April 2013 Blue Cross and Blue Shield of Wyoming Preferred ... · If an indicator is present in the column(s), ... cefadroxil. cefdinir: cefpodoxime. cefprozil: ceftriaxone (Rocephin)

2278 WY © Prime Therapeutics LLC 03/13

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Blue Cross and Blue Shield of Wyoming Preferred Drug ListApril 2013

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IMember Prescription Benefit . . . . . . . . . . . . . . . . . . . IPrior Authorization . . . . . . . . . . . . . . . . . . . . . . . . . . . IHow To Use This List . . . . . . . . . . . . . . . . . . . . . . . . IVGeneric Substitution . . . . . . . . . . . . . . . . . . . . . . . . . .VKey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .V

Therapeutic Class Drug List . . . . . . . . . . . . . . . . . . 1Anti-Infective Agents . . . . . . . . . . . . . . . . . . . . . . . . 1Cancer Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Hormones, Diabetes and Related Drugs . . . . . . . . . 4Heart and Circulatory Drugs . . . . . . . . . . . . . . . . . . 6Respiratory Agents . . . . . . . . . . . . . . . . . . . . . . . . . 8Gastrointestinal Drugs . . . . . . . . . . . . . . . . . . . . . . . 8

Genitourinary Drugs. . . . . . . . . . . . . . . . . . . . . . . . . 9Central Nervous System Drugs . . . . . . . . . . . . . . . 10Pain Relief Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . 11Neuromuscular Drugs . . . . . . . . . . . . . . . . . . . . . . 12Supplements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Blood Modifying Drugs . . . . . . . . . . . . . . . . . . . . . 13Topical Products . . . . . . . . . . . . . . . . . . . . . . . . . . 13Miscellaneous Categories . . . . . . . . . . . . . . . . . . . 16

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

CONTENTS

Blue Cross Blue Shield of Wyoming is an independent licensee of the Blue Cross and Blue Shield Association

IBlue Cross Blue Shield of Wyoming Preferred Drug List April 2013

INTRODUCTION

This Blue Cross Blue Shield of Wyoming (BCBSWY) Preferred Drug List, also called a patient medication guide, includes Brand drugs and Generic drugs. This guide, current at time of printing and subject to change, is updated quarterly. Members and physicians can review the most up-to-date version of the Preferred Drug List at www.wyomingblue.com/pharmacy.

The Preferred Drug List includes a list of prescription drugs, insulin, and diabetic supplies that reflect the current recommendations of BCBSWY. The Preferred Drug List is developed in conjunction with Prime Therapeutics’ National Pharmacy & Therapeutics Committee, which includes practicing physicians and pharmacists dedicated to providing patients with high-quality, cost-effective drug therapy. The Committee includes physicians and pharmacists from throughout the country. Prime Therapeutics does not have voting privileges. Drugs are reviewed in terms of safety, efficacy, and clinical uniqueness.

MEMBER PRESCRIPTION BENEFIT

Medications and supplies on this list are Preferred products. Drugs or supplies not listed are Non-Preferred (NP). Coverage of Preferred and Non-Preferred drugs will vary depending on your individual prescription benefit.

Some drugs may be excluded from coverage. For example, drugs indicated for cosmetic purposes, e.g., Propecia, for hair growth, are not covered. Prescription drugs may be excluded from coverage if there are over-the-counter (OTC) versions marketed. OTC drugs are not covered with the exception of insulin and selected diabetic supplies.

PRIOR AUTHORIZATION

The following drugs, including generic versions if available, are subject to PA. This list is subject to change.

Drugs are selected for prior authorization (PA) because of actual or potential misuse or overuse that may be of clinical and/or economic concern. Drugs selected for PA require that specific clinical criteria are met before the drugs will be covered under a member’s prescription benefit. The following drugs, including generic versions if available, are subject to PA.

Not all drugs on the following list are on the Preferred Drug List. Coverage of Preferred and Non-Preferred drugs will vary depending on your individual prescription benefit. This list is subject to change. For information about benefit coverage on specific drugs, please call 800.442.2376.

Prior Authorization List

ABSTRALACTEMRA ACTHAR HP gelACTIMMUNEADCIRCAADVATEAFINITORALDURAZYMEALFERON NALPHANATEALPHANINE SDAMEVIVEAMPYRAAPOKYN

ARALAST NPARANESPARCALYSTAUBAGIOAVONEXBARACLUDEBEBULIN VH BENEFIXBENLYSTA benzoyl peroxide cleansing cloths

(Triaz Foaming Cloths)benzoyl peroxide kit, 7% (Neobenz Micro Wash)benzoyl peroxide pads, 9% (Triaz)BERINERT

IIBlue Cross Blue Shield of Wyoming Preferred Drug List April 2013

BETASERONBOSULIFBPO Creamy WashBRAVELLEBUPHENYLCAPRELSACARBAGLUCAYSTONCEREZYMECETROTIDE CHENODALchorionic gonadotropinCIMZIACINRYZECOMETRIQCOPAXONECOPEGUSCORIFACTDELOS lotnEGRIFTAELAPRASEELELYSOELIGARDENBRELEPOGENepoprostenol sodium (Flolan)ERIVEDGEEXJADEEXTAVIAEYLEAFABRAZYME FEIBA VHfentanyl citrate lollipops (Actiq)FENTORAFERRIPROXFIRAZYRFIRMAGONFOLLISTIM AQFORTEO FUZEONganciclovir inj (Cytovene)GANIRELIX ACETATEGATTEXGENOTROPINGILENYAGLASSIAGLEEVEC GONAL-FHELIXATE FSHEMOFIL MHEPSERA

HEXALENHUMATE-P HUMATROPEHUMIRAHYCAMTINICLUSIGILARISINCIVEKINCRELEXINFERGENINLYTAINTRON AJAKAFIJETREAJUXTAPIDKALBITORKALYDECOKINERET KOATE-DVIKOGENATE FSKORLYMKRYSTEXXAKUVANLAZANDALETAIRISLEUKINEleuprolide acetate inj, 5 mg/mLLUCENTISLUMIZYMELUPRON DEPOTLUPRON DEPOT-PEDLUVERISLYSODRENMACUGENMAKENAMATULANEMENOPURminocycline ext-release tabs, 45 mg, 90 mg, 135 mg

(Solodyn)MONOCLATE-PMONONINEMOZOBILMYOZYMENAGLAZYMENEULASTANEUMEGANEUPOGENNEXAVARNORDITROPINNovarelNOVOSEVEN

IIIBlue Cross Blue Shield of Wyoming Preferred Drug List April 2013

NOVOSEVEN RTNOXAFILNPLATENUTROPINNUTROPIN AQoctreotide acetate (Sandostatin)OMNITROPEONSOLISORENCIAORFADINOVIDRELPEGASYSPEG-INTRONPOMALYSTPregnylPROCRITPROFILNINE SDPROLASTIN PROLASTIN CPROMACTAPULMOZYMERAVICTIREBETOL solnREBIFRECOMBINATERELISTORREMICADEREMODULINREPRONEXREVLIMIDRIBAPAKRIBASPHERE 400 mg, 600 mgRIBATABribavirin 200 mg (Copegus, Rebetol)SAIZENSAMSCASANDOSTATIN LAR DEPOTSEROSTIMsildenafil 20 mg (Revatio)SIMPONISOLIRISSOLODYN tabs, 55 mg, 65 mg, 80 mg, 105 mg, 115 mgSOMATULINE DEPOTSOMAVERTSPRYCELSTELARASTIVARGASUBSYSSUCRAIDSUTENT

SYLATRONSYNAGISTARCEVATARGRETIN capsTASIGNATEMODARTEV-TROPINTHALOMIDTHROMBATE IIITOBITRACLEERTRELSTAR DEPOTTRELSTAR LATRELSTAR MIXJECTtretinoin capsTYKERBTYSABRITYVASOTYZEKAVALCYTEVANOSVELETRIVELTINVENTAVISVFEND suspVICTRELISVISUDYNEVIVITROL voriconazole tabs (Vfend)VOTRIENTVPRIVWILATEXALKORIXELJANZXELODAXENAZINEXGEVAXIAFLEXXOLAIRXTANDIXYNTHAXYREMZAVESCAZELBORAFZEMAIRAZIANAZOLINZAZOMETAZORBTIVEZYTIGA

IVBlue Cross Blue Shield of Wyoming Preferred Drug List April 2013

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 Corticosteroids. All drugs listed, whether generic or brand, are Preferred drugs.

1 The first column of the chart lists the drug name. Generic drugs are shown in lower-case boldface type.

Example: budesonide ext-release

Preferred 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 Preferred Drug List. Any exceptions are noted and some listings contain additional information about specific products or dosage forms.

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

Example: DETROL LA

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

• Some products may show a strength, if so only that strength indicated is on the Preferred Drug List.

Example: XIFAXAN 550 mg

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

2 The columns indicate the Utilization Management (UM) program(s) that apply to the prescription drug (e.g., Prior Authorization and Quantity Limits). 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.

1 2

VBlue Cross Blue Shield of Wyoming Preferred Drug List April 2013

GENERIC SUBSTITUTION

BCBSWY encourages generic utilization as a way to provide high-quality drugs at a reduced cost. Generic drugs are as safe and effective as their brand-name counterparts, but are usually less expensive. Generic drugs are manufactured under the same strict standards of FDA’s Good Manufacturing Practice regulations that are required for brand products including batch requirements for identity, strength, purity, and quality.

An FDA-approved generic drug may be substituted for the brand counterpart because it:

• Contains the same active ingredient(s) as the brand drug

• Is identical in strength, dosage form, and route of administration

• Is therapeutically equivalent and can be expected to have the same clinical effect and safety profile

To encourage the use of generic drugs, Preferred brand drugs usually become Non-Preferred after the generic equivalent version is added to the drug guide. If the brand drug you are looking for does not appear on this list, it may be present under the generic name. You can ask your pharmacist for assistance.

KEY

caps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .capsuleschew tabs . . . . . . . . . . . . . . . . . . . . . . . chewable tabletsconc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . concentratecrm. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . creamext-release . . . . . . . . . . . . . . . . . . . . . . extended-releaseinhal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . inhalation inj . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . injectionlotn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . lotionNP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . non-preferred

ODT . . . . . . . . . . . . . . . . . . . . . . orally disintegrating tabsoint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ointmentOSM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . osmotic-releasesoln . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .solutionSL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . sublingualsupp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . suppositoriessusp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .suspensiontabs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .tablets

2013

Blue Cross Blue Shield of Wyoming Preferred Drug List, April 2013 1

Drug Name Prio

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ANTI-INFECTIVE AGENTS

PENICILLINS

amoxicillin caps, susp, tabs

AMOXICILLIN chew tabs

amoxicillin/potassium clavulanate chewtabs, susp, tabs (Augmentin)

amoxicillin/potassium clavulanate ext-release (Augmentin XR)

ampicillin caps

AMPICILLIN susp

AUGMENTIN susp, 125 mg/5 mL

dicloxacillin

penicillin v potassium

CEPHALOSPORINS

cefadroxil

cefdinir

cefpodoxime

cefprozil

ceftriaxone (Rocephin)

cefuroxime (Ceftin)

cephalexin, NP = tabs (Keflex)

SUPRAX

MACROLIDES

azithromycin susp, tabs (Zithromax)

clarithromycin ext-release (Biaxin XL)

clarithromycin immediate-release (Biaxin)

DIFICID

ERY-TAB

ERYTHROCIN STEARATE

ERYTHROMYCIN delayed-release

ERYTHROMYCIN BASE

ERYTHROMYCIN ETHYLSUCCINATE

ZITHROMAX packets

TETRACYCLINES

demeclocycline

Drug Name Prio

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Lim

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doxycycline hyclate

minocycline (Dynacin, Minocin)

TETRACYCLINE

FLUOROQUINOLONES

CIPRO susp

ciprofloxacin tabs, 250 mg, 500 mg,750 mg (Cipro)

levofloxacin (Levaquin)

AMINOGLYCOSIDES

neomycin sulfate

paromomycin

TOBI •TUBERCULOSIS

ethambutol (Myambutol)

ISONIAZID syrup

isoniazid tabs

isoniazid/rifampin (Rifamate)

MYCOBUTIN

PRIFTIN

pyrazinamide

rifampin (Rifadin)

FUNGAL INFECTIONS

fluconazole (Diflucan)

flucytosine (Ancobon)

griseofulvin microsize (Grifulvin V)

itraconazole (Sporanox)

ketoconazole tabs

LAMISIL granules

NOXAFIL •nystatin oral

SPORANOX soln

terbinafine tabs (Lamisil)

VFEND susp •voriconazole tabs (Vfend) •VIRAL INFECTIONS

2013

2 Blue Cross Blue Shield of Wyoming Preferred Drug List, April 2013

Drug Name Prio

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Cytomegalovirus

VALCYTE •Hepatitis

BARACLUDE •EPIVIR-HBV

HEPSERA •INCIVEK •PEGASYS •ribavirin 200 mg (Copegus, Rebetol) •VICTRELIS •Herpes

acyclovir (Zovirax)

famciclovir (Famvir)

valacyclovir (Valtrex)

HIV/AIDS

abacavir (Ziagen)

APTIVUS

ATRIPLA

COMPLERA

CRIXIVAN

didanosine delayed-release (Videx EC)

EDURANT

EMTRIVA

EPIVIR oral soln

EPZICOM

FUZEON •INTELENCE

INVIRASE

ISENTRESS

KALETRA

lamivudine (Epivir)

lamivudine/zidovudine (Combivir)

LEXIVA

nevirapine tabs (Viramune)

NORVIR

Drug Name Prio

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Lim

its

PREZISTA

RESCRIPTOR

REYATAZ

SELZENTRY

stavudine (Zerit)

STRIBILD

SUSTIVA

TRIZIVIR

TRUVADA

VIDEX

VIRACEPT

VIRAMUNE susp

VIRAMUNE XR

VIREAD

zidovudine

Influenza

RELENZA

TAMIFLU

MALARIA

atovaquone/proguanil 250-100 mg (Malarone)

ATOVAQUONE/PROGUANIL 62.5-25 mg

chloroquine phosphate (Aralen)

COARTEM

DARAPRIM

hydroxychloroquine (Plaquenil)

MALARONE 62.5-25 mg

mefloquine

PRIMAQUINE

WORM INFECTIONS

ALBENZA

BILTRICIDE

STROMECTOL

OTHER ANTI-INFECTIVES

clindamycin (Cleocin, Cleocin Pediatric)

DAPSONE

2013


Drug Name Prio

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erythromycin/sulfisoxazole

metronidazole tabs (Flagyl)

NEBUPENT

sulfamethoxazole/trimethoprim (Bactrim)

trimethoprim

vancomycin (Vancocin)

XIFAXAN 550 mg

ZYVOX

CANCER DRUGSThe list of drugs below includes selected oral andinjectable cancer drugs on the Preferred Drug List.However, all generic cancer drugs are Preferred. Allbrand drugs are on the Preferred Drug List until a genericversion is available and has been added to the PreferredDrug List. Typically, after the generic has been added,the corresponding brand becomes Non-Preferred.

AFINITOR •ALKERAN tabs

anastrozole (Arimidex)

bicalutamide (Casodex)

BOSULIF •CAPRELSA •CEENU

COMETRIQ •CYCLOPHOSPHAMIDE tabs

ELIGARD •EMCYT

ERIVEDGE •ETOPOSIDE caps

exemestane (Aromasin)

FARESTON

flutamide

GLEEVEC •HEXALEN •HYCAMTIN caps •hydroxyurea (Hydrea)

ICLUSIG •

Drug Name Prio

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INLYTA •JAKAFI •letrozole (Femara)

LEUCOVORIN CALCIUM tabs, 10 mg, 15 mg

leucovorin calcium tabs, 5 mg, 25 mg

LEUKERAN

LYSODREN •MATULANE •megestrol (Megace)

mercaptopurine (Purinethol)

MESNEX tabs

methotrexate

MYLERAN

NEXAVAR •NILANDRON

OFORTA •POMALYST •SPRYCEL •STIVARGA •SUTENT •SYLATRON •TABLOID

tamoxifen

TARCEVA •TARGRETIN caps •TASIGNA •TEMODAR •tretinoin caps •TYKERB •VOTRIENT •XALKORI •XELODA •XTANDI •ZELBORAF •ZOLINZA •

2013


Drug Name Prio

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ZYTIGA •HORMONES, DIABETES AND RELATED DRUGS

CORTICOSTEROIDS

budesonide ext-release (Entocort EC)

CORTISONE

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

DEXAMETHASONE soln; tabs, 1 mg, 2 mg

DEXAMETHASONE INTENSOL

fludrocortisone

hydrocortisone (Cortef)

methylprednisolone (Medrol)

prednisolone (Prelone)

prednisolone sodium phosphate (Orapred)

PREDNISOLONE SODIUM PHOSPHATE5 mg/5 mL

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

prednisone tabs, 1 mg, 2.5 mg, 5 mg, 10 mg,20 mg

MALE HORMONES

ANDRODERM

ANDROGEL

ANDROID

ANDROXY

danazol

METHITEST

testosterone cypionate (Depo-Testosterone)

testosterone enanthate (Delatestryl)

ESTROGENS

CLIMARA PRO

DIVIGEL

estradiol patches (Climara)

estradiol tabs (Estrace)

estradiol/norethindrone acetate (Activella)

estropipate 0.75 mg, 1.5 mg

ESTROPIPATE 3 mg

Drug Name Prio

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FEMHRT LOW DOSE

JINTELI

PREMARIN

PREMPHASE

PREMPRO

VIVELLE-DOT

PROGESTINS

medroxyprogesterone acetate (Provera)

norethindrone acetate (Aygestin)

progesterone micronized (Prometrium)

BIRTH CONTROL

AMETHYST

ELLA

levonorgestrel (Plan B, Plan B One-Step)

NECON 1-50

NECON 10-11

NUVARING

OGESTREL

oral contraceptive generics

ORTHO EVRA

ORTHO TRI-CYCLEN LO

ZOVIA 1/50

INFERTILITY

CETROTIDE •chorionic gonadotropin •clomiphene (Clomid)

FOLLISTIM AQ •GONAL-F •OVIDREL •REPRONEX •DIABETES

acarbose (Precose)

BYDUREON

BYETTA

glimepiride (Amaryl)

2013


Drug Name Prio

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glipizide (Glucotrol)

glipizide ext-release (Glucotrol XL)

glipizide/metformin (Metaglip)

GLUCAGON EMERGENCY KIT

glyburide (Micronase)

glyburide micronized (Glynase)

glyburide/metformin (Glucovance)

GLYBURIDE, distributor of Diabeta

JANUMET

JANUMET XR

JANUVIA

JUVISYNC

KOMBIGLYZE XR

metformin (Glucophage)

metformin ext-release (Glucophage XR)

nateglinide (Starlix)

ONGLYZA

pioglitazone (Actos)

pioglitazone/metformin (Actoplus Met)

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

Drug Name Prio

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Lim

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Basal Insulins

LANTUS

LEVEMIR

THYROID REGULATION

levothyroxine (Synthroid)

liothyronine (Cytomel)

methimazole (Tapazole)

propylthiouracil

GROWTH HORMONE

INCRELEX •OMNITROPE •OTHER HORMONES AND RELATED DRUGS

ACTONEL

alendronate 5 mg, 10 mg, 35 mg,70 mg (Fosamax)

ALENDRONATE 40 mg

cabergoline

calcitonin-salmon (Miacalcin)

calcitriol (Rocaltrol)

desmopressin (DDAVP)

ETIDRONATE

EVISTA

FORTEO •ibandronate (Boniva)

levocarnitine (Carnitor)

methylergonovine

ORFADIN •SENSIPAR

STIMATE

SYNAREL

HEART AND CIRCULATORY DRUGS

ANGIOTENSIN CONVERTING ENZYME (ACE)INHIBITORS AND COMBINATIONS

benazepril (Lotensin)

benazepril/hydrochlorothiazide (LotensinHCT)

2013


Drug Name Prio

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captopril

CAPTOPRIL/HYDROCHLOROTHIAZIDE

enalapril (Vasotec)

enalapril/hydrochlorothiazide (Vaseretic)

fosinopril

fosinopril/hydrochlorothiazide

lisinopril (Prinivil, Zestril)

lisinopril/hydrochlorothiazide (Prinzide,Zestoretic)

moexipril (Univasc)

moexipril/hydrochlorothiazide (Uniretic)

perindopril (Aceon)

quinapril (Accupril)

quinapril/hydrochlorothiazide (Accuretic)

ramipril (Altace)

trandolapril (Mavik)

ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS)AND COMBINATIONS

DIOVAN

losartan (Cozaar)

losartan/hydrochlorothiazide (Hyzaar)

valsartan/hydrochlorothiazide (Diovan HCT)

BETA BLOCKERS AND COMBINATIONS

acebutolol (Sectral)

atenolol (Tenormin)

atenolol/chlorthalidone (Tenoretic)

bisoprolol (Zebeta)

bisoprolol/hydrochlorothiazide (Ziac)

carvedilol (Coreg)

labetalol (Trandate)

metoprolol succinate ext-release (Toprol XL)

metoprolol tartrate (Lopressor)

nadolol (Corgard)

PINDOLOL

propranolol ext-release (Inderal LA)

Drug Name Prio

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PROPRANOLOL soln

propranolol tabs

PROPRANOLOL/HYDROCHLOROTHIAZIDE

TIMOLOL tabs

CALCIUM CHANNEL BLOCKERS ANDCOMBINATIONS

amlodipine (Norvasc)

amlodipine/benazepril (Lotrel)

CADUET

diltiazem (Cardizem)

diltiazem ext-release – 24 hr (Cardizem CD,Dilacor XR, Tiazac)

EXFORGE

EXFORGE HCT

felodipine ext-release

nifedipine ext-release – 24 hr (Adalat CC,Procardia XL)

VERAPAMIL 40 mg

verapamil 80 mg, 120 mg (Calan)

verapamil ext-release, NP = 100 mg, 200 mg,300 mg (Calan SR, Isoptin SR, Verelan)

CHEST PAIN

isosorbide dinitrate, NP = ext-release, SLtabs (Isordil)

isosorbide mononitrate (Monoket)

isosorbide mononitrate ext-release (Imdur)

NITRO-BID

nitroglycerin (Nitro-Dur)

NITROSTAT

CHOLESTEROL LOWERING

atorvastatin (Lipitor)

cholestyramine (Questran, Questran Light)

colestipol (Colestid)

fenofibrate (Lofibra, Tricor)

fenofibrate micronized (Lofibra)

gemfibrozil (Lopid)

2013


Drug Name Prio

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lovastatin (Mevacor)

NIASPAN

pravastatin (Pravachol)

simvastatin (Zocor)

WELCHOL

FLUID RETENTION

ACETAZOLAMIDE 125 mg

acetazolamide 250 mg

acetazolamide ext-release (Diamox Sequels)

amiloride

amiloride/hydrochlorothiazide

bumetanide

chlorothiazide

chlorthalidone 25 mg

CHLORTHALIDONE 50 mg

furosemide, NP = soln, 8 mg/mL (Lasix)

hydrochlorothiazide caps (Microzide)

hydrochlorothiazide tabs, 25 mg, 50 mg

indapamide

methazolamide (Neptazane)

metolazone (Zaroxolyn)

spironolactone (Aldactone)

spironolactone/hydrochlorothiazide (Aldactazide)

torsemide (Demadex)

triamterene/hydrochlorothiazide (Dyazide,Maxzide, Maxzide-25)

HEART RHYTHM

amiodarone (Cordarone, Pacerone)

disopyramide (Norpace)

flecainide (Tambocor)

MEXILETINE

propafenone (Rythmol)

propafenone ext-release (Rythmol SR)

quinidine gluconate ext-release

Drug Name Prio

r A

utho

rizat

ion

Qua

ntity

Lim

its

quinidine sulfate

QUINIDINE SULFATE ext-release

sotalol (Betapace, Betapace AF)

OTHER HEART RELATED DRUGS

ADCIRCA •clonidine (Catapres, Catapres-TTS)

DIBENZYLINE

DIGOXIN soln

digoxin tabs (Lanoxin)

doxazosin (Cardura)

eplerenone (Inspra)

guanfacine (Tenex)

hydralazine

LANOXIN tabs

methyldopa

midodrine

minoxidil

prazosin (Minipress)

sildenafil (Revatio) •terazosin

TRACLEER •ERECTILE DYSFUNCTION

CAVERJECT

MUSE

VIAGRA •BEE STING KITS

EPIPEN

EPIPEN-JR

RESPIRATORY AGENTS

ANTIHISTAMINES

cyproheptadine

promethazine supp, 12.5 mg, 25 mg; syrup;tabs

PROMETHEGAN supp, 50 mg

NASAL PRODUCTS

2013


Drug Name Prio

r A

utho

rizat

ion

Qua

ntity

Lim

its

ASTEPRO

azelastine (Astelin)

BACTROBAN NASAL

FLUNISOLIDE

fluticasone propionate (Flonase)

ipratropium (Atrovent)

COUGH/COLD/ALLERGY

acetylcysteine

SSKI

ASTHMA/COPD

ADVAIR DISKUS

ADVAIR HFA

albuterol inhal soln, syrup, tabs (Accuneb)

ASMANEX, NP = 7 metered doses

ATROVENT HFA

budesonide (Pulmicort Respules)

COMBIVENT

COMBIVENT RESPIMAT

cromolyn sodium inhal soln

DULERA

FLOVENT DISKUS

FLOVENT HFA

FORADIL AEROLIZER

ipratropium inhal soln

ipratropium/albuterol (Duoneb)

montelukast (Singulair)

PROAIR HFA

PULMICORT RESPULES 1 mg/2 mL

QVAR

SEREVENT DISKUS

SPIRIVA HANDIHALER

SYMBICORT

terbutaline

theophylline ext-release

VENTOLIN HFA

Drug Name Prio

r A

utho

rizat

ion

Qua

ntity

Lim

its

zafirlukast (Accolate)

OTHER RESPIRATORY DRUGS

FIRAZYR •KALYDECO •PULMOZYME •GASTROINTESTINAL DRUGS

LAXATIVES

lactulose

PEG – electrolytes for soln (Colyte, Golytely,Nulytely)

polyethylene glycol 3350 powder

ULCER/GERD

CARAFATE susp

cimetidine, NP = 200 mg

dicyclomine caps, tabs (Bentyl)

DICYCLOMINE soln

famotidine tabs (Pepcid)

glycopyrrolate (Robinul)

hyoscyamine (Levsin, Levsin/SL)

hyoscyamine ext-release (Levbid)

lansoprazole delayed-release (Prevacid)

misoprostol (Cytotec)

NEXIUM

omeprazole delayed-release (Prilosec)

PROPANTHELINE BROMIDE

PYLERA

ranitidine (Zantac)

sucralfate (Carafate)

NAUSEA AND VOMITING

EMEND

granisetron

meclizine 12.5 mg, 25 mg (Antivert)

ondansetron soln, tabs (Zofran)

ondansetron tabs, 24 mg

ondansetron ODT (Zofran ODT)

2013


Drug Name Prio

r A

utho

rizat

ion

Qua

ntity

Lim

its

TRANSDERM-SCOP

trimethobenzamide (Tigan)

DIGESTIVE ENZYMES

CREON

ZENPEP

OTHER GASTROINTESTINAL DRUGS

ASACOL

ASACOL HD

balsalazide (Colazal)

calcium acetate caps (Phoslo)

CANASA

CHENODAL •DELZICOL

DIPHENOXYLATE/ATROPINE soln

diphenoxylate/atropine tabs (Lomotil)

lactulose

LIALDA

loperamide

mesalamine

metoclopramide (Reglan)

PENTASA

RENVELA

sulfasalazine (Azulfidine)

sulfasalazine delayed-release (Azulfidine EN-Tabs)

ursodiol (Actigall, Urso 250, Urso Forte)

GENITOURINARY DRUGS

URINARY TRACT INFECTIONS

MACRODANTIN 25 mg

nitrofurantoin susp (Furadantin)

nitrofurantoin macrocrystalline (Macrodantin)

nitrofurantoin monohydrate/macrocrystalline (Macrobid)

URINARY TRACT SPASMS

DETROL LA

Drug Name Prio

r A

utho

rizat

ion

Qua

ntity

Lim

its

oxybutynin

oxybutynin ext-release (Ditropan XL)

tolterodine (Detrol)

VESICARE

VAGINAL PRODUCTS

ACID JELLY

CLEOCIN supp

clindamycin (Cleocin)

metronidazole (MetroGel-Vaginal)

PREMARIN

terconazole (Terazol)

VAGIFEM

OTHER GENITOURINARY DRUGS

alfuzosin ext-release (Uroxatral)

AVODART

CYSTAGON

CYTRA-K soln

CYTRA-3

ELMIRON

finasteride (Proscar)

K-PHOS MF

K-PHOS NO. 2

POTASSIUM CITRATE ext-release

potassium citrate/citric acidpowder (Polycitra-K)

sodium citrate/citric acid (Shohl's)

tamsulosin (Flomax)

TRICITRATES

CENTRAL NERVOUS SYSTEM DRUGS

ANXIETY

alprazolam (Xanax)

alprazolam ext-release (Xanax XR)

buspirone, NP = 7.5 mg

DIAZEPAM oral soln

diazepam tabs (Valium)

2013


Drug Name Prio

r A

utho

rizat

ion

Qua

ntity

Lim

its

hydroxyzine hcl

HYDROXYZINE PAMOATE 100 mg

hydroxyzine pamoate 25 mg, 50 mg (Vistaril)

lorazepam (Ativan)

lorazepam conc (Lorazepam Intensol)

DEPRESSION

amitriptyline

bupropion (Wellbutrin)

bupropion ext-release (Wellbutrin SR,Wellbutrin XL)

citalopram (Celexa)

clomipramine (Anafranil)

desipramine (Norpramin)

doxepin caps, 10 mg, 25 mg, 50 mg, 100 mg;soln

DOXEPIN 75 mg

escitalopram (Lexapro)

fluoxetine caps; soln; tabs, 10 mg,20 mg (Prozac)

fluvoxamine

imipramine hcl (Tofranil)

mirtazapine (Remeron)

nortriptyline caps (Pamelor)

NORTRIPTYLINE soln

paroxetine hcl (Paxil)

paroxetine hcl ext-release (Paxil CR)

phenelzine (Nardil)

sertraline (Zoloft)

tranylcypromine (Parnate)

trazodone

venlafaxine

venlafaxine ext-release caps (Effexor XR)

venlafaxine ext-release tabs, NP = 225 mg

PSYCHOTIC AND BIPOLAR DISORDERS

chlorpromazine

clozapine (Clozaril)

Drug Name Prio

r A

utho

rizat

ion

Qua

ntity

Lim

its

FLUPHENAZINE DECANOATE

FLUPHENAZINE HCL elixir, soln

fluphenazine hcl tabs

haloperidol decanoate (Haldol)

haloperidol lactate oral soln

haloperidol tabs

lithium carbonate caps, tabs

LITHIUM CARBONATE caps, 150 mg

lithium carbonate ext-release300 mg (Lithobid)

lithium carbonate ext-release 450 mg

LITHIUM CITRATE

loxapine (Loxitane)

olanzapine (Zyprexa)

olanzapine ODT (Zyprexa Zydis)

perphenazine

prochlorperazine

quetiapine (Seroquel)

risperidone (Risperdal)

risperidone ODT, NP = 0.25 mg (Risperdal M-Tab)

SEROQUEL XR

thiothixene

trifluoperazine

ziprasidone (Geodon)

SLEEP AIDS

estazolam

phenobarbital elixir; tabs, 15 mg, 16.2 mg,30 mg, 32.4 mg, 60 mg, 100 mg

temazepam (Restoril)

zaleplon (Sonata)

zolpidem (Ambien)

zolpidem ext-release (Ambien CR)

HYPERACTIVITY/NARCOLEPSY

amphetamine/dextroamphetamine (Adderall)

2013


Drug Name Prio

r A

utho

rizat

ion

Qua

ntity

Lim

its

amphetamine/dextroamphetamine ext-release (Adderall XR)

caffeine citrate (Cafcit)

dextroamphetamine tabs, 5 mg

dextroamphetamine ext-release (DexedrineSpansule)

methylphenidate (Ritalin)

METHYLPHENIDATE ext-release 10 mg

methylphenidate ext-release 20 mg (RitalinSR)

modafinil (Provigil)

STRATTERA

VYVANSE

MULTIPLE SCLEROSIS

BETASERON •COPAXONE •REBIF •OTHER CENTRAL NERVOUS SYSTEM DRUGS

bupropion ext-release (Zyban)

CHANTIX

disulfiram (Antabuse)

donepezil (Aricept)

donepezil ODT (Aricept ODT)

galantamine tabs (Razadyne)

galantamine ext-release (Razadyne ER)

NAMENDA

NICOTROL INHALER

NICOTROL NS

ORAP

rivastigmine caps (Exelon)

XENAZINE •PAIN RELIEF DRUGS

NON-NARCOTIC DRUGS

BUPAP

butalbital/acetaminophen

Drug Name Prio

r A

utho

rizat

ion

Qua

ntity

Lim

its

butalbital/acetaminophen/caffeine, NP =caps, 50-500-40 mg (Esgic, Esgic-Plus,Fioricet)

butalbital/aspirin/caffeine (Fiorinal)

salsalate

NARCOTIC DRUGS

acetaminophen/codeine (Tylenol w/Codeine)

AVINZA

buprenorphine (Subutex)

buprenorphine/naloxone (Suboxone)

butalbital/aspirin/caffeine/codeinecaps (Fiorinal w/Codeine)

CODEINE SULFATE 15 mg, 30 mg, 60 mg

fentanyl (Duragesic)

fentanyl (Actiq) •hydrocodone/acetaminophen, NP = soln,

7.5-325 mg/15 mL; tabs, 2.5-325 mg,5-300 mg, 7.5-300 mg, 10-300 mg

hydrocodone/ibuprofen (Ibudone, Reprexain,Vicoprofen)

hydromorphone soln, tabs (Dilaudid)

HYDROMORPHONE supp

methadone conc, 10 mg/mL; soln

methadone tabs (Dolophine)

morphine sulfate conc, soln

morphine sulfate ext-release – 12 hr (MSContin)

MORPHINE SULFATE supp, tabs

NUCYNTA ER

oxycodone caps, conc

OXYCODONE conc, soln

oxycodone tabs, 5 mg, 15 mg,30 mg (Roxicodone)

oxycodone/acetaminophen, NP = tabs,2.5-325 mg (Percocet)

oxycodone/aspirin (Percodan)

OXYCONTIN •

2013


Drug Name Prio

r A

utho

rizat

ion

Qua

ntity

Lim

its

SUBOXONE

tramadol (Ultram)

tramadol/acetaminophen (Ultracet)

RHEUMATOID AND OSTEOARTHRITIS

CELEBREX

diclofenac potassium (Cataflam)

diclofenac sodium delayed-release

diclofenac sodium ext-release (Voltaren-XR)

ENBREL •etodolac

flurbiprofen

HUMIRA •ibuprofen

indomethacin

ketoprofen

leflunomide (Arava)

meloxicam tabs (Mobic)

nabumetone

naproxen (Naprosyn)

naproxen delayed-release (EC-Naprosyn)

naproxen sodium (Anaprox)

oxaprozin (Daypro)

piroxicam (Feldene)

RIDAURA

sulindac (Clinoril)

MIGRAINE HEADACHES

acetaminophen/isometheptene/dichloralphenazone

IMITREX nasal

MIGRANAL

naratriptan (Amerge)

rizatriptan (Maxalt)

rizatriptan ODT (Maxalt-MLT)

sumatriptan inj, tabs (Imitrex)

GOUT

Drug Name Prio

r A

utho

rizat

ion

Qua

ntity

Lim

its

allopurinol (Zyloprim)

probenecid

probenecid/colchicine

NEUROMUSCULAR DRUGS

SEIZURES

carbamazepine (Tegretol)

carbamazepine ext-release (Carbatrol,Tegretol-XR)

CELONTIN

clonazepam (Klonopin)

DIASTAT

DILANTIN

divalproex delayed-release (Depakote,Depakote Sprinkle)

divalproex ext-release (Depakote ER)

ethosuximide (Zarontin)

gabapentin (Neurontin)

lamotrigine, NP = ext-release (Lamictal)

levetiracetam (Keppra)

levetiracetam ext-release (Keppra XR)

oxcarbazepine (Trileptal)

phenytoin chew tabs, susp (Dilantin)

phenytoin sodium ext-release (Dilantin,Phenytek)

primidone (Mysoline)

SABRIL

TEGRETOL-XR 100 mg

topiramate (Topamax, Topamax Sprinkle)

valproic acid (Depakene)

zonisamide (Zonegran)

PARKINSON'S DISEASE

amantadine, NP = tabs

APOKYN •AZILECT

benztropine

bromocriptine (Parlodel)

2013


Drug Name Prio

r A

utho

rizat

ion

Qua

ntity

Lim

its

carbidopa/levodopa (Sinemet)

carbidopa/levodopa ext-release (Sinemet CR)

carbidopa/levodopa ODT (Parcopa)

COMTAN

pramipexole (Mirapex)

ropinirole (Requip)

selegiline caps (Eldepryl)

selegiline tabs

STALEVO

trihexyphenidyl

MUSCLE RELAXANTS

baclofen

chlorzoxazone (Parafon Forte)

cyclobenzaprine (Flexeril)

dantrolene (Dantrium)

metaxalone (Skelaxin)

methocarbamol (Robaxin)

orphenadrine citrate ext-release

orphenadrine/aspirin/caffeine 25-385-30 mg

ORPHENADRINE/ASPIRIN/CAFFEINE50-770-60 mg

tizanidine tabs (Zanaflex)

OTHER NEUROMUSCULAR DRUGS

MESTINON syrup

MESTINON TIMESPAN

pyridostigmine tabs (Mestinon)

RILUTEK

SUPPLEMENTS

VITAMINS

ergocalciferol (Drisdol)

MEPHYTON

MULTIVITAMINS

pediatric multivitamins

pediatric vitamins ADC

PRENAPLUS

Drug Name Prio

r A

utho

rizat

ion

Qua

ntity

Lim

its

PRENATABS FA, RX

PRENATAL AD, PLUS, PLUS/IRON,VITAMINS PLUS

TRI-VIT/FLUORIDE/IRON

TRINATE

VINATE GT, ONE

MINERALS AND ELECTROLYTES

FLUOR-A-DAY

FLURA-DROPS 0.55 mg/drop

K-PHOS

potassium bicarbonate/chlorideeffervescent tabs, 25 mEq

potassium chloride packets, 20 mEq (K-Lor)

potassium chloride packets, 25 mEq (Klor-Con 25)

potassium chloride soln, 10%

POTASSIUM CHLORIDE soln, 20%

potassium chloride ext-release caps, 10mEq (Micro-K)

potassium chloride ext-release tabs, 10mEq (K-Tabs)

potassium chloride ext-release tabs, 8 mEq

potassium chloride microencapsulated tabs,10 mEq, 20 mEq

potassium phosphate/sodiumphosphates (K-Phos Neutral)

sodium fluoride chew tabs; soln, 0.275 mg/drop, 1.1 mg/mL

SODIUM FLUORIDE tabs

BLOOD MODIFYING DRUGS

anagrelide (Agrylin)

ARANESP •cilostazol (Pletal)

clopidogrel 75 mg (Plavix)

cyanocobalamin inj

dipyridamole (Persantine)

EFFIENT

2013


Drug Name Prio

r A

utho

rizat

ion

Qua

ntity

Lim

its

enoxaparin (Lovenox)

folic acid tabs

NEULASTA •NEUMEGA •NEUPOGEN •pentoxifylline ext-release (Trental)

PROCRIT •warfarin (Coumadin)

XARELTO

TOPICAL PRODUCTS

EYE

Anti-infectives

BACITRACIN oint

bacitracin/polymyxin B oint

CILOXAN oint

ciprofloxacin soln (Ciloxan)

erythromycin oint

gentamicin oint, soln (Garamycin)

NATACYN susp

neomycin/polymyxin B/bacitracin oint

neomycin/polymyxin B/gramicidinsoln (Neosporin)

ofloxacin soln (Ocuflox)

polymyxin B/trimethoprim soln (Polytrim)

sulfacetamide sodium soln (Bleph-10)

tobramycin soln (Tobrex)

TOBREX oint

trifluridine soln (Viroptic)

VIGAMOX soln

Steroids and Combination Products

ALREX susp

dexamethasone sodium phosphate soln

fluorometholone susp (FML Liquifilm)

LOTEMAX oint, susp

Drug Name Prio

r A

utho

rizat

ion

Qua

ntity

Lim

its

neomycin/polymyxin B/bacitracin/hydrocortisone oint

neomycin/polymyxin B/dexamethasone oint,susp (Maxitrol)

prednisolone acetate susp (Pred Forte)

sulfacetamide sodium/prednisolone soln

tobramycin/dexamethasone susp (Tobradex)

ZYLET

Glaucoma

ALPHAGAN P 0.1% soln

AZOPT susp

brimonidine soln, 0.15% (Alphagan P)

brimonidine soln, 0.2%

carteolol soln

dorzolamide soln (Trusopt)

dorzolamide/timolol maleate soln (Cosopt)

latanoprost soln (Xalatan)

LEVOBUNOLOL soln, 0.25%

levobunolol soln, 0.5% (Betagan)

LUMIGAN soln

metipranolol soln (Optipranolol)

pilocarpine soln, 1%, 2%, 4% (Isopto Carpine)

timolol maleate soln (Timoptic, Timoptic-XE)

TRAVATAN Z soln

Other Eye Products

ATROPINE SULFATE oint

atropine sulfate soln (Isopto Atropine)

azelastine soln (Optivar)

cromolyn sodium soln

cyclopentolate soln, 1% (Cyclogyl)

diclofenac soln (Voltaren)

flurbiprofen soln (Ocufen)

homatropine soln (Isopto Homatropine)

ketorolac soln (Acular, Acular LS)

PATADAY

2013


Drug Name Prio

r A

utho

rizat

ion

Qua

ntity

Lim

its

EAR

acetic acid soln

benzocaine/antipyrine soln

CIPRO HC

CIPRODEX

hydrocortisone/acetic acid soln (Vosol HC)

neomycin/polymyxin B/hydrocortisone soln,susp (Cortisporin)

ofloxacin soln

MOUTH AND THROAT (LOCAL)

cevimeline (Evoxac)

chlorhexidine rinse (Peridex)

lidocaine viscous

nystatin susp

pilocarpine tabs (Salagen)

sodium fluoride crm, gel (Prevident)

triamcinolone dental paste

ANORECTAL AGENTS

CORTIFOAM

hydrocortisone crm, 2.5% (Anusol-HC)

hydrocortisone enema (Cortenema)

hydrocortisone acetate supp, 25 mg (Anusol-HC)

SKIN CONDITIONS/PRODUCTS

Acne

adapalene crm, gel, 0.1% (Differin)

CLARAVIS

clindamycin (Cleocin-T)

clindamycin/benzoyl peroxide (Benzaclin,Duac)

DIFFERIN gel, 0.3%; lotn

DUAC CS

ERYTHROMYCIN gel

erythromycin pads, soln

erythromycin/benzoyl peroxide (Benzamycin)

FINACEA

Drug Name Prio

r A

utho

rizat

ion

Qua

ntity

Lim

its

isotretinoin 10 mg, 20 mg, 40 mg

METROGEL 1%

metronidazole (Metrocream, Metrolotion)

metronidazole gel, 0.75%

ORACEA

RETIN-A MICRO

sulfacetamide sodium/sulfur 10-5% crm,emulsion, lotion

TAZORAC

tretinoin, NP = Avita gel (Retin-A)

Anti-infectives

BACTROBAN crm

ciclopirox (Loprox, Penlac)

econazole

GENTAMICIN topical

ketoconazole crm, shampoo, 2% (Nizoral)

mupirocin, NP = Centany (Bactroban)

nystatin topical

silver sulfadiazine (Silvadene)

Corticosteroids

alclometasone (Aclovate)

amcinonide crm

betamethasone dipropionate

betamethasone dipropionate,augmented (Diprolene)

betamethasone valerate

clobetasol (Olux, Temovate)

desonide (Desowen)

DESOXIMETASONE crm, 0.05%

desoximetasone crm, 0.25%; gel;oint (Topicort)

DIFLORASONE crm, NP = emollient crm

diflorasone oint

fluocinolone crm, oint

fluocinolone oil (Derma-Smoothe/FS)

fluocinolone soln (Synalar)

2013


Drug Name Prio

r A

utho

rizat

ion

Qua

ntity

Lim

its

fluocinonide

fluticasone propionate (Cutivate)

halobetasol (Ultravate)

hydrocortisone topical, 2.5%

hydrocortisone valerate (Westcort)

mometasone (Elocon)

NYSTATIN/TRIAMCINOLONE

SYNALAR crm, oint

triamcinolone

TRIAMCINOLONE oint, 0.5%; NP = 0.05%

Other Skin Products

aluminum chloride soln (Drysol)

calcipotriene crm, soln (Dovonex)

CARAC

ELIDEL

FLUOROPLEX

fluorouracil crm, soln (Efudex)

imiquimod (Aldara)

lidocaine jelly, 2%; oint, 5%; soln,4% (Xylocaine)

lidocaine/prilocaine crm (Emla)

LIDOCAINE/PRILOCAINE kit

LIDODERM

lindane

malathion (Ovide)

PANRETIN

permethrin crm

PICATO

podofilox soln (Condylox)

PROTOPIC

selenium sulfide (Selsun)

SOLARAZE

SORIATANE

TARGRETIN gel

ULESFIA

Drug Name Prio

r A

utho

rizat

ion

Qua

ntity

Lim

its

XERAC AC

ZYCLARA

MISCELLANEOUS CATEGORIES

DIABETIC SUPPLIESMany other diabetic supplies including Insulin Syringes,Lancets and Lancet Devices are Preferred for plansthat cover them, however, only commonly prescribedproducts are shown on the Preferred Drug List.

BLOOD GLUCOSE METER – BAYERBREEZE 2, CONTOUR, CONTOUR LINK,CONTOUR NEXT, DIDGET

BLOOD GLUCOSE METER – ROCHE ACCU-CHEK AVIVA PLUS, COMPACT, NANOSMARTVIEW, VOICEMATE

CALIBRATION LIQUID – BAYER AUTODISC,BREEZE 2, CONTOUR, CONTOUR NEXT

CALIBRATION LIQUID – ROCHE ACCU-CHEK ACTIVE, AVIVA, COMFORT,COMPACT, INSTANT, SMARTVIEW;ACCUTREND

INSULIN PEN NEEDLES – NOVOFINE,NOVOTWIST, VARIOUS

INSULIN SYRINGES - VARIOUS

LANCET DEVICES - VARIOUS

LANCETS - VARIOUS

TEST STRIPS - ROCHE ACCU-CHEKACTIVE, AVIVA, AVIVA PLUS, COMFORT,COMPACT, SMARTVIEW; ACCUTREND

TEST STRIPS – BAYER AUTODISC, BREEZE2, CONTOUR, CONTOUR NEXT

RESPIRATORY INHALER-ASSIST DEVICESThe Preferred Drug List includes most spacerdevices. The most commonly prescribed productsare AEROCHAMBER, EASIVENT, E-Z SPACER,INSPIREASE, and MICROCHAMBER.

MISCELLANEOUS DRUGS

azathioprine (Imuran)

CELLCEPT oral susp

CHEMET

CUPRIMINE

2013


Drug Name Prio

r A

utho

rizat

ion

Qua

ntity

Lim

its

cyclosporine (Sandimmune)

cyclosporine modified caps, 25 mg, 100 mg;soln (Neoral)

mycophenolate mofetil caps, tabs (Cellcept)

MYFORTIC

naltrexone (Revia)

PROGRAF inj

RAPAMUNE

REVLIMID •SANDIMMUNE

sodium polystyrene sulfonate

SYPRINE

tacrolimus caps (Prograf)

THALOMID •ZORTRESS

2013


INDEX

A

abacavir........................................................................... 2acarbose.......................................................................... 4acebutolol........................................................................ 6acetaminophen/codeine............................................... 11acetaminophen/isometheptene/dichloralphenazone 12ACETAZOLAMIDE 125 mg.............................................. 7acetazolamide 250 mg................................................... 7acetazolamide ext-release............................................. 7acetic acid ear soln......................................................15acetylcysteine................................................................. 8ACID JELLY..................................................................... 9ACTONEL......................................................................... 5acyclovir.......................................................................... 2adapalene crm, gel, 0.1%.............................................15ADCIRCA..........................................................................7ADVAIR DISKUS..............................................................8ADVAIR HFA.................................................................... 8AFINITOR......................................................................... 3ALBENZA..........................................................................2albuterol inhal soln, syrup, tabs................................... 8alclometasone............................................................... 15ALENDRONATE 40 mg................................................... 5alendronate 5 mg, 10 mg, 35 mg, 70 mg...................... 5alfuzosin ext-release...................................................... 9ALKERAN tabs................................................................. 3allopurinol......................................................................12ALPHAGAN P 0.1% eye soln.........................................14alprazolam....................................................................... 9alprazolam ext-release................................................... 9ALREX eye susp............................................................ 14aluminum chloride soln............................................... 16amantadine, NP = tabs.................................................12amcinonide crm............................................................ 15AMETHYST...................................................................... 4amiloride.......................................................................... 7amiloride/hydrochlorothiazide.......................................7amiodarone......................................................................7amitriptyline...................................................................10amlodipine....................................................................... 6amlodipine/benazepril.................................................... 6amoxicillin/potassium clavulanate chew tabs, susp,tabs.................................................................................1

amoxicillin/potassium clavulanate ext-release............1amoxicillin caps, susp, tabs..........................................1AMOXICILLIN chew tabs................................................. 1amphetamine/dextroamphetamine..............................10amphetamine/dextroamphetamine ext-release..........11ampicillin caps................................................................1AMPICILLIN susp............................................................. 1anagrelide...................................................................... 13anastrozole...................................................................... 3

ANDRODERM.................................................................. 4ANDROGEL......................................................................4ANDROID......................................................................... 4ANDROXY........................................................................ 4APOKYN......................................................................... 12APTIVUS...........................................................................2ARANESP.......................................................................13ASACOL........................................................................... 9ASACOL HD.....................................................................9ASMANEX, NP = 7 metered doses..................................8ASTEPRO.........................................................................8atenolol............................................................................ 6atenolol/chlorthalidone.................................................. 6atorvastatin......................................................................6atovaquone/proguanil 250-100 mg............................... 2ATOVAQUONE/PROGUANIL 62.5-25 mg....................... 2ATRIPLA........................................................................... 2ATROPINE SULFATE eye oint...................................... 14atropine sulfate eye soln............................................. 14ATROVENT HFA..............................................................8AUGMENTIN susp, 125 mg/5 mL.................................... 1AVINZA........................................................................... 11AVODART.........................................................................9azathioprine...................................................................16azelastine eye soln.......................................................14azelastine nasal.............................................................. 8AZILECT......................................................................... 12azithromycin susp, tabs................................................ 1AZOPT eye susp............................................................14

B

bacitracin/polymyxin B eye oint................................. 14BACITRACIN eye oint.................................................... 14baclofen......................................................................... 13BACTROBAN crm.......................................................... 15BACTROBAN NASAL...................................................... 8balsalazide.......................................................................9BARACLUDE.................................................................... 2benazepril........................................................................ 5benazepril/hydrochlorothiazide.....................................5benzocaine/antipyrine ear soln................................... 15benztropine....................................................................12betamethasone dipropionate.......................................15betamethasone dipropionate, augmented................. 15betamethasone valerate...............................................15BETASERON..................................................................11bicalutamide.................................................................... 3BILTRICIDE...................................................................... 2bisoprolol.........................................................................6bisoprolol/hydrochlorothiazide..................................... 6BLOOD GLUCOSE METER – BAYER BREEZE 2,CONTOUR, CONTOUR LINK, CONTOUR NEXT,DIDGET.........................................................................16

BLOOD GLUCOSE METER – ROCHE ACCU-CHEKAVIVA PLUS, COMPACT, NANO SMARTVIEW,VOICEMATE................................................................. 16

2013


BOSULIF...........................................................................3brimonidine eye soln, 0.15%....................................... 14brimonidine eye soln, 0.2%......................................... 14bromocriptine................................................................12budesonide......................................................................8budesonide ext-release..................................................4bumetanide......................................................................7BUPAP............................................................................11buprenorphine...............................................................11buprenorphine/naloxone..............................................11bupropion...................................................................... 10bupropion ext-release.................................................. 10bupropion ext-release.................................................. 11buspirone, NP = 7.5 mg................................................. 9butalbital/acetaminophen.............................................11butalbital/acetaminophen/caffeine, NP = caps,50-500-40 mg............................................................... 11

butalbital/aspirin/caffeine.............................................11butalbital/aspirin/caffeine/codeine caps.....................11BYDUREON......................................................................4BYETTA............................................................................ 4

C

cabergoline......................................................................5CADUET........................................................................... 6caffeine citrate.............................................................. 11calcipotriene crm, soln................................................ 16calcitonin-salmon........................................................... 5calcitriol........................................................................... 5calcium acetate caps..................................................... 9CALIBRATION LIQUID – BAYER AUTODISC, BREEZE2, CONTOUR, CONTOUR NEXT.................................16

CALIBRATION LIQUID – ROCHE ACCU-CHEKACTIVE, AVIVA, COMFORT, COMPACT, INSTANT,SMARTVIEW; ACCUTREND........................................16

CANASA........................................................................... 9CAPRELSA.......................................................................3captopril...........................................................................6CAPTOPRIL/HYDROCHLOROTHIAZIDE........................6CARAC........................................................................... 16CARAFATE susp..............................................................8carbamazepine.............................................................. 12carbamazepine ext-release..........................................12carbidopa/levodopa...................................................... 13carbidopa/levodopa ext-release.................................. 13carbidopa/levodopa ODT............................................. 13carteolol eye soln.........................................................14carvedilol......................................................................... 6CAVERJECT.....................................................................7CEENU............................................................................. 3cefadroxil......................................................................... 1cefdinir............................................................................. 1cefpodoxime....................................................................1cefprozil........................................................................... 1ceftriaxone.......................................................................1cefuroxime.......................................................................1

CELEBREX.....................................................................12CELLCEPT oral susp..................................................... 16CELONTIN......................................................................12cephalexin, NP = tabs.................................................... 1CETROTIDE..................................................................... 4cevimeline......................................................................15CHANTIX........................................................................ 11CHEMET.........................................................................16CHENODAL...................................................................... 9chlorhexidine oral rinse...............................................15chloroquine phosphate..................................................2chlorothiazide..................................................................7chlorpromazine............................................................. 10chlorthalidone 25 mg..................................................... 7CHLORTHALIDONE 50 mg............................................. 7chlorzoxazone............................................................... 13cholestyramine................................................................6chorionic gonadotropin................................................. 4ciclopirox....................................................................... 15cilostazol........................................................................13CILOXAN eye oint..........................................................14cimetidine, NP = 200 mg................................................8CIPRODEX..................................................................... 15ciprofloxacin eye soln..................................................14ciprofloxacin tabs, 250 mg, 500 mg, 750 mg................1CIPRO HC...................................................................... 15CIPRO susp......................................................................1citalopram......................................................................10CLARAVIS...................................................................... 15clarithromycin ext-release............................................. 1clarithromycin immediate-release.................................1CLEOCIN supp.................................................................9CLIMARA PRO.................................................................4clindamycin..................................................................... 2clindamycin................................................................... 15clindamycin/benzoyl peroxide.....................................15clindamycin crm............................................................. 9clobetasol...................................................................... 15clomiphene...................................................................... 4clomipramine.................................................................10clonazepam................................................................... 12clonidine.......................................................................... 7clopidogrel 75 mg.........................................................13clozapine........................................................................10COARTEM........................................................................ 2CODEINE SULFATE 15 mg, 30 mg, 60 mg...................11colestipol......................................................................... 6COMBIVENT.....................................................................8COMBIVENT RESPIMAT.................................................8COMETRIQ.......................................................................3COMPLERA......................................................................2COMTAN........................................................................ 13COPAXONE....................................................................11CORTIFOAM.................................................................. 15CORTISONE.....................................................................4CREON............................................................................. 9

2013


CRIXIVAN......................................................................... 2cromolyn sodium eye soln..........................................14cromolyn sodium inhal soln..........................................8CUPRIMINE....................................................................16cyanocobalamin inj...................................................... 13cyclobenzaprine............................................................13cyclopentolate eye soln, 1%........................................14CYCLOPHOSPHAMIDE tabs........................................... 3cyclosporine..................................................................17cyclosporine modified caps, 25 mg, 100 mg; soln.... 17cyproheptadine............................................................... 7CYSTAGON......................................................................9CYTRA-3...........................................................................9CYTRA-K soln.................................................................. 9

D

danazol.............................................................................4dantrolene......................................................................13DAPSONE........................................................................ 2DARAPRIM....................................................................... 2DELZICOL........................................................................ 9demeclocycline............................................................... 1desipramine...................................................................10desmopressin..................................................................5desonide........................................................................ 15DESOXIMETASONE crm, 0.05%...................................15desoximetasone crm, 0.25%; gel; oint....................... 15DETROL LA......................................................................9dexamethasone elixir; tabs, 0.5 mg, 0.75 mg, 1.5 mg,4 mg, 6 mg.................................................................... 4

DEXAMETHASONE INTENSOL...................................... 4dexamethasone sodium phosphate eye soln............ 14DEXAMETHASONE soln; tabs, 1 mg, 2 mg.................... 4dextroamphetamine ext-release..................................11dextroamphetamine tabs, 5 mg.................................. 11DIASTAT.........................................................................12DIAZEPAM oral soln........................................................ 9diazepam tabs.................................................................9DIBENZYLINE.................................................................. 7diclofenac eye soln...................................................... 14diclofenac potassium...................................................12diclofenac sodium delayed-release............................ 12diclofenac sodium ext-release.................................... 12dicloxacillin..................................................................... 1dicyclomine caps, tabs.................................................. 8DICYCLOMINE soln......................................................... 8didanosine delayed-release...........................................2DIFFERIN gel, 0.3%; lotn...............................................15DIFICID............................................................................. 1DIFLORASONE crm, NP = emollient crm...................... 15diflorasone oint.............................................................15DIGOXIN soln...................................................................7digoxin tabs.................................................................... 7DILANTIN........................................................................12diltiazem...........................................................................6diltiazem ext-release – 24 hr......................................... 6

DIOVAN............................................................................ 6DIPHENOXYLATE/ATROPINE soln.................................9diphenoxylate/atropine tabs.......................................... 9dipyridamole..................................................................13disopyramide...................................................................7disulfiram.......................................................................11divalproex delayed-release..........................................12divalproex ext-release..................................................12DIVIGEL............................................................................4donepezil....................................................................... 11donepezil ODT.............................................................. 11dorzolamide/timolol maleate eye soln........................14dorzolamide eye soln...................................................14doxazosin........................................................................ 7DOXEPIN 75 mg............................................................ 10doxepin caps, 10 mg, 25 mg, 50 mg, 100 mg; soln....10doxycycline hyclate........................................................1DUAC CS....................................................................... 15DULERA........................................................................... 8

E

econazole.......................................................................15EDURANT.........................................................................2EFFIENT......................................................................... 13ELIDEL............................................................................16ELIGARD.......................................................................... 3ELLA................................................................................. 4ELMIRON..........................................................................9EMCYT............................................................................. 3EMEND............................................................................. 8EMTRIVA.......................................................................... 2enalapril........................................................................... 6enalapril/hydrochlorothiazide........................................6ENBREL..........................................................................12enoxaparin.....................................................................14EPIPEN.............................................................................7EPIPEN-JR....................................................................... 7EPIVIR-HBV......................................................................2EPIVIR oral soln...............................................................2eplerenone.......................................................................7EPZICOM..........................................................................2ergocalciferol................................................................ 13ERIVEDGE....................................................................... 3ERY-TAB.......................................................................... 1ERYTHROCIN STEARATE..............................................1erythromycin/benzoyl peroxide...................................15erythromycin/sulfisoxazole............................................3ERYTHROMYCIN BASE..................................................1ERYTHROMYCIN delayed-release.................................. 1ERYTHROMYCIN ETHYLSUCCINATE........................... 1erythromycin eye oint.................................................. 14ERYTHROMYCIN gel.....................................................15erythromycin pads, soln..............................................15escitalopram..................................................................10estazolam.......................................................................10estradiol/norethindrone acetate.................................... 4

2013


estradiol patches............................................................ 4estradiol tabs.................................................................. 4estropipate 0.75 mg, 1.5 mg..........................................4ESTROPIPATE 3 mg....................................................... 4ethambutol.......................................................................1ethosuximide.................................................................12ETIDRONATE...................................................................5etodolac......................................................................... 12ETOPOSIDE caps............................................................ 3EVISTA............................................................................. 5exemestane..................................................................... 3EXFORGE........................................................................ 6EXFORGE HCT................................................................6

F

famciclovir....................................................................... 2famotidine tabs............................................................... 8FARESTON...................................................................... 3felodipine ext-release.....................................................6FEMHRT LOW DOSE...................................................... 4fenofibrate....................................................................... 6fenofibrate micronized................................................... 6fentanyl.......................................................................... 11fentanyl patches........................................................... 11FINACEA........................................................................ 15finasteride........................................................................9FIRAZYR...........................................................................8flecainide......................................................................... 7FLOVENT DISKUS...........................................................8FLOVENT HFA.................................................................8fluconazole...................................................................... 1flucytosine....................................................................... 1fludrocortisone................................................................4FLUNISOLIDE.................................................................. 8fluocinolone crm, oint..................................................15fluocinolone oil............................................................. 15fluocinolone soln..........................................................15fluocinonide...................................................................16FLUOR-A-DAY................................................................13fluorometholone eye susp...........................................14FLUOROPLEX................................................................16fluorouracil crm, soln...................................................16fluoxetine caps; soln; tabs, 10 mg, 20 mg................. 10FLUPHENAZINE DECANOATE..................................... 10FLUPHENAZINE HCL elixir, soln...................................10fluphenazine hcl tabs...................................................10FLURA-DROPS 0.55 mg/drop........................................13flurbiprofen....................................................................12flurbiprofen eye soln....................................................14flutamide.......................................................................... 3fluticasone propionate................................................. 16fluticasone propionate nasal spray.............................. 8fluvoxamine................................................................... 10folic acid tabs............................................................... 14FOLLISTIM AQ.................................................................4FORADIL AEROLIZER.....................................................8

FORTEO........................................................................... 5fosinopril..........................................................................6fosinopril/hydrochlorothiazide...................................... 6furosemide, NP = soln, 8 mg/mL.................................. 7FUZEON........................................................................... 2

G

gabapentin.....................................................................12galantamine ext-release...............................................11galantamine tabs.......................................................... 11gemfibrozil.......................................................................6gentamicin eye oint, soln............................................ 14GENTAMICIN topical......................................................15GLEEVEC......................................................................... 3glimepiride.......................................................................4glipizide............................................................................5glipizide/metformin......................................................... 5glipizide ext-release....................................................... 5GLUCAGON EMERGENCY KIT...................................... 5glyburide..........................................................................5GLYBURIDE, distributor of Diabeta................................. 5glyburide/metformin....................................................... 5glyburide micronized..................................................... 5glycopyrrolate................................................................. 8GONAL-F.......................................................................... 4granisetron...................................................................... 8griseofulvin microsize....................................................1guanfacine....................................................................... 7

H

halobetasol.................................................................... 16haloperidol decanoate..................................................10haloperidol lactate oral soln........................................10haloperidol tabs............................................................10HEPSERA.........................................................................2HEXALEN......................................................................... 3homatropine eye soln.................................................. 14HUMALOG........................................................................5HUMALOG MIX 50/50, 75/25...........................................5HUMIRA..........................................................................12HUMULIN 70/30............................................................... 5HUMULIN N......................................................................5HUMULIN R......................................................................5HYCAMTIN caps.............................................................. 3hydralazine...................................................................... 7hydrochlorothiazide caps.............................................. 7hydrochlorothiazide tabs, 25 mg, 50 mg......................7hydrocodone/acetaminophen, NP = soln, 7.5-325mg/15 mL; tabs, 2.5-325 mg, 5-300 mg, 7.5-300 mg,10-300 mg.................................................................... 11

hydrocodone/ibuprofen................................................11hydrocortisone................................................................4hydrocortisone/acetic acid ear soln........................... 15hydrocortisone acetate supp, 25 mg..........................15hydrocortisone enema................................................. 15hydrocortisone rectal crm, 2.5%.................................15

2013


hydrocortisone topical, 2.5%.......................................16hydrocortisone valerate...............................................16hydromorphone soln, tabs.......................................... 11HYDROMORPHONE supp.............................................11hydroxychloroquine....................................................... 2hydroxyurea.................................................................... 3hydroxyzine hcl............................................................ 10HYDROXYZINE PAMOATE 100 mg..............................10hydroxyzine pamoate 25 mg, 50 mg...........................10hyoscyamine................................................................... 8hyoscyamine ext-release............................................... 8

I

ibandronate..................................................................... 5ibuprofen....................................................................... 12ICLUSIG............................................................................3imipramine hcl.............................................................. 10imiquimod......................................................................16IMITREX nasal............................................................... 12INCIVEK............................................................................2INCRELEX........................................................................ 5indapamide...................................................................... 7indomethacin.................................................................12INLYTA............................................................................. 3INSULIN PEN NEEDLES – NOVOFINE, NOVOTWIST,VARIOUS...................................................................... 16

INSULIN SYRINGES - VARIOUS.................................. 16INTELENCE......................................................................2INVIRASE......................................................................... 2ipratropium/albuterol......................................................8ipratropium inhal soln....................................................8ipratropium nasal........................................................... 8ISENTRESS......................................................................2isoniazid/rifampin........................................................... 1ISONIAZID syrup..............................................................1isoniazid tabs..................................................................1isosorbide dinitrate, NP = ext-release, SL tabs........... 6isosorbide mononitrate..................................................6isosorbide mononitrate ext-release..............................6isotretinoin 10 mg, 20 mg, 40 mg............................... 15itraconazole..................................................................... 1

J

JAKAFI..............................................................................3JANUMET......................................................................... 5JANUMET XR...................................................................5JANUVIA...........................................................................5JINTELI............................................................................. 4JUVISYNC........................................................................ 5

K

KALETRA..........................................................................2KALYDECO...................................................................... 8ketoconazole crm, shampoo, 2%................................15ketoconazole tabs.......................................................... 1ketoprofen..................................................................... 12

ketorolac eye soln........................................................14KOMBIGLYZE XR............................................................ 5K-PHOS.......................................................................... 13K-PHOS MF......................................................................9K-PHOS NO. 2................................................................. 9

L

labetalol........................................................................... 6lactulose.......................................................................... 8lactulose.......................................................................... 9LAMISIL granules............................................................. 1lamivudine....................................................................... 2lamivudine/zidovudine................................................... 2lamotrigine, NP = ext-release...................................... 12LANCET DEVICES - VARIOUS..................................... 16LANCETS - VARIOUS................................................... 16LANOXIN tabs.................................................................. 7lansoprazole delayed-release........................................8LANTUS............................................................................5latanoprost eye soln.................................................... 14leflunomide....................................................................12letrozole........................................................................... 3LEUCOVORIN CALCIUM tabs, 10 mg, 15 mg.................3leucovorin calcium tabs, 5 mg, 25 mg......................... 3LEUKERAN.......................................................................3LEVEMIR.......................................................................... 5levetiracetam................................................................. 12levetiracetam ext-release.............................................12LEVOBUNOLOL eye soln, 0.25%.................................. 14levobunolol eye soln, 0.5%..........................................14levocarnitine....................................................................5levofloxacin..................................................................... 1levonorgestrel................................................................. 4levothyroxine...................................................................5LEXIVA............................................................................. 2LIALDA..............................................................................9lidocaine/prilocaine crm...............................................16LIDOCAINE/PRILOCAINE kit......................................... 16lidocaine jelly, 2%; oint, 5%; soln, 4%........................16lidocaine viscous..........................................................15LIDODERM..................................................................... 16lindane........................................................................... 16liothyronine..................................................................... 5lisinopril........................................................................... 6lisinopril/hydrochlorothiazide........................................6LITHIUM CARBONATE caps, 150 mg........................... 10lithium carbonate caps, tabs.......................................10lithium carbonate ext-release 300 mg........................ 10lithium carbonate ext-release 450 mg........................ 10LITHIUM CITRATE.........................................................10loperamide.......................................................................9lorazepam...................................................................... 10lorazepam conc............................................................ 10losartan............................................................................ 6losartan/hydrochlorothiazide.........................................6LOTEMAX eye oint, susp...............................................14

2013


lovastatin......................................................................... 7loxapine......................................................................... 10LUMIGAN eye soln.........................................................14LYSODREN...................................................................... 3

M

MACRODANTIN 25 mg....................................................9MALARONE 62.5-25 mg.................................................. 2malathion....................................................................... 16MATULANE...................................................................... 3meclizine 12.5 mg, 25 mg.............................................. 8medroxyprogesterone acetate...................................... 4mefloquine.......................................................................2megestrol.........................................................................3meloxicam tabs.............................................................12MEPHYTON....................................................................13mercaptopurine...............................................................3mesalamine..................................................................... 9MESNEX tabs...................................................................3MESTINON syrup...........................................................13MESTINON TIMESPAN................................................. 13metaxalone.................................................................... 13metformin........................................................................ 5metformin ext-release.................................................... 5methadone conc, 10 mg/mL; soln.............................. 11methadone tabs............................................................ 11methazolamide................................................................ 7methimazole.................................................................... 5METHITEST......................................................................4methocarbamol............................................................. 13methotrexate................................................................... 3methyldopa......................................................................7methylergonovine........................................................... 5methylphenidate........................................................... 11METHYLPHENIDATE ext-release 10 mg.......................11methylphenidate ext-release 20 mg............................11methylprednisolone........................................................4metipranolol eye soln.................................................. 14metoclopramide.............................................................. 9metolazone...................................................................... 7metoprolol succinate ext-release..................................6metoprolol tartrate..........................................................6METROGEL 1%............................................................. 15metronidazole..................................................................9metronidazole................................................................15metronidazole gel, 0.75%.............................................15metronidazole tabs.........................................................3MEXILETINE.....................................................................7midodrine.........................................................................7MIGRANAL..................................................................... 12minocycline..................................................................... 1minoxidil.......................................................................... 7mirtazapine.................................................................... 10misoprostol..................................................................... 8modafinil........................................................................ 11moexipril.......................................................................... 6

moexipril/hydrochlorothiazide.......................................6mometasone..................................................................16montelukast.....................................................................8morphine sulfate conc, soln........................................11morphine sulfate ext-release – 12 hr..........................11MORPHINE SULFATE supp, tabs................................. 11mupirocin, NP = Centany.............................................15MUSE................................................................................7MYCOBUTIN.................................................................... 1mycophenolate mofetil caps, tabs..............................17MYFORTIC..................................................................... 17MYLERAN.........................................................................3

N

nabumetone...................................................................12nadolol............................................................................. 6naltrexone......................................................................17NAMENDA...................................................................... 11naproxen........................................................................12naproxen delayed-release............................................12naproxen sodium..........................................................12naratriptan..................................................................... 12NATACYN eye susp.......................................................14nateglinide....................................................................... 5NEBUPENT...................................................................... 3NECON 10-11.................................................................. 4NECON 1-50.................................................................... 4neomycin/polymyxin B/bacitracin/hydrocortisoneeye oint........................................................................ 14

neomycin/polymyxin B/bacitracin eye oint................ 14neomycin/polymyxin B/dexamethasone eye oint,susp..............................................................................14

neomycin/polymyxin B/gramicidin eye soln.............. 14neomycin/polymyxin B/hydrocortisone ear soln,susp..............................................................................15

neomycin sulfate............................................................ 1NEULASTA..................................................................... 14NEUMEGA......................................................................14NEUPOGEN................................................................... 14nevirapine tabs............................................................... 2NEXAVAR.........................................................................3NEXIUM............................................................................ 8NIASPAN.......................................................................... 7NICOTROL INHALER.................................................... 11NICOTROL NS............................................................... 11nifedipine ext-release – 24 hr........................................6NILANDRON.....................................................................3NITRO-BID........................................................................6nitrofurantoin macrocrystalline.....................................9nitrofurantoin monohydrate/macrocrystalline.............9nitrofurantoin susp.........................................................9nitroglycerin.................................................................... 6NITROSTAT......................................................................6norethindrone acetate....................................................4nortriptyline caps......................................................... 10NORTRIPTYLINE soln................................................... 10

2013


NORVIR............................................................................ 2NOVOLIN 70/30............................................................... 5NOVOLIN N......................................................................5NOVOLIN R......................................................................5NOVOLOG........................................................................5NOVOLOG MIX 70/30......................................................5NOXAFIL...........................................................................1NUCYNTA ER................................................................ 11NUVARING....................................................................... 4NYSTATIN/TRIAMCINOLONE....................................... 16nystatin oral.................................................................... 1nystatin susp................................................................ 15nystatin topical............................................................. 15

O

ofloxacin ear soln.........................................................15ofloxacin eye soln........................................................ 14OFORTA........................................................................... 3OGESTREL...................................................................... 4olanzapine..................................................................... 10olanzapine ODT............................................................ 10omeprazole delayed-release..........................................8OMNITROPE.................................................................... 5ondansetron ODT........................................................... 8ondansetron soln, tabs..................................................8ondansetron tabs, 24 mg...............................................8ONGLYZA.........................................................................5ORACEA.........................................................................15oral contraceptive generics...........................................4ORAP..............................................................................11ORFADIN..........................................................................5orphenadrine/aspirin/caffeine 25-385-30 mg..............13ORPHENADRINE/ASPIRIN/CAFFEINE 50-770-60 mg. 13orphenadrine citrate ext-release................................. 13ORTHO EVRA..................................................................4ORTHO TRI-CYCLEN LO................................................ 4OVIDREL.......................................................................... 4oxaprozin....................................................................... 12oxcarbazepine............................................................... 12oxybutynin.......................................................................9oxybutynin ext-release...................................................9oxycodone/acetaminophen, NP = tabs, 2.5-325 mg.. 11oxycodone/aspirin........................................................ 11oxycodone caps, conc.................................................11OXYCODONE conc, soln...............................................11oxycodone tabs, 5 mg, 15 mg, 30 mg.........................11OXYCONTIN...................................................................11

P

PANRETIN......................................................................16paromomycin.................................................................. 1paroxetine hcl............................................................... 10paroxetine hcl ext-release........................................... 10PATADAY....................................................................... 14pediatric multivitamins.................................................13pediatric vitamins ADC................................................ 13

PEGASYS.........................................................................2PEG – electrolytes for soln........................................... 8penicillin v potassium....................................................1PENTASA......................................................................... 9pentoxifylline ext-release.............................................14perindopril....................................................................... 6permethrin crm............................................................. 16perphenazine.................................................................10phenelzine..................................................................... 10phenobarbital elixir; tabs, 15 mg, 16.2 mg, 30 mg,32.4 mg, 60 mg, 100 mg.............................................10

phenytoin chew tabs, susp......................................... 12phenytoin sodium ext-release.....................................12PICATO...........................................................................16pilocarpine eye soln, 1%, 2%, 4%............................... 14pilocarpine tabs............................................................ 15PINDOLOL........................................................................6pioglitazone..................................................................... 5pioglitazone/metformin.................................................. 5piroxicam....................................................................... 12podofilox soln............................................................... 16polyethylene glycol 3350 powder................................. 8polymyxin B/trimethoprim eye soln............................14POMALYST...................................................................... 3potassium bicarbonate/chloride effervescent tabs,25 mEq......................................................................... 13

potassium chloride ext-release caps, 10 mEq........... 13potassium chloride ext-release tabs, 10 mEq............13potassium chloride ext-release tabs, 8 mEq..............13potassium chloride microencapsulated tabs, 10mEq, 20 mEq...............................................................13

potassium chloride packets, 20 mEq......................... 13potassium chloride packets, 25 mEq......................... 13potassium chloride soln, 10%.....................................13POTASSIUM CHLORIDE soln, 20%..............................13potassium citrate/citric acid powder............................ 9POTASSIUM CITRATE ext-release................................. 9potassium phosphate/sodium phosphates................13pramipexole...................................................................13PRANDIN..........................................................................5pravastatin.......................................................................7prazosin........................................................................... 7prednisolone................................................................... 4prednisolone acetate eye susp................................... 14prednisolone sodium phosphate.................................. 4PREDNISOLONE SODIUM PHOSPHATE 5 mg/5 mL.....4PREDNISONE soln, 5 mg/5 mL; tabs, 50 mg.................. 4prednisone tabs, 1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg... 4PREMARIN crm................................................................9PREMARIN tabs...............................................................4PREMPHASE................................................................... 4PREMPRO........................................................................4PRENAPLUS.................................................................. 13PRENATABS FA, RX..................................................... 13PRENATAL AD, PLUS, PLUS/IRON, VITAMINS PLUS.13PREZISTA........................................................................ 2

2013


PRIFTIN............................................................................ 1PRIMAQUINE................................................................... 2primidone.......................................................................12PROAIR HFA....................................................................8probenecid.....................................................................12probenecid/colchicine.................................................. 12prochlorperazine...........................................................10PROCRIT........................................................................14progesterone micronized...............................................4PROGRAF inj................................................................. 17promethazine supp, 12.5 mg, 25 mg; syrup; tabs....... 7PROMETHEGAN supp, 50 mg........................................ 7propafenone.................................................................... 7propafenone ext-release................................................ 7PROPANTHELINE BROMIDE..........................................8PROPRANOLOL/HYDROCHLOROTHIAZIDE.................6propranolol ext-release..................................................6PROPRANOLOL soln.......................................................6propranolol tabs............................................................. 6propylthiouracil...............................................................5PROTOPIC..................................................................... 16PULMICORT RESPULES 1 mg/2 mL.............................. 8PULMOZYME................................................................... 8PYLERA............................................................................8pyrazinamide................................................................... 1pyridostigmine tabs..................................................... 13

Q

quetiapine...................................................................... 10quinapril...........................................................................6quinapril/hydrochlorothiazide....................................... 6quinidine gluconate ext-release....................................7quinidine sulfate............................................................. 7QUINIDINE SULFATE ext-release................................... 7QVAR................................................................................8

R

ramipril.............................................................................6ranitidine..........................................................................8RAPAMUNE....................................................................17REBIF............................................................................. 11RELENZA......................................................................... 2RENVELA......................................................................... 9REPRONEX......................................................................4RESCRIPTOR.................................................................. 2RETIN-A MICRO............................................................ 15REVLIMID....................................................................... 17REYATAZ......................................................................... 2ribavirin 200 mg..............................................................2RIDAURA........................................................................12rifampin............................................................................1RILUTEK.........................................................................13risperidone.................................................................... 10risperidone ODT, NP = 0.25 mg.................................. 10rivastigmine caps......................................................... 11rizatriptan.......................................................................12

rizatriptan ODT..............................................................12ropinirole....................................................................... 13

S

SABRIL........................................................................... 12salsalate.........................................................................11SANDIMMUNE............................................................... 17selegiline caps.............................................................. 13selegiline tabs...............................................................13selenium sulfide........................................................... 16SELZENTRY.....................................................................2SENSIPAR........................................................................5SEREVENT DISKUS........................................................8SEROQUEL XR..............................................................10sertraline........................................................................10sildenafil.......................................................................... 7silver sulfadiazine.........................................................15simvastatin...................................................................... 7sodium citrate/citric acid............................................... 9sodium fluoride chew tabs; soln, 0.275 mg/drop, 1.1mg/mL.......................................................................... 13

sodium fluoride crm, gel............................................. 15SODIUM FLUORIDE tabs.............................................. 13sodium polystyrene sulfonate.....................................17SOLARAZE.....................................................................16SORIATANE................................................................... 16sotalol.............................................................................. 7SPIRIVA HANDIHALER................................................... 8spironolactone................................................................ 7spironolactone/hydrochlorothiazide.............................7SPORANOX soln..............................................................1SPRYCEL......................................................................... 3SSKI..................................................................................8STALEVO....................................................................... 13stavudine......................................................................... 2STIMATE.......................................................................... 5STIVARGA........................................................................3STRATTERA...................................................................11STRIBILD..........................................................................2STROMECTOL................................................................. 2SUBOXONE....................................................................12sucralfate......................................................................... 8sulfacetamide sodium/prednisolone eye soln........... 14sulfacetamide sodium/sulfur 10-5% crm, emulsion,lotion............................................................................ 15

sulfacetamide sodium eye soln.................................. 14sulfamethoxazole/trimethoprim.....................................3sulfasalazine....................................................................9sulfasalazine delayed-release....................................... 9sulindac......................................................................... 12sumatriptan inj, tabs.................................................... 12SUPRAX........................................................................... 1SUSTIVA...........................................................................2SUTENT............................................................................3SYLATRON.......................................................................3SYMBICORT.....................................................................8

2013


SYNALAR crm, oint........................................................16SYNAREL......................................................................... 5SYPRINE........................................................................ 17

T

TABLOID...........................................................................3tacrolimus caps............................................................ 17TAMIFLU...........................................................................2tamoxifen......................................................................... 3tamsulosin....................................................................... 9TARCEVA......................................................................... 3TARGRETIN caps............................................................ 3TARGRETIN gel............................................................. 16TASIGNA.......................................................................... 3TAZORAC.......................................................................15TEGRETOL-XR 100 mg.................................................12temazepam.................................................................... 10TEMODAR........................................................................ 3terazosin.......................................................................... 7terbinafine tabs...............................................................1terbutaline........................................................................8terconazole...................................................................... 9testosterone cypionate.................................................. 4testosterone enanthate.................................................. 4TEST STRIPS – BAYER AUTODISC, BREEZE 2,CONTOUR, CONTOUR NEXT.....................................16

TEST STRIPS - ROCHE ACCU-CHEK ACTIVE, AVIVA,AVIVA PLUS, COMFORT, COMPACT, SMARTVIEW;ACCUTREND................................................................16

TETRACYCLINE...............................................................1THALOMID..................................................................... 17theophylline ext-release.................................................8thiothixene.....................................................................10timolol maleate eye soln..............................................14TIMOLOL tabs.................................................................. 6tizanidine tabs...............................................................13TOBI..................................................................................1tobramycin/dexamethasone eye susp........................14tobramycin eye soln.....................................................14TOBREX eye oint...........................................................14tolterodine....................................................................... 9topiramate......................................................................12torsemide.........................................................................7TRACLEER.......................................................................7tramadol.........................................................................12tramadol/acetaminophen............................................. 12trandolapril...................................................................... 6TRANSDERM-SCOP........................................................9tranylcypromine............................................................ 10TRAVATAN Z eye soln.................................................. 14trazodone.......................................................................10tretinoin, NP = Avita gel.............................................. 15tretinoin caps.................................................................. 3triamcinolone................................................................ 16triamcinolone dental paste..........................................15TRIAMCINOLONE oint, 0.5%; NP = 0.05%................... 16

triamterene/hydrochlorothiazide................................... 7TRICITRATES.................................................................. 9trifluoperazine............................................................... 10trifluridine eye soln...................................................... 14trihexyphenidyl............................................................. 13trimethobenzamide......................................................... 9trimethoprim....................................................................3TRINATE.........................................................................13TRI-VIT/FLUORIDE/IRON.............................................. 13TRIZIVIR........................................................................... 2TRUVADA.........................................................................2TYKERB............................................................................3

U

ULESFIA......................................................................... 16ursodiol............................................................................9

V

VAGIFEM..........................................................................9valacyclovir..................................................................... 2VALCYTE..........................................................................2valproic acid..................................................................12valsartan/hydrochlorothiazide.......................................6vancomycin..................................................................... 3venlafaxine.................................................................... 10venlafaxine ext-release caps....................................... 10venlafaxine ext-release tabs, NP = 225 mg................ 10VENTOLIN HFA............................................................... 8VERAPAMIL 40 mg..........................................................6verapamil 80 mg, 120 mg.............................................. 6verapamil ext-release, NP = 100 mg, 200 mg, 300 mg. 6VESICARE........................................................................9VFEND susp.....................................................................1VIAGRA............................................................................ 7VICTOZA.......................................................................... 5VICTRELIS....................................................................... 2VIDEX............................................................................... 2VIGAMOX eye soln........................................................ 14VINATE GT, ONE...........................................................13VIRACEPT........................................................................ 2VIRAMUNE susp.............................................................. 2VIRAMUNE XR.................................................................2VIREAD.............................................................................2VIVELLE-DOT...................................................................4voriconazole tabs........................................................... 1VOTRIENT........................................................................3VYVANSE....................................................................... 11

W

warfarin.......................................................................... 14WELCHOL........................................................................ 7

X

XALKORI.......................................................................... 3XARELTO....................................................................... 14XELODA........................................................................... 3

2013


XENAZINE...................................................................... 11XERAC AC..................................................................... 16XIFAXAN 550 mg.............................................................3XTANDI.............................................................................3

Y

Z

zafirlukast........................................................................ 8zaleplon..........................................................................10ZELBORAF....................................................................... 3ZENPEP............................................................................9zidovudine....................................................................... 2ziprasidone.................................................................... 10ZITHROMAX packets....................................................... 1ZOLINZA...........................................................................3zolpidem........................................................................ 10zolpidem ext-release.................................................... 10zonisamide.................................................................... 12ZORTRESS.................................................................... 17ZOVIA 1/50.......................................................................4ZYCLARA....................................................................... 16ZYLET.............................................................................14ZYTIGA............................................................................. 4ZYVOX..............................................................................3

Documents

April 2013 Blue Cross and Blue Shield of Wyoming Preferred ... · If an indicator is present in the column(s), ... cefadroxil. cefdinir: cefpodoxime. cefprozil: ceftriaxone (Rocephin)