October Blue Cross and Blue Shield of Illinois Drug Formulary. Contents

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2656-A IL © Prime Therapeutics LLC 08/12

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 bcbsil.com for the most up-to-date information.

To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click on Search.

Blue Cross and Blue Shield of Illinois Drug Formulary

October 2012

Introduction . . . .I How formulary drugs are selected . . . .I How member payment is determined . . . .I How to use this list . . . . II Drugs used to treat multiple conditions . . . .III Generic drugs . . . .III Consider talking to your doctor about generic drugs . . .III Coverage considerations . . . .III Dispensing Limits (DL) . . . IV Prior Authorization (PA) . . . . X Step Therapy (ST) . . . . X Specialty drugs . . . .XI Prime Therapeutics Specialty Pharmacy Program . . . . .XI Abbreviation/acronym key . . . .XI

Contents

Therapeutic Class Drug List . . . . 1

Anti-Infective Drugs . . . . 1

Cancer Drugs . . . . 2

Hormones, Diabetes and Related Drugs . . . . 3

Heart And Circulatory Drugs . . . . 4

Respiratory Agents . . . . 6

Gastrointestinal Drugs . . . . 7

Genitourinary Drugs . . . . 7

Central Nervous System Drugs . . . . 8

Pain Relief Drugs . . . . 9

Neuromuscular Drugs . . . . 10

Supplements . . . .11

Blood Modifying Drugs . . . .11

Topical Drugs . . . . 12

Miscellaneous Categories . . . . 14

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I Blue Cross and Blue Shield of Illinois October 2012 Drug Formulary

Introduction

Blue Cross and Blue Shield of Illinois is pleased to present the 2012 Drug Formulary . This is a list of formulary drugs which includes Formulary Brand drugs and a partial listing of generic drugs . Members are encouraged to show this list to their physicians and pharmacists. Physicians are encouraged to prescribe drugs on this list, when right for the member. However decisions regarding therapy and treatment are always between members and their physician.

Drug Formulary Updates — This list is regularly updated as generic drugs become available and changes take place in the pharmaceuticals market . For the most up-to-date information, visit bcbsil.com and log in to Blue Access for MembersSM_or

call the number on the back of your ID card . Physicians can access the list from the provider portal at bcbsil.com .

How formulary drugs are selected

Drugs on this list are selected based on the recommendations of a committee made up of physicians and pharmacists from throughout the country . The committee, which includes at least one representative from your health plan, reviews drugs regulated by the U .S . Food and Drug Administration (FDA) .

Both drugs that are newly approved by the FDA as well as those that have been on the market for some time are considered . Drugs are selected based on safety, efficacy, cost and how they compare to other drugs currently on the list .

How member payment is determined

This list shows prescription drug products in tiers . Generally, each drug is placed into one of three or four member payment tiers: generic, Formulary Brand or Non-Formulary Brand (not listed in this document) . Specialty drugs can either be within the previous three tiers or can be a separate fourth tier depending on your benefit design . To verify your payment amount for a specialty drug, visit bcbsil.com and log in to Blue Access for Members or call the number on the back of your ID card .

Your pharmacy benefit includes coverage for almost all prescription drugs, although some exclusions may apply . For example, drugs indicated for cosmetic purposes, e .g ., Propecia, for hair growth, may not be covered .

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II Blue Cross and Blue Shield of Illinois October 2012 Drug Formulary

How to use this list

This list is organized into broad therapeutic categories . For example, Hormones, Diabetes and Related Drugs is a broad category . Within most categories, drugs are sub-grouped based upon drug class, for example under Hormones, Diabetes and Related Drugs you will find Estrogens . All drugs listed, whether generic or brand, are formulary drugs .

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The first column of the chart lists the drug name . Generic drugs are shown in lower-case boldface type . Most generic drugs are followed by a reference brand drug in (parentheses) . The reference brand drug is a non-formulary (NF) brand and is only included as a reference to the brand . Some generic products have no reference brand .

Example: budesonide ext-release (Entocort EC – brand is NF) Formulary brand drugs are listed in all CAPITAL letters . Example: ZYTIGA

The following examples are given to assist you and your doctor in reading listings that include specific strengths and dosage forms . These examples can be applied to other drugs on the formulary . Any exceptions are noted and some listings contain additional information about specific products or dosage forms .

→

Extended-release and delayed-release products require their own entry.

Example: DETROL LA

The long-acting product Detrol LA is on the formulary, but requires a separate entry from the non ext-release product Detrol .

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Some products may show a strength, if so only that strength indicated is on the formulary.

Example: XIFAXAN 550 mg

The Xifaxan 550 mg is on formulary in this case, but the Xifaxan 200 mg is not because it is not listed .

2 The second column indicates if the drug is a specialty drug . Note: Additional information about specialty drugs can be found in this document under the header for Specialty Drugs .

3 The remaining columns indicate the Utilization Management (UM) program(s) that apply to the prescription drug (e .g ., Prior Authorization, Dispensing Limits, and Step Therapy) . If an indicator is present in the column(s), then the UM program noted is possibly applied to your benefit . Some plans may have UM on additional medications beyond those noted in this document .

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III Blue Cross and Blue Shield of Illinois October 2012 Drug Formulary

Drugs used to treat multiple conditions

Some drugs in the same dosage form may be used to treat more than one medical condition . In these instances, each medication is classified according to its first FDA-approved use . Please check the index if you do not find your particular medication in the class/condition section that corresponds to your use .

Generic drugs

Using generic drugs, when right for you, can help you save on your out-of-pocket medication costs . Generic drugs must be approved by the FDA just as brand drugs are, and must meet the same strict standards .

There are two types of generic drugs:

→

A generic equivalent is made with the same active ingredient(s) at the same dosage as the reference drug .

→

A generic alternative is a drug typically used to treat the same condition, but the active ingredient(s) differs from the brand drug . According to the FDA, compared to its brand counterpart, an FDA-approved generic drug:

→

Is chemically the same

→

Works just as well in the body

→

Is as safe and effective

→

Meets the same standards set by the FDA

The main difference between the reference brand drug and the generic equivalent is that the generic often costs much less . Brand drugs in Tier 2 typically move to Tier 3 after a generic equivalent becomes available . You may be responsible for the generic member payment amount plus the difference in cost between the brand and generic drug if you or your doctor requests the reference brand rather than the generic . Generic drugs have the lowest member payment amount .

Consider talking to your doctor about generic drugs

If your doctor writes a prescription for a brand drug that does not have a generic equivalent, consider asking if an appropriate generic alternative is available .

You can also let your pharmacist know that you would like a generic equivalent for a brand drug, whenever one is available . Your pharmacist can usually substitute a generic equivalent for its brand counterpart without a new prescription from your doctor . Only your doctor can determine whether a generic alternative is right for you and must prescribe the medication .

Coverage considerations

Most prescription drug benefit plans provide coverage for up to a 30- to 34-day supply of medication, with some exceptions . Your plan may also provide coverage for up to a 90-day supply of maintenance medications . Maintenance medications are those drugs you may take on an ongoing basis for conditions such as high blood pressure, diabetes or high cholesterol .

Over-the-Counter Exclusions: Some benefit plans do not provide coverage for prescription medications that have an over-the-counter version . You should refer to your benefit plan booklet for details about your particular benefits .

Compounded Medications: Some benefit plans do not provide coverage for compounded medications . Please see your plan materials or call the number on the back of your ID card to determine whether compounded medications are covered and/or verify your payment amount .

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IV Blue Cross and Blue Shield of Illinois October 2012 Drug Formulary

Dispensing Limits (DL)

Drug dispensing limits help encourage medication use as intended by the FDA . Coverage limits are placed on medications in certain drug categories . For the formulary medications listed in this document, if a dispensing limit applies, it will be noted next to the medication with a dot under the dispensing limits column as explained in the section “How to Use This List” . Limits may include:

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Quantity of covered medication per prescription

→

Quantity of covered medication in a given time period

→

Coverage only for members within a certain age range

→

Coverage only for members of a specific gender

If your doctor prescribes a greater quantity of medication than what the dispensing limit allows, you can still get the medication . However, you will be responsible for the full cost of the prescription beyond what your coverage allows .

The following brand drugs, and their generic equivalents, if available, have dispensing limits . Some of these dispensing limits may not apply to all members or may vary based on state regulations . Some dispensing limits listed below may apply across multiple medications within a drug class . Some plans may exclude coverage for certain agents or drug categories, like those used for erectile dysfunction (example: Viagra) . Some drugs may not be available through mail service . Coverage for some drug categories, such as specialty or other select non-specialty medications, may be limited to a 30-day supply at a time depending on your particular benefit plan . Please see your plan materials or call the number on the back of your ID card to verify if you are uncertain of any plan limitations or exclusions . This list is subject to change .

Brand Name (Generic Name) Dosage Form Dispensing Limit

Abilify 2 mg, 5 mg (aripiprazole) tabs 60 tabs/30 days

Abilify 10 mg, 15 mg, 20 mg, 30 mg (aripiprazole) tabs 30 tabs/30 days

Abilify Discmelt (aripiprazole) tabs 60 tabs/30 days

Abilify (aripiprazole) oral soln 750 mL/30 days

Abstral (fentanyl) sublingual tabs 120 tabs/30 days

Accuneb 0 .63 mg/3 mL, 1 .25 mg/3 mL (albuterol) inhal soln 375 mL/Rx

Aciphex (rabeprazole delayed-release) tabs 60 tabs/30 days (limit one proton pump inhibitor in 30 days)

Actiq (fentanyl) lollipops 120 lollipops/30 days

Actonel 5 mg, 30 mg (risedronate) tabs 30 tabs/30 days

Actonel 35 mg (risedronate) tabs 4 tabs/30 days

Actonel 150 mg (risedronate) tabs 1 tab/30 days

Adcirca (tadalafil) tabs 60 tabs/30 days

Advair Diskus (fluticasone/salmeterol) inhaler 1 inhaler (60 doses)/Rx

Advair HFA (fluticasone/salmeterol) inhaler 1 inhaler/Rx

albuterol 0.083% inhal soln 375 mL/Rx

albuterol 0.5% inhal soln 60 mL/Rx

Aldara (imiquimod) crm 48 packets/365 days; 12 packets/Rx

Alinia (nitazoxanide) oral soln 60 mL/30 days

Alora (estradiol) patches 28 patches/28 days

Alsuma (sumatriptan) inj 12 syringe cartridges/30 days

Alvesco (ciclesonide) inhaler 2 inhalers/Rx

Ambien (zolpidem) tabs 30 tabs/30 days (across insomnia agents)

Ambien CR (zolpidem ext-release) tabs 30 tabs/30 days (across insomnia agents)

Amerge (naratriptan) tabs 18 tabs/30 days (across all oral migraine agents)

Ampyra (dalfampridine ext-release) tabs 60 tabs/30 days

Androderm 2 mg, 2 .5 mg (testosterone) patches 60 patches/30 days

Androderm 4 mg, 5 mg (testosterone) patches 30 patches/30 days

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V Blue Cross and Blue Shield of Illinois October 2012 Drug Formulary

Brand Name (Generic Name) Dosage Form Dispensing Limit

Androgel 2 .5 g (testosterone) packets 30 packets/30 days

Androgel 5 g (testosterone) packets 60 packets/30 days

Anzemet 50 mg (dolasetron) tabs 6 tabs/30 days

Anzemet 100 mg (dolasetron) tabs 3 tabs/30 days

Arcalyst (rilonacept) inj 4 vials/30 days

Arixtra (fondaparinux) inj 360 units/270 days (across Arixtra, Fragmin, and Lovenox)

Asmanex (mometasone) inhaler 1 inhaler/Rx

Astelin (azelastine) nasal spray 2 bottles/30 days

Astepro (azelastine) nasal spray 2 bottles/30 days

Atralin (tretinoin) gel Under age 40

Atrovent 0 .03% (ipratropium) nasal spray 1 bottle/30 days

Atrovent 0 .06%(ipratropium) nasal spray 3 bottles/30 days

Atrovent HFA (ipratropium) inhaler 2 inhalers/Rx

Avinza (morphine sulfate ext-release) caps 30 caps/30 days

Avonex (interferon beta-1a) inj 1 package/28 days

Avita – tretinoin crm, gel Under age 40

Axert (almotriptan) tabs 18 tabs/30 days (across all oral migraine agents)

Bactroban Nasal 2% (mupirocin) oint 10-1 g single-use tubes

Beconase AQ (beclomethasone dipropionate) nasal spray 1 bottle/30 days

Betaseron (interferon beta-1b) inj 14 vials/28 days

Biaxin XL (clarithromycin ext-release) tabs 28 tabs/30 days

Boniva 3 mg/3 mL (ibandronate) inj 1 injection/90 days

Boniva 150 mg (ibandronate) tabs 1 tab/30 days

Bravelle (urofollitropin) inj 60 vials/Rx

butorphanol nasal spray 2 bottles/30 days

Butrans (buprenorphine) patches 4 patches/30 days

Bydureon (exenatide ext-release) inj 4 trays/28 days

Byetta (exenatide) pen 1 pen/30 days

Caverject (alprostadil) inj 8 units/30 days; males only (limit one agent for erectile

dysfunction/30 days)

Cayston (aztreonam) inhal soln 84 vials/56 days

Celebrex 50 mg, 100 mg, 200 mg (celecoxib) caps 60 caps/30 days

Celebrex 400 mg (celecoxib) caps 30 caps/30 days

Cetrotide 0 .25 mg (cetrorelix) inj 12 kits/Rx

Cetrotide 3 mg (cetrorelix) inj 1 kit/Rx

chorionic gonadotropin inj 20 mL/Rx

Cialis 2 .5 mg, 5 mg (tadalafil) tabs 30 tabs/30 days; males only (limit one agent for erectile

Cialis 10 mg, 20 mg (tadalafil) tabs 8 tabs/30 days; males only (limit one agent for erectile

ciprofloxacin ext-release, 500 mg tabs 3 tabs/30 days

ciprofloxacin ext-release, 1000 mg tabs 14 tabs/30 days

Climara (estradiol) patches 28 patches/28 days

Clomid (clomiphene) tabs 10 tabs/Rx

Cold and cough products various Age 5 or older

Combivent and Combivent Respimat (ipratropium/albuterol)

inhaler 2 inhalers/Rx

Copaxone (glatiramer) inj 30 syringes/30 days

Crinone (progesterone) vaginal gel 60 applicators/Rx

cromolyn sodium inhal soln 240 mL/Rx

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Brand Name (Generic Name) Dosage Form Dispensing Limit

Cymbalta 30 mg (duloxetine) caps 90 caps/30 days

D .H .E . 45 1 mg/mL (dihydroergotamine) inj 10 mL/30 days

Desoxyn (methamphetamine) tabs 150 tabs/30 days

Dexilant (dexlansoprazole delayed-release) caps 60 caps/30 days (limit one proton pump inhibitor in 30 days)

Diastat (diazepam) rectal gel 5 packages/30 days

Differin 0 .1% (adapalene) crm, gel Under age 40

Differin 0 .3% (adapalene) gel Under age 40

Differin (adapalene) lotn Under age 40

Diflucan (fluconazole) tabs 90 tabs/180 days

Diflucan (fluconazole) oral susp 35 mL/30 days

Duexis (ibuprofen/famotidine) tabs 90 tabs/30 days

Dulera (mometasone/formoterol) inhaler 1 inhaler/Rx

Duoneb (ipratropium/albuterol) inhal soln 540 mL/Rx

Duragesic (fentanyl) patches 15 patches/30 days

Edex (alprostadil) inj 8 cartridges/30 days; males only (Limit one agent for erectile

Edluar (zolpidem) sublingual tabs 30 tabs/30 days (across all insomnia agents)

Ella (ulipristal) tabs 2 tabs/365 days

Emend 40 mg, 80 mg, and 125 mg (aprepitant) caps 12 caps/30 days

Emend Tri-Pack (aprepitant) caps 6 caps/30 days

Epiduo (adapalene/benzoyl peroxide) gel Under age 40

Exalgo 8 mg (hydromorphone ext-release) tabs 240 tabs/30 days (across all strengths)

Extavia (interferon beta-1b) inj 1 package/30 days

Fentora (fentanyl) buccal tabs 120 tabs/30 days

Flonase (fluticasone propionate) nasal spray 1 bottle/30 days

Flovent Diskus, Flovent HFA (fluticasone) inhaler 2 inhalers/Rx

Flunisolide nasal spray 1 bottle/30 days

Follistim AQ 75 units/vial (follitropin beta) inj 60 vials/Rx

Follistim AQ 150 units/vial (follitropin beta) inj 30 vials/Rx

Follistim AQ 300 units/cartridge (follitropin beta) inj 15 cartridges/Rx Follistim AQ 600 units/cartridge (follitropin beta) inj 8 cartridges/Rx Follistim AQ 900 units/cartridge (follitropin beta) inj 5 cartridges/Rx

Foradil Aerolizer (formoterol) inhaler 1 inhaler (60 doses)/Rx

Forteo (teriparatide) inj 1 pen/30 days

Fosamax 5 mg, 10 mg (alendronate) tabs 30 tabs/30 days

Fosamax 35 mg, 70 mg (alendronate) tabs 4 tabs/30 days

Fosamax Plus D (alendronate/cholecalciferol) tabs 4 tabs/30 days

Fragmin (dalteparin) inj 360 unit/270 days (across Lovenox, Fragmin, and Arixtra)

Frova (frovatriptan) tabs 18 tabs/30 days (across all oral migraine agents)

Ganirelix Acetate inj 12 syringes (0 .5 mL/syringe)/Rx

Gelnique (oxybutynin) gel 30 packets/30 days

Gilenya (fingolimod) caps 30 caps/30 days

Glucose Test Strips (All) strips 204 strips/30 days

Gonal F 450 units/vial (follitropin alfa) inj 10 vials/Rx

Gonal F 1,050 units/vial (follitropin alfa) inj 5 vials/Rx

Gonal F RFF 75 units/vial (follitropin alfa) inj 60 vials/Rx

Gonal F RFF Pen 300 units/cartridge (follitropin alfa) inj 15 cartridges/Rx Gonal F RFF Pen 450 units/cartridge (follitropin alfa) inj 10 cartridges/Rx Gonal F RFF Pen 900 units/cartridge (follitropin alfa) inj 5 cartridges/Rx

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VII Blue Cross and Blue Shield of Illinois October 2012 Drug Formulary

Brand Name (Generic Name) Dosage Form Dispensing Limit

granisetron tabs 15 tabs/30 days

Granisol (granisetron) oral soln 30 mL/30 days

Imitrex (sumatriptan) nasal spray 12 spray unit devices/30 days

Imitrex STATDose (sumatriptan) inj 12 syringe cartridges/30 days

Imitrex (sumatriptan) inj 12 vials/30 days

Imitrex (sumatriptan) tabs 18 tabs/30 days (across all oral migraine agents)

Insulins (All) inj 100 mL/30 days

Insulin pen needles, syringes (All) pen needles,

syringes

300 units/30 days

Intermezzo (zolpidem) sublinqual tabs 30 tabs/30 days (across all insomnia agents)

ipratropium inhal soln 375 mL/Rx

Janumet (sitagliptin/metformin) tabs 60 tabs/30 days

Janumet XR 50-500 mg, 100-1000 mg (sitagliptin/metformin ext-release)

tabs 30 tabs/30 days

Janumet XR 50-1000 mg (sitagliptin/metformin ext-release)

Januvia (sitagliptin) tabs 30 tabs/30 days

Jentadueto (linagliptin/metformin) tabs 60 tabs/30 days

Juvisync (sitagliptin/simvastatin) tabs 30 tabs/30 days

Kadian 20 mg, 30 mg, 50 mg, 60 mg, 80 mg, 100 mg (morphine sulfate ext-release)

caps 120 caps/30 days

Kadian 10 mg, 200 mg (morphine sulfate ext-release)

caps 120 caps/30 days

ketorolac tabs 20 tabs/30 days

Kombiglyze XR 5-500 mg, 5-1000 mg (saxagliptin/metformin ext-release)

Kombiglyze XR 2 .5-1000 mg (saxagliptin/ metformin ext-release)

Lamisil (terbinafine) tabs 90 tabs/180 days

Latuda (lurasidone) tabs 30 tabs/30 days

Lazanda (fentanyl) nasal spray 30 bottles/30 days

Letairis (ambrisentan) tabs 30 tabs/30 days

Levitra (vardenafil) tabs 8 tabs/30 days; males only (limit one agent for erectile

Lovenox (enoxaparin) inj 360 units/270 days (across Lovenox, Fragmin, and Arixtra)

Lumigan (bimatoprost) ophthalmic soln 2 .5 mL/30 days

Lunesta (eszopiclone) tabs 30 tabs/30 days (across all insomnia agents)

Luveris (lutropin alfa) inj 14 vials/Rx

Marinol (dronabinol) caps 60 caps/30 days

Maxair Autohaler (pirbuterol) inhaler 1 inhaler/Rx

Maxalt/Maxalt-MLT (rizatriptan) tabs 18 tabs/30 days (across all oral migraine agents)

Menopur (menotropins) inj 60 vials/Rx

Menostar (estradiol) patches 28 patches/28 days

Migranal (dihydroergotamine) nasal spray 8 vials/30 days

Muse (alprostadil) supp 8 supps/30 days; males only (limit one agent for erectile

dysfunction/ 30 days)

Namenda 5 mg (memantine) tabs 30 tabs/30 days

Namenda 10 mg (memantine) tabs 60 tabs/30 days

Namenda Titration Pak (memantine) tabs 49 tabs (1 pack)/365 days – no coverage at mail

Nasacort AQ (triamcinolone) nasal spray 1 bottle/30 days

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VIII Blue Cross and Blue Shield of Illinois October 2012 Drug Formulary

Brand Name (Generic Name) Dosage Form Dispensing Limit

Nexium (esomeprazole delayed-release) caps, packets 60 caps, packets/30 days (limit one proton pump inhibitor in 30 days)

Nucynta (tapentadol) tabs 180 tabs/30 days

Nucynta ER (tapentadol ext-release) tabs 60 tabs/30 days

Omnaris (ciclesonide) nasal spray 1 bottle/30 days

ondansetron 24 mg tabs 4 tabs/30 days

Onglyza (saxagliptin) tabs 30 tabs/30 days

Onsolis (fentanyl) buccal film 120 films/30 days (not covered at mail)

Ovidrel (choriogonadotropin alfa) inj 2 syringes/Rx

Oxycontin (oxycodone ext-release) tabs 120 tabs/30 days

Oxytrol (oxybutynin) patches 8 patches/30 days

Patanase (olopatadine) nasal spray 1 bottle/30 days

Penlac (ciclopirox) nail soln 13 .2 mL/30 days

Plan B (levonorgestrel) tabs Covered for females age 16 yrs and under with Rx –

4 tabs/365 days

Plan B One-Step (levonorgestrel) tabs Covered for females age 16 yrs and under with Rx –

2 tabs/365 days

Pradaxa (dabigatran) caps 60 caps/30 days

Prevacid (lansoprazole delayed-release) caps 60 caps/30 days (limit one proton pump inhibitor in 30 days) Prevacid Solutab (lansoprazole delayed-release) orally disintegrating

tabs

60 tabs/30 days (limit one proton pump inhibitor in 30 days) Prilosec (omeprazole delayed-release) caps 60 caps/30 days (limit one proton pump inhibitor in 30 days)

Pristiq (desvenlafaxine ext-release) tabs 60 tabs/30 days

Proair HFA (albuterol) inhaler 2 inhalers/Rx

Prochieve (progesterone) gel 60 applicators/Rx

Promacta 25 mg (eltrombopag) tabs 90 tabs/30 days

Promacta 12 .5 mg, 50 mg, 75 mg (eltrombopag) tabs 30 tabs/30 days

Protonix (pantoprazole delayed-release) granules 60 packets/30 days (limit one proton pump inhibitor in 30 days) Protonix (pantoprazole delayed-release) tabs 60 tabs/30 days (limit one proton pump inhibitor in 30 days)

Proventil HFA (albuterol) inhaler 2 inhalers/Rx

Prozac Weekly (fluoxetine delayed-release) caps 4 caps/28 days

Pulmicort Flexhaler 180 mcg (budesonide) inhaler 2 inhalers/Rx

Pulmicort Flexhaler 90 mcg (budesonide) inhaler 1 inhaler/Rx

Pulmicort Respules 1 mg/2 mL (budesonide) inhal susp 180 mL/Rx

Pulmicort Respules 0 .25 mg/2 mL, 0 .5 mg/2 mL (budesonide)

inhal susp 180 mL/Rx

Pylera (bismuth/metronidazole/tetracycline) caps 120 caps/30 days

Qvar (beclomethasone) inhaler 2 inhalers/Rx

Rebif 22 mcg/0 .5 mL, 44 mcg/0 .5 mL (interferon beta-1a)

inj 12 syringes/28 days

Rebif titration pack (interferon beta-1a) inj 1 kit/28 days

Regranex (becaplermin) gel 60 grams/365 days

Relenza (zanamivir) inhaler 1 inhaler (20 doses)/120 days

Relpax (eletriptan) tabs 18 tabs/30 days (across all oral migraine agents)

Repronex (menotropins) inj 60 vials/Rx

Retin-A (tretinoin) crm, gel Under age 40

Retin-A Micro (tretinoin microsphere) gel Under age 40

Revatio (sildenafil) tabs 90 tabs/30 days (across all strengths)

ReVia (naltrexone) tabs 180 tabs/365 days

Rhinocort Aqua (budesonide) nasal spray 2 bottles/30 days

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Brand Name (Generic Name) Dosage Form Dispensing Limit

Ryzolt (tramadol ext-release) tabs 30 tabs/30 days

Samsca 15 mg (tolvaptan) tabs 30 tabs/30 days

Samsca 30 mg (tolvaptan) tabs 60 tabs/30 days

Sancuso (granisetron) patches 2 patches/30 days

Savella (milnacipran) tabs 60 tabs/30 days

Savella Titration Pack (milnacipran) pack 1 pack/30 days

Serevent Diskus (salmeterol) inhaler 1 inhaler (60 doses)/Rx

Silenor (doxepin) tabs 30 tabs/30 days (across all insomnia agents)

Simponi (golimumab) inj 1 syringe/30 days

Sonata (zaleplon) caps 30 caps/30 days (across all insomnia agents)

Spiriva Handihaler (tiotropium) inhaler 1 package (30 doses)/Rx

Sporanox (itraconazole) caps 360 caps/180 days

Sporanox (itraconazole) soln 22 bottles (3,300 mL)/180 days

Sprix (ketorolac) nasal spray 5 bottles/30 days

Staxyn (vardenafil) tabs 8 tabs/30 days, males only (limit one agent for erectile

Suboxone (buprenorphine/naloxone) sublingual films,

tabs

90 films, tabs/30 days

Subsys (fentanyl) sublingual spray 120 doses/30 days

Subutex (buprenorphine) sublingual tabs 90 tabs/30 days

Sumatriptan nasal spray 12 spray unit devices/30 days

Sumavel DosePro (sumatriptan) inj 12 injection devices/30 days

Symbicort (budesonide/formoterol) inhaler 1 inhaler/Rx

Symlin (pramlintide) inj 4 vials/30 days

SymlinPen (pramlintide) inj 2 boxes/30 days

Tamiflu 30 mg (oseltamivir) caps 40 caps/120 days

Tamiflu 45 mg, 75 mg (oseltamivir) caps 20 caps/120 days

Tamiflu 6 mg/mL (oseltamivir) oral susp 360 mL/120 days

Testim (testosterone) gel 60 tubes (300 g)/30 days

tizanidine 2 mg tabs 180 tabs/30 days

Tobi (tobramycin) inhal soln 1 package (56 ampules)/56 days

Tracleer (bosentan) tabs 60 tabs/30 days

Tradjenta (linagliptin) tabs 30 tabs/30 days

Travatan Z (travoprost) ophth soln 2 .5 mL/30 days

Tretin-X (tretinoin) crm Under age 40

Treximet (sumatriptan/naproxen sodium) tabs 18 tabs/30 days (across all oral migraine agents)

Ultram (tramadol) tabs 240 tabs/30 days

Ultram ER (tramadol ext-release) tabs 30 tabs/30 days

Veltin (clindamycin/tretinoin) gel Under age 40

Ventolin HFA (albuterol) inhaler 2 inhalers/Rx

Veramyst (fluticasone furoate) nasal spray 1 bottle/30 days

Viagra (sildenafil) tabs 8 tabs/30 days; males only (limit one agent for erectile

Victoza (liraglutide) inj 3 pens/30 days

Vimovo (naproxen/esomeprazole) tabs 60 tabs/30 days

Vivelle-Dot (estradiol) patches 28 patches/28 days

Vyvanse (lisdexamfetamine) caps 30 caps/30 days

Xalatan (latanoprost) ophth soln 2 .5 mL/30 days

Xanax XR (alprazolam ext-release) tabs 60 tabs/30 days

Xarelto 10 mg (rivaroxaban) tabs 35 tabs/90 days

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X Blue Cross and Blue Shield of Illinois October 2012 Drug Formulary

Brand Name (Generic Name) Dosage Form Dispensing Limit

Xenazine 12 .5 mg (tetrabenazine) tabs 240 tabs/30 days

Xenazine 25 mg (tetrabenazine) tabs 120 tabs/30 days

Xifaxan 200 mg (rifaximin) tabs 9 tabs/30 days

Xifaxan 550 mg (rifaximin) tabs 60 tabs/30 days

Xopenex 0 .31 mg, 0 .63 mg, 1 .25 mg (levalbuterol) nebulized soln 375 mL/Rx Xopenex Concentrate 1 .25 mg/ 0 .5 mL

(levalbuterol)

nebulized soln 90 units/Rx

Xopenex HFA (levalbuterol) inhaler 2 inhalers/Rx

Xyrem (sodium oxybate) oral soln 540 mL/30 days

Zanaflex (tizanidine) caps 180 caps/30 days

Zanaflex (tizanidine) 4 mg tabs 180 tabs/30 days

Zegerid (omeprazole/sodium bicarbonate) caps 60 units/30 days (limit one proton pump inhibitor in 30 days) Zegerid (omeprazole/sodium bicarbonate) powder 60 units/30 days (limit one proton pump inhibitor in 30 days)

Zetia (ezetimibe) tabs 30 tabs/30 days

Ziana (clindamycin/tretinoin) gel Under age 40

Zioptan (tafluprost) ophth soln 30 single-use containers/30 days

Zithromax (azithromycin) tabs 60 tabs/150 days

Zofran (ondansetron) oral soln 100 mL/30 days

Zofran/Zofran ODT 4 mg, 8 mg (ondansetron) tabs 30 tabs/30 days

Zolpimist (zolpidem) oral spray 1 bottle/30 days (limit one insomnia agent per 30 days)

Zomig (zolmitriptan) nasal spray 2 bottle (12 spray units)/30 days

Zomig/Zomig ZMT (zolmitriptan) tabs 18 tabs/30 days (across all oral migraine agents)

Zuplenz (ondansetron) films 12 films/30 days

Zyvox (linezolid) oral susp 600 mL/180 days

Zyvox (linezolid) tabs 56 tabs/180 days

Prior Authorization (PA): Your benefit plan may require prior authorization for certain drugs that are high-cost or have the potential for misuse . This means that your doctor will need to submit a prior authorization request for coverage of these medications, and the request will need to be approved, before the medication will be covered under your plan . For the formulary medications listed in this document, if a prior authorization is commonly required it will be noted next to the medication with a dot under the prior authorization column as noted in the section “How To Use This List” . Some plans may have prior authorization on additional medications beyond those noted in this document .

Step Therapy (ST): Your benefit plan may include a step therapy program . This means you may need to try another proven, cost-effective medication before coverage may be available for the drug included in the program . Many brand drugs have less-expensive generic or brand alternatives that might be an option for you . For the formulary medications listed in this document, if a step therapy is commonly required it will be noted next to the medication with a dot under the step therapy column as noted in the section “How To Use This List” . Some plans may have step therapy programs on additional medications beyond those noted in this document .

Remember, medication decisions are between you and your doctor. Only your doctor can determine which medication is right for you . Discuss any questions or concerns you have about medications you are taking or are prescribed with your doctor .

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XI Blue Cross and Blue Shield of Illinois October 2012 Drug Formulary

Specialty drugs

Specialty drugs are used in the treatment of medical conditions such as hepatitis, hemophilia, multiple sclerosis and rheumatoid arthritis . Specialty drugs may be oral or injectable medications that can either be self-administered or administered by a health care professional . For a current list of specialty medications, visit myprime.com or bcbsil.com and log in to Blue Access for Members . Note that some drug classes may be excluded by some plans and therefore may not be covered under your pharmacy benefit . Your plan may have a different coverage level for specialty drugs . If you have questions about your coverage for specialty medications or your prescription drug benefit, call the number on the back of your ID card .

Prime Therapeutics Specialty Pharmacy Program

Through Prime Therapeutics Specialty Pharmacy, members can have covered specialty medications delivered directly to them or their doctor’s office . When you receive specialty medications through Prime, you also receive at no additional charge the following services:

→

Coordination of coverage between you, your doctor and your health plan

→

Educational materials about your particular condition and information about managing potential medication side effects

→

Syringes, sharps containers and other supplies with every shipment for self-injectables

→

24/7/365 phone access to a pharmacist for urgent medication issues To order through Prime Therapeutics Specialty Pharmacy:

→

Have your doctor call or fax your prescription to Prime Therapeutics Specialty Pharmacy . Your doctor can call 877 .627 .6337 or fax to 877 .828 .3939 .

→

If you have an existing prescription for a covered specialty medication, you can call 877 .627 .6337 to transfer your prescription .

→

A Prime Therapeutics coordinator will contact you to arrange delivery of your medication .

→

The prescription can be shipped directly to you or your prescribing doctor’s office . Each package is individually marked for each member . Refrigerated drugs are shipped in temperature-controlled packaging .

If you have questions, please contact Prime Therapeutics Specialty Pharmacy at 877 .627 .6337, visit www .primetherapeutics .com/ specialty, or call the number on the back of your ID card .

*_{Blue Cross and Blue Shield of Illinois is a Division of Health Care Service Corporation, a Mutual Legal Reserve Company (“HCSC”) . HCSC is an independent licensee of the} Blue Cross Blue Shield Association . HCSC contracts with Prime Therapeutics to provide pharmacy benefit management and mail order pharmacy services and to administer this specialty pharmacy program . HCSC, as well as several other independent Blue Cross and Blue Shield licensees, has an ownership interest in Prime Therapeutics LLC .

Abbreviation/acronym key

caps capsules oint ointment

conc concentrate OSM osmotic release

crm cream PA prior authorization

DL dispensing limits SL sublingual

ext-release extended-release soln solution

inj injection supp suppositories

lotn lotion susp suspension

NF non-formulary ST step therapy

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1

2012

Blue Cross and Blue Shield of Illinois October 2012 Drug Formulary

Drug Name Spec ia lt y Pr ior A ut hor iz at io n D isp ensi ng L im its Ste p T he ra py ANTI-INFECTIVE DRUGS PENICILLINS amoxicillin/potassium clavulanate (Augmentin – brand is NF) amoxicillin/potassium clavulanate ext-release (Augmentin XR – brand is NF)

amoxicillin, NF = chew tabs, 125 mg ampicillin caps dicloxacillin penicillin v potassium CEPHALOSPORINS cefadroxil cefdinir cefpodoxime cefprozil

ceftriaxone (Rocephin – brand is NF)

cefuroxime (Ceftin – brand is NF)

cephalexin, NF = tabs (Keflex – brand is NF) SUPRAX tabs

MACROLIDES

azithromycin susp (Zithromax – brand is NF)

azithromycin tabs (Zithromax – brand is NF) •

clarithromycin (Biaxin – brand is NF)

clarithromycin ext-release (Biaxin XL – brand is NF)

• ZITHROMAX packets

TETRACYCLINES

demeclocycline

doxycycline hyclate (Periostat, Vibramycin – brands are NF)

minocycline (Dynacin, Minocin – brands are NF) FLUOROQUINOLONES

ciprofloxacin (Cipro – brand is NF)

levofloxacin (Levaquin – brand is NF) AMINOGLYCOSIDES neomycin sulfate paromomycin TOBI • • Drug Name Spec ia lt y Pr ior A ut hor iz at io n D isp ensi ng L im its Ste p T he ra py TUBERCULOSIS

ethambutol (Myambutol – brand is NF)

isoniazid tabs

isoniazid/rifampin (Rifamate – brand is NF) MYCOBUTIN

PRIFTIN

pyrazinamide

rifampin (Rifadin – brand is NF) FUNGAL INFECTIONS

fluconazole (Diflucan – brand is NF) •

flucytosine (Ancobon – brand is NF)

griseofulvin microsize

itraconazole (Sporanox – brand is NF) •

ketoconazole tabs

NOXAFIL •

nystatin oral

terbinafine (Lamisil – brand is NF) •

VFEND susp •

voriconazole (Vfend tabs – brand is NF) • VIRAL INFECTIONS Cytomegalovirus VALCYTE Hepatitis BARACLUDE HEPSERA INCIVEK • • PEGASYS • •

ribavirin (Copegus, Rebetol – brands are NF) •

VICTRELIS • •

Herpes

acyclovir (Zovirax – brand is NF)

famciclovir (Famvir – brand is NF)

valacyclovir (Valtrex – brand is NF)

HIV/AIDS

abacavir(Ziagen) APTIVUS ATRIPLA CRIXIVAN

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Drug Name Spec ia lt y Pr ior A ut hor iz at io n D isp ensi ng L im its Ste p T he ra py

didanosine delayed-release (Videx EC – brand is NF) EMTRIVA EPIVIR soln EPZICOM FUZEON • INTELENCE INVIRASE ISENTRESS KALETRA

lamivudine (Epivir tabs – brand is NF)

lamivudine/zidovudine (Combivir – brand is NF) LEXIVA

nevirapine tabs (Viramune) NORVIR

PREZISTA RESCRIPTOR REYATAZ SELZENTRY

stavudine (Zerit – brand is NF) SUSTIVA TRIZIVIR TRUVADA VIDEX VIRACEPT VIRAMUNE VIRAMUNE XR VIREAD ZIAGEN

zidovudine (Retrovir – brand is NF) MALARIA

atovaquone/proguanil 250-100 mg

(Malarone 250-100 mg – brand is NF)

chloroquine phosphate (Aralen – brand is NF) DARAPRIM

hydroxychloroquine (Plaquenil – brand is NF) MALARONE 62 .5-25 mg mefloquine PRIMAQUINE Drug Name Spec ia lt y Pr ior A ut hor iz at io n D isp ensi ng L im its Ste p T he ra py WORM INFECTIONS ALBENZA BILTRICIDE STROMECTOL OTHER ANTI-INFECTIVES

clindamycin (Cleocin, Cleocin Pediatric – brands are NF)

DAPSONE

erythromycin/sulfisoxazole metronidazole (Flagyl – brand is NF)

sulfamethoxazole/trimethoprim (Bactrim – brand is NF)

trimethoprim

vancomycin (Vancocin – brand is NF)

XIFAXAN 550 mg •

ZYVOX •

CANCER DRUGS

AFINITOR • •

ALKERAN tabs

anastrozole (Arimidex – brand is NF)

bicalutamide (Casodex – brand is NF) CEENU

CYCLOPHOSPHAMIDE tabs EMCYT

exemestane (Aromasin – brand is NF) FARESTON

flutamide

hydroxyurea (Hydrea – brand is NF) IRESSA

letrozole (Femara – brand is NF)

LEUCOVORIN CALCIUM tabs, 10 mg, 15 mg

leucovorin calcium tabs, 5 mg, 25 mg

LEUKERAN

leuprolide acetate •

megestrol (Megace – brand is NF)

mercaptopurine (Purinethol – brand is NF) MESNEX tabs

methotrexate

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2012

norethindrone acetate/ethinyl estradiol

(Femhrt 1/5 – brand is NF)

VIVELLE-DOT •

PROGESTINS

medroxyprogesterone acetate (Provera – brand is NF)

norethindrone acetate (Aygestin – brand is NF)

progesterone micronized (Prometrium – brand is NF)

BIRTH CONTROL

ELLA •

levonorgestrel (Plan B, Plan B One-Step – brands are NF)

•

NUVARING •

oral contraceptives – all generics •

ORTHO TRI-CYCLEN LO •

INFERTILITY

chorionic gonadotropin • •

clomiphene (Clomid – brand is NF) •

FOLLISTIM AQ • •

GANIRELIX ACETATE • •

REPRONEX • •

DIABETES

acarbose (Precose – brand is NF)

glimepiride (Amaryl – brand is NF)

glipizide (Glucotrol – brand is NF)

glipizide ext-release (Glucotrol XL – brand is NF) GLUCAGON EMERGENCY KIT

glyburide (Micronase – brand is NF)

glyburide micronized (Glynase – brand is NF)

glyburide/metformin (Glucovance – brand is NF) JANUMET • JANUMET XR • JANUVIA • JUVISYNC • KOMBIGLYZE XR •

metformin (Glucophage – brand is NF)

Drug Name Spec ia lt y Pr ior A ut hor iz at io n D isp ensi ng L im its Ste p T he ra py NILANDRON SYLATRON • • TABLOID tamoxifen TRETINOIN caps • • TREXALL XALKORI • • ZELBORAF • • ZYTIGA • •

HORMONES, DIABETES AND RELATED DRUGS CORTICOSTEROIDS

budesonide ext-release (Entocort EC – brand is NF)

dexamethasone elixir; tabs, 0.5 mg, 0.75 mg, 1.5 mg, 4 mg, 6 mg

DEXAMETHASONE soln, 0 .5 mg/5 mL

fludrocortisone

hydrocortisone (Cortef – brand is NF)

methylprednisolone (Medrol – brand is NF)

prednisolone (Prelone – brand is NF)

prednisolone sodium phosphate (Orapred, Pediapred – brands are NF)

PREDNISONE soln, 5 mg/5 mL; tabs, 50 mg

prednisone tabs, 1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg PREDNISONE INTENSOL MALE HORMONES ANDROGEL • • ANDROXY • danazol • TESTIM • • ESTROGENS DIVIGEL ENJUVIA

estradiol (Climara – brand is NF) •

estradiol (Estrace – brand is NF)

estradiol/norethindrone acetate (Activella – brand is NF)

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2012

metformin ext-release (Glucophage XR – brand is NF)

metformin ext-release OSM (Fortamet – brand is NF)

nateglinide (Starlix – brand is NF)

ONGLYZA • PRANDIN VICTOZA • • DIABETES – INSULINS Rapid-Acting Insulins HUMALOG • NOVOLOG • Short-Acting Insulins HUMULIN R • NOVOLIN R • Intermediate-Acting Insulins HUMALOG MIX 50/50, 75/25 • HUMULIN N • HUMULIN 70/30 • NOVOLIN N • NOVOLIN 70/30 • NOVOLOG MIX 70/30 • Basal Insulins LANTUS • LEVEMIR • THYROID REGULATION

levothyroxine – includes Levoxyl (Synthroid – brand is NF)

liothyronine (Cytomel – brand is NF)

methimazole (Tapazole – brand is NF)

propylthiouracil

GROWTH HORMONE

INCRELEX •

OMNITROPE • •

OTHER HORMONES AND RELATED DRUGS

ACTONEL •

alendronate tabs, 40 mg (Fosamax – brand is NF) alendronate tabs, 5 mg, 10 mg, 35 mg, 70 mg (Fosamax – brand is NF) • Drug Name Spec ia lt y Pr ior A ut hor iz at io n D isp ensi ng L im its Ste p T he ra py cabergoline

calcitonin-salmon (Miacalcin – brand is NF)

calcitriol (Rocaltrol – brand is NF)

desmopressin (DDAVP – brand is NF)

etidronate 400 mg (Didronel – brand is NF) EVISTA

FORTEO • • •

levocarnitine (Carnitor – brand is NF)

methylergonovine

octreotide (Sandostatin – brand is NF) • SENSIPAR

STIMATE ZEMPLAR

HEART AND CIRCULATORY DRUGS

ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS AND COMBINATIONS

benazepril (Lotensin – brand is NF)

benazepril/hydrochlorothiazide (Lotensin HCT – brand is NF)

captopril

captopril/hydrochlorothiazide 25-25 mg, 50-25 mg

enalapril (Vasotec – brand is NF)

enalapril/hydrochlorothiazide (Vaseretic – brand is NF)

fosinopril

fosinopril/hydrochlorothiazide lisinopril (Prinivil – brand is NF)

lisinopril/hydrochlorothiazide (Prinzide – brand is NF)

moexipril (Univasc – brand is NF)

moexipril/hydrochlorothiazide (Uniretic – brand is NF)

perindopril (Aceon – brand is NF)

quinapril (Accupril – brand is NF)

quinapril/hydrochlorothiazide (Accuretic – brand is NF)

ramipril (Altace – brand is NF)

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2012

ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS) AND COMBINATIONS

BENICAR BENICAR HCT DIOVAN DIOVAN HCT

losartan (Cozaar – brand is NF)

losartan/hydrochlorothiazide (Hyzaar – brand is NF)

BETA BLOCKERS AND COMBINATIONS

acebutolol (Sectral – brand is NF)

atenolol (Tenormin – brand is NF)

atenolol/chlorthalidone (Tenoretic – brand is NF)

bisoprolol (Zebeta – brand is NF)

bisoprolol/hydrochlorothiazide (Ziac – brand is NF)

carvedilol (Coreg – brand is NF) INNOPRAN XL

labetalol (Trandate – brand is NF)

metoprolol succinate ext-release (Toprol XL – brand is NF)

metoprolol tartrate (Lopressor – brand is NF)

nadolol (Corgard – brand is NF) PINDOLOL

PROPRANOLOL soln

propranolol tabs

propranolol ext-release (Inderal LA – brand is NF)

TIMOLOL

CALCIUM CHANNEL BLOCKERS AND COMBINATIONS

amlodipine (Norvasc – brand is NF)

amlodipine/benazepril (Lotrel – brand is NF)

diltiazem (Cardizem – brand is NF)

diltiazem ext-release (Cardizem CD,

Cardizem LA, Dilacor XR, Tiazac – brands are NF)

felodipine ext-release

nifedipine ext-release (Adalat CC, Procardia XL – brands are NF)

verapamil (Calan – brand is NF)

verapamil ext-release (Calan SR, Isoptin SR, Verelan, Verelan PM – brands are NF)

Drug Name Spec ia lt y Pr ior A ut hor iz at io n D isp ensi ng L im its Ste p T he ra py CHEST PAIN

isosorbide dinitrate, NF = SL tabs (Isordil – brand is NF)

isosorbide mononitrate (Monoket – brand is NF)

isosorbide mononitrate ext-release (Imdur – brand is NF)

nitroglycerin (Nitro-Dur – brand is NF) NITROSTAT

CHOLESTEROL LOWERING

atorvastatin (Lipitor – brand is NF)

cholestyramine (Questran, Questran Light – brands are NF)

colestipol (Colestid – brand is NF)

CRESTOR •

fenofibrate (Lofibra – brand is NF)

fenofibrate micronized (Lofibra – brand is NF)

gemfibrozil (Lopid – brand is NF)

lovastatin (Mevacor – brand is NF) NIASPAN

pravastatin (Pravachol – brand is NF)

simvastatin (Zocor – brand is NF) TRICOR

TRILIPIX WELCHOL FLUID RETENTION

acetazolamide

acetazolamide ext-release (Diamox Sequels – brand is NF) amiloride amiloride/hydrochlorothiazide bumetanide chlorothiazide chlorthalidone 25 mg, 50 mg furosemide, NF = soln, 8 mg/mL (Lasix – brand is NF)

hydrochlorothiazide caps (Microzide – brand is NF)

hydrochlorothiazide tabs indapamide

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2012

metolazone (Zaroxolyn – brand is NF)

spironolactone (Aldactone – brand is NF)

spironolactone/hydrochlorothiazide

(Aldactazide – brand is NF)

torsemide (Demadex – brand is NF)

triamterene/hydrochlorothiazide (Dyazide, Maxzide, Maxzide-25 – brands are NF) HEART RHYTHM

amiodarone (Cordarone, Pacerone – brands are NF)

disopyramide (Norpace – brand is NF)

flecainide (Tambocor – brand is NF) MEXILETINE

MULTAQ

propafenone (Rythmol – brand is NF)

propafenone ext-release (Rythmol SR – brand is NF)

quinidine gluconate ext-release quinidine sulfate

sotalol (Betapace, Betapace AF – brands are NF) OTHER HEART RELATED DRUGS

ADCIRCA • • •

clonidine (Catapres, Catapres-TTS – brands are NF)

DIBENZYLINE

digoxin tabs (Lanoxin – brand is NF)

doxazosin (Cardura – brand is NF)

eplerenone (Inspra – brand is NF)

guanfacine (Tenex – brand is NF)

hydralazine methyldopa midodrine minoxidil

prazosin (Minipress – brand is NF)

terazosin TRACLEER • • ERECTILE DYSFUNCTION CIALIS • • Drug Name Spec ia lt y Pr ior A ut hor iz at io n D isp ensi ng L im its Ste p T he ra py

BEE STING KITS EPIPEN EPIPEN-JR RESPIRATORY AGENTS ANTIHISTAMINES cetirizine syrup cyproheptadine promethazine NASAL PRODUCTS ASTEPRO •

azelastine (Astelin – brand is NF) •

fluticasone propionate (Flonase – brand is NF) •

ipratropium (Atrovent – brand is NF) •

NASONEX •

triamcinolone (Nasacort AQ – brand is NF) • COUGH/COLD/ALLERGY

acetylcysteine

ASTHMA/COPD

ADVAIR DISKUS •

ADVAIR HFA •

albuterol inhal soln, 0.083%, 0.5% •

albuterol syrup, tabs

albuterol 0.63 mg/3 mL, 1.25 mg/3 mL

(Accuneb – brand is NF)

•

ASMANEX •

ATROVENT HFA •

budesonide (Pulmicort Respules – brand is NF) •

COMBIVENT, NF = Respimat •

cromolyn inhal soln •

DULERA •

FLOVENT DISKUS •

FLOVENT HFA •

FORADIL AEROLIZER •

ipratropium inhal soln •

ipratropium/albuterol (Duoneb – brand is NF) •

montelukast (Singulair)

PROAIR HFA •

QVAR •

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2012

Drug Name Spec ia lt y Pr ior A ut hor iz at io n D isp ensi ng L im its Ste p T he ra py SPIRIVA HANDIHALER • SYMBICORT • terbutaline theophylline ext-release VENTOLIN HFA •

zafirlukast (Accolate – brand is NF) OTHER RESPIRATORY DRUGS

FIRAZYR • KALYDECO • PULMOZYME • GASTROINTESTINAL DRUGS LAXATIVES lactulose

PEG – electrolytes for soln (Colyte, Golytely, Nulytely – brands are NF)

loperamide

ULCER/GERD

cimetidine

dicyclomine caps, tabs (Bentyl – brand is NF)

famotidine (Pepcid – brand is NF)

glycopyrrolate (Robinul – brand is NF)

hyoscyamine (Anaspaz, Levsin, Levsin/SL – brands are NF)

hyoscyamine ext-release

(Levbid, Symax DuoTab – brands are NF)

lansoprazole delayed-release (Prevacid – brand is NF)

•

methscopolamine (Pamine, Pamine Forte – brands are NF)

misoprostol (Cytotec – brand is NF)

NEXIUM • •

omeprazole delayed-release (Prilosec – brand is NF)

•

pantoprazole delayed-release (Protonix – brand is NF)

• PREVPAC

PYLERA •

ranitidine (Zantac – brand is NF)

sucralfate (Carafate – brand is NF)

NAUSEA AND VOMITING

EMEND caps •

granisetron •

meclizine (Antivert – brand is NF)

ondansetron (Zofran, Zofran ODT – brands are NF)

•

ondansetron 24 mg •

trimethobenzamide (Tigan – brand is NF) DIGESTIVE ENZYMES

CREON ZENPEP

OTHER GASTROINTESTINAL DRUGS ASACOL

ASACOL HD

balsalazide (Colazal – brand is NF)

calcium acetate (Eliphos, Phoslo – brands are NF)

CANASA

CHENODAL •

diphenoxylate/atropine tabs (Lomotil – brand is NF)

lactulose

LIALDA

mesalamine

metoclopramide (Reglan – brand is NF) PENTASA

RENVELA

sulfasalazine (Azulfidine – brand is NF)

sulfasalazine delayed-release (Azulfidine EN-Tabs – brand is NF)

ursodiol (Actigall, Urso 250, Urso Forte – brands are NF)

GENITOURINARY DRUGS URINARY TRACT INFECTIONS

nitrofurantoin (Furadantin – brand is NF)

nitrofurantoin macrocrystalline

(Macrodantin – brand is NF)

nitrofurantoin monohydrate/

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2012

URINARY TRACT SPASMS DETROL

DETROL LA

oxybutynin

oxybutynin ext-release (Ditropan XL – brand is NF)

VESICARE

VAGINAL PRODUCTS CLEOCIN supp

clindamycin (Cleocin crm – brand is NF)

CRINONE •

ESTRACE crm

metronidazole (MetroGel-Vaginal – brand is NF)

terconazole (Terazol – brand is NF) VAGIFEM

OTHER GENITOURINARY DRUGS

alfuzosin ext-release (Uroxatral – brand is NF) AVODART

CYSTAGON

finasteride (Proscar – brand is NF)

potassium citrate ext-release (Urocit-K – brand is NF)

potassium citrate/citric acid (Polycitra-K – brand is NF)

sodium citrate/citric acid (Shohl’s – brand is NF)

tamsulosin (Flomax – brand is NF) CENTRAL NERVOUS SYSTEM DRUGS ANXIETY

alprazolam (Xanax – brand is NF)

buspirone, NF = 7.5 mg

DIAZEPAM oral soln, 1 mg/mL

diazepam tabs (Valium – brand is NF)

hydroxyzine hcl

hydroxyzine pamoate (Vistaril – brand is NF)

lorazepam (Ativan – brand is NF)

lorazepam conc (Lorazepam Intensol – brand is NF) Drug Name Spec ia lt y Pr ior A ut hor iz at io n D isp ensi ng L im its Ste p T he ra py DEPRESSION amitriptyline

bupropion (Wellbutrin – brand is NF)

bupropion ext-release (Wellbutrin SR, Wellbutrin XL – brands are NF)

citalopram (Celexa – brand is NF)

clomipramine (Anafranil – brand is NF)

desipramine (Norpramin – brand is NF)

doxepin, NF = caps, 150 mg

escitalopram (Lexapro – brand is NF)

fluoxetine, NF = 60 mg (Prozac – brand is NF)

imipramine hcl (Tofranil – brand is NF)

mirtazapine (Remeron, Remeron SolTab – brands are NF)

nortriptyline (Pamelor – brand is NF)

paroxetine hcl (Paxil – brand is NF)

paroxetine hcl ext-release (Paxil CR – brand is NF)

phenelzine (Nardil – brand is NF)

sertraline (Zoloft – brand is NF)

tranylcypromine (Parnate – brand is NF)

trazodone venlafaxine

venlafaxine ext-release caps (Effexor XR – brand is NF)

venlafaxine ext-release tabs, NF = 225 mg

PSYCHOTIC AND BIPOLAR DISORDERS

chlorpromazine

clozapine (Clozaril – brand is NF) FLUPHENAZINE HCL conc, elixir

fluphenazine hcl tabs

haloperidol decanoate (Haldol – brand is NF)

haloperidol lactate oral soln haloperidol tabs

lithium carbonate

lithium carbonate ext-release 300 mg

(Lithobid – brand is NF)

lithium carbonate ext-release 450 mg loxapine (Loxitane – brand is NF)

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olanzapine (Zyprexa, Zyprexa Zydis – brands are NF)

perphenazine prochlorperazine

quetiapine (Seroquel – brand is NF)

risperidone, NF = ODT, 0.25 mg (Risperdal, Risperdal M-Tab – brands are NF)

SEROQUEL XR

thiothixene trifluoperazine

ziprasidone (Geodon – brand is NF) SLEEP AIDS

estazolam

phenobarbital, NF = tabs, 64.8 mg, 97.2 mg temazepam (Restoril – brand is NF)

zaleplon (Sonata – brand is NF) •

zolpidem (Ambien – brand is NF) •

zolpidem ext-release (Ambien CR – brand is NF) • HYPERACTIVITY/NARCOLEPSY

amphetamine/dextroamphetamine (Adderall – brand is NF)

amphetamine/dextroamphetamine ext-release (Adderall XR – brand is NF)

caffeine citrate (Cafcit – brand is NF)

dextroamphetamine

dextroamphetamine ext-release (Dexedrine Spansule – brand is NF) INTUNIV

methylphenidate tabs (Ritalin – brand is NF)

methylphenidate ext-release caps; tabs, 20 mg (Ritalin LA, Ritalin SR – brands are NF)

VYVANSE •

MULTIPLE SCLEROSIS

BETASERON • •

COPAXONE • •

REBIF • •

OTHER CENTRAL NERVOUS SYSTEM DRUGS

bupropion ext-release (Zyban – brand is NF) CHANTIX

disulfiram (Antabuse – brand is NF)

donepezil (Aricept, Aricept ODT – brands are NF) EXELON patches, soln

galantamine (Razadyne – brand is NF)

galantamine ext-release (Razadyne ER – brand is NF)

naltrexone (ReVia – brand is NF) • NICOTROL INHALER

NICOTROL NS ORAP

rivastigmine (Exelon – brand is NF) PAIN RELIEF DRUGS

NON-NARCOTIC DRUGS

butalbital/acetaminophen (Sedapap – brand is NF)

butalbital/acetaminophen/caffeine (Esgic, Esgic-Plus, Fioricet – brands are NF)

butalbital/aspirin/caffeine (Fiorinal – brand is NF)

salsalate

NARCOTIC DRUGS

acetaminophen/codeine (Tylenol w/Codeine – brand is NF)

buprenorphine (Subutex – brand is NF) •

butalbital/aspirin/caffeine/codeine (Fiorinal w/Codeine – brand is NF) CODEINE SULFATE 15 mg

DILAUDID

fentanyl (Actiq – brand is NF) • •

fentanyl (Duragesic – brand is NF) •

hydrocodone/acetaminophen, NF = soln, 10-325 mg/15 mL

hydrocodone/ibuprofen (Ibudone, Reprexain, Vicoprofen – brands are NF)

hydromorphone liquid, tabs (Dilaudid tabs – brand is NF)

KADIAN •

methadone conc, soln

methadone tabs (Dolophine – brand is NF)

morphine sulfate conc, soln

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2012

morphine sulfate ext-release (MS Contin – brand is NF)

MORPHINE SULFATE supp, tabs

NUCYNTA ER •

oxycodone caps

oxycodone conc; tabs, 5 mg, 15 mg, 30 mg

(Roxicodone – brand is NF)

oxycodone/acetaminophen (Percocet, Tylox – brands are NF)

oxycodone/aspirin (Percodan – brand is NF)

OXYCONTIN •

SUBOXONE •

tramadol (Ultram – brand is NF) •

tramadol/acetaminophen (Ultracet – brand is NF)

RHEUMATOID AND OSTEOARTHRITIS

CELEBREX • •

diclofenac potassium (Cataflam – brand is NF)

diclofenac sodium delayed-release

diclofenac sodium ext-release (Voltaren-XR – brand is NF) etodolac HUMIRA • • ibuprofen indomethacin ketoprofen

leflunomide (Arava – brand is NF)

meloxicam tabs (Mobic – brand is NF)

nabumetone

naproxen (Naprosyn – brand is NF)

naproxen delayed-release (EC-Naprosyn – brand is NF)

naproxen sodium (Anaprox – brand is NF)

oxaprozin (Daypro – brand is NF)

piroxicam (Feldene – brand is NF)

sulindac (Clinoril – brand is NF) MIGRAINE HEADACHES

acetaminophen/isometheptene/ dichloralphenazone

IMITREX nasal spray •

Drug Name Spec ia lt y Pr ior A ut hor iz at io n D isp ensi ng L im its Ste p T he ra py MAXALT • MAXALT-MLT • MIGRANAL •

naratriptan (Amerge – brand is NF) •

sumatriptan inj, tabs (Imitrex – brand is NF) • GOUT

allopurinol (Zyloprim – brand is NF) COLCRYS

probenecid

probenecid/colchicine

NEUROMUSCULAR DRUGS SEIZURES

carbamazepine (Tegretol – brand is NF)

carbamazepine ext-release (Carbatrol, Tegretol-XR – brands are NF)

CELONTIN

clonazepam (Klonopin – brand is NF)

DIASTAT •

DILANTIN 30 mg DILANTIN INFATABS

divalproex delayed-release (Depakote Sprinkles, Depakote – brands are NF)

divalproex ext-release (Depakote ER – brand is NF)

ethosuximide (Zarontin – brand is NF)

gabapentin (Neurontin – brand is NF) GABITRIL

lamotrigine (Lamictal – brand is NF)

levetiracetam (Keppra – brand is NF) LYRICA

oxcarbazepine (Trileptal – brand is NF)

phenytoin sodium ext-release (Dilantin, Phenytek – brands are NF)

phenytoin susp (Dilantin – brand is NF)

primidone (Mysoline – brand is NF) SABRIL

TEGRETOL-XR 100 mg

topiramate (Topamax Sprinkle, Topamax – brands are NF)

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2012

valproic acid (Depakene – brand is NF)

zonisamide (Zonegran – brand is NF) PARKINSON’S DISEASE

amantadine, NF = tabs

APOKYN •

AZILECT

benztropine

bromocriptine (Parlodel – brand is NF)

carbidopa/levodopa (Parcopa, Sinemet – brands are NF)

carbidopa/levodopa ext-release (Sinemet CR – brand is NF)

COMTAN

pramipexole (Mirapex – brand is NF)

ropinirole (Requip – brand is NF)

selegiline caps (Eldepryl – brand is NF)

selegiline tabs trihexyphenidyl

MUSCLE RELAXANTS

baclofen

chlorzoxazone (Parafon Forte – brand is NF)

cyclobenzaprine (Fexmid, Flexeril – brands are NF)

dantrolene (Dantrium – brand is NF)

metaxalone (Skelaxin – brand is NF)

methocarbamol (Robaxin – brand is NF)

orphenadrine citrate ext-release

orphenadrine/aspirin/caffeine 25-385-30 mg

tizanidine (Zanaflex – brand is NF) • OTHER NEUROMUSCULAR DRUGS

MESTINON syrup MESTINON TIMESPAN

pyridostigmine (Mestinon tabs – brand is NF) RILUTEK

SUPPLEMENTS VITAMINS

ergocalciferol (Drisdol – brand is NF) MEPHYTON Drug Name Spec ia lt y Pr ior A ut hor iz at io n D isp ensi ng L im its Ste p T he ra py MULTIVITAMINS pediatric multivitamins pediatric vitamins ADC

PRENAPLUS PRENATABS FA

PRENATAL VITAMINS PLUS

PRENATAL 19, PRENATAL LOW IRON, PRENATAL PLUS, PRENATAL PLUS/IRON SE-NATAL 19

MINERALS AND ELECTROLYTES K-PHOS

potassium bicarbonate/chloride effervescent tabs, 25 mEq

potassium chloride packet; soln, 10% potassium chloride ext-release (K-Tabs –

brand is NF)

potassium chloride ext-release caps

(Micro-K – brand is NF)

potassium phosphate/sodium phosphates

(K-Phos Neutral – brand is NF)

sodium fluoride, NF = tabs, 1.1 mg

BLOOD MODIFYING DRUGS

anagrelide (Agrylin – brand is NF)

ARANESP • •

cilostazol (Pletal – brand is NF)

clopidogrel (Plavix 300mg – brand is NF)

cyanocobalamin inj

dipyridamole (Persantine – brand is NF) DROXIA

enoxaparin (Lovenox – brand is NF except 300 mg/mL)

•

EPOGEN • •

folic acid tabs, 1 mg

LOVENOX 300 mg/3 mL •

NEULASTA •

NEUPOGEN •

pentoxifylline ext-release (Trental – brand is NF)

PLAVIX 75 mg

PROCRIT • •

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Drug Name Spec ia lt y Pr ior A ut hor iz at io n D isp ensi ng L im its Ste p T he ra py TOPICAL DRUGS EYE Anti-infectives bacitracin/polymyxin B oint ciprofloxacin (Ciloxan – brand is NF)

erythromycin oint

gentamicin (Garamycin – brand is NF) NATACYN

neomycin/polymyxin B/bacitracin oint neomycin/polymyxin B/gramicidin

(Neosporin – brand is NF)

ofloxacin (Ocuflox – brand is NF)

polymyxin B/trimethoprim (Polytrim – brand is NF)

sulfacetamide sodium (Bleph-10 – brand is NF)

tobramycin (Tobrex – brand is NF)

trifluridine (Viroptic – brand is NF) VIGAMOX

Steroids and Combination Products

dexamethasone sodium phosphate soln fluorometholone (FML Liquifilm – brand is NF) LOTEMAX

neomycin/polymyxin B/bacitracin/ hydrocortisone oint

neomycin/polymyxin B/dexamethasone

(Maxitrol – brand is NF)

prednisolone acetate (Pred Forte – brand is NF) PREDNISOLONE SODIUM PHOSPHATE soln, 1%

sulfacetamide sodium/prednisolone soln

TOBRADEX oint

tobramycin/dexamethasone (Tobradex susp – brand is NF) ZYLET Glaucoma ALPHAGAN P 0 .1% AZOPT brimonidine soln, 0.2%

brimonidine soln, 0.15% (Alphagan P – brand is NF) carteolol soln Drug Name Spec ia lt y Pr ior A ut hor iz at io n D isp ensi ng L im its Ste p T he ra py

dorzolamide (Trusopt – brand is NF)

dorzolamide/timolol maleate (Cosopt – brand is NF)

latanoprost (Xalatan – brand is NF) •

levobunolol 0.5% (Betagan – brand is NF)

LUMIGAN •

metipranolol (Optipranolol – brand is NF)

pilocarpine (Isopto Carpine – brand is NF)

timolol maleate (Timoptic, Timoptic-XE – brands are NF)

TRAVATAN Z •

Other Eye Products

atropine sulfate soln (Isopto Atropine – brand is NF)

azelastine (Optivar – brand is NF)

cromolyn sodium soln

cyclopentolate (Cyclogyl – brand is NF)

diclofenac soln (Voltaren – brand is NF)

flurbiprofen (Ocufen – brand is NF)

homatropine (Isopto Homatropine – brand is NF)

ketorolac (Acular, Acular LS – brands are NF) PATADAY

tropicamide (Mydriacyl – brand is NF) EAR

acetic acid soln (Vosol – brand is NF)

benzocaine/antipyrine soln

CIPRODEX

hydrocortisone/acetic acid soln (Vosol hc – brand is NF)

neomycin/polymyxin B/hydrocortisone

(Cortisporin – brand is NF)

ofloxacin soln

MOUTH AND THROAT (local)

chlorhexidine oral rinse (Peridex – brand is NF)

clotrimazole troche

EVOXAC

lidocaine viscous nystatin susp

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2012

sodium fluoride (Prevident – brand is NF)

triamcinolone dental paste

ANORECTAL AGENTS CORTIFOAM

hydrocortisone acetate rectal crm, supp

(Anusol-HC, Proctocort – brands are NF)

hydrocortisone enema (Cortenema – brand is NF)

SKIN CONDITIONS/PRODUCTS Acne

adapalene (Differin – brand is NF) •

clindamycin (Cleocin T – brand is NF)

clindamycin/benzoyl peroxide (Benzaclin, Duac – brands are NF)

DIFFERIN gel, 0 .3% •

erythromycin gel, pads, soln erythromycin/benzoyl peroxide

(Benzamycin – brand is NF) FINACEA

isotretinoin caps

metronidazole (Metrocream, Metrolotion – brands are NF)

metronidazole topical gel

sulfacetamide sodium/sulfur, NF = susp, 10-5%

TAZORAC

tretinoin (Retin-A – brand is NF) •

Anti-infectives

ciclopirox (Loprox – brand is NF)

ciclopirox (Penlac – brand is NF) •

econazole

ketoconazole (Nizoral – brand is NF)

mupirocin oint (Bactroban – brand is NF)

nystatin topical

silver sulfadiazine (Silvadene – brand is NF)

Corticosteroids

alclometasone (Aclovate – brand is NF)

amcinonide crm

betamethasone dipropionate

betamethasone dipropionate, augmented

(Diprolene – brand is NF) Drug Name Spec ia lt y Pr ior A ut hor iz at io n D isp ensi ng L im its Ste p T he ra py

betamethasone valerate crm, lotn

clobetasol (Olux, Temovate – brands are NF)

desonide (Desowen – brand is NF)

desoximetasone crm, 0.25%; gel; oint, 0.25% (Topicort – brand is NF)

diflorasone oint

fluocinolone (Derma-Smoothe/FS – brand is NF)

fluocinolone crm, oint fluocinonide

fluticasone propionate (Cutivate – brand is NF)

halobetasol (Ultravate – brand is NF)

hydrocortisone topical

hydrocortisone valerate (Westcort – brand is NF)

mometasone (Elocon – brand is NF)

triamcinolone crm; lotn; oint, 0.025%, 0.1%

Other Skin Products

aluminum chloride (Drysol – brand is NF)

calcipotriene crm, soln (Dovonex) CARAC

DOVONEX ELIDEL FLUOROPLEX

fluorouracil (Efudex – brand is NF)

imiquimod (Aldara – brand is NF) •

lidocaine topical (Xylocaine – brand is NF)

lidocaine/prilocaine crm (Emla – brand is NF)

lindane

malathion (Ovide – brand is NF)

permethrin

podofilox (Condylox – brand is NF) PROTOPIC

selenium sulfide (Selsun – brand is NF) SOLARAZE

SORIATANE XERAC AC ZYCLARA

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2012

MISCELLANEOUS CATEGORIES (includes supplies and devices) DIABETIC SUPPLIES

BAYER ASCENSIA, BREEZE 2, CONTOUR, CONTOUR NEXT test strips

• BAYER FINGERSTIX, MICROLET, SINGLE-LET

lancets

BD MICROTAINER, ULTRAFINE lancets INSULIN PEN NEEDLES – BD ULTRAFINE,

NOVOFINE, NOVOTWIST

•

INSULIN SYRINGES – BD •

ROCHE ACCU-CHEK ACTIVE, AVIVA, AVIVA PLUS, COMFORT, COMPACT, SMARTVIEW test strips

•

ROCHE ACCU-CHEK FASTCLIX, MULTICLIX, SOFT TOUCH, SOFTCLIX lancets