin)................................................................. 54 nitrofurantoin monohydrate macrocrystalline cap 100 mg (Macrobid)................................................................ 54 nitrofurantoin susp 25 mg/5ml (Furadantin)................. 54 nitroglycerin cap cr 2.5 mg............................................ 29 nitroglycerin cap cr 6.5 mg............................................ 29 nitroglycerin cap cr 9 mg............................................... 29 nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)......... 29 nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur)......... 29 nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur)......... 29 nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)......... 29 NITROSTAT – nitroglycerin sl tab 0.3 mg.........................29 NITROSTAT – nitroglycerin sl tab 0.4 mg.........................29 NITROSTAT – nitroglycerin sl tab 0.6 mg.........................29 nizatidine cap 150 mg.....................................................51 nizatidine cap 300 mg (Axid)..........................................51 nizatidine oral soln 15 mg/ml (Axid)..............................51 NIZORAL – ketoconazole shampoo 2%..........................107 NORCO – hydrocodone-acetaminophen tab 10-325 mg.................................................................................... 71 NORCO – hydrocodone-acetaminophen tab 5-325 mg.....71 NORCO – hydrocodone-acetaminophen tab 7.5-325 mg.................................................................................... 71 norelgestromin-ethinyl estradiol td ptwk 150-35 mcg/24hr (Ortho evra)................................................... 19 norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg (Femcon fe)................................................ 19 norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg (Ovcon-35)...................................................................... 19 norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg (Brevicon-28).................................................................. 19 norethindrone & ethinyl estradiol tab 1 mg-35 mcg (Norinyl 1+35).................................................................19 norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg (Loestrin fe 1.5/30)................................................ 19 norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg (Loestrin fe 1/20)................................................... 19 norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg (Loestrin 1.5/30-21)............................................... 19 norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg (Loestrin 1/20-21)........................................................... 19 norethindrone acetate tab 5 mg (Aygestin).................. 20 norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg (Estrostep fe).................................................. 19 norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg (Ortho-novum 7/7/7)....................................... 19 norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mgmcg (Tri-norinyl 28).......................................................19 norethindrone tab 0.35 mg (Nor-qd)..............................19 norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg (Ortho-cyclen)................................................................ 19 norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg (Ortho tri-cyclen)............................................ 19 norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg........ 19 NORINYL 1+35 – norethindrone & ethinyl estradiol tab 1 mg-35 mcg.......................................................................19 NORPACE – disopyramide phosphate cap 100 mg..........33 NORPACE – disopyramide phosphate cap 150 mg..........34 NORPRAMIN – desipramine hcl tab 100 mg.................... 59 NORPRAMIN – desipramine hcl tab 10 mg...................... 59 NORPRAMIN – desipramine hcl tab 150 mg.................... 59 NORPRAMIN – desipramine hcl tab 25 mg...................... 59 NORPRAMIN – desipramine hcl tab 50 mg...................... 59 NORPRAMIN – desipramine hcl tab 75 mg...................... 59 NOR-QD – norethindrone tab 0.35 mg............................. 19 nortriptyline hcl cap 10 mg (Pamelor)...........................59 nortriptyline hcl cap 25 mg (Pamelor)...........................59 nortriptyline hcl cap 50 mg (Pamelor)...........................59 nortriptyline hcl cap 75 mg (Pamelor)...........................59 NORVASC – amlodipine besylate tab 10 mg....................32 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 145 2015 NORVASC – amlodipine besylate tab 2.5 mg...................32 NORVASC – amlodipine besylate tab 5 mg......................32 NORVIR – ritonavir cap 100 mg......................................... 7 NORVIR – ritonavir oral soln 80 mg/ml...............................7 NORVIR – ritonavir tab 100 mg.......................................... 7 NOVOLIN 70/30 – insulin isophane & regular (human) inj 100 unit/ml (70-30).......................................................... 23 NOVOLIN 70/30 RELION – insulin isophane & regular (human) inj 100 unit/ml (70-30)....................................... 23 NOVOLIN N – insulin isophane (human) inj 100 unit/ ml..................................................................................... 23 NOVOLIN N RELION – insulin isophane (human) inj 100 unit/ml.............................................................................. 23 NOVOLIN R – insulin regular (human) inj 100 unit/ml....... 23 NOVOLIN R RELION – insulin regular (human) inj 100 unit/ml.............................................................................. 23 NOVOLOG FLEXPEN – insulin aspart soln pen-injector 100 unit/ml....................................................................... 23 NOVOLOG – insulin aspart inj 100 unit/ml........................23 NOVOLOG MIX 70/30 – insulin aspart prot & aspart (human) inj 100 unit/ml (70-30)....................................... 23 NOVOLOG MIX 70/30 PREFILL – insulin aspart prot & aspart sus pen-inj 100 unit/ml (70-30).............................23 NOVOLOG PENFILL – insulin aspart inj 100 unit/ml........ 23 NOVOLOG PENFILL – insulin aspart soln cartridge 100 unit/ml.............................................................................. 23 NOXAFIL – posaconazole susp 40 mg/ml.......................... 5 NOXAFIL – posaconazole tab delayed release 100 mg......5 NUCYNTA ER – tapentadol hcl tab sr 12hr 100 mg..........71 NUCYNTA ER – tapentadol hcl tab sr 12hr 150 mg..........71 NUCYNTA ER – tapentadol hcl tab sr 12hr 200 mg..........71 NUCYNTA ER – tapentadol hcl tab sr 12hr 250 mg..........71 NUCYNTA ER – tapentadol hcl tab sr 12hr 50 mg........... 71 NUCYNTA – tapentadol hcl tab 100 mg........................... 71 NUCYNTA – tapentadol hcl tab 50 mg............................. 71 NUCYNTA – tapentadol hcl tab 75 mg............................. 71 NULYTELY/FLAVOR PACKS – peg 3350-kcl-sod bicarbnacl for soln 420 gm....................................................... 49 NUMOISYN – artificial saliva - lozenge...........................101 NUTRI-TAB OB + DHA – prenat w/o a w/ fe bisglyc-fa tab 32-1 mg & omega cap pack............................................ 86 NUTRI-TAB OB – prenatal vit w/o vit a w/ fe bisglycinatefa tab 32-1 mg.................................................................86 NUVARING – etonogestrel-ethinyl estradiol va ring 0.120-0.015 mg/24hr....................................................... 19 NYMALIZE – nimodipine oral soln 60 mg/20ml.................32 nystatin cream 100000 unit/gm....................................107 nystatin oint 100000 unit/gm........................................107 nystatin oral powder......................................................... 6 nystatin susp 100000 unit/ml....................................... 101 nystatin tab 500000 unit................................................... 6 nystatin topical powder ...............................................107 nystatin-triamcinolone cream 100000-0.1 unit/gm%....................................................................................107 nystatin-triamcinolone oint 100000-0.1 unit/gm-%..... 107 146 O OB COMPLETE/DHA – prenat w/ iron cbn-fe asp glyc-faomega cap 30-10-1-200 mg............................................ 86 OB COMPLETE ONE – prenatal w/o a w/fecbn-fe asp glyc-fa-fish cap 50-1-476 mg...........................................86 OB COMPLETE PETITE – prenat w/o a w/fecbnfeaspglyc-fa-omega cap 35-5-1-200 mg..........................86 OB COMPLETE PREMIER – prenatal vit w/ fe cbn-fe asp glyc-fa tab 30-20-1 mg.................................................... 86 OB COMPLETE – prenatal vit w/ iron carbonyl-fa tab 50-1.25 mg...................................................................... 86 OB-NATAL ONE – prenatal vit w/ fe cbn-fe asp glyc-faomega 3 cap 27-1mg...................................................... 86 OBSTETRIX DHA – prenat w/fecbn-fa-dss tab 29-1 mg & omega 3 cap 387 mg pak............................................... 86 OBSTETRIX EC – prenatal vit w/ dss-iron carbonyl-fa tab 29-1 mg........................................................................... 86 O-CAL FA – prenatal vit w/ fe fumarate-fa tab 27-1 mg.................................................................................... 86 O-CAL PRENATAL – prenatal vit w/ fe fumarate-fa tab 15-1 mg........................................................................... 86 octreotide acetate inj 1000 mcg/ml (1 mg/ml) (Sandostatin).................................................................. 27 octreotide acetate inj 100 mcg/ml (0.1 mg/ml) (Sandostatin).................................................................. 27 octreotide acetate inj 200 mcg/ml (0.2 mg/ml) (Sandostatin).................................................................. 27 octreotide acetate inj 500 mcg/ml (0.5 mg/ml) (Sandostatin).................................................................. 27 octreotide acetate inj 50 mcg/ml (0.05 mg/ml) (Sandostatin).................................................................. 27 OCUFEN – flurbiprofen sodium ophth soln 0.03%............ 99 OCUFLOX – ofloxacin ophth soln 0.3%............................99 OFLOXACIN – ofloxacin tab 400 mg.................................. 4 ofloxacin ophth soln 0.3% (Ocuflox)............................. 99 ofloxacin otic soln 0.3%............................................... 101 olanzapine-fluoxetine hcl cap 12-25 mg (Symbyax).....67 olanzapine-fluoxetine hcl cap 12-50 mg (Symbyax).....67 olanzapine-fluoxetine hcl cap 3-25 mg (Symbyax).......67 olanzapine-fluoxetine hcl cap 6-25 mg (Symbyax).......67 olanzapine-fluoxetine hcl cap 6-50 mg (Symbyax).......67 olanzapine orally disintegrating tab 10 mg (Zyprexa zydis)...............................................................................61 olanzapine orally disintegrating tab 15 mg (Zyprexa zydis)...............................................................................61 olanzapine orally disintegrating tab 20 mg (Zyprexa zydis)...............................................................................61 olanzapine orally disintegrating tab 5 mg (Zyprexa zydis)...............................................................................61 olanzapine tab 10 mg (Zyprexa).................................... 61 olanzapine tab 15 mg (Zyprexa).................................... 61 olanzapine tab 2.5 mg (Zyprexa)................................... 61 olanzapine tab 20 mg (Zyprexa).................................... 61 olanzapine tab 5 mg (Zyprexa)...................................... 61 olanzapine tab 7.5 mg (Zyprexa)................................... 61 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 2015 OLUX – clobetasol propionate foam 0.05%.................... 107 OLUX-E – clobetasol propionate emulsion foam 0.05%.............................................................................107 OLYSIO – simeprevir sodium cap 150 mg (base equivalent)......................................................................... 7 omeprazole cap delayed release 10 mg (Prilosec)....... 51 omeprazole cap delayed release 20 mg (Prilosec)....... 51 omeprazole cap delayed release 40 mg (Prilosec)....... 51 OMNARIS – ciclesonide nasal susp 50 mcg/act............... 46 OMNIFLEX DIAPHRAGM – diaphragms........................ 110 OMNIPRED – prednisolone acetate ophth susp 1%......... 99 OMNITROPE – somatropin for inj 5.8 mg.........................27 OMNITROPE – somatropin inj 10 mg/1.5ml..................... 27 OMNITROPE – somatropin inj 5 mg/1.5ml....................... 27 ondansetron hcl oral soln 4 mg/5ml (Zofran)............... 52 ondansetron hcl tab 24 mg............................................ 52 ondansetron hcl tab 4 mg (Zofran)................................52 ondansetron hcl tab 8 mg (Zofran)................................52 ondansetron orally disintegrating tab 4 mg (Zofran odt).................................................................................. 52 ondansetron orally disintegrating tab 8 mg (Zofran odt).................................................................................. 52 ONETOUCH ULTRA BLUE – glucose blood test strip................................................................................ 110 ONETOUCH ULTRA TEST STRIP – glucose blood test strip................................................................................ 110 ONETOUCH VERIO TEST STRIP – glucose blood test strip................................................................................ 110 ONGLYZA – saxagliptin hcl tab 2.5 mg (base equiv)........ 22 ONGLYZA – saxagliptin hcl tab 5 mg (base equiv)........... 22 OPANA – oxymorphone hcl tab 10 mg............................. 72 OPANA – oxymorphone hcl tab 5 mg............................... 71 OPSUMIT – macitentan tab 10 mg................................... 45 orphenadrine citrate tab sr 12hr 100 mg.......................83 ORTHO-CEPT – desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg.......................................................................19 ORTHO-CYCLEN – norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg.............................................................. 19 ORTHO DIAPHRAGM COIL SPRI – diaphragm coil spring kit 100 mm.....................................................................110 ORTHO DIAPHRAGM COIL SPRI – diaphragm coil spring kit 105 mm.....................................................................110 ORTHO DIAPHRAGM COIL SPRI – diaphragm coil spring kit 50 mm.......................................................................110 ORTHO DIAPHRAGM FLAT SPRI – diaphragm flat spring kit 55 mm.......................................................................110 ORTHO DIAPHRAGM FLAT SPRI – diaphragm flat spring kit 60 mm.......................................................................110 ORTHO DIAPHRAGM FLAT SPRI – diaphragm flat spring kit 65 mm.......................................................................110 ORTHO DIAPHRAGM FLAT SPRI – diaphragm flat spring kit 70 mm.......................................................................111 ORTHO DIAPHRAGM FLAT SPRI – diaphragm flat spring kit 75 mm.......................................................................111 ORTHO DIAPHRAGM FLAT SPRI – diaphragm flat spring kit 80 mm.......................................................................111 ORTHO DIAPHRAGM FLAT SPRI – diaphragm flat spring kit 85 mm.......................................................................111 ORTHO DIAPHRAGM FLAT SPRI – diaphragm flat spring kit 90 mm.......................................................................111 ORTHO DIAPHRAGM FLAT SPRI – diaphragm flat spring kit 95 mm.......................................................................111 ORTHO EVRA – norelgestromin-ethinyl estradiol td ptwk 150-35 mcg/24hr............................................................. 19 ORTHO MICRONOR – norethindrone tab 0.35 mg.......... 19 ORTHO-NOVUM 1/35 – norethindrone & ethinyl estradiol tab 1 mg-35 mcg............................................................. 20 ORTHO-NOVUM 7/7/7 – norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg........................................... 20 ORTHO TRI-CYCLEN – norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg.................................. 19 OTICIN HC NR – pramoxine-hc-chloroxylenol otic soln 10-10-1 mg/ml............................................................... 101 OVACE PLUS WASH – sulfacetamide sodium liquid 10%................................................................................107 OVACE WASH – sulfacetamide sodium liquid 10%........ 107 OVCON-35 – norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg.......................................................................20 OVIDE – malathion lotion 0.5%...................................... 107 OVIDREL – Benefit Limits may apply – choriogonadotropin alfa inj 250 mcg/0.5ml......................27 OXANDRIN – oxandrolone tab 10 mg.............................. 16 OXANDRIN – oxandrolone tab 2.5 mg............................. 16 oxandrolone tab 10 mg (Oxandrin)................................16 oxandrolone tab 2.5 mg (Oxandrin)...............................16 oxaprozin tab 600 mg (Daypro)..................................... 75 oxazepam cap 10 mg...................................................... 56 oxazepam cap 15 mg...................................................... 56 oxazepam cap 30 mg...................................................... 56 oxcarbazepine tab 150 mg (Trileptal)............................ 80 oxcarbazepine tab 300 mg (Trileptal)............................ 80 oxcarbazepine tab 600 mg (Trileptal)............................ 80 oxybutynin chloride syrup 5 mg/5ml.............................54 oxybutynin chloride tab 5 mg........................................ 54 oxybutynin chloride tab sr 24hr 10 mg (Ditropan xl).....................................................................................54 oxybutynin chloride tab sr 24hr 15 mg (Ditropan xl).....................................................................................54 oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl)......54 oxycodone-aspirin tab 4.8355-325 mg (Percodan)....... 72 oxycodone hcl cap 5 mg................................................ 72 oxycodone hcl conc 100 mg/5ml (20 mg/ml) (Oxycodone hcl).............................................................72 OXYCODONE HCL ER – oxycodone hcl tab er 12hr deter 10 mg...............................................................................72 OXYCODONE HCL ER – oxycodone hcl tab er 12hr deter 20 mg...............................................................................72 OXYCODONE HCL ER – oxycodone hcl tab er 12hr deter 40 mg...............................................................................72 OXYCODONE HCL ER – oxycodone hcl tab er 12hr deter 80 mg...............................................................................72 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 147 2015 OXYCODONE HCL – oxycodone hcl conc 100 mg/5ml (20 mg/ml).............................................................................. 72 OXYCODONE HCL – oxycodone hcl soln 5 mg/5ml.........72 oxycodone hcl soln 5 mg/5ml (Oxycodone hcl)........... 72 oxycodone hcl tab 10 mg...............................................72 oxycodone hcl tab 15 mg (Roxicodone)....................... 72 oxycodone hcl tab 20 mg...............................................72 oxycodone hcl tab 30 mg (Roxicodone)....................... 72 oxycodone hcl tab 5 mg (Roxicodone)......................... 72 oxycodone-ibuprofen tab 5-400 mg...............................72 oxycodone w/ acetaminophen tab 10-325 mg (Percocet)....................................................................... 72 oxycodone w/ acetaminophen tab 2.5-325 mg (Percocet)....................................................................... 72 oxycodone w/ acetaminophen tab 5-325 mg (Percocet)....................................................................... 72 oxycodone w/ acetaminophen tab 7.5-325 mg (Percocet)....................................................................... 72 OXYCONTIN – oxycodone hcl tab er 12hr deter 10 mg.................................................................................... 72 OXYCONTIN – oxycodone hcl tab er 12hr deter 15 mg.................................................................................... 72 OXYCONTIN – oxycodone hcl tab er 12hr deter 20 mg.................................................................................... 72 OXYCONTIN – oxycodone hcl tab er 12hr deter 30 mg.................................................................................... 72 OXYCONTIN – oxycodone hcl tab er 12hr deter 40 mg.................................................................................... 72 OXYCONTIN – oxycodone hcl tab er 12hr deter 60 mg.................................................................................... 72 OXYCONTIN – oxycodone hcl tab er 12hr deter 80 mg.................................................................................... 72 oxymorphone hcl tab 10 mg (Opana)............................72 oxymorphone hcl tab 5 mg (Opana)..............................72 P PAIRE OB – prenat w/ fe poly cmplx-fe asp-fe gly-fa tab & dha cap pak.....................................................................86 PAMELOR – nortriptyline hcl cap 10 mg.......................... 59 PAMELOR – nortriptyline hcl cap 25 mg.......................... 59 PAMELOR – nortriptyline hcl cap 50 mg.......................... 59 PAMELOR – nortriptyline hcl cap 75 mg.......................... 59 PAMINE FORTE – methscopolamine bromide tab 5 mg.................................................................................... 51 PAMINE – methscopolamine bromide tab 2.5 mg.............51 pantoprazole sodium ec tab 20 mg (base equiv) (Protonix)........................................................................ 51 pantoprazole sodium ec tab 40 mg (base equiv) (Protonix)........................................................................ 51 PARAFON FORTE DSC – chlorzoxazone tab 500 mg..... 83 paricalcitol cap 1 mcg (Zemplar)................................... 27 paricalcitol cap 2 mcg (Zemplar)................................... 27 paricalcitol cap 4 mcg (Zemplar)................................... 27 PARLODEL – bromocriptine mesylate cap 5 mg.............. 81 PARNATE – tranylcypromine sulfate tab 10 mg............... 59 paromomycin sulfate cap 250 mg................................... 5 148 paroxetine hcl tab 10 mg (Paxil).................................... 59 paroxetine hcl tab 20 mg (Paxil).................................... 59 paroxetine hcl tab 30 mg (Paxil).................................... 59 paroxetine hcl tab 40 mg (Paxil).................................... 59 paroxetine hcl tab sr 24hr 12.5 mg (Paxil cr)................ 59 paroxetine hcl tab sr 24hr 25 mg (Paxil cr)...................59 paroxetine hcl tab sr 24hr 37.5 mg (Paxil cr)................ 59 PAXIL CR – paroxetine hcl tab sr 24hr 12.5 mg............... 59 PAXIL CR – paroxetine hcl tab sr 24hr 25 mg.................. 59 PAXIL CR – paroxetine hcl tab sr 24hr 37.5 mg............... 59 PAXIL – paroxetine hcl tab 10 mg.................................... 59 PAXIL – paroxetine hcl tab 20 mg.................................... 59 PAXIL – paroxetine hcl tab 30 mg.................................... 59 PAXIL – paroxetine hcl tab 40 mg.................................... 59 pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/ ml ................................................................................... 86 pediatric multiple vitamins w/ fluoride chew tab 0.25 mg .................................................................................. 86 pediatric multiple vitamins w/ fluoride chew tab 1 mg ......................................................................................... 87 pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml ......................................................................................... 87 pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml ......................................................................................... 87 pediatric vitamins acd w/ fluoride soln 0.25 mg/ml ..... 87 pediatric vitamins acd w/ fluoride soln 0.5 mg/ml ....... 87 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm (Golytely)........................................................................ 49 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm (Colyte-flavor packs)..................................................... 49 peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/flavor pack).................................................... 49 PEGASYS – peginterferon alfa-2a inj 180 mcg/0.5ml......... 8 PEGASYS – peginterferon alfa-2a inj 180 mcg/ml.............. 8 PEGASYS PROCLICK – peginterferon alfa-2a inj 135 mcg/0.5ml.......................................................................... 8 PEGASYS PROCLICK – peginterferon alfa-2a inj 180 mcg/0.5ml.......................................................................... 8 PEGINTRON – peginterferon alfa-2b for inj kit 120 mcg/0.5ml.......................................................................... 8 PEG-INTRON – peginterferon alfa-2b for inj kit 120 mcg/0.5ml.......................................................................... 7 PEGINTRON – peginterferon alfa-2b for inj kit 150 mcg/0.5ml.......................................................................... 8 PEG-INTRON – peginterferon alfa-2b for inj kit 150 mcg/0.5ml.......................................................................... 7 PEGINTRON – peginterferon alfa-2b for inj kit 50 mcg/0.5ml.......................................................................... 8 PEG-INTRON – peginterferon alfa-2b for inj kit 50 mcg/0.5ml.......................................................................... 7 PEGINTRON – peginterferon alfa-2b for inj kit 80 mcg/0.5ml.......................................................................... 8 PEG-INTRON – peginterferon alfa-2b for inj kit 80 mcg/0.5ml.......................................................................... 7 PEG-INTRON REDIPEN PAK 4 – peginterferon alfa-2b for inj kit 120 mcg/0.5ml......................................................... 8 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 2015 PEG-INTRON REDIPEN PAK 4 – peginterferon alfa-2b for inj kit 150 mcg/0.5ml......................................................... 8 PEG-INTRON REDIPEN PAK 4 – peginterferon alfa-2b for inj kit 50 mcg/0.5ml........................................................... 8 PEG-INTRON REDIPEN PAK 4 – peginterferon alfa-2b for inj kit 80 mcg/0.5ml........................................................... 8 PEG-INTRON REDIPEN – peginterferon alfa-2b for inj kit 120 mcg/0.5ml................................................................... 8 PEG-INTRON REDIPEN – peginterferon alfa-2b for inj kit 150 mcg/0.5ml................................................................... 8 PEG-INTRON REDIPEN – peginterferon alfa-2b for inj kit 50 mcg/0.5ml..................................................................... 7 PEG-INTRON REDIPEN – peginterferon alfa-2b for inj kit 80 mcg/0.5ml..................................................................... 8 penicillin v potassium for soln 125 mg/5ml.................... 1 penicillin v potassium for soln 250 mg/5ml.................... 1 penicillin v potassium tab 250 mg...................................1 penicillin v potassium tab 500 mg...................................1 PENLAC NAIL LACQUER – ciclopirox solution 8%........ 107 PENTASA – mesalamine cap cr 250 mg.......................... 53 PENTASA – mesalamine cap cr 500 mg.......................... 53 pentazocine w/ naloxone tab 50-0.5 mg........................72 pentoxifylline tab cr 400 mg...........................................97 PEPCID – famotidine for susp 40 mg/5ml.........................51 PEPCID – famotidine tab 20 mg.......................................51 PEPCID – famotidine tab 40 mg.......................................51 PERCOCET – oxycodone w/ acetaminophen tab 10-325 mg.................................................................................... 72 PERCOCET – oxycodone w/ acetaminophen tab 2.5-325 mg.................................................................................... 72 PERCOCET – oxycodone w/ acetaminophen tab 5-325 mg.................................................................................... 72 PERCOCET – oxycodone w/ acetaminophen tab 7.5-325 mg.................................................................................... 72 PERCODAN – oxycodone-aspirin tab 4.8355-325 mg...... 72 PERIDEX – chlorhexidine gluconate soln 0.12%............ 101 perindopril erbumine tab 2 mg...................................... 39 perindopril erbumine tab 4 mg (Aceon)........................ 39 perindopril erbumine tab 8 mg (Aceon)........................ 39 permethrin cream 5% (Elimite).................................... 107 perphenazine tab 16 mg................................................. 61 perphenazine tab 2 mg................................................... 61 perphenazine tab 4 mg................................................... 61 perphenazine tab 8 mg................................................... 61 PERSANTINE – dipyridamole tab 25 mg..........................97 PERSANTINE – dipyridamole tab 50 mg..........................97 PERSANTINE – dipyridamole tab 75 mg..........................97 phenazopyridine hcl tab 100 mg (Pyridium)................. 55 phenazopyridine hcl tab 200 mg (Pyridium)................. 55 phenelzine sulfate tab 15 mg (Nardil)............................59 phenobarbital elixir 20 mg/5ml...................................... 63 PHENOBARBITAL – phenobarbital tab 100 mg............... 63 PHENOBARBITAL – phenobarbital tab 15 mg................. 63 PHENOBARBITAL – phenobarbital tab 30 mg................. 63 PHENOBARBITAL – phenobarbital tab 60 mg................. 63 phenobarbital tab 16.2 mg............................................. 63 phenobarbital tab 32.4 mg............................................. 63 phenobarbital tab 64.8 mg............................................. 63 phenobarbital tab 97.2 mg............................................. 63 phenylephrine hcl ophth soln 10%................................99 phenylephrine hcl ophth soln 2.5%...............................99 PHENYTEK – phenytoin sodium extended cap 200 mg.................................................................................... 80 PHENYTEK – phenytoin sodium extended cap 300 mg.................................................................................... 80 phenytoin chew tab 50 mg (Dilantin infatabs).............. 80 phenytoin sodium extended cap 100 mg (Dilantin)......80 phenytoin sodium extended cap 200 mg (Phenytek).......................................................................80 phenytoin sodium extended cap 300 mg (Phenytek).......................................................................80 phenytoin susp 125 mg/5ml (Dilantin).......................... 80 PHOSLO – calcium acetate (phosphate binder) cap 667 mg (169 mg ca)...............................................................53 pilocarpine hcl ophth soln 1% (Isopto carpine)............99 pilocarpine hcl ophth soln 2% (Isopto carpine)............99 pilocarpine hcl ophth soln 4% (Isopto carpine)............99 pilocarpine hcl tab 5 mg (Salagen)..............................101 pilocarpine hcl tab 7.5 mg (Salagen)...........................101 pioglitazone hcl-glimepiride tab 30-2 mg (Duetact)......22 pioglitazone hcl-glimepiride tab 30-4 mg (Duetact)......22 pioglitazone hcl-metformin hcl tab 15-500 mg (Actoplus met)............................................................... 22 pioglitazone hcl-metformin hcl tab 15-850 mg (Actoplus met)............................................................... 22 pioglitazone hcl tab 15 mg (base equiv) (Actos).......... 22 pioglitazone hcl tab 30 mg (base equiv) (Actos).......... 22 pioglitazone hcl tab 45 mg (base equiv) (Actos).......... 22 piroxicam cap 10 mg (Feldene)..................................... 75 piroxicam cap 20 mg (Feldene)..................................... 75 PLAN B – levonorgestrel tab 0.75 mg.............................. 20 PLAN B ONE-STEP – levonorgestrel tab 1.5 mg..............20 PLAQUENIL – hydroxychloroquine sulfate tab 200 mg.....10 PLAVIX – clopidogrel bisulfate tab 300 mg (base equiv)............................................................................... 97 PLAVIX – clopidogrel bisulfate tab 75 mg (base equiv).....97 PLEGRIDY – peginterferon beta-1a soln pen-injector 125 mcg/0.5ml........................................................................ 67 PLEGRIDY – peginterferon beta-1a soln prefilled syringe 125 mcg/0.5ml................................................................. 67 PLEGRIDY STARTER PACK – peginterferon beta-1a soln pen-inj 63 & 94 mcg/0.5ml pack......................................67 PLEGRIDY STARTER PACK – peginterferon beta-1a soln pref syr 63 & 94 mcg/0.5ml pack.................................... 67 PLETAL – cilostazol tab 100 mg.......................................97 PLETAL – cilostazol tab 50 mg.........................................97 PNV-DHA+DOCUSATE – prenatal w/o vit a w/ fe fum-dssfa-dha cap 27-1.25-300 mg............................................. 87 PNV-DHA – prenat w/o a w/fefum-methfol-fa-dha cap 27-0.6-0.4-300 mg........................................................... 87 PNV FERROUS FUMARATE/DOCU – prenatal vit w/ dssfe fumarate-fa tab 29-1 mg............................................. 87 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 149 2015 PNV-FIRST – prenatal mv w/ fe polysac cmplx-fa-dha cap 29-1-200 mg.................................................................... 87 PNV FOLIC ACID + IRON MUL – prenatal vit w/ fe fumarate-fa tab 27-1 mg..................................................87 PNV-OB/DHA – prenatal mv w/fe fum-fa tab 65-1 mg & dha cap 250 mg pack .................................................... 87 PNV OB+DHA – prenat w/o a w/fecbn-fegl-dss-fa tab & dha cap 250 mg pack..................................................... 87 PNV-OMEGA – prenat w/o a w/ fe fumerate-methylfolatefa-omega 3 cap............................................................... 87 PNV PRENATAL PLUS MULTIVI – prenatal vit w/ fe fumarate-fa tab 27-1 mg..................................................87 PNV-SELECT – prenatal vit w/ fe fum-methylfolate-fa tab 27-0.6-0.4 mg.................................................................. 87 PNV TABS 29-1 – prenatal vit w/ iron carbonyl-fa tab 29-1 mg.................................................................................... 87 PNV-TOTAL – prenat w/ fe cbn-fe bisglyc-fa-fish oil cap 35-5-1.2 mg..................................................................... 87 PNV-VP-U – prenatal w/o a vit w/ fe fumarate-fa cap 106.5-1 mg...................................................................... 87 podofilox soln 0.5% (Condylox)...................................107 polyethylene glycol 3350 oral packet............................49 polyethylene glycol 3350 oral powder.......................... 49 polymyxin b-trimethoprim ophth soln 10000 unit/ ml-0.1% (Polytrim)......................................................... 99 POLYTRIM – polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%..................................................................... 99 potassium bicarbonate effer tab 25 meq...................... 92 potassium chloride cap cr 10 meq (Micro-k)................ 93 potassium chloride cap cr 8 meq (Micro-k).................. 93 POTASSIUM CHLORIDE ER – potassium chloride tab cr 20 meq (1500 mg)...........................................................93 potassium chloride microencapsulated crys cr tab 10 meq..................................................................................93 potassium chloride microencapsulated crys cr tab 20 meq..................................................................................93 potassium chloride oral liq 10% (20 meq/15ml)............93 potassium chloride oral liq 20% (40 meq/15ml)............93 potassium chloride powder packet 20 meq..................93 potassium chloride tab cr 10 meq (K-tab).................... 93 potassium chloride tab cr 8 meq (600 mg)................... 93 potassium citrate & citric acid powder pack 3300-1002 mg....................................................................................55 potassium citrate tab cr 10 meq (1080 mg) (Urocit-k 10)....................................................................................55 potassium citrate tab cr 15 meq (1620 mg) (Urocit-k 15)....................................................................................55 potassium citrate tab cr 5 meq (540 mg) (Urocit-k 5)......................................................................................55 pot bicarbonate & chloride effer tab 25 meq................ 92 pot phos monobasic w/sod phos di & monobas tab 155-852-130mg (K-phos neutral).................................. 92 PRADAXA – dabigatran etexilate mesylate cap 150 mg (etexilate base eq)...........................................................96 PRADAXA – dabigatran etexilate mesylate cap 75 mg (etexilate base eq)...........................................................96 150 pramipexole dihydrochloride tab 0.125 mg (Mirapex)......................................................................... 81 pramipexole dihydrochloride tab 0.25 mg (Mirapex)......................................................................... 81 pramipexole dihydrochloride tab 0.5 mg (Mirapex)......81 pramipexole dihydrochloride tab 0.75 mg (Mirapex)......................................................................... 81 pramipexole dihydrochloride tab 1.5 mg (Mirapex)......82 pramipexole dihydrochloride tab 1 mg (Mirapex)........ 81 PRAMOSONE – pramoxine-hc cream 1-1%................... 107 PRAMOSONE – pramoxine-hc cream 1-2.5%................ 107 PRAMOTIC – pramoxine-chloroxylenol otic liquid 1-0.1%............................................................................101 pramoxine-chloroxylenol otic liquid 1-0.1% (Pramotic)..................................................................... 101 pramoxine-hc-chloroxylenol aqueous otic soln 10-10-1 mg/ml (Cortane-b aqueous)........................................101 pramoxine-hc-chloroxylenol otic soln 10-10-1 mg/ml (Cortane-b-otic)............................................................ 101 pramoxine-hc cream 1-2.5% (Pramosone).................. 107 PRANDIN – repaglinide tab 0.5 mg.................................. 22 PRANDIN – repaglinide tab 1 mg..................................... 22 PRANDIN – repaglinide tab 2 mg..................................... 22 PRAVACHOL – pravastatin sodium tab 20 mg................. 44 PRAVACHOL – pravastatin sodium tab 40 mg................. 44 PRAVACHOL – pravastatin sodium tab 80 mg................. 44 pravastatin sodium tab 10 mg....................................... 44 pravastatin sodium tab 20 mg (Pravachol)................... 44 pravastatin sodium tab 40 mg (Pravachol)................... 44 pravastatin sodium tab 80 mg (Pravachol)................... 44 prazosin hcl cap 1 mg (Minipress)................................ 39 prazosin hcl cap 2 mg (Minipress)................................ 39 prazosin hcl cap 5 mg (Minipress)................................ 39 PRECOSE – acarbose tab 100 mg...................................22 PRECOSE – acarbose tab 25 mg.................................... 22 PRECOSE – acarbose tab 50 mg.................................... 22 PRED FORTE – prednisolone acetate ophth susp 1%..... 99 PRED-G – gentamicin-prednisolone ace ophth susp 0.3-1%..............................................................................99 PRED MILD – prednisolone acetate ophth susp 0.12%...............................................................................99 prednicarbate cream 0.1% (Dermatop)........................107 prednicarbate oint 0.1% (Dermatop)............................107 prednisolone acetate ophth susp 1% (Pred forte)........99 PREDNISOLONE SODIUM PHOSP – prednisolone sodium phosphate ophth soln 1%................................... 99 prednisolone sod phosphate oral soln 15 mg/5ml (base equiv)....................................................................15 prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) (Pediapred).............................................15 prednisolone syrup 15 mg/5ml (usp solution equivalent) (Prelone)..................................................... 15 PREDNISONE INTENSOL – prednisone conc 5 mg/ ml..................................................................................... 15 PREDNISONE – prednisone oral soln 5 mg/5ml.............. 15 PREDNISONE – prednisone tab 10 mg dose pack...........15 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 2015 PREDNISONE – prednisone tab 50 mg............................15 PREDNISONE – prednisone tab 5 mg dose pack............ 15 prednisone tab 10 mg.....................................................15 prednisone tab 1 mg.......................................................15 prednisone tab 2.5 mg....................................................15 prednisone tab 20 mg.....................................................15 prednisone tab 5 mg.......................................................15 PREFERA OB + DHA – prenat-fe poly cmplx-fe heme poly-fa tab & omega 3 cap pck....................................... 87 PREFERAOB ONE – prenat-fe poly cmplx-fe heme polyfa-dha cap 22-6-1-200 mg...............................................87 PREFERA OB – prenat vit-fe poly cmplx-fe heme poly-fa tab 28-6-1 mg.................................................................. 87 PREFOL-DHA – prenatal w/o vit a w/ fe fum-dss-fa-dha cap 26-1.2-300 mg.......................................................... 87 PRELONE – prednisolone syrup 15 mg/5ml (usp solution equivalent)....................................................................... 16 PREMARIN – estrogens, conjugated tab 0.3 mg.............. 17 PREMARIN – estrogens, conjugated tab 0.45 mg............ 17 PREMARIN – estrogens, conjugated tab 0.625 mg.......... 17 PREMARIN – estrogens, conjugated tab 0.9 mg.............. 17 PREMARIN – estrogens, conjugated tab 1.25 mg............ 17 PREMARIN – estrogens, conjugated vaginal cream 0.625 mg/gm.............................................................................. 55 PREMPHASE – conj est 0.625(14)/conj est-medroxypro ac tab 0.625-5mg(14)...................................................... 17 PREMPRO – conjugated estrogen-medroxyprogest acetate tab 0.3-1.5 mg.................................................... 18 PREMPRO – conjugated estrogen-medroxyprogest acetate tab 0.45-1.5 mg.................................................. 18 PREMPRO – conjugated estrogen-medroxyprogest acetate tab 0.625-2.5 mg................................................ 18 PREMPRO – conjugated estrogen-medroxyprogest acetate tab 0.625-5 mg................................................... 18 PRENA1/QUATREFOLIC – prenat w/o a w/fefum-methfolfa-dha cap 30-0.6-0.4-200 mg.........................................89 PRENA1 CHEW – prenat w/ b2-b6-b12-d3-folic acid chew tab 1.4 mg....................................................................... 89 PRENA1 PEARL – prenat w/oa w/fefum-na fered-fa-dha cap cr 30-1.4-200 mg...................................................... 89 PRENA1 PLUS/QUATREFOLIC – prenat w/o a w/ fe chelate-l methylfol-fa tab & dha cap pk........................... 89 PRENAISSANCE 90 DHA – prenat w/o a w/fecbn-fegldss-fa tab 90 &dha cap 300mg pak................................ 88 PRENAISSANCE BALANCE – prenatal w/o vit a w/ fe cbn-dss-fa-dha cap 30-1-260 mg.................................... 87 PRENAISSANCE DHA – prenat w/o a w/fecbn-fegl-dss-fa tab & dha cap 250 mg pack............................................87 PRENAISSANCE HARMONY DHA – prenat w/fe poly-na fered-fa tab 27-1 & omega cap dr 380mg....................... 87 PRENAISSANCE NEXT-B – prenatal w/ calcium-vit b6-faginger tab 1.22 mg.......................................................... 88 PRENAISSANCE NEXT – prenatal w/ calcium-vit b6-faginger tab 1.2 mg............................................................ 88 PRENAISSANCE PLUS – prenatal w/o a w/fe cbn-dss-fadha cap 28-1-250 mg...................................................... 88 PRENAISSANCE – prenatal w/o vit a w/ fe fum-dss-fa-dha cap 29-1.25-325 mg........................................................ 87 PRENAISSANCE PROMISE – prenat w/o a w/fecbn-fegldss-fa tab & dha cap 300 mg pack................................. 88 PRENAPLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg.................................................................................... 88 PRENATABS FA – prenatal vit w/ fe fumarate-fa tab 29-1 mg.................................................................................... 88 PRENATABS RX – prenatal vit w/ iron carbonyl-fa tab 29-1 mg........................................................................... 88 PRENATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg........................................................................... 88 PRENATAL 19 – prenatal vit w/ fe fumarate-fa chew tab 29-1 mg........................................................................... 88 PRENATAL AD – prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg........................................................................... 88 PRENATAL LOW IRON – prenatal vit w/ fe fumarate-fa tab 27-0.8 mg.................................................................. 88 PRENATAL LOW IRON – prenatal vit w/ fe fumarate-fa tab 27-1 mg..................................................................... 88 PRENATAL ONE DAILY – prenatal vit w/ fe fumarate-fa tab 27-0.8 mg.................................................................. 88 PRENATAL PLUS IRON – prenatal vit w/ iron carbonyl-fa tab 29-1 mg..................................................................... 88 PRENATAL PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg.................................................................................... 88 PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-0.8 mg.................................................................................... 88 PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-1 mg.................................................................................... 88 PRENATAL-U – prenatal w/o a vit w/ fe fumarate-fa cap 106.5-1 mg...................................................................... 88 PRENATAL VITAMINS PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg..................................................88 PRENATE AM – prenatal w/ calcium-vit b6-vit b12-faginger tab 1 mg............................................................... 88 PRENATE DHA – prenat w/o a w/feaspg-methfol-fa-dha cap 18-0.6-0.4-300 mg.................................................... 88 PRENATE DHA – prenat w/o a w/fefum-methfol-fa-dha cap 28-0.6-0.4-300 mg.................................................... 88 PRENATE ELITE – prenatal vit w/ fe fum-methylfolate-fa tab 26-0.6-0.4 mg............................................................ 88 PRENATE ELITE – prenatal w/ fe asp gly-l methylfol-fa tab 20-0.6-0.4 mg............................................................ 88 PRENATE ENHANCE – prenat w/o a w/fefum-methfol-fadha cap 28-0.6-0.4-400 mg............................................. 88 PRENATE ESSENTIAL – prenat w/o a w/feaspg-methfolfa-dha cap 18-0.6-0.4-300 mg.........................................88 PRENATE ESSENTIAL – prenat w/o a w/feasp-methylf-faomeg cap 29-0.6-0.4-340 mg.......................................... 88 PRENATE MINI – prenat w/oa w/fecb-feasp-meth-fa-dha cap 18-0.6-0.4-350 mg.................................................... 88 PRENATE PIXIE – prenat w/o a w/feaspg-methfol-fa-dha cap 10-0.6-0.4-200 mg.................................................... 88 PRENATE – prenat mv & min w/ l-methylfolate-fa chew tab 0.6-0.4 mg................................................................. 88 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 151 2015 PRENATE RESTORE – prenat w/o a w/fefum-methfol-fadha cap 27-0.6-0.4-400 mg............................................. 89 PRENATE STAR – prenatal vit w/ fe asparto glycinate-fa tab 20-1 mg..................................................................... 89 PRENEXA – prenatal w/o vit a w/ fe fum-dss-fa-dha cap 27-1.25-300 mg............................................................... 89 PREPLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg.................................................................................... 89 PREQUE 10 – prenatal mv w/fe carbonyl-dss-fa-dha tab 15-25-0.5-50 mg.............................................................. 89 PRETAB – prenatal vit w/ fe fumarate-fa tab 29-1 mg...... 89 PREVACID – lansoprazole cap delayed release 15 mg.................................................................................... 51 PREVACID – lansoprazole cap delayed release 30 mg.................................................................................... 51 PREVIDENT 5000 BOOSTER – sodium fluoride paste 1.1%...............................................................................101 PREVIDENT 5000 DRY MOUTH – sodium fluoride gel 1.1% (0.5% f).................................................................101 PREVIDENT 5000 ENAMEL PRO – sodium fluoridepotassium nitrate paste 1.1-5%..................................... 101 PREVIDENT 5000 PLUS – sodium fluoride cream 1.1%...............................................................................101 PREVIDENT 5000 SENSITIVE – sodium fluoridepotassium nitrate paste 1.1-5%..................................... 101 PREVIDENT FLUORIDE – sodium fluoride gel 1.1% (0.5% f).......................................................................... 101 PREVIDENT – sodium fluoride rinse 0.2%..................... 101 PREVPAC – amoxicillin cap-clarithro tab-lansopraz cap dr therapy pack.................................................................... 51 PREZISTA – darunavir ethanolate susp 100 mg/ml (base equiv)................................................................................. 8 PREZISTA – darunavir ethanolate tab 150 mg (base equiv)................................................................................. 8 PREZISTA – darunavir ethanolate tab 600 mg (base equiv)................................................................................. 8 PREZISTA – darunavir ethanolate tab 75 mg (base equiv)................................................................................. 8 PREZISTA – darunavir ethanolate tab 800 mg (base equiv)................................................................................. 8 PRILOSEC – omeprazole cap delayed release 10 mg......51 PRILOSEC – omeprazole cap delayed release 20 mg......51 PRILOSEC – omeprazole cap delayed release 40 mg......51 PRIMAQUINE PHOSPHATE – primaquine phosphate tab 26.3 mg............................................................................10 primidone tab 250 mg (Mysoline).................................. 80 primidone tab 50 mg (Mysoline).................................... 80 PRINIVIL – lisinopril tab 10 mg.........................................39 PRINIVIL – lisinopril tab 20 mg.........................................39 PRINIVIL – lisinopril tab 5 mg...........................................39 PR NATAL 400 EC – prenat-fe bis-fe prot succ-fa-ca tab & omega cap dr 400 pk...................................................... 87 PR NATAL 400 – prenat-fe bis-fe prot succ-fa-ca tab & omega 3 cap 400 pk....................................................... 87 PR NATAL 430 EC – prenat-fe bis-fe prot succ-fa-ca tab & omega cap dr 430 pk...................................................... 87 152 PR NATAL 430 – prenat-fe bis-fe prot succ-fa-ca tab & omega 3 cap 430 pk....................................................... 87 PROAIR HFA – albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv).........................................................48 probenecid tab 500 mg...................................................76 PROCARDIA – nifedipine cap 10 mg............................... 32 PROCARDIA XL – nifedipine tab sr 24hr osmotic 30 mg.................................................................................... 32 PROCARDIA XL – nifedipine tab sr 24hr osmotic 60 mg.................................................................................... 32 PROCARDIA XL – nifedipine tab sr 24hr osmotic 90 mg.................................................................................... 32 prochlorperazine maleate tab 10 mg (Compazine).......61 prochlorperazine maleate tab 5 mg (Compazine).........62 prochlorperazine suppos 25 mg....................................62 PROCRIT – epoetin alfa inj 10000 unit/ml........................ 95 PROCRIT – epoetin alfa inj 20000 unit/ml........................ 95 PROCRIT – epoetin alfa inj 2000 unit/ml.......................... 94 PROCRIT – epoetin alfa inj 3000 unit/ml.......................... 94 PROCRIT – epoetin alfa inj 40000 unit/ml........................ 95 PROCRIT – epoetin alfa inj 4000 unit/ml.......................... 95 PROCTOCORT – hydrocortisone acetate suppos 30 mg.................................................................................. 102 PROCTOCORT – hydrocortisone rectal cream 1%........ 102 PROCTOFOAM HC – hydrocortisone acetate w/ pramoxine rectal foam 1-1%......................................... 102 PRODRIN – acetaminophen-isometheptene-caffeine tab 325-65-20 mg.................................................................. 76 progesterone im in oil 50 mg/ml....................................20 progesterone micronized cap 100 mg (Prometrium).................................................................. 20 progesterone micronized cap 200 mg (Prometrium).................................................................. 20 PROGRAF – tacrolimus cap 0.5 mg............................... 111 PROGRAF – tacrolimus cap 1 mg.................................. 111 PROGRAF – tacrolimus cap 5 mg.................................. 112 promethazine-dm syrup 6.25-15 mg/5ml....................... 47 promethazine hcl suppos 12.5 mg................................ 45 promethazine hcl suppos 25 mg................................... 45 promethazine hcl suppos 50 mg................................... 45 promethazine hcl syrup 6.25 mg/5ml............................ 46 promethazine hcl tab 12.5 mg........................................46 promethazine hcl tab 25 mg...........................................46 promethazine hcl tab 50 mg...........................................46 PROMETHAZINE VC/CODEINE – phenylephrinepromethazine w/ codeine syrup 5-6.25-10 mg/5ml.......... 46 PROMETHAZINE VC PLAIN – promethazine & phenylephrine syrup 6.25-5 mg/5ml................................ 46 promethazine w/ codeine syrup 6.25-10 mg/5ml.......... 47 PROMETRIUM – progesterone micronized cap 100 mg.................................................................................... 20 PROMETRIUM – progesterone micronized cap 200 mg.................................................................................... 20 propafenone hcl cap sr 12hr 225 mg (Rythmol sr)....... 34 propafenone hcl cap sr 12hr 325 mg (Rythmol sr)....... 34 propafenone hcl cap sr 12hr 425 mg (Rythmol sr)....... 34 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 2015 propafenone hcl tab 150 mg (Rythmol).........................34 propafenone hcl tab 225 mg (Rythmol).........................34 propafenone hcl tab 300 mg.......................................... 34 proparacaine hcl ophth soln 0.5% (Alcaine).................99 PROPRANOLOL/HYDROCHLOROTH – propranolol & hydrochlorothiazide tab 40-25 mg................................... 39 PROPRANOLOL/HYDROCHLOROTH – propranolol & hydrochlorothiazide tab 80-25 mg................................... 39 propranolol hcl cap sr 24hr 120 mg (Inderal la)........... 30 propranolol hcl cap sr 24hr 160 mg (Inderal la)........... 30 propranolol hcl cap sr 24hr 60 mg (Inderal la)............. 30 propranolol hcl cap sr 24hr 80 mg (Inderal la)............. 30 propranolol hcl tab 10 mg..............................................30 propranolol hcl tab 20 mg..............................................30 propranolol hcl tab 40 mg..............................................30 propranolol hcl tab 60 mg..............................................30 propranolol hcl tab 80 mg..............................................30 propylthiouracil tab 50 mg............................................. 24 PROSCAR – finasteride tab 5 mg.................................... 55 PROSED/DS – methenamine-hyosc-meth blue-benz acidphenyl sal tab 81.6mg..................................................... 54 PROTONIX – pantoprazole sodium ec tab 20 mg (base equiv)............................................................................... 51 PROTONIX – pantoprazole sodium ec tab 40 mg (base equiv)............................................................................... 51 PROTOPIC – tacrolimus oint 0.03%............................... 107 PROTOPIC – tacrolimus oint 0.1%................................. 107 protriptyline hcl tab 10 mg (Vivactil)............................. 59 protriptyline hcl tab 5 mg (Vivactil)............................... 59 PROVERA – medroxyprogesterone acetate tab 10 mg.................................................................................... 20 PROVERA – medroxyprogesterone acetate tab 2.5 mg.................................................................................... 20 PROVERA – medroxyprogesterone acetate tab 5 mg...... 20 PROVIDA OB – prenatal w/o a w/fe fum-fe poly-fa cap 20-20-1.25 mg................................................................. 89 PROVIGIL – modafinil tab 100 mg................................... 66 PROVIGIL – modafinil tab 200 mg................................... 66 PROZAC – fluoxetine hcl cap 10 mg................................ 59 PROZAC – fluoxetine hcl cap 20 mg................................ 59 PROZAC – fluoxetine hcl cap 40 mg................................ 59 PROZAC WEEKLY – fluoxetine hcl cap delayed release 90 mg...............................................................................59 PULMICORT – budesonide inhalation susp 0.25 mg/2ml............................................................................. 48 PULMICORT – budesonide inhalation susp 0.5 mg/2ml............................................................................. 48 PULMOZYME – dornase alfa inhal soln 1 mg/ml..............49 PUREFE OB PLUS – prenatal w/o a w/fe fum-fe poly-fa cap 162.115.2-1 mg........................................................ 89 PURINETHOL – mercaptopurine tab 50 mg..................... 13 pyrazinamide tab 500 mg................................................. 5 PYRIDIUM – phenazopyridine hcl tab 100 mg..................55 PYRIDIUM – phenazopyridine hcl tab 200 mg..................55 pyridostigmine bromide tab 60 mg (Mestinon).............83 Q QNASL – beclomethasone dipropionate nasal aerosol 80 mcg/act............................................................................ 46 QNASL CHILDRENS – beclomethasone dipropionate nasal aerosol 40 mcg/act................................................ 46 QUARTETTE – levonor-eth est tab 0.15-0.02/0.025/0.03 mg ð est 0.01 mg.......................................................20 QUESTRAN – cholestyramine powder 4 gm/dose............44 QUESTRAN – cholestyramine powder packets 4 gm....... 44 QUESTRAN LIGHT – cholestyramine light powder 4 gm/ dose................................................................................. 44 quetiapine fumarate tab 100 mg (Seroquel)..................62 quetiapine fumarate tab 200 mg (Seroquel)..................62 quetiapine fumarate tab 25 mg (Seroquel)....................62 quetiapine fumarate tab 300 mg (Seroquel)..................62 quetiapine fumarate tab 400 mg (Seroquel)..................62 quetiapine fumarate tab 50 mg (Seroquel)....................62 QUFLORA PEDIATRIC – pediatric multiple vitamins w/ fluoride chew tab 0.25 mg...............................................89 QUFLORA PEDIATRIC – pediatric multiple vitamins w/ fluoride chew tab 1 mg....................................................89 QUFLORA PEDIATRIC – pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml.................................................. 89 QUFLORA PEDIATRIC – pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml.................................................... 89 quinapril hcl tab 10 mg (Accupril)................................. 39 quinapril hcl tab 20 mg (Accupril)................................. 39 quinapril hcl tab 40 mg (Accupril)................................. 39 quinapril hcl tab 5 mg (Accupril)................................... 39 quinapril-hydrochlorothiazide tab 10-12.5 mg (Accuretic)...................................................................... 39 quinapril-hydrochlorothiazide tab 20-12.5 mg (Accuretic)...................................................................... 40 quinapril-hydrochlorothiazide tab 20-25 mg (Accuretic)...................................................................... 40 quinidine gluconate tab cr 324 mg................................34 QUINIDINE SULFATE – quinidine sulfate tab 200 mg...... 34 quinidine sulfate tab 300 mg..........................................34 R rabeprazole sodium ec tab 20 mg (Aciphex)................ 51 raloxifene hcl tab 60 mg (Evista)................................... 27 ramipril cap 1.25 mg (Altace)......................................... 40 ramipril cap 10 mg (Altace)............................................ 40 ramipril cap 2.5 mg (Altace)........................................... 40 ramipril cap 5 mg (Altace)..............................................40 RANEXA – ranolazine tab sr 12hr 1000 mg......................29 RANEXA – ranolazine tab sr 12hr 500 mg....................... 29 ranitidine hcl cap 150 mg...............................................51 ranitidine hcl cap 300 mg...............................................51 ranitidine hcl syrup 15 mg/ml (75 mg/5ml)................... 51 ranitidine hcl tab 150 mg (Zantac).................................51 ranitidine hcl tab 300 mg (Zantac).................................51 RAPAMUNE – sirolimus oral soln 1 mg/ml..................... 112 RAPAMUNE – sirolimus tab 0.5 mg............................... 112 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 153 2015 RAPAMUNE – sirolimus tab 1 mg.................................. 112 RAPAMUNE – sirolimus tab 2 mg.................................. 112 RAZADYNE ER – galantamine hydrobromide cap sr 24hr 16 mg...............................................................................67 RAZADYNE ER – galantamine hydrobromide cap sr 24hr 24 mg...............................................................................67 RAZADYNE ER – galantamine hydrobromide cap sr 24hr 8 mg.................................................................................67 RAZADYNE – galantamine hydrobromide oral soln 4 mg/ ml..................................................................................... 67 RAZADYNE – galantamine hydrobromide tab 12 mg....... 67 RAZADYNE – galantamine hydrobromide tab 4 mg......... 67 RAZADYNE – galantamine hydrobromide tab 8 mg......... 67 REAPHIRM – prenatal mv w/ fe polysac cmplx-fa-dha cap 29-1-200 mg.................................................................... 89 REBETOL – ribavirin cap 200 mg.......................................8 REBIF – interferon beta-1a inj 22 mcg/0.5ml (12mu/ml) (44 mcg/ml)......................................................................67 REBIF – interferon beta-1a inj 44 mcg/0.5ml (24mu/ml) (88 mcg/ml)......................................................................68 REBIF REBIDOSE – interferon beta-1a inj 22 mcg/0.5ml (12mu/ml) (44 mcg/ml).................................................... 68 REBIF REBIDOSE – interferon beta-1a inj 44 mcg/0.5ml (24mu/ml) (88 mcg/ml).................................................... 68 REBIF REBIDOSE TITRATION – interferon beta-1a inj 6 x 8.8 mcg/0.2ml & 6 x 22 mcg/0.5ml..................................68 REBIF TITRATION PACK – interferon beta-1a inj 6 x 8.8 mcg/0.2ml & 6 x 22 mcg/0.5ml........................................68 REGLAN – metoclopramide hcl tab 10 mg....................... 53 REGLAN – metoclopramide hcl tab 5 mg......................... 53 RELION R – insulin regular (human) inj 100 unit/ml..........23 RELNATE DHA – prenatal vit w/ fe fum-fa-omega 3 cap 28-1-200 mg.................................................................... 89 REMERON – mirtazapine tab 15 mg................................ 59 REMERON – mirtazapine tab 30 mg................................ 59 REMERON – mirtazapine tab 45 mg................................ 59 REMERON SOLTAB – mirtazapine orally disintegrating tab 15 mg........................................................................ 59 REMERON SOLTAB – mirtazapine orally disintegrating tab 30 mg........................................................................ 59 REMERON SOLTAB – mirtazapine orally disintegrating tab 45 mg........................................................................ 59 RENAGEL – sevelamer hcl tab 400 mg............................53 RENAGEL – sevelamer hcl tab 800 mg............................53 RENVELA – sevelamer carbonate packet 0.8 gm.............53 RENVELA – sevelamer carbonate packet 2.4 gm.............53 RENVELA – sevelamer carbonate tab 800 mg................. 53 repaglinide tab 0.5 mg (Prandin)................................... 22 repaglinide tab 1 mg (Prandin)...................................... 22 repaglinide tab 2 mg (Prandin)...................................... 22 REPREXAIN – hydrocodone-ibuprofen tab 2.5-200 mg.................................................................................... 72 REPREXAIN – hydrocodone-ibuprofen tab 5-200 mg.......72 REPRONEX – Benefit Limits may apply – menotropins for inj 75 unit.........................................................................27 REQUIP – ropinirole hydrochloride tab 0.25 mg............... 82 154 REQUIP – ropinirole hydrochloride tab 0.5 mg................. 82 REQUIP – ropinirole hydrochloride tab 1 mg.................... 82 REQUIP – ropinirole hydrochloride tab 2 mg.................... 82 REQUIP – ropinirole hydrochloride tab 3 mg.................... 82 REQUIP – ropinirole hydrochloride tab 4 mg.................... 82 REQUIP – ropinirole hydrochloride tab 5 mg.................... 82 REQUIP XL – ropinirole hydrochloride tab sr 24hr 12 mg (base equivalent)............................................................. 82 REQUIP XL – ropinirole hydrochloride tab sr 24hr 2 mg (base equivalent)............................................................. 82 REQUIP XL – ropinirole hydrochloride tab sr 24hr 4 mg (base equivalent)............................................................. 82 REQUIP XL – ropinirole hydrochloride tab sr 24hr 6 mg (base equivalent)............................................................. 82 REQUIP XL – ropinirole hydrochloride tab sr 24hr 8 mg (base equivalent)............................................................. 82 RESCRIPTOR – delavirdine mesylate tab 100 mg............. 8 RESCRIPTOR – delavirdine mesylate tab 200 mg............. 8 RESERPINE – reserpine tab 0.1 mg................................ 40 RESERPINE – reserpine tab 0.25 mg.............................. 40 RESTORIL – temazepam cap 15 mg............................... 63 RESTORIL – temazepam cap 22.5 mg............................ 63 RESTORIL – temazepam cap 30 mg............................... 63 RESTORIL – temazepam cap 7.5 mg.............................. 63 RETIN-A – tretinoin cream 0.025%.................................107 RETIN-A – tretinoin cream 0.05%...................................107 RETIN-A – tretinoin cream 0.1%.....................................108 RETIN-A – tretinoin gel 0.01%........................................108 RETIN-A – tretinoin gel 0.025%......................................108 RETROVIR – zidovudine cap 100 mg................................ 8 RETROVIR – zidovudine syrup 10 mg/ml...........................8 REVATIO – sildenafil citrate tab 20 mg............................ 45 REVIA – naltrexone hcl tab 50 mg..................................110 REVLIMID – lenalidomide cap 10 mg............................. 112 REVLIMID – lenalidomide cap 15 mg............................. 112 REVLIMID – lenalidomide cap 20 mg............................. 112 REVLIMID – lenalidomide cap 25 mg............................. 112 REVLIMID – lenalidomide cap 5 mg............................... 112 REVLIMID – lenalidomide caps 2.5 mg.......................... 112 REYATAZ – atazanavir sulfate cap 150 mg (base equiv)................................................................................. 8 REYATAZ – atazanavir sulfate cap 200 mg (base equiv)................................................................................. 8 REYATAZ – atazanavir sulfate cap 300 mg (base equiv)................................................................................. 8 REYATAZ – atazanavir sulfate oral powder packet 50 mg (base equiv).......................................................................8 RHINOCORT AQUA – budesonide nasal susp 32 mcg/ act.................................................................................... 46 RIBASPHERE RIBAPAK – ribavirin tab 400 mg................. 8 RIBASPHERE RIBAPAK – ribavirin tab 400 mg & ribavirin tab 600 mg dose pack...................................................... 8 RIBASPHERE RIBAPAK – ribavirin tab 600 mg................. 8 RIBASPHERE – ribavirin tab 400 mg................................. 8 RIBASPHERE – ribavirin tab 600 mg................................. 8 RIBATAB – ribavirin tab 400 mg.........................................8 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 2015 RIBATAB – ribavirin tab 400 mg & ribavirin tab 600 mg dose pack.......................................................................... 9 RIBATAB – ribavirin tab 600 mg.........................................8 ribavirin cap 200 mg (Rebetol).........................................9 ribavirin tab 200 mg (Copegus)....................................... 9 RIFADIN – rifampin cap 150 mg.........................................5 RIFADIN – rifampin cap 300 mg.........................................5 RIFAMATE – isoniazid & rifampin cap 150-300 mg............ 5 rifampin cap 150 mg (Rifadin)..........................................5 rifampin cap 300 mg (Rifadin)..........................................5 RIGHT STEP PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-0.8 mg.................................................................. 89 RILUTEK – riluzole tab 50 mg.......................................... 83 riluzole tab 50 mg (Rilutek)............................................ 83 rimantadine hydrochloride tab 100 mg (Flumadine)...... 9 RIOMET – metformin hcl oral soln 500 mg/5ml................ 22 risedronate sodium tab 150 mg (Actonel).....................27 RISPERDAL M-TAB – risperidone orally disintegrating tab 0.5 mg..............................................................................62 RISPERDAL M-TAB – risperidone orally disintegrating tab 1 mg.................................................................................62 RISPERDAL M-TAB – risperidone orally disintegrating tab 2 mg.................................................................................62 RISPERDAL M-TAB – risperidone orally disintegrating tab 3 mg.................................................................................62 RISPERDAL M-TAB – risperidone orally disintegrating tab 4 mg.................................................................................62 RISPERDAL – risperidone soln 1 mg/ml...........................62 RISPERDAL – risperidone tab 0.25 mg............................ 62 RISPERDAL – risperidone tab 0.5 mg..............................62 RISPERDAL – risperidone tab 1 mg.................................62 RISPERDAL – risperidone tab 2 mg.................................62 RISPERDAL – risperidone tab 3 mg.................................62 RISPERDAL – risperidone tab 4 mg.................................62 risperidone orally disintegrating tab 0.25 mg...............62 risperidone orally disintegrating tab 0.5 mg (Risperdal m-tab).............................................................................. 62 risperidone orally disintegrating tab 1 mg (Risperdal m-tab).............................................................................. 62 risperidone orally disintegrating tab 2 mg (Risperdal m-tab).............................................................................. 62 risperidone orally disintegrating tab 3 mg (Risperdal m-tab).............................................................................. 62 risperidone orally disintegrating tab 4 mg (Risperdal m-tab).............................................................................. 62 risperidone soln 1 mg/ml (Risperdal)............................62 risperidone tab 0.25 mg (Risperdal).............................. 62 risperidone tab 0.5 mg (Risperdal)................................ 62 risperidone tab 1 mg (Risperdal)................................... 62 risperidone tab 2 mg (Risperdal)................................... 62 risperidone tab 3 mg (Risperdal)................................... 62 risperidone tab 4 mg (Risperdal)................................... 62 RITALIN LA – methylphenidate hcl cap sr 24hr 10 mg......66 RITALIN LA – methylphenidate hcl cap sr 24hr 20 mg......66 RITALIN LA – methylphenidate hcl cap sr 24hr 30 mg......66 RITALIN LA – methylphenidate hcl cap sr 24hr 40 mg......66 RITALIN – methylphenidate hcl tab 10 mg....................... 66 RITALIN – methylphenidate hcl tab 20 mg....................... 66 RITALIN – methylphenidate hcl tab 5 mg......................... 66 rivastigmine tartrate cap 1.5 mg (Exelon)..................... 68 rivastigmine tartrate cap 3 mg (Exelon)........................68 rivastigmine tartrate cap 4.5 mg (Exelon)..................... 68 rivastigmine tartrate cap 6 mg (Exelon)........................68 rizatriptan benzoate orally disintegrating tab 10 mg (Maxalt-mlt).....................................................................76 rizatriptan benzoate orally disintegrating tab 5 mg (Maxalt-mlt).....................................................................76 rizatriptan benzoate tab 10 mg (Maxalt)........................76 rizatriptan benzoate tab 5 mg (Maxalt)..........................76 R-NATAL OB – prenatal w/o a w/fe cbn-fa-dha cap 20-1-320 mg.................................................................... 89 ROBAXIN-750 – methocarbamol tab 750 mg................... 83 ROBAXIN – methocarbamol tab 500 mg.......................... 83 ROBINUL FORTE – glycopyrrolate tab 2 mg....................51 ROBINUL – glycopyrrolate tab 1 mg.................................51 ROCALTROL – calcitriol cap 0.25 mcg.............................27 ROCALTROL – calcitriol cap 0.5 mcg.............................. 27 ROCALTROL – calcitriol oral soln 1 mcg/ml..................... 28 ropinirole hydrochloride tab 0.25 mg (Requip).............82 ropinirole hydrochloride tab 0.5 mg (Requip)...............82 ropinirole hydrochloride tab 1 mg (Requip)................. 82 ropinirole hydrochloride tab 2 mg (Requip)................. 82 ropinirole hydrochloride tab 3 mg (Requip)................. 82 ropinirole hydrochloride tab 4 mg (Requip)................. 82 ropinirole hydrochloride tab 5 mg (Requip)................. 82 ropinirole hydrochloride tab sr 24hr 12 mg (base equivalent) (Requip xl).................................................. 82 ropinirole hydrochloride tab sr 24hr 2 mg (base equivalent) (Requip xl).................................................. 82 ropinirole hydrochloride tab sr 24hr 4 mg (base equivalent) (Requip xl).................................................. 82 ropinirole hydrochloride tab sr 24hr 6 mg (base equivalent) (Requip xl).................................................. 82 ropinirole hydrochloride tab sr 24hr 8 mg (base equivalent) (Requip xl).................................................. 82 ROWASA – mesalamine rectal enema 4 gm & cleanser wipe kit.............................................................................53 ROXICODONE – oxycodone hcl tab 15 mg......................73 ROXICODONE – oxycodone hcl tab 30 mg......................73 ROXICODONE – oxycodone hcl tab 5 mg........................72 RYTHMOL – propafenone hcl tab 150 mg........................34 RYTHMOL – propafenone hcl tab 225 mg........................34 RYTHMOL SR – propafenone hcl cap sr 12hr 225 mg..... 34 RYTHMOL SR – propafenone hcl cap sr 12hr 325 mg..... 34 RYTHMOL SR – propafenone hcl cap sr 12hr 425 mg..... 34 S SALAGEN – pilocarpine hcl tab 5 mg............................. 101 SALAGEN – pilocarpine hcl tab 7.5 mg.......................... 101 SALEX CREAM – salicylic acid cream 6% & cleanser liqd kit................................................................................... 108 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 155 2015 SALEX LOTION – salicylic acid lotion 6% & cleanser liqd kit................................................................................... 108 SALEX – salicylic acid shampoo 6%.............................. 108 salicylic acid cream 6%................................................ 108 salicylic acid cream 6% & cleanser liqd kit (Salex cream)........................................................................... 108 salicylic acid film forming liquid 27.5% (Virasal)........108 salicylic acid foam 6% (Salvax)................................... 108 salicylic acid gel 6% (Keralyt)......................................108 salicylic acid lotion 6%.................................................108 salicylic acid lotion 6% & cleanser liqd kit (Salex lotion)............................................................................ 108 SALICYLIC ACID – salicylic acid soln 26%.................... 108 salicylic acid shampoo 6% (Salex).............................. 108 salsalate tab 500 mg....................................................... 68 salsalate tab 750 mg....................................................... 68 SALVAX – salicylic acid foam 6%...................................108 SAMSCA – tolvaptan tab 15 mg....................................... 28 SAMSCA – tolvaptan tab 30 mg....................................... 28 SANDIMMUNE – cyclosporine cap 100 mg.................... 112 SANDIMMUNE – cyclosporine cap 25 mg...................... 112 SANDIMMUNE – cyclosporine oral soln 100 mg/ml........112 SANDOSTATIN – octreotide acetate inj 1000 mcg/ml (1 mg/ml).............................................................................. 28 SANDOSTATIN – octreotide acetate inj 100 mcg/ml (0.1 mg/ml).............................................................................. 28 SANDOSTATIN – octreotide acetate inj 200 mcg/ml (0.2 mg/ml).............................................................................. 28 SANDOSTATIN – octreotide acetate inj 500 mcg/ml (0.5 mg/ml).............................................................................. 28 SANDOSTATIN – octreotide acetate inj 50 mcg/ml (0.05 mg/ml).............................................................................. 28 SEASONIQUE – levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7)...................................................... 20 SECTRAL – acebutolol hcl cap 200 mg............................30 SECTRAL – acebutolol hcl cap 400 mg............................30 SELECT-OB+DHA – prenatal mv w/fe poly-fa chw 29-1 mg & dha cap 250 mg pak ............................................ 89 SELECT-OB – prenatal vit w/ fe polysac cmplx-fa chew tab 29-1 mg..................................................................... 89 SELECT-OB – prenat w/ fepolycmplx-methylfol-fa chew tab 29-0.6-0.4 mg............................................................ 89 selegiline hcl cap 5 mg (Eldepryl)................................. 82 selegiline hcl tab 5 mg................................................... 82 selenium sulfide lotion 2.5%........................................ 108 SELENIUM SULFIDE – selenium sulfide-pyrithione zinc in urea shampoo 2.25%.................................................... 108 SELZENTRY – maraviroc tab 150 mg................................ 9 SELZENTRY – maraviroc tab 300 mg................................ 9 SE-NATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg.................................................................................... 89 SE-NATAL 19 – prenatal vit w/ fe fumarate-fa chew tab 29-1 mg........................................................................... 89 SENSIPAR – cinacalcet hcl tab 30 mg (base equiv)......... 28 SENSIPAR – cinacalcet hcl tab 60 mg (base equiv)......... 28 SENSIPAR – cinacalcet hcl tab 90 mg (base equiv)......... 28 156 SEREVENT DISKUS – salmeterol xinafoate aer pow ba 50 mcg/dose (base equiv)............................................... 48 SEROQUEL – quetiapine fumarate tab 100 mg................62 SEROQUEL – quetiapine fumarate tab 200 mg................62 SEROQUEL – quetiapine fumarate tab 25 mg..................62 SEROQUEL – quetiapine fumarate tab 300 mg................62 SEROQUEL – quetiapine fumarate tab 400 mg................62 SEROQUEL – quetiapine fumarate tab 50 mg..................62 sertraline hcl oral conc 20 mg/ml (Zoloft).....................59 sertraline hcl tab 100 mg (Zoloft).................................. 59 sertraline hcl tab 25 mg (Zoloft).................................... 60 sertraline hcl tab 50 mg (Zoloft).................................... 60 SE-TAN DHA – prenatal w/fe fum-fe poly -fa-omega 3 cap 15-15-1 mg...................................................................... 89 SETON ET-EC – prenat-fe bis-fe prot succ-fa-ca tab & omega cap dr 430 pk...................................................... 89 SETONET – prenat-fe bis-fe prot succ-fa-ca tab & omega 3 cap 430 pk................................................................... 89 SHOHLS SOLUTION MODIFIED – sodium citrate & citric acid soln 500-334 mg/5ml............................................... 55 SIGNIFOR – pasireotide diaspartate inj 0.3 mg/ml (base equiv)............................................................................... 28 SIGNIFOR – pasireotide diaspartate inj 0.6 mg/ml (base equiv)............................................................................... 28 SIGNIFOR – pasireotide diaspartate inj 0.9 mg/ml (base equiv)............................................................................... 28 sildenafil citrate tab 20 mg (Revatio).............................45 SILVADENE – silver sulfadiazine cream 1%...................108 silver nitrate-potassium nitrate applicator 75-25% (Arzol silver nitrate).....................................................108 silver sulfadiazine cream 1% (Silvadene)................... 108 SIMBRINZA – brinzolamide-brimonidine tartrate ophth susp 1-0.2%.....................................................................99 SIMPONI – golimumab subcutaneous soln auto-injector 100 mg/ml........................................................................75 SIMPONI – golimumab subcutaneous soln auto-injector 50 mg/0.5ml.....................................................................75 SIMPONI – golimumab subcutaneous soln prefilled syringe 100 mg/ml........................................................... 75 SIMPONI – golimumab subcutaneous soln prefilled syringe 50 mg/0.5ml........................................................ 75 simvastatin tab 10 mg (Zocor)....................................... 44 simvastatin tab 20 mg (Zocor)....................................... 44 simvastatin tab 40 mg (Zocor)....................................... 44 simvastatin tab 5 mg (Zocor)......................................... 44 simvastatin tab 80 mg (Zocor)....................................... 44 SINEMET – carbidopa & levodopa tab 10-100 mg............82 SINEMET – carbidopa & levodopa tab 25-100 mg............82 SINEMET – carbidopa & levodopa tab 25-250 mg............82 SINEMET CR – carbidopa & levodopa tab cr 25-100 mg.................................................................................... 82 SINEMET CR – carbidopa & levodopa tab cr 50-200 mg.................................................................................... 82 SINGULAIR – montelukast sodium chew tab 4 mg (base equiv)............................................................................... 48 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 2015 SINGULAIR – montelukast sodium chew tab 5 mg (base equiv)............................................................................... 49 SINGULAIR – montelukast sodium tab 10 mg (base equiv)............................................................................... 48 sirolimus tab 0.5 mg (Rapamune)................................112 sirolimus tab 1 mg (Rapamune)...................................112 sirolimus tab 2 mg (Rapamune)...................................112 SKELAXIN – metaxalone tab 800 mg...............................83 sodium chloride irrigation soln 0.9%............................ 55 sodium chloride soln nebu 0.9%................................... 47 sodium chloride soln nebu 3%...................................... 47 sodium chloride soln nebu 7% (Hyper-sal)...................47 sodium citrate & citric acid soln 500-334 mg/5ml (Shohls solution modi)..................................................55 sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) (Luride)............................................................................93 sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) (Luride)............................................................................93 sodium fluoride chew tab 1 mg f (from 2.2 mg naf) (Luride)............................................................................93 sodium fluoride cream 1.1% (Prevident 5000 plus).............................................................................. 101 sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride).........................................................................101 sodium fluoride paste 1.1% (Prevident 5000 boost)............................................................................ 101 sodium fluoride-potassium nitrate paste 1.1-5% (Prevident 5000 sensi).................................................101 sodium fluoride rinse 0.2% (Prevident).......................101 SODIUM FLUORIDE – sodium fluoride tab 1 mg f (from 2.2 mg naf)...................................................................... 93 sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf).................................................................................. 93 sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) (Luride)............................................................................93 sodium phenylbutyrate oral powder 3 gm/teaspoonful (Buphenyl)...................................................................... 28 sodium polystyrene sulfonate powder (Kayexalate)..................................................................112 sodium thiosulfate-salicylic acid lotion 25-1%........... 108 SOMA – carisoprodol tab 350 mg.....................................83 SONATA – zaleplon cap 10 mg........................................63 SONATA – zaleplon cap 5 mg..........................................63 SORIATANE – acitretin cap 10 mg.................................108 SORIATANE – acitretin cap 17.5 mg..............................108 SORIATANE – acitretin cap 25 mg.................................108 sotalol hcl (afib/afl) tab 120 mg (Betapace af).............. 30 sotalol hcl (afib/afl) tab 160 mg (Betapace af).............. 30 sotalol hcl (afib/afl) tab 80 mg (Betapace af)................ 30 sotalol hcl tab 120 mg (Betapace)................................. 30 sotalol hcl tab 160 mg (Betapace)................................. 30 sotalol hcl tab 240 mg.................................................... 30 sotalol hcl tab 80 mg (Betapace)................................... 30 SOVALDI – sofosbuvir tab 400 mg.....................................9 SPIRIVA HANDIHALER – tiotropium bromide monohydrate inhal cap 18 mcg (base equiv)...................49 SPIRIVA RESPIMAT – tiotropium bromide monohydrate inhal aerosol 2.5 mcg/act................................................ 49 spironolactone & hydrochlorothiazide tab 25-25 mg (Aldactazide)...................................................................42 spironolactone tab 100 mg (Aldactone)........................ 42 spironolactone tab 25 mg (Aldactone).......................... 42 spironolactone tab 50 mg (Aldactone).......................... 42 SPORANOX – itraconazole cap 100 mg.............................6 SPORANOX PULSEPAK – itraconazole cap 100 mg......... 6 SPRYCEL – dasatinib tab 100 mg....................................13 SPRYCEL – dasatinib tab 140 mg....................................13 SPRYCEL – dasatinib tab 20 mg......................................13 SPRYCEL – dasatinib tab 50 mg......................................13 SPRYCEL – dasatinib tab 70 mg......................................13 SPRYCEL – dasatinib tab 80 mg......................................13 SPS – sodium polystyrene sulfonate oral susp 15 gm/60ml......................................................................... 112 STALEVO 100 – carbidopa-levodopa-entacapone tabs 25-100-200 mg................................................................ 82 STALEVO 125 – carbidopa-levodopa-entacapone tabs 31.25-125-200 mg........................................................... 82 STALEVO 150 – carbidopa-levodopa-entacapone tabs 37.5-150-200 mg............................................................. 82 STALEVO 200 – carbidopa-levodopa-entacapone tabs 50-200-200 mg................................................................ 83 STALEVO 50 – carbidopa-levodopa-entacapone tabs 12.5-50-200 mg............................................................... 83 STALEVO 75 – carbidopa-levodopa-entacapone tabs 18.75-75-200 mg............................................................. 83 stannous fluoride conc 0.63% (Gel-kam oral care ri)................................................................................... 101 STARLIX – nateglinide tab 120 mg...................................22 STARLIX – nateglinide tab 60 mg.................................... 22 stavudine cap 15 mg (Zerit)............................................. 9 stavudine cap 20 mg (Zerit)............................................. 9 stavudine cap 30 mg (Zerit)............................................. 9 stavudine cap 40 mg (Zerit)............................................. 9 stavudine for oral soln 1 mg/ml (Zerit)............................9 STELARA – ustekinumab soln prefilled syringe 45 mg/0.5ml........................................................................ 108 STELARA – ustekinumab soln prefilled syringe 90 mg/ ml................................................................................... 108 STRIBILD – elvitegrav-cobicis-emtricitab-tenofov tab 150-150-200-300 mg......................................................... 9 STROMECTOL – ivermectin tab 3 mg..............................10 STROVITE – b-complex w/ c & folic acid tab....................89 SUBOXONE – buprenorphine hcl-naloxone hcl sl film 12-3 mg (base equiv)...............................................................73 SUBOXONE – buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (base equiv)..................................................... 73 SUBOXONE – buprenorphine hcl-naloxone hcl sl film 4-1 mg (base equiv)...............................................................73 SUBOXONE – buprenorphine hcl-naloxone hcl sl film 8-2 mg (base equiv)...............................................................73 sucralfate tab 1 gm (Carafate)....................................... 51 SULAR – nisoldipine tab sr 24hr 17 mg............................32 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 157 2015 SULAR – nisoldipine tab sr 24hr 34 mg............................33 SULAR – nisoldipine tab sr 24hr 8.5 mg...........................32 sulfacetamide sodium liquid 10% (Ovace wash)........ 108 sulfacetamide sodium lotion 10% (acne) (Klaron)......108 sulfacetamide sodium ophth soln 10% (Bleph-10).......99 sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)%................................................................ 99 SULFACETAMIDE SODIUM – sulfacetamide sodium ophth oint 10%................................................................ 99 sulfacetamide sodium-sulfur in urea emulsion 10-4%.............................................................................108 sulfacetamide sodium-sulfur w/ sunscreens cream 10-5% ........................................................................... 108 sulfacetamide sodium w/ sulfur cleansing pad 10-4% (Sumaxin)......................................................................108 sulfacetamide sodium w/ sulfur cream 10-5%............ 108 sulfacetamide sodium w/ sulfur emulsion 10-1%....... 108 sulfacetamide sodium w/ sulfur emulsion 10-5%....... 108 sulfacetamide sodium w/ sulfur foam 10-5% (Clarifoam ef)...................................................................................108 sulfacetamide sodium w/ sulfur lotion 10-5%.............108 sulfacetamide sodium w/ sulfur susp 8-4% (Sumaxin ts)...................................................................................108 sulfacetamide sodium w/ sulfur wash 9-4.5% (Sumadan wash).......................................................... 108 sulfacetamide sodium w/ sulfur wash 9-4% (Sumaxin wash).............................................................................108 sulfamethoxazole-trimethoprim susp 200-40 mg/5ml............................................................................ 11 sulfamethoxazole-trimethoprim tab 400-80 mg (Bactrim)......................................................................... 11 sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrim ds)....................................................................11 SULFAMYLON – mafenide acetate packet for topical soln 5% (50 gm)....................................................................108 sulfasalazine tab 500 mg (Azulfidine)........................... 53 sulfasalazine tab delayed release 500 mg (Azulfidine en-tabs)........................................................................... 53 sulindac tab 150 mg........................................................75 sulindac tab 200 mg........................................................75 SUMADAN WASH – sulfacetamide sodium w/ sulfur wash 9-4.5%............................................................................108 sumatriptan succinate inj 6 mg/0.5ml (Imitrex)............ 76 sumatriptan succinate solution auto-injector 4 mg/0.5ml (Imitrex statdose sys)................................... 76 sumatriptan succinate solution auto-injector 6 mg/0.5ml (Imitrex statdose sys)................................... 76 sumatriptan succinate solution cartridge 4 mg/0.5ml (Imitrex statdose ref)..................................................... 76 sumatriptan succinate solution cartridge 6 mg/0.5ml (Imitrex statdose ref)..................................................... 76 SUMATRIPTAN SUCCINATE – sumatriptan succinate inj 4 mg/0.5ml.......................................................................76 SUMATRIPTAN SUCCINATE – sumatriptan succinate solution prefilled syringe 6 mg/0.5ml............................... 76 sumatriptan succinate tab 100 mg (Imitrex)................. 76 158 sumatriptan succinate tab 25 mg (Imitrex)................... 76 sumatriptan succinate tab 50 mg (Imitrex)................... 76 SUMATRIPTAN – sumatriptan nasal spray 20 mg/act...... 76 SUMATRIPTAN – sumatriptan nasal spray 5 mg/act........ 76 SUMAXIN – sulfacetamide sodium w/ sulfur cleansing pad 10-4%.............................................................................108 SUMAXIN TS – sulfacetamide sodium w/ sulfur susp 8-4%...............................................................................109 SUMAXIN WASH – sulfacetamide sodium w/ sulfur wash 9-4%...............................................................................109 SUPRAX – cefixime cap 400 mg........................................ 2 SUPRAX – cefixime for susp 100 mg/5ml.......................... 2 SUPRAX – cefixime for susp 200 mg/5ml.......................... 2 SUPRAX – cefixime for susp 500 mg/5ml.......................... 2 SURESTEP PRO TEST STRIPS – glucose blood test strip................................................................................ 110 SUSTIVA – efavirenz cap 200 mg...................................... 9 SUSTIVA – efavirenz cap 50 mg........................................ 9 SUSTIVA – efavirenz tab 600 mg.......................................9 SUTENT – sunitinib malate cap 12.5 mg (base equivalent)....................................................................... 13 SUTENT – sunitinib malate cap 25 mg (base equivalent)....................................................................... 13 SUTENT – sunitinib malate cap 37.5 mg (base equivalent)....................................................................... 13 SUTENT – sunitinib malate cap 50 mg (base equivalent)....................................................................... 13 SYLATRON – peginterferon alfa-2b for inj kit 296 mcg..... 13 SYLATRON – peginterferon alfa-2b for inj kit 444 mcg..... 13 SYLATRON – peginterferon alfa-2b for inj kit 4 x 296 mcg.................................................................................. 13 SYLATRON – peginterferon alfa-2b for inj kit 4 x 444 mcg.................................................................................. 14 SYLATRON – peginterferon alfa-2b for inj kit 888 mcg..... 13 SYMAX DUOTAB – hyoscyamine sulfate tab cr 0.375 mg (0.125 mg ir/0.25 mg cr)..................................................52 SYMBICORT – budesonide-formoterol fumarate dihyd aerosol 160-4.5 mcg/act.................................................. 49 SYMBICORT – budesonide-formoterol fumarate dihyd aerosol 80-4.5 mcg/act.................................................... 49 SYMBYAX – olanzapine-fluoxetine hcl cap 12-25 mg.......68 SYMBYAX – olanzapine-fluoxetine hcl cap 12-50 mg.......68 SYMBYAX – olanzapine-fluoxetine hcl cap 3-25 mg.........68 SYMBYAX – olanzapine-fluoxetine hcl cap 6-25 mg.........68 SYMBYAX – olanzapine-fluoxetine hcl cap 6-50 mg.........68 SYNALAR – fluocinolone acetonide cream 0.025%........ 109 SYNALAR – fluocinolone acetonide oint 0.025%............ 109 SYNTHROID – levothyroxine sodium tab 100 mcg...........24 SYNTHROID – levothyroxine sodium tab 112 mcg...........24 SYNTHROID – levothyroxine sodium tab 125 mcg...........24 SYNTHROID – levothyroxine sodium tab 137 mcg...........24 SYNTHROID – levothyroxine sodium tab 150 mcg...........24 SYNTHROID – levothyroxine sodium tab 175 mcg...........24 SYNTHROID – levothyroxine sodium tab 200 mcg...........24 SYNTHROID – levothyroxine sodium tab 25 mcg.............24 SYNTHROID – levothyroxine sodium tab 300 mcg...........24 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 2015 SYNTHROID – levothyroxine sodium tab 50 mcg.............24 SYNTHROID – levothyroxine sodium tab 75 mcg.............24 SYNTHROID – levothyroxine sodium tab 88 mcg.............24 T TABLOID – thioguanine tab 40 mg................................... 14 TACLONEX – calcipotriene-betamethasone dipropionate oint 0.005-0.064%..........................................................109 TACLONEX – calcipotriene-betamethasone dipropionate susp 0.005-0.064%........................................................109 tacrolimus cap 0.5 mg (Prograf).................................. 112 tacrolimus cap 1 mg (Prograf)..................................... 112 tacrolimus cap 5 mg (Prograf)..................................... 112 tacrolimus oint 0.03% (Protopic)................................. 109 tacrolimus oint 0.1% (Protopic)................................... 109 TAMIFLU – oseltamivir phosphate cap 30 mg (base equiv)................................................................................. 9 TAMIFLU – oseltamivir phosphate cap 45 mg (base equiv)................................................................................. 9 TAMIFLU – oseltamivir phosphate cap 75 mg (base equiv)................................................................................. 9 TAMIFLU – oseltamivir phosphate for susp 6 mg/ml (base equiv)................................................................................. 9 tamoxifen citrate tab 10 mg (base equivalent)............. 14 tamoxifen citrate tab 20 mg (base equivalent)............. 14 tamsulosin hcl cap 0.4 mg (Flomax)............................. 55 TANDEM PLUS – fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu cap..................................................... 95 TAPAZOLE – methimazole tab 10 mg..............................24 TAPAZOLE – methimazole tab 5 mg................................24 TARCEVA – erlotinib hcl tab 100 mg (base equivalent)....................................................................... 14 TARCEVA – erlotinib hcl tab 150 mg (base equivalent)....................................................................... 14 TARCEVA – erlotinib hcl tab 25 mg (base equivalent)...... 14 TARGRETIN – bexarotene cap 75 mg............................. 14 TARGRETIN – bexarotene gel 1%................................. 109 TARON-BC – prenat w/o a w/ fe cbnyl-fa tab 20-1 mg & vit b6 tab pak....................................................................... 89 TARON-C DHA – prenatal w/fe fum-fe poly -fa-omega 3 cap 53.5-38-1 mg............................................................ 90 TARON-DUO EC – prenat-fe bis-fe prot succ-fa-ca tab & omega cap dr 400 pk...................................................... 90 TARON-PREX – prenatal w/o vit a w/ fe fum-dss-fa-dha cap 30-1.2-265 mg.......................................................... 90 TASIGNA – nilotinib hcl cap 150 mg (base equivalent).....14 TASIGNA – nilotinib hcl cap 200 mg (base equivalent).....14 TAZORAC – tazarotene cream 0.05%............................109 TAZORAC – tazarotene cream 0.1%..............................109 TAZORAC – tazarotene gel 0.05%................................. 109 TAZORAC – tazarotene gel 0.1%................................... 109 TECFIDERA – dimethyl fumarate capsule delayed release 120 mg.............................................................................68 TECFIDERA – dimethyl fumarate capsule delayed release 240 mg.............................................................................68 TECFIDERA STARTER PACK – dimethyl fumarate capsule dr starter pack 120 mg & 240 mg...................... 68 TEGRETOL – carbamazepine susp 100 mg/5ml.............. 80 TEGRETOL – carbamazepine tab 200 mg....................... 80 TEGRETOL-XR – carbamazepine tab sr 12hr 100 mg..... 80 TEGRETOL-XR – carbamazepine tab sr 12hr 200 mg..... 80 TEGRETOL-XR – carbamazepine tab sr 12hr 400 mg..... 80 telmisartan-amlodipine tab 40-10 mg (Twynsta).......... 40 telmisartan-amlodipine tab 40-5 mg (Twynsta)............ 40 telmisartan-amlodipine tab 80-10 mg (Twynsta).......... 40 telmisartan-amlodipine tab 80-5 mg (Twynsta)............ 40 telmisartan-hydrochlorothiazide tab 40-12.5 mg (Micardis hct)................................................................. 40 telmisartan-hydrochlorothiazide tab 80-12.5 mg (Micardis hct)................................................................. 40 telmisartan-hydrochlorothiazide tab 80-25 mg (Micardis hct)................................................................. 40 telmisartan tab 20 mg (Micardis)................................... 40 telmisartan tab 40 mg (Micardis)................................... 40 telmisartan tab 80 mg (Micardis)................................... 40 temazepam cap 15 mg (Restoril)................................... 63 temazepam cap 22.5 mg (Restoril)................................ 64 temazepam cap 30 mg (Restoril)................................... 64 temazepam cap 7.5 mg (Restoril).................................. 64 TEMODAR – temozolomide cap 100 mg.......................... 14 TEMODAR – temozolomide cap 140 mg.......................... 14 TEMODAR – temozolomide cap 180 mg.......................... 14 TEMODAR – temozolomide cap 20 mg............................ 14 TEMODAR – temozolomide cap 250 mg.......................... 14 TEMODAR – temozolomide cap 5 mg.............................. 14 TEMOVATE – clobetasol propionate cream 0.05%........ 109 TEMOVATE – clobetasol propionate gel 0.05%..............109 TEMOVATE – clobetasol propionate oint 0.05%.............109 TEMOVATE – clobetasol propionate soln 0.05%............109 TEMOVATE E – clobetasol propionate emollient base cream 0.05%................................................................. 109 temozolomide cap 100 mg (Temodar)........................... 14 temozolomide cap 140 mg (Temodar)........................... 14 temozolomide cap 180 mg (Temodar)........................... 14 temozolomide cap 20 mg (Temodar).............................14 temozolomide cap 250 mg (Temodar)........................... 14 temozolomide cap 5 mg (Temodar)...............................14 TENEX – guanfacine hcl tab 1 mg....................................40 TENEX – guanfacine hcl tab 2 mg....................................40 TENORETIC 100 – atenolol & chlorthalidone tab 100-25 mg.................................................................................... 40 TENORETIC 50 – atenolol & chlorthalidone tab 50-25 mg.................................................................................... 40 TENORMIN – atenolol tab 100 mg................................... 30 TENORMIN – atenolol tab 25 mg..................................... 30 TENORMIN – atenolol tab 50 mg..................................... 30 TERAZOL 3 – terconazole vaginal cream 0.8%................55 TERAZOL 7 – terconazole vaginal cream 0.4%................55 terazosin hcl cap 10 mg................................................. 40 terazosin hcl cap 1 mg................................................... 40 terazosin hcl cap 2 mg................................................... 40 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 159 2015 terazosin hcl cap 5 mg................................................... 40 terbinafine hcl tab 250 mg (Lamisil)................................6 terbutaline sulfate tab 2.5 mg........................................ 49 terbutaline sulfate tab 5 mg........................................... 49 terconazole vaginal cream 0.4% (Terazol 7)................. 55 terconazole vaginal cream 0.8% (Terazol 3)................. 55 terconazole vaginal suppos 80 mg................................55 TESSALON PERLES – benzonatate cap 100 mg.............47 testosterone cypionate im inj in oil 100 mg/ml (Depotestosterone).................................................................. 16 testosterone cypionate im inj in oil 200 mg/ml (Depotestosterone).................................................................. 16 testosterone enanthate im inj in oil 200 mg/ml............ 16 TESTRED – methyltestosterone cap 10 mg..................... 16 tetracaine hcl ophth soln 0.5%...................................... 99 TETRACYCLINE HCL – tetracycline hcl cap 250 mg......... 4 TETRACYCLINE HCL – tetracycline hcl cap 500 mg......... 4 THALOMID – thalidomide cap 100 mg........................... 112 THALOMID – thalidomide cap 150 mg........................... 112 THALOMID – thalidomide cap 200 mg........................... 112 THALOMID – thalidomide cap 50 mg............................. 112 theophylline soln 80 mg/15ml........................................ 49 theophylline tab sr 12hr 100 mg.................................... 49 theophylline tab sr 12hr 200 mg.................................... 49 theophylline tab sr 12hr 300 mg.................................... 49 theophylline tab sr 12hr 450 mg.................................... 49 theophylline tab sr 24hr 400 mg.................................... 49 theophylline tab sr 24hr 600 mg.................................... 49 THERA-FLUR-N – sodium fluoride gel 1.1% (0.5% f)..... 101 THERANATAL CORE NUTRITION – prenatal vit w/ fe fumarate-fa tab 27-1 mg..................................................90 thioridazine hcl tab 100 mg............................................62 thioridazine hcl tab 10 mg..............................................62 thioridazine hcl tab 25 mg..............................................62 thioridazine hcl tab 50 mg..............................................62 thiothixene cap 10 mg.................................................... 63 thiothixene cap 1 mg...................................................... 62 thiothixene cap 2 mg...................................................... 63 thiothixene cap 5 mg...................................................... 63 THYROGEN – thyrotropin alfa for inj 1.1 mg.................. 110 thyroid tab 30 mg (1/2 grain) (Armour thyroid).............24 thyroid tab 60 mg (1 grain) (Armour thyroid)................24 thyroid tab 90 mg (1 1/2 grain) (Armour thyroid)..........24 tiagabine hcl tab 2 mg (Gabitril).................................... 80 tiagabine hcl tab 4 mg (Gabitril).................................... 80 TIAZAC – diltiazem hcl extended release beads cap sr 24hr 120 mg.................................................................... 33 TIAZAC – diltiazem hcl extended release beads cap sr 24hr 180 mg.................................................................... 33 TIAZAC – diltiazem hcl extended release beads cap sr 24hr 240 mg.................................................................... 33 TIAZAC – diltiazem hcl extended release beads cap sr 24hr 300 mg.................................................................... 33 TIAZAC – diltiazem hcl extended release beads cap sr 24hr 360 mg.................................................................... 33 160 TIAZAC – diltiazem hcl extended release beads cap sr 24hr 420 mg.................................................................... 33 ticlopidine hcl tab 250 mg..............................................97 TIGAN – trimethobenzamide hcl cap 300 mg................... 52 TIKOSYN – dofetilide cap 125 mcg (0.125 mg)................ 34 TIKOSYN – dofetilide cap 250 mcg (0.25 mg).................. 34 TIKOSYN – dofetilide cap 500 mcg (0.5 mg).................... 34 timolol maleate ophth gel forming soln 0.25% (Timoptic-xe)................................................................ 100 timolol maleate ophth gel forming soln 0.5% (Timoptic-xe)................................................................ 100 timolol maleate ophth soln 0.25% (Timoptic)............. 100 timolol maleate ophth soln 0.5% (Timoptic)............... 100 TIMOPTIC – timolol maleate ophth soln 0.25%.............. 100 TIMOPTIC – timolol maleate ophth soln 0.5%................ 100 TIMOPTIC-XE – timolol maleate ophth gel forming soln 0.25%.............................................................................100 TIMOPTIC-XE – timolol maleate ophth gel forming soln 0.5%...............................................................................100 TINDAMAX – tinidazole tab 250 mg................................. 11 TINDAMAX – tinidazole tab 500 mg................................. 11 tinidazole tab 250 mg (Tindamax)..................................11 tinidazole tab 500 mg (Tindamax)..................................11 TIROSINT – levothyroxine sodium cap 100 mcg.............. 25 TIROSINT – levothyroxine sodium cap 112 mcg.............. 25 TIROSINT – levothyroxine sodium cap 125 mcg.............. 25 TIROSINT – levothyroxine sodium cap 137 mcg.............. 25 TIROSINT – levothyroxine sodium cap 13 mcg................ 24 TIROSINT – levothyroxine sodium cap 150 mcg.............. 25 TIROSINT – levothyroxine sodium cap 25 mcg................ 25 TIROSINT – levothyroxine sodium cap 50 mcg................ 25 TIROSINT – levothyroxine sodium cap 75 mcg................ 25 TIROSINT – levothyroxine sodium cap 88 mcg................ 25 TIVICAY – dolutegravir sodium tab 50 mg (base equiv)......9 tizanidine hcl cap 2 mg (Zanaflex).................................83 tizanidine hcl cap 4 mg (Zanaflex).................................83 tizanidine hcl cap 6 mg (Zanaflex).................................83 tizanidine hcl tab 2 mg................................................... 83 tizanidine hcl tab 4 mg (Zanaflex)................................. 83 TL-CARE DHA – prenatal w/fe fumarate-fa-dss-fish oil cap 27-1-500 mg.................................................................... 90 TL FOLATE – prenatal vit w/ fe fum-methylfolate-fa tab 27-0.5-0.5 mg.................................................................. 90 TL-SELECT DHA – prenatal w/o vit a w/ fe fum-doc-fa-dha cap 29-1.25-350 mg........................................................ 90 TL-SELECT – prenatal w/o vit a w/ fe fum-dss-fa-dha cap 29-1.25-325 mg............................................................... 90 TOBI PODHALER – tobramycin inhal cap 28 mg............... 5 TOBI – tobramycin nebu soln 300 mg/5ml..........................5 TOBRADEX – tobramycin-dexamethasone ophth susp 0.3-0.1%.........................................................................100 tobramycin-dexamethasone ophth susp 0.3-0.1% (Tobradex).................................................................... 100 tobramycin nebu soln 300 mg/5ml (Tobi)....................... 5 tobramycin ophth soln 0.3% (Tobrex)......................... 100 TOBREX – tobramycin sulfate ophth soln 0.3%..............100 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 2015 TOFRANIL – imipramine hcl tab 10 mg............................ 60 TOFRANIL – imipramine hcl tab 25 mg............................ 60 TOFRANIL – imipramine hcl tab 50 mg............................ 60 tolazamide tab 250 mg....................................................22 TOLAZAMIDE – tolazamide tab 500 mg...........................22 TOLBUTAMIDE – tolbutamide tab 500 mg....................... 22 tolmetin sodium cap 400 mg..........................................75 tolterodine tartrate tab 1 mg (Detrol).............................54 tolterodine tartrate tab 2 mg (Detrol).............................54 TOPAMAX SPRINKLE – topiramate sprinkle cap 15 mg.................................................................................... 80 TOPAMAX SPRINKLE – topiramate sprinkle cap 25 mg.................................................................................... 80 TOPAMAX – topiramate tab 100 mg................................ 80 TOPAMAX – topiramate tab 200 mg................................ 80 TOPAMAX – topiramate tab 25 mg.................................. 80 TOPAMAX – topiramate tab 50 mg.................................. 80 TOPICORT – desoximetasone cream 0.05%................. 109 TOPICORT – desoximetasone cream 0.25%................. 109 TOPICORT – desoximetasone gel 0.05%.......................109 TOPICORT – desoximetasone oint 0.25%......................109 topiramate sprinkle cap 15 mg (Topamax sprinkle)..... 80 topiramate sprinkle cap 25 mg (Topamax sprinkle)..... 80 topiramate tab 100 mg (Topamax).................................80 topiramate tab 200 mg (Topamax).................................80 topiramate tab 25 mg (Topamax)...................................80 topiramate tab 50 mg (Topamax)...................................80 TOPROL XL – metoprolol succinate tab sr 24hr 100 mg.................................................................................... 30 TOPROL XL – metoprolol succinate tab sr 24hr 200 mg.................................................................................... 30 TOPROL XL – metoprolol succinate tab sr 24hr 25 mg.................................................................................... 30 TOPROL XL – metoprolol succinate tab sr 24hr 50 mg.................................................................................... 30 torsemide tab 100 mg (Demadex)..................................42 torsemide tab 10 mg (Demadex)....................................42 torsemide tab 20 mg (Demadex)....................................42 torsemide tab 5 mg (Demadex)......................................42 TRACLEER – bosentan tab 125 mg................................. 45 TRACLEER – bosentan tab 62.5 mg................................ 45 tramadol-acetaminophen tab 37.5-325 mg (Ultracet)......................................................................... 73 tramadol hcl tab 50 mg (Ultram).................................... 73 tramadol hcl tab sr 24hr 100 mg (Ultram er).................73 tramadol hcl tab sr 24hr 200 mg (Ultram er).................73 tramadol hcl tab sr 24hr 300 mg (Ultram er).................73 tramadol hcl tab sr 24hr biphasic release 200 mg....... 73 tramadol hcl tab sr 24hr biphasic release 300 mg....... 73 TRANDATE – labetalol hcl tab 100 mg.............................30 TRANDATE – labetalol hcl tab 200 mg.............................30 TRANDATE – labetalol hcl tab 300 mg.............................30 trandolapril tab 1 mg (Mavik)......................................... 40 trandolapril tab 2 mg (Mavik)......................................... 40 trandolapril tab 4 mg (Mavik)......................................... 40 tranexamic acid tab 650 mg (Lysteda).......................... 96 TRANSDERM-SCOP – scopolamine td patch 72hr 1.5 mg.................................................................................... 52 TRANXENE T – clorazepate dipotassium tab 15 mg........ 56 TRANXENE T – clorazepate dipotassium tab 3.75 mg..... 56 TRANXENE T – clorazepate dipotassium tab 7.5 mg....... 56 tranylcypromine sulfate tab 10 mg (Parnate)............... 60 TRAVOPROST – travoprost ophth soln 0.004%............. 100 trazodone hcl tab 100 mg...............................................60 trazodone hcl tab 150 mg...............................................60 trazodone hcl tab 300 mg...............................................60 trazodone hcl tab 50 mg.................................................60 TREAGAN OTIC – antipyrine-benzocaine-polycosanol otic sol 5.4-1.4-0.0097%.......................................................101 tretinoin cap 10 mg......................................................... 14 tretinoin cream 0.025% (Retin-a)................................. 109 tretinoin cream 0.05% (Retin-a)................................... 109 tretinoin cream 0.1% (Retin-a)..................................... 109 tretinoin gel 0.01% (Retin-a).........................................109 tretinoin gel 0.025% (Retin-a).......................................109 TRIADVANCE – prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg........................................................................... 90 triamcinolone acetonide cream 0.025%...................... 109 triamcinolone acetonide cream 0.1%.......................... 109 triamcinolone acetonide cream 0.5%.......................... 109 triamcinolone acetonide dental paste 0.1%................ 101 triamcinolone acetonide lotion 0.025%....................... 109 triamcinolone acetonide lotion 0.1%........................... 109 triamcinolone acetonide nasal aerosol suspension 55 mcg/act (Nasacort aq)................................................... 46 triamcinolone acetonide oint 0.025%.......................... 109 triamcinolone acetonide oint 0.1%.............................. 109 TRIAMCINOLONE ACETONIDE – triamcinolone acetonide oint 0.5%.......................................................109 triamterene & hydrochlorothiazide cap 37.5-25 mg (Dyazide)......................................................................... 42 triamterene & hydrochlorothiazide tab 37.5-25 mg (Maxzide-25)................................................................... 42 triamterene & hydrochlorothiazide tab 75-50 mg (Maxzide).........................................................................42 TRIANEX – triamcinolone acetonide oint 0.05%............. 109 triazolam tab 0.125 mg................................................... 64 triazolam tab 0.25 mg (Halcion)..................................... 64 TRICARE PRENATAL COMPLEAT – prenat w/o a fefumfa tab 27-1 mg & fish oil chew cap pak........................... 90 TRICARE PRENATAL DHA ONE – prenatal w/fe fumarate-fa-dss-fish oil cap 27-1-500 mg........................90 TRICARE – prenatal vit w/ fe fumarate-fa tab 27-1 mg..... 90 TRICOR – fenofibrate tab 145 mg.................................... 44 TRICOR – fenofibrate tab 48 mg...................................... 44 trifluoperazine hcl tab 10 mg......................................... 63 trifluoperazine hcl tab 1 mg........................................... 63 trifluoperazine hcl tab 2 mg........................................... 63 trifluoperazine hcl tab 5 mg........................................... 63 trifluridine ophth soln 1% (Viroptic)............................ 100 trihexyphenidyl hcl elixir 0.4 mg/ml.............................. 83 trihexyphenidyl hcl tab 2 mg......................................... 83 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 161 2015 trihexyphenidyl hcl tab 5 mg......................................... 83 TRILEPTAL – oxcarbazepine tab 150 mg.........................80 TRILEPTAL – oxcarbazepine tab 300 mg.........................80 TRILEPTAL – oxcarbazepine tab 600 mg.........................80 TRILIPIX – choline fenofibrate cap dr 135 mg (fenofibric acid equiv)....................................................................... 44 TRILIPIX – choline fenofibrate cap dr 45 mg (fenofibric acid equiv)....................................................................... 44 trimethobenzamide hcl cap 300 mg (Tigan)..................52 trimethoprim tab 100 mg................................................ 11 TRINATAL GT – prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg........................................................................... 90 TRINATAL RX 1 – prenatal vit w/ fe fumarate-fa tab 60-1 mg.................................................................................... 90 TRINATAL ULTRA – prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg..................................................................... 90 TRINATE – prenatal vit w/ fe fumarate-fa tab 28-1 mg......90 TRI-NORINYL 28 – norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg............................................. 20 TRI-TABS DHA – prenat w/o a w/ fe bisglyc-fa tab 32-1 mg & omega cap pack.................................................... 90 TRIVEEN-DUO DHA – prenat-fe bis-fe prot succ-fa-ca tab & omega 3 cap 400 pk....................................................90 TRIVEEN-PRX RNF – prenatal w/o vit a w/ fe fum-dss-fadha cap 26-1.2-300 mg................................................... 90 TRIZIVIR – abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg................................................................ 9 tropicamide ophth soln 0.5%....................................... 100 tropicamide ophth soln 1% (Mydriacyl)...................... 100 trospium chloride cap sr 24hr 60 mg............................ 54 trospium chloride tab 20 mg..........................................54 TRUSOPT – dorzolamide hcl ophth soln 2%.................. 100 TRUVADA – emtricitabine-tenofovir disoproxil fumarate tab 200-300 mg................................................................. 9 trypsin w/ castor oil & peruvian balsam oint (Xenaderm)................................................................... 109 trypsin w/ castor oil & peruvian balsam spray (Granulex)..................................................................... 109 TUSSIONEX PENNKINETIC EXT – hydrocod polstchlorphen polst cr susp 10-8 mg/5ml.............................. 47 TWYNSTA – telmisartan-amlodipine tab 40-10 mg...........40 TWYNSTA – telmisartan-amlodipine tab 40-5 mg.............40 TWYNSTA – telmisartan-amlodipine tab 80-10 mg...........40 TWYNSTA – telmisartan-amlodipine tab 80-5 mg.............40 TYBOST – cobicistat tab 150 mg....................................... 9 TYKERB – lapatinib ditosylate tab 250 mg (base equiv)............................................................................... 14 TYLENOL/CODEINE #3 – acetaminophen w/ codeine tab 300-30 mg....................................................................... 73 TYLENOL/CODEINE #4 – acetaminophen w/ codeine tab 300-60 mg....................................................................... 73 TYLENOL/CODEINE – acetaminophen w/ codeine tab 300-15 mg....................................................................... 73 TYZEKA – telbivudine tab 600 mg......................................9 162 U ULTIMATECARE ONE NF – prenatal w/fe cbnyl-fe asp glyc-fa-dss-omega cap 20-7-1 mg...................................90 ULTIMATECARE ONE – prenatal vit w/ fe cbn-fe asp glycfa-omega 3 cap 27-1mg.................................................. 90 ULTIMATE OB DHA – prenat w/ fe poly cmplx-fe asp-fe gly-fa tab & dha cap pak................................................. 90 ULTRACET – tramadol-acetaminophen tab 37.5-325 mg.................................................................................... 73 ULTRAM ER – tramadol hcl tab sr 24hr 100 mg...............73 ULTRAM ER – tramadol hcl tab sr 24hr 200 mg...............73 ULTRAM ER – tramadol hcl tab sr 24hr 300 mg...............73 ULTRAM – tramadol hcl tab 50 mg.................................. 73 ULTRA TABS – prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg........................................................................... 90 ULTRAVATE – halobetasol propionate cream 0.05%..... 109 ULTRAVATE – halobetasol propionate oint 0.05%......... 109 URAMAXIN – urea cream 45%.......................................109 URAMAXIN – urea gel 45%............................................109 URAMAXIN – urea lotion 45%........................................ 109 urea cream 39% (Aluvea)............................................. 109 urea cream 40%.............................................................109 urea cream 45% (Uramaxin)......................................... 110 urea cream 50%.............................................................110 urea gel 40%.................................................................. 110 urea gel 45% (Uramaxin).............................................. 110 urea in lactic acid vehicle foam 35% (Hydro 35).........110 urea lotion 40%..............................................................110 urea lotion 45% (Uramaxin)..........................................110 URECHOLINE – bethanechol chloride tab 10 mg.............55 URECHOLINE – bethanechol chloride tab 25 mg.............55 URECHOLINE – bethanechol chloride tab 50 mg.............55 URECHOLINE – bethanechol chloride tab 5 mg...............54 UREX – methenamine hippurate tab 1 gm....................... 54 UROCIT-K 10 – potassium citrate tab cr 10 meq (1080 mg)...................................................................................55 UROCIT-K 15 – potassium citrate tab cr 15 meq (1620 mg)...................................................................................55 UROCIT-K 5 – potassium citrate tab cr 5 meq (540 mg)...................................................................................55 UROXATRAL – alfuzosin hcl tab sr 24hr 10 mg............... 56 URSO 250 – ursodiol tab 250 mg.....................................53 ursodiol cap 300 mg (Actigall).......................................53 ursodiol tab 250 mg (Urso 250)..................................... 53 ursodiol tab 500 mg (Urso forte)................................... 54 URSO FORTE – ursodiol tab 500 mg...............................53 V valacyclovir hcl tab 1 gm (Valtrex).................................. 9 valacyclovir hcl tab 500 mg (Valtrex).............................. 9 VALCYTE – valganciclovir hcl for soln 50 mg/ml (base equiv)................................................................................. 9 VALCYTE – valganciclovir hcl tab 450 mg......................... 9 valganciclovir hcl tab 450 mg (Valcyte).......................... 9 VALIUM – diazepam tab 10 mg........................................57 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 2015 VALIUM – diazepam tab 2 mg..........................................56 VALIUM – diazepam tab 5 mg..........................................56 valproate sodium syrup 250 mg/5ml (base equiv) (Depakene)......................................................................80 valproic acid cap 250 mg (Depakene)........................... 80 valsartan-hydrochlorothiazide tab 160-12.5 mg (Diovan hct)....................................................................40 valsartan-hydrochlorothiazide tab 160-25 mg (Diovan hct).................................................................................. 40 valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovan hct).................................................................... 40 valsartan-hydrochlorothiazide tab 320-25 mg (Diovan hct).................................................................................. 40 valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan hct).................................................................................. 40 valsartan tab 160 mg (Diovan)....................................... 40 valsartan tab 320 mg (Diovan)....................................... 40 valsartan tab 40 mg (Diovan)......................................... 40 valsartan tab 80 mg (Diovan)......................................... 40 VALTREX – valacyclovir hcl tab 1 gm................................ 9 VALTREX – valacyclovir hcl tab 500 mg............................ 9 VANCOCIN HCL – vancomycin hcl cap 125 mg...............11 VANCOCIN HCL – vancomycin hcl cap 250 mg...............11 vancomycin hcl cap 125 mg (Vancocin hcl)................. 11 vancomycin hcl cap 250 mg (Vancocin hcl)................. 11 VASERETIC – enalapril maleate & hydrochlorothiazide tab 10-25 mg......................................................................... 40 VASOTEC – enalapril maleate tab 10 mg........................ 40 VASOTEC – enalapril maleate tab 2.5 mg........................40 VASOTEC – enalapril maleate tab 20 mg........................ 40 VASOTEC – enalapril maleate tab 5 mg.......................... 40 VECTICAL – calcitriol oint 3 mcg/gm.............................. 110 VEMAVITE-PRX 2 – prenatal w/o vit a w/ fe fum-dss-fadha cap 27-1.25-300 mg................................................. 90 VENA-BAL DHA – prenat w/fe poly-na fered-fa tab 27-1 & omega cap dr 430mg...................................................... 90 VENATAL-FA – prenatal vit w/ fe fumarate-fa tab 29-1 mg.................................................................................... 90 venlafaxine hcl cap sr 24hr 150 mg (base equivalent) (Effexor xr)..................................................................... 60 venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) (Effexor xr)..................................................................... 60 venlafaxine hcl cap sr 24hr 75 mg (base equivalent) (Effexor xr)..................................................................... 60 VENLAFAXINE HCL ER – venlafaxine hcl tab sr 24hr 150 mg (base equivalent).......................................................60 VENLAFAXINE HCL ER – venlafaxine hcl tab sr 24hr 225 mg (base equivalent).......................................................60 VENLAFAXINE HCL ER – venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent).......................................................60 VENLAFAXINE HCL ER – venlafaxine hcl tab sr 24hr 75 mg (base equivalent).......................................................60 venlafaxine hcl tab 100 mg............................................ 60 venlafaxine hcl tab 25 mg.............................................. 60 venlafaxine hcl tab 37.5 mg........................................... 60 venlafaxine hcl tab 50 mg.............................................. 60 venlafaxine hcl tab 75 mg.............................................. 60 venlafaxine hcl tab sr 24hr 150 mg (base equivalent) (Venlafaxine hcl er)....................................................... 60 venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent) (Venlafaxine hcl er)....................................................... 60 venlafaxine hcl tab sr 24hr 75 mg (base equivalent) (Venlafaxine hcl er)....................................................... 60 VERAMYST – fluticasone furoate nasal susp 27.5 mcg/ spray................................................................................ 46 verapamil hcl cap sr 24hr 100 mg (Verelan pm)........... 33 verapamil hcl cap sr 24hr 120 mg (Verelan)................. 33 verapamil hcl cap sr 24hr 180 mg (Verelan)................. 33 verapamil hcl cap sr 24hr 200 mg (Verelan pm)........... 33 verapamil hcl cap sr 24hr 240 mg (Verelan)................. 33 verapamil hcl cap sr 24hr 300 mg (Verelan pm)........... 33 verapamil hcl cap sr 24hr 360 mg (Verelan)................. 33 verapamil hcl tab 120 mg (Calan).................................. 33 verapamil hcl tab 80 mg (Calan).................................... 33 verapamil hcl tab cr 120 mg (Calan sr)......................... 33 verapamil hcl tab cr 180 mg (Calan sr)......................... 33 verapamil hcl tab cr 240 mg (Calan sr)......................... 33 VERAPAMIL HCL – verapamil hcl tab 40 mg................... 33 VERELAN PM – verapamil hcl cap sr 24hr 100 mg.......... 33 VERELAN PM – verapamil hcl cap sr 24hr 200 mg.......... 33 VERELAN PM – verapamil hcl cap sr 24hr 300 mg.......... 33 VERELAN – verapamil hcl cap sr 24hr 120 mg................ 33 VERELAN – verapamil hcl cap sr 24hr 180 mg................ 33 VERELAN – verapamil hcl cap sr 24hr 240 mg................ 33 VERELAN – verapamil hcl cap sr 24hr 360 mg................ 33 VERIPRED 20 – prednisolone sod phosphate oral soln 20 mg/5ml (base equiv)........................................................16 VFEND – voriconazole for susp 40 mg/ml.......................... 6 VFEND – voriconazole tab 200 mg.................................... 6 VFEND – voriconazole tab 50 mg...................................... 6 VIAGRA – Benefit Limits may apply – sildenafil citrate tab 100 mg.............................................................................45 VIAGRA – Benefit Limits may apply – sildenafil citrate tab 25 mg...............................................................................45 VIAGRA – Benefit Limits may apply – sildenafil citrate tab 50 mg...............................................................................45 VICOPROFEN – hydrocodone-ibuprofen tab 7.5-200 mg.................................................................................... 73 VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/ ml).................................................................................... 22 VICTRELIS – boceprevir cap 200 mg.................................9 VIDEX – didanosine for soln 2 gm......................................9 VIDEX – didanosine for soln 4 gm......................................9 VIDEX EC – didanosine delayed release capsule 125 mg...................................................................................... 9 VIDEX EC – didanosine delayed release capsule 200 mg...................................................................................... 9 VIDEX EC – didanosine delayed release capsule 250 mg...................................................................................... 9 VIDEX EC – didanosine delayed release capsule 400 mg...................................................................................... 9 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 163 2015 VIEKIRA PAK – ombitas-paritapre-riton & dasab tab pak 12.5-75-50 & 250 mg........................................................ 9 VIGAMOX – moxifloxacin hcl ophth soln 0.5% (base equiv)............................................................................. 100 VINACAL B – prenat w/o a w/fecbn-feglu-fa tab 20-1 mg & vit b6 tab pak...................................................................90 VINACAL – prenatal w/o a w/ fe carbonyl-fe gluc-dss-fa tab 27-1mg...................................................................... 90 VINATE AZ EXTRA – prenatal vit w/ fe bisglycinate chelate-fa tab 29-1 mg.................................................... 91 VINATE CALCIUM – prenatal vit w/ iron carbonyl-fe glucfa tab 27-1 mg.................................................................91 VINATE CARE – prenatal w/o a vit w/ fe fum-fa tab chew 40-1 mg........................................................................... 91 VINATE C – prenatal w/o a vit w/ fe fumarate-fa tab 30-1 mg.................................................................................... 91 VINATE DHA RF – prenat w/o a w/fefum-methylfolomegas cap 27-1.13 mg................................................. 91 VINATE GT – prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg.................................................................................... 91 VINATE IC – prenatal w/o a w/fe fum-fe poly-fa cap 162.115.2-1 mg............................................................... 91 VINATE II – prenatal vit w/ fe bisglycinate chelate-fa tab 29-1 mg........................................................................... 91 VINATE M – prenatal vit w/ sel-fe fumarate-fa tab 27-1 mg.................................................................................... 91 VINATE ONE – prenatal vit w/ fe fumarate-fa tab 60-1 mg.................................................................................... 91 VINATE ULTRA – prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg........................................................................... 91 VIRACEPT – nelfinavir mesylate tab 250 mg..................... 9 VIRACEPT – nelfinavir mesylate tab 625 mg..................... 9 VIRAMUNE – nevirapine susp 50 mg/5ml.......................... 9 VIRAMUNE – nevirapine tab 200 mg................................. 9 VIRAMUNE XR – nevirapine tab sr 24hr 100 mg..............10 VIRAMUNE XR – nevirapine tab sr 24hr 400 mg..............10 VIRASAL – salicylic acid film forming liquid 27.5%......... 110 VIREAD – tenofovir disoproxil fumarate oral powder 40 mg/gm.............................................................................. 10 VIREAD – tenofovir disoproxil fumarate tab 150 mg......... 10 VIREAD – tenofovir disoproxil fumarate tab 200 mg......... 10 VIREAD – tenofovir disoproxil fumarate tab 250 mg......... 10 VIREAD – tenofovir disoproxil fumarate tab 300 mg......... 10 VIROPTIC – trifluridine ophth soln 1%............................100 VIRT-ADVANCE – prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg........................................................................... 91 VIRT-BAL DHA PLUS – prenat w/fe poly-na fered-fa tab 27-1 & omega cap dr 380mg.......................................... 91 VIRT-CARE ONE – prenatal vit w/ fe cbn-fe asp glyc-faomega 3 cap 27-1mg...................................................... 91 VIRT-C DHA – prenatal w/fe fum-fe poly -fa-omega 3 cap 53.5-38-1 mg................................................................... 91 VIRT NATE – prenatal vit w/ fe fumarate-fa tab 28-1 mg.................................................................................... 91 VIRT-PN DHA – prenat w/o a w/fefum-methfol-fa-dha cap 27-0.6-0.4-300 mg........................................................... 91 164 VIRT-PN PLUS – prenat w/o a w/ fe fumeratemethylfolate-fa-omega 3 cap........................................... 91 VIRT-PN – prenatal vit w/ fe fum-methylfolate-fa tab 27-0.6-0.4 mg.................................................................. 91 VIRTPREX – prenatal w/o vit a w/ fe fum-dss-fa-dha cap 26-1.2-300 mg................................................................. 91 VIRT-SELECT – prenatal w/o vit a w/ fe fum-dss-fa-dha cap 29-1.25-325 mg........................................................ 91 VIRT-VITE GT – prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg........................................................................... 91 VISTARIL – hydroxyzine pamoate cap 25 mg.................. 57 VISTARIL – hydroxyzine pamoate cap 50 mg.................. 57 VITAFOL-NANO – prenatal w/o a w/ fefum-l methylfol-fa tab 18-0.6-0.4 mg............................................................ 91 VITAFOL-OB+DHA – prenatal mv w/fe fum-fa tab 65-1 mg & dha cap 250 mg pack .................................................91 VITAFOL-OB – prenatal vit w/ fe fumarate-fa tab 65-1 mg.................................................................................... 91 VITAFOL-ONE – prenatal mv w/ fe polysac cmplx-fa-dha cap 29-1-200 mg............................................................. 91 VITAFOL-PN – prenatal vit w/ fe fumarate-fa tab 65-1 mg.................................................................................... 91 VITAFOL ULTRA – prenat w/fe poly-methylfol-fa-dha cap 29-0.6-0.4-200 mg........................................................... 91 VITAMEDMD ONE RX/QUATREFO – prenat w/o a w/ fefum-methfol-fa-dha cap 30-0.6-0.4-200 mg.................. 91 VITAMEDMD PLUS RX/QUATRE – prenat w/o a w/ fe chelate-l methylfol-fa tab & dha cap pk........................... 91 VITAMEDMD REDICHEW RX – prenat w/ b2-b6-b12-d3folic acid chew tab 1.4 mg.............................................. 92 VITAPEARL – prenat w/oa w/fefum-na fered-fa-dha cap cr 30-1.4-200 mg................................................................. 92 VITA-PREN – prenatal vit w/ docusate-iron-fa tab 65-1 mg.................................................................................... 91 VIVA DHA – prenatal vit w/ fe fum-fa-omega 3 cap 28-1-200 mg.................................................................... 92 VIVELLE-DOT – estradiol td patch biweekly 0.025 mg/24hr............................................................................18 VIVELLE-DOT – estradiol td patch biweekly 0.0375 mg/24hr............................................................................18 VIVELLE-DOT – estradiol td patch biweekly 0.05 mg/24hr............................................................................18 VIVELLE-DOT – estradiol td patch biweekly 0.075 mg/24hr............................................................................18 VIVELLE-DOT – estradiol td patch biweekly 0.1 mg/24hr............................................................................18 V-NATAL DHA – prenat w/o a w/ fe bisglyc-fa tab 32-1 mg & omega cap pack.......................................................... 90 V-NATAL – prenatal vit w/o vit a w/ fe bisglycinate-fa tab 32-1 mg........................................................................... 90 VOL-NATE – prenatal vit w/ fe fumarate-fa tab 28-1 mg.................................................................................... 92 VOL-PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg.................................................................................... 92 VOL-TAB RX – prenatal vit w/ iron carbonyl-fa tab 29-1 mg.................................................................................... 92 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 2015 VOLTAREN – diclofenac sodium gel 1%........................ 110 VOLTAREN-XR – diclofenac sodium tab sr 24hr 100 mg.................................................................................... 75 voriconazole for susp 40 mg/ml (Vfend)......................... 6 voriconazole tab 200 mg (Vfend).....................................6 voriconazole tab 50 mg (Vfend).......................................6 VOSPIRE ER – albuterol sulfate tab sr 12hr 4 mg............49 VOSPIRE ER – albuterol sulfate tab sr 12hr 8 mg............49 VOTRIENT – pazopanib hcl tab 200 mg (base equiv).......14 VP-CH PLUS – prenatal w/o a w/fe cbn-dss-fa-dha cap 29-1-265 mg.................................................................... 92 VP-CH-PNV – prenatal w/o vit a w/ fe cbn-dss-fa-dha cap 30-1-260 mg.................................................................... 92 VP CH ULTRA – prenat w/o a w/fe fum-fe cbn-dss-fa-dha cap 27-1-260 mg............................................................. 92 VP-GGR-B6 PRENATAL – prenatal w/ calcium-vit b6-faginger tab 1.2 mg............................................................ 92 VP-HEME OB + DHA – prenat-fe poly cmplx-fe heme poly-fa tab & omega 3 cap pck....................................... 92 VP-HEME OB – prenat vit-fe poly cmplx-fe heme poly-fa tab 28-6-1 mg.................................................................. 92 VP-HEME ONE – prenat-fe poly cmplx-fe heme poly-fadha cap 22-6-1-200 mg...................................................92 VP-PNV-DHA – prenatal vit w/ fe fum-fa-omega 3 cap 28-1-215.8 mg................................................................. 92 VYVANSE – lisdexamfetamine dimesylate cap 10 mg......66 VYVANSE – lisdexamfetamine dimesylate cap 20 mg......66 VYVANSE – lisdexamfetamine dimesylate cap 30 mg......66 VYVANSE – lisdexamfetamine dimesylate cap 40 mg......66 VYVANSE – lisdexamfetamine dimesylate cap 50 mg......66 VYVANSE – lisdexamfetamine dimesylate cap 60 mg......66 VYVANSE – lisdexamfetamine dimesylate cap 70 mg......66 W warfarin sodium tab 10 mg (Coumadin)........................96 warfarin sodium tab 1 mg (Coumadin)..........................96 warfarin sodium tab 2.5 mg (Coumadin).......................96 warfarin sodium tab 2 mg (Coumadin)..........................96 warfarin sodium tab 3 mg (Coumadin)..........................96 warfarin sodium tab 4 mg (Coumadin)..........................96 warfarin sodium tab 5 mg (Coumadin)..........................96 warfarin sodium tab 6 mg (Coumadin)..........................96 warfarin sodium tab 7.5 mg (Coumadin).......................96 WELLBUTRIN – bupropion hcl tab 100 mg...................... 60 WELLBUTRIN – bupropion hcl tab 75 mg........................ 60 WELLBUTRIN SR – bupropion hcl tab sr 12hr 100 mg.....60 WELLBUTRIN SR – bupropion hcl tab sr 12hr 150 mg.....60 WELLBUTRIN SR – bupropion hcl tab sr 12hr 200 mg.....60 WELLBUTRIN XL – bupropion hcl tab sr 24hr 150 mg..... 60 WELLBUTRIN XL – bupropion hcl tab sr 24hr 300 mg..... 60 WESTCORT – hydrocortisone valerate oint 0.2%...........110 WESTHROID-P – thyroid tab 130 mg...............................25 WESTHROID-P – thyroid tab 16.25 mg............................25 WESTHROID-P – thyroid tab 32.5 mg..............................25 WESTHROID-P – thyroid tab 48.75 mg (3/4 grain)...........25 WESTHROID-P – thyroid tab 65 mg.................................25 WESTHROID-P – thyroid tab 97.5 mg..............................25 WESTHROID – thyroid tab 113.75 mg............................. 25 WESTHROID – thyroid tab 130 mg.................................. 25 WESTHROID – thyroid tab 146.25 mg............................. 25 WESTHROID – thyroid tab 16.25 mg............................... 25 WESTHROID – thyroid tab 162.5 mg (2 1/2 grain)........... 25 WESTHROID – thyroid tab 195 mg.................................. 25 WESTHROID – thyroid tab 260 mg.................................. 25 WESTHROID – thyroid tab 32.5 mg................................. 25 WESTHROID – thyroid tab 325 mg (5 grain).................... 25 WESTHROID – thyroid tab 48.75 mg (3/4 grain).............. 25 WESTHROID – thyroid tab 65 mg.................................... 25 WESTHROID – thyroid tab 81.25 mg............................... 25 WESTHROID – thyroid tab 97.5 mg................................. 25 WIDE-SEAL SILICONE DIAPHR – diaphragm wide seal 60 mm............................................................................111 WIDE-SEAL SILICONE DIAPHR – diaphragm wide seal 65 mm............................................................................111 WIDE-SEAL SILICONE DIAPHR – diaphragm wide seal 70 mm............................................................................111 WIDE-SEAL SILICONE DIAPHR – diaphragm wide seal 75 mm............................................................................111 WIDE-SEAL SILICONE DIAPHR – diaphragm wide seal 80 mm............................................................................111 WIDE-SEAL SILICONE DIAPHR – diaphragm wide seal 85 mm............................................................................111 WIDE-SEAL SILICONE DIAPHR – diaphragm wide seal 90 mm............................................................................111 WIDE-SEAL SILICONE DIAPHR – diaphragm wide seal 95 mm............................................................................111 WP THYROID – thyroid tab 113.75 mg............................ 25 WP THYROID – thyroid tab 130 mg................................. 25 WP THYROID – thyroid tab 16.25 mg.............................. 25 WP THYROID – thyroid tab 32.5 mg................................ 25 WP THYROID – thyroid tab 48.75 mg (3/4 grain)............. 25 WP THYROID – thyroid tab 65 mg................................... 25 WP THYROID – thyroid tab 81.25 mg.............................. 25 WP THYROID – thyroid tab 97.5 mg................................ 25 X XALATAN – latanoprost ophth soln 0.005%................... 100 XALKORI – crizotinib cap 200 mg.................................... 14 XALKORI – crizotinib cap 250 mg.................................... 14 XANAX – alprazolam tab 0.25 mg.................................... 57 XANAX – alprazolam tab 0.5 mg...................................... 57 XANAX – alprazolam tab 1 mg......................................... 57 XANAX – alprazolam tab 2 mg......................................... 57 XANAX XR – alprazolam tab sr 24hr 0.5 mg.................... 57 XANAX XR – alprazolam tab sr 24hr 1 mg....................... 57 XANAX XR – alprazolam tab sr 24hr 2 mg....................... 57 XANAX XR – alprazolam tab sr 24hr 3 mg....................... 57 XARELTO – rivaroxaban tab 10 mg................................. 96 XARELTO – rivaroxaban tab 15 mg................................. 96 XARELTO – rivaroxaban tab 20 mg................................. 96 XARELTO STARTER PACK – rivaroxaban tab starter therapy pack 15 mg & 20 mg..........................................96 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 165 2015 XELJANZ – tofacitinib citrate tab 5 mg (base equivalent)....................................................................... 75 XELODA – capecitabine tab 150 mg................................ 14 XELODA – capecitabine tab 500 mg................................ 14 XENADERM – trypsin w/ castor oil & peruvian balsam oint................................................................................. 110 XIFAXAN – rifaximin tab 200 mg...................................... 11 XIFAXAN – rifaximin tab 550 mg...................................... 11 XODOL – hydrocodone-acetaminophen tab 10-300 mg.................................................................................... 73 XODOL – hydrocodone-acetaminophen tab 5-300 mg..... 73 XODOL – hydrocodone-acetaminophen tab 7.5-300 mg.................................................................................... 73 XOPENEX CONCENTRATE – levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv).................................... 49 XOPENEX – levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)............................................................................... 49 XOPENEX – levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv)............................................................................... 49 XOPENEX – levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv)............................................................................... 49 XTANDI – enzalutamide cap 40 mg..................................14 XYLOCAINE – lidocaine hcl soln 4%..............................110 XYREM – sodium oxybate oral solution 500 mg/ml.......... 68 XYZAL – levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml)...................................................................... 46 XYZAL – levocetirizine dihydrochloride tab 5 mg.............. 46 Y YASMIN 28 – drospirenone-ethinyl estradiol tab 3-0.03 mg.................................................................................... 20 YAZ – drospirenone-ethinyl estradiol tab 3-0.02 mg......... 20 YODOXIN – iodoquinol tab 210 mg.................................. 10 YODOXIN – iodoquinol tab 650 mg.................................. 10 Z zafirlukast tab 10 mg (Accolate).................................... 49 zafirlukast tab 20 mg (Accolate).................................... 49 zaleplon cap 10 mg (Sonata)..........................................64 zaleplon cap 5 mg (Sonata)........................................... 64 ZANAFLEX – tizanidine hcl cap 2 mg...............................83 ZANAFLEX – tizanidine hcl cap 4 mg...............................83 ZANAFLEX – tizanidine hcl cap 6 mg...............................83 ZANAFLEX – tizanidine hcl tab 4 mg............................... 83 ZANTAC – ranitidine hcl tab 150 mg................................ 52 ZANTAC – ranitidine hcl tab 300 mg................................ 52 ZARONTIN – ethosuximide cap 250 mg...........................80 ZARONTIN – ethosuximide soln 250 mg/5ml................... 80 ZATEAN-CH – prenatal w/o a w/fe cbn-dss-fa-dha cap 27-1-250 mg.................................................................... 92 ZATEAN-PN DHA – prenat w/o a w/fefum-methfol-fa-dha cap 27-0.6-0.4-300 mg.................................................... 92 ZATEAN-PN PLUS – prenat w/o a w/ fe fumeratemethylfolate-fa-omega 3 cap........................................... 92 ZATEAN-PN – prenatal vit w/ fe fum-methylfolate-fa tab 27-0.6-0.4 mg.................................................................. 92 166 ZEBETA – bisoprolol fumarate tab 10 mg........................ 30 ZEBETA – bisoprolol fumarate tab 5 mg.......................... 30 ZELBORAF – vemurafenib tab 240 mg (base equivalent)....................................................................... 14 ZEMPLAR – paricalcitol cap 1 mcg.................................. 28 ZEMPLAR – paricalcitol cap 2 mcg.................................. 28 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 10000-34000-55000 unit..................................................52 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 15000-51000-82000 unit..................................................52 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 20000-68000-109000 unit................................................52 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 25000-85000-136000 unit................................................52 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 3000-10000-16000 unit....................................................52 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 40000-136000-218000 unit..............................................52 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 5000-17000-27000 unit....................................................52 ZERIT – stavudine cap 15 mg.......................................... 10 ZERIT – stavudine cap 20 mg.......................................... 10 ZERIT – stavudine cap 30 mg.......................................... 10 ZERIT – stavudine cap 40 mg.......................................... 10 ZERIT – stavudine for oral soln 1 mg/ml...........................10 ZESTORETIC – lisinopril & hydrochlorothiazide tab 10-12.5 mg...................................................................... 40 ZESTORETIC – lisinopril & hydrochlorothiazide tab 20-12.5 mg...................................................................... 41 ZESTORETIC – lisinopril & hydrochlorothiazide tab 20-25 mg.................................................................................... 41 ZESTRIL – lisinopril tab 10 mg......................................... 41 ZESTRIL – lisinopril tab 2.5 mg........................................ 41 ZESTRIL – lisinopril tab 20 mg......................................... 41 ZESTRIL – lisinopril tab 30 mg......................................... 41 ZESTRIL – lisinopril tab 40 mg......................................... 41 ZESTRIL – lisinopril tab 5 mg........................................... 41 ZETIA – ezetimibe tab 10 mg........................................... 44 ZETONNA – ciclesonide nasal aerosol soln 37 mcg/act (50 mcg/valve)................................................................. 46 ZIAC – bisoprolol & hydrochlorothiazide tab 10-6.25 mg.................................................................................... 41 ZIAC – bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg.................................................................................... 41 ZIAC – bisoprolol & hydrochlorothiazide tab 5-6.25 mg.................................................................................... 41 ZIAGEN – abacavir sulfate soln 20 mg/ml (base equiv)............................................................................... 10 ZIAGEN – abacavir sulfate tab 300 mg (base equiv)........ 10 zidovudine cap 100 mg (Retrovir)..................................10 zidovudine syrup 10 mg/ml (Retrovir)........................... 10 zidovudine tab 300 mg................................................... 10 zinc sulfate cap 220 mg (50 mg elemental zn)..............93 ZINGIBER – prenatal w/ calcium-vit b6-fa-ginger tab 1.2 mg.................................................................................... 92 ziprasidone hcl cap 20 mg (Geodon)............................ 63 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 2015 ziprasidone hcl cap 40 mg (Geodon)............................ 63 ziprasidone hcl cap 60 mg (Geodon)............................ 63 ziprasidone hcl cap 80 mg (Geodon)............................ 63 ZITHROMAX – azithromycin for susp 100 mg/5ml............. 3 ZITHROMAX – azithromycin for susp 200 mg/5ml............. 3 ZITHROMAX – azithromycin powd pack for susp 1 gm...... 3 ZITHROMAX – azithromycin tab 250 mg............................3 ZITHROMAX – azithromycin tab 500 mg............................3 ZITHROMAX – azithromycin tab 600 mg............................3 ZITHROMAX TRI-PAK – azithromycin tab 500 mg............. 3 ZITHROMAX Z-PAK – azithromycin tab 250 mg................ 3 ZOCOR – simvastatin tab 10 mg......................................44 ZOCOR – simvastatin tab 20 mg......................................44 ZOCOR – simvastatin tab 40 mg......................................44 ZOCOR – simvastatin tab 5 mg........................................44 ZOCOR – simvastatin tab 80 mg......................................44 ZOFRAN ODT – ondansetron orally disintegrating tab 4 mg.................................................................................... 52 ZOFRAN ODT – ondansetron orally disintegrating tab 8 mg.................................................................................... 52 ZOFRAN – ondansetron hcl oral soln 4 mg/5ml................52 ZOFRAN – ondansetron hcl tab 4 mg.............................. 52 ZOFRAN – ondansetron hcl tab 8 mg.............................. 52 ZOLINZA – vorinostat cap 100 mg................................... 14 ZOLOFT – sertraline hcl oral conc 20 mg/ml.................... 60 ZOLOFT – sertraline hcl tab 100 mg................................ 60 ZOLOFT – sertraline hcl tab 25 mg.................................. 60 ZOLOFT – sertraline hcl tab 50 mg.................................. 60 zolpidem tartrate tab 10 mg (Ambien)...........................64 zolpidem tartrate tab 5 mg (Ambien).............................64 zolpidem tartrate tab cr 12.5 mg (Ambien cr)............... 64 zolpidem tartrate tab cr 6.25 mg (Ambien cr)............... 64 ZONATUSS – benzonatate cap 150 mg........................... 47 ZONEGRAN – zonisamide cap 100 mg............................80 ZONEGRAN – zonisamide cap 25 mg..............................80 zonisamide cap 100 mg (Zonegran).............................. 80 zonisamide cap 25 mg (Zonegran)................................ 81 zonisamide cap 50 mg....................................................81 ZOVIRAX – acyclovir cap 200 mg.................................... 10 ZOVIRAX – acyclovir oint 5%......................................... 110 ZOVIRAX – acyclovir susp 200 mg/5ml............................ 10 ZOVIRAX – acyclovir tab 400 mg..................................... 10 ZOVIRAX – acyclovir tab 800 mg..................................... 10 ZYBAN – bupropion hcl (smoking deterrent) tab sr 12hr 150 mg.............................................................................68 ZYLOPRIM – allopurinol tab 100 mg................................ 76 ZYLOPRIM – allopurinol tab 300 mg................................ 76 ZYMAXID – gatifloxacin ophth soln 0.5%....................... 100 ZYPREXA – olanzapine tab 10 mg...................................63 ZYPREXA – olanzapine tab 15 mg...................................63 ZYPREXA – olanzapine tab 2.5 mg..................................63 ZYPREXA – olanzapine tab 20 mg...................................63 ZYPREXA – olanzapine tab 5 mg.....................................63 ZYPREXA – olanzapine tab 7.5 mg..................................63 ZYPREXA ZYDIS – olanzapine orally disintegrating tab 10 mg.................................................................................... 63 ZYPREXA ZYDIS – olanzapine orally disintegrating tab 15 mg.................................................................................... 63 ZYPREXA ZYDIS – olanzapine orally disintegrating tab 20 mg.................................................................................... 63 ZYTIGA – abiraterone acetate tab 250 mg....................... 14 ZYVOX – linezolid tab 600 mg..........................................11 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2015 Closed Basic 5 Tier Formulary 167
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