BCBSM/BCN Custom Select Drug ListPage 5 BCBSM and BCN Custom Select Drug List The BCBSM and BCN Custom Select Drug List is a useful reference and educational tool for prescribers,

Custom Select Drug List

BLUE CROSS BLUE SHIELD OF MICHIGAN BLUE CARE NETWORK OF MICHIGAN

Custom Select Drug List – January 2014

BCBSM and BCN Custom Select Drug list October 2013

Table of contentsBCBSM and BCN Custom Select Drug List introduction............................................ 5How to read the Custom Select Drug List.................................................................. 9

Anti-infectives1A 10Penicillins.......................................................................................................1B 10Cephalosporins..............................................................................................1C 10Tetracyclines..................................................................................................1D 11Macrolides......................................................................................................1E 11Quinolones.....................................................................................................1F 11Sulfonamides and Combinations....................................................................1G 12Urinary Tract Agents......................................................................................1H 12Antifungals.....................................................................................................1I 13Antivirals.......................................................................................................1J 14Antiretrovirals.................................................................................................1K 14Antimalarials...................................................................................................1M 15Antiparasitics/Anthelmintics............................................................................1N 15Miscellaneous Anti-infectives.........................................................................1L 15Antituberculars...............................................................................................

Cardiovascular, hypertension, cholesterol2A 16Lipid-lowering Agents.....................................................................................2B 17Beta Blockers and Combinations...................................................................2C 17ACE-Inhibitors and Combinations..................................................................2D 18Angiotensin II Receptor Blockers and Combinations......................................2E 18Calcium Channel Blockers and Combinations................................................2G 19Cardiovascular Treatment..............................................................................2F 19Diuretics.......................................................................................................2J 20Alpha-adrenergic Agents................................................................................2H 20Nitrates and Combinations.............................................................................2I 20Anticoagulants and Hemostasis Agents.........................................................2K 21Miscellaneous Antihypertensives....................................................................

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Central nervous system3A 22Antidepressants.............................................................................................3B 23Antipsychotics................................................................................................3C 23Anxiolytics......................................................................................................3D 24Sedative/Hypnotics.........................................................................................3E 24CNS Stimulants..............................................................................................3F 25Nonsteroidal Anti-inflammatory Drugs............................................................3G 25Salicylates......................................................................................................3H 25Narcotics.......................................................................................................3I 26Narcotic/Analgesic Combinations...................................................................3J 26Narcotic Mixed Agonist/Antagonist.................................................................3K 26Narcotic Antagonists......................................................................................3M 27Migraine Therapy...........................................................................................3O 27Parkinsons Disease and Related Disorders...................................................3P 28Anticonvulsants..............................................................................................3Q 29Skeletal Muscle Relaxants.............................................................................3R 29Myesthenia Gravis..........................................................................................3S 29Miscellaneous CNS........................................................................................

Gastrointestinal agents4C 30Other Ulcer Therapy.......................................................................................4D 30Antidiarrheals and Antispasmodics................................................................4A 30H2-Receptor Antagonists...............................................................................4B 30Proton Pump Inhibitors...................................................................................4E 31Antiemetics....................................................................................................4F 31Bile Acids.......................................................................................................4G 31Digestive Enzymes.........................................................................................4H 32Miscellaneous Gastrointestinal Agents...........................................................

Obstetrics and gynecology5B 33Contraceptives-Biphasic.................................................................................5C 33Contraceptives-Triphasic................................................................................5A 33Contraceptives-Monophasic...........................................................................5E 34Contraceptives-Postcoital...............................................................................5F 34Progestins......................................................................................................5G 34Estrogens.......................................................................................................5D 34Contraceptives-Misc.......................................................................................5K 35Vaginal Anti-infective/Antifungal.....................................................................5H 35Estrogen/Progestin Combinations..................................................................5J 35Infertility Treatment........................................................................................5L 35Miscellaneous OB-GYN.................................................................................

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Rheumatology and musculoskeletal6B 36Gout Therapy.................................................................................................6C 36Corticosteroids...............................................................................................6D 36Miscellaneous Rheumatologic Agents............................................................6A 36Salicylates......................................................................................................6E 37Osteoporosis/Hormonal Treatment................................................................6F 37Osteoporosis/Bone Resorption.......................................................................

Endocrinology7A 38Antithyroid Agents..........................................................................................7B 38Thyroid Hormones..........................................................................................7C 38Corticosteroids...............................................................................................7D 38Androgens......................................................................................................7E 39Miscellaneous Endocrine................................................................................7F 39Insulins.......................................................................................................7G 40Non-insulin Hypoglycemic Agents..................................................................7H 40Growth Hormone and Related Products.........................................................

Antineoplastics and immunosuppresants8A 41Alkylating Agents............................................................................................8B 41Antimetabolites...............................................................................................8C 41Immunomodulators........................................................................................8D 42Hormonal Agents...........................................................................................8E 42Miscellaneous Antineoplastic Agents.............................................................8F 42Adjuvant Therapy...........................................................................................8G 43Kinase Inhibitors and Molecular Target Inhibitors...........................................

Immunology and hematology9A 44Immunoglobulins............................................................................................9B 44Hematopoietic Agents....................................................................................9C 44Interferons and MS Therapy...........................................................................

Dermatology10A 45Very High Potency Corticosteriods.................................................................10B 45High Potency Corticosteroids.........................................................................10C 45Medium Potency Corticosteroids....................................................................10D 45Low Potency Corticosteroids..........................................................................10H 46Topical Antifungals.........................................................................................10G 46Topical Antibacterials.....................................................................................10F 46Acne Treatment..............................................................................................10E 46Topical Anesthetics........................................................................................10I 46Topical Antivirals............................................................................................10J 47Wound and Burn Therapy..............................................................................10K 47Antipsoriatic/Antiseborrheic............................................................................10L 47Scabicides/Pediculicides................................................................................10M 47Miscellaneous Dermatologicals......................................................................

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Ophthalmology11A 48Ophthalmic Beta Blockers..............................................................................11D 48Ophthalmic Anti-inflammatory Agents............................................................11B 48Other Glaucoma Agents.................................................................................11C 48Cycloplegic Mydriatics....................................................................................11E 49Ophthalmic Anti-infectives..............................................................................11F 49Ophthalmic Steroids.......................................................................................11G 50Ophthalmic Anti-infective/Steroid Combinations.............................................11H 50Miscellaneous Ophthalmic Agents.................................................................

Otic and nasal preparations12A 51Nasal Preparations.........................................................................................12B 51Otic Preparations...........................................................................................

Respiratory, cough and cold13A 52Antihistamines................................................................................................13B 52Antihistamine/Decongestant Combinations....................................................13F 52Oral Beta-Agonists.........................................................................................13G 52Inhaled Beta-Agonists....................................................................................13H 52Inhaled Steroids.............................................................................................13J 53Theophyllines.................................................................................................13K 53Epinephrine....................................................................................................13I 53Intranasal Steroids.........................................................................................13L 53Miscellaneous Pulmonary Agents..................................................................

Urology14A 54Urinary Antispasmodics..................................................................................14B 54Miscellaneous Urologicals..............................................................................14C 54BPH Treatment..............................................................................................

Vitamins and supplements15A 55Vitamins and Minerals....................................................................................15B 56Potassium Replacement................................................................................

Diagnostic and other miscellaneous16A 57Diagnostics and Other Miscellaneous............................................................

Lifestyle modification17C 58Smoking Cessation........................................................................................

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BCBSM and BCN Custom Select Drug List

The BCBSM and BCN Custom Select Drug List is a useful reference and educational tool for prescribers, pharmacists and members. The Custom Select Drug List is based on our Custom Drug List (previously called the “Custom Formulary”), but provides lower cost and better value for our customers’ and members’ health care dollars. This list is used for all BCBSM and BCN small group and individual members, including those who enrolled through the Health Insurance Marketplace. Other groups and individuals may also choose a pharmacy benefit that uses this drug list. We regularly update this list with medications approved by the U.S. Food and Drug Administration and reviewed by the BCBSM and BCN Pharmacy and Therapeutics Committee. That means the list represents the clinical judgment of Michigan physicians, pharmacists and other experts in the diagnosis and treatment of disease and the promotion of health. These medications are selected based on safety, clinical effectiveness and opportunity for cost savings. It’s why we can say that the BCBSM and BCN Custom Select Drug List will help maintain quality of care and contain costs for our members. Several drugs and drug categories are excluded from coverage under this benefit, including:

• Brand-name drugs that have generic equivalents • Over-the-counter medications (unless considered preventive by United States Preventive

Services Task Force) • Lifestyle drugs (drugs for erectile dysfunction or weight loss) • Drugs prescribed for cosmetic purposes • Drugs used to treat heartburn and acid reflux (except select generic versions) • Drugs that treat cough and colds, including most antihistamines • Prenatal vitamins • Compounded products, with some exceptions for BCBSM

Tier descriptions

Tier 1: Generics – Lowest copayment All drugs in this category are generic drugs. Members pay the lowest copayment for generics, which make them the most cost-effective option for treatment. BCN groups generic drugs into two tiers:

Tier 1A: Preferred Generics — Lowest generic drug copayment This tier includes commonly prescribed generic drugs that treat chronic diseases such as depression, hypertension, cholesterol, diabetes, heart disease and congestive heart failure. Offering these drugs at the lowest copayment makes these drugs more accessible to members and helps ensure they continue to take these important drugs regularly as prescribed.

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Tier 1B: Generics — Higher generic drug copayment Tier 1B includes generic drugs that aren’t in Tier 1A. The Tier 1B copayment is higher than the Tier 1A copayment, but is still lower than the copayment for brand name drugs.

Tiers 1A and 1B only apply to BCN. BCBSM considers all generic drugs Tier 1.

Tier 2: Preferred Brand — Higher copayment This tier includes preferred, brand-name drugs that don’t have a generic equivalent. These drugs are more expensive than generics, and members pay a higher copayment for them. Tier 3: Nonpreferred Brands — Highest copayment This tier includes brand-name drugs for which there is either a generic alternative or a more cost-effective preferred brand-name drug available. Members pay the highest copayment for these nonspecialty drugs. Tier 4: Preferred Specialty — Lowest specialty drug copayment Specialty drugs in Tier 4 are generally more effective and less expensive than nonpreferred specialty drugs in Tier 5. Tier 5: Nonpreferred Specialty — Highest specialty drug copayment Members pay the highest copayment for specialty drugs in Tier 5. That’s because there may be a more cost-effective generic or preferred brand available. Go to bcbsm.com/pharmacy for more information on specialty drugs.

What you need to know

Use this list to find information about drug coverage and therapeutic options for BCBSM and BCN members. Physicians are encouraged to prescribe preferred medications whenever possible.

The BCBSM/BCN Custom Drug List is divided into major drug classes by chapter for easy use. Products approved for more than one use may be included in more than one chapter. Within each chapter, drugs are identified according to their tier placement (Tiers 1 through 5).

BCBSM and BCN respect the judgment of the dispensing pharmacists and expect them to contact the prescriber when a prescription for a drug or dose may not be appropriate for a patient. We also encourage pharmacists to contact the prescriber to suggest an alternative when a BCBSM or BCN member’s prescription is written for a Tier 3 or Tier 5 (nonpreferred) drug or a drug that is not covered.

About new generics: When a generic version of a Tier 2 or Tier 3 drug becomes available, the generic version is generally added to Tier 1. The original branded version will not be covered.

http://bcbsm.com/pharmacy

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Coverage and applicable copayment amounts for drugs on the BCBSM and BCN Custom Select Drug List are based on a member’s drug plan. Not all drugs included in the BCBSM and BCN Custom Select Drug List are necessarily covered by each patient’s plan. Medications excluded from a BCBSM and BCN member’s pharmacy benefit may be covered under their medical benefit. Examples include serums, vaccines and other medications that are generally administered in a physician’s office under the supervision of appropriate health care personnel and not normally dispensed to the patient for self-administration.

How prior approval, step therapy and quantity limits work

Prior approval

Prior approval may be necessary for coverage of certain medications. In these cases, the member must meet clinical criteria or provide other information before coverage is approved.

Criteria are based on current medical information and approved by the BCBSM and BCN Pharmacy and Therapeutics Committee.

Step therapy

Drugs subject to step therapy may require previous treatment with one or more preferred drugs before coverage is approved.

Dose optimization and quantity limits

BCBSM/BCN dose optimization programs encourage appropriate prescribing of medications intended for once-daily administration. Quantities of these medications are limited to single daily doses of appropriate strengths.

BCBSM/BCN sets quantity limits based on clinical appropriateness and manufacturer-recommended dosing for particular drugs.

The Blue Care Network Prior Authorization and Step Therapy Guidelines and the BCBSM Prior Authorization and Step-Therapy Program provide a list of drugs that require prior approval or must meet step-therapy requirements prior to coverage. To view the current version, please go to bcbsm.com/RxInfo.

http://www.bcbsm.com/RxInfo

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Obtaining prior approval or step therapy

For members:

BBCCBBSSMM BBCCNN Members should consult their prescription drug benefit packet for information on how to obtain prior approval, or call the Customer Service number on the back of their Blues member ID card for additional information.

To request approval for a drug, the member’s doctor can contact the BCN Pharmacy Help Desk or submit a medication request that can be downloaded from Web-DENIS.

For physicians:

BBCCBBSSMM BBCCNN Physicians can request approval one of four ways: 1. Web - bcbsm.com

a. Log in as a provider b. Select Medication Prior

Authorization 2. Call - 1-800-437-3803 3. Fax - 1-866-601-4425 4. Write

Blue Cross Blue Shield of Michigan Pharmacy Services P.O. BOX 2320 Detroit, MI 48231-2320

Physicians can request approval by calling the BCN Pharmacy Help Desk:

1. Call: 1-800-437-3803 a. Provide your NPI number and the member’s contract number or enrollee ID b. Enter the requested information accurately and completely so your request is routed correctly

2. Fax: 1-877-442-3778 3. Write:

Blue Care Network Pharmacy Services Help Desk Mail Code C303 Southfield, MI 48076

Physicians can download the medication request forms through web-DENIS under BCBSM or BCN Provider Publications and Resources. Be sure to identify urgent requests, and return completed request forms to the Pharmacy Services Clinical Help Desk for review. We notify the physician of approved requests and process the member’s claim accordingly. If a request isn’t approved, we‘ll notify the member and physician in writing. The notification includes the reason for the denial and an explanation of the appeal rights and the appeals process.

This document is current at the time of publication and is subject to change. Please go to bcbsm.com/pharmacy and click Drug Lists for the most up-to-date information regarding the BCBSM/BCN Custom Select Drug List.

http://www.bcbsm.com/providers.html

http://www.bcbsm.com/pharmacy

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How to read the Custom Select Drug List

This drug list shows the drug’s copayment tier and whether the drug has special requirements for coverage. If two drug names are shown (generic and brand), coverage is provided for the generic. The brand-name

drug is included for informational purposes only.

Drugs are organized based on drug

class

The generic drug, atorvastatin calcium,

requires a Tier 1A copayment for BCN

and Tier 1 copayment for BCBSM.

Quantity limits apply for both plans. Its

brand-name equivalent (in parentheses)

is not covered.

The generic drug, fenofibric acid

(choline), requires a Tier 1 copayment

for BCBSM, and Tier 1B copayment for

BCN. BCBSM requires step therapy.

BCN requires prior approval and

quantity limits apply.

Niaspan is a brand-name drug that

requires a Tier 2 copayment.

Crestor is a brand-name drug that

requires a Tier 3 copayment. It requires

step therapy for coverage and quantity

limits apply for both BCBSM and BCN.

Kynamro is a brand-name specialty

drug. It requires a Tier 2 copayment for

BCBSM members with a three-tier drug

plan, and a Tier 4 copayment for all

other drug plans.

The misc column lists the <s> indicator

which indicates specialty drugs. You

may also see PREVN under this

column, which identifies preventive

drugs.

BCBSM: The information in this section

applies to members with a BCBSM drug

plan.

BCN: The information in this section

applies to members with a BCN drug

plan.

Prior approval: is required for

coverage.

Step therapy: Criteria must be met prior

to coverage.

Quantity limits: Prescriptions cannot

exceed a specific quantity per fill.

12

11

10

9

8

7

6

5

4

3

2

1

2

1 10 10 11 12 11 12

7

8 9

3

4

5

6

1. ANTI-INFECTIVES

5-Tier PA3-Tier TierQLST QLSTPAmisc.

1A. Penicillins

Drug

BCBSM BCN

1 1amoxicillin (Amoxil) 1A1 1amoxicillin/potassium clavulanate (Augmentin, ES) 1A1 1amoxicillin/potassium clavulanate (Augmentin XR) 1B1 1ampicillin trihydrate (Ampicillin) 1B1 1dicloxacillin sodium (Dicloxacillin) 1B1 1penicillin v potassium (Penicillin VK) 1B2 2Augmentin susp 23 3Moxatag 3


1B. Cephalosporins

Drug

BCBSM BCN

1 1cefaclor (Ceclor, ER) 1B1 1cefadroxil hydrate (Duricef) 1B1 1cefdinir (Omnicef) 1B1 1cefditoren pivoxil (Spectracef) 1B1 1cefpodoxime proxetil (Vantin) 1B1 1cefprozil (Cefzil) 1B1 1cefuroxime axetil (Ceftin) 1B1 1cephalexin (Keflex) 1B2 2Ceftin 250mg/5ml 23 3Cedax 33 3Ceftin 125mg/5ml 33 3Suprax 33 3Suprax susp 3


1C. Tetracyclines

Drug

BCBSM BCN

1 1doxycycline hyclate (Vibramycin, Vibratabs) 1A1 1demeclocycline hcl (Declomycin) 1B1 1doxycycline hyclate (Periostat) 1B1 1doxycycline monohydrate (Monodox) 1B1 1minocycline hcl (Minocin, Dynacin) 1B1 1tetracycline hcl (Tetracycline) 1B2 2Vibramycin suspension 23 3Vibramycin syrup 3

Page 10BCBSM/BCN Custom Select Drug List (January 2014)

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply <s> - Specialty Drug


1D. Macrolides

Drug

BCBSM BCN

1 1azithromycin (Zithromax) 1A1 1clarithromycin (Biaxin, XL) 1B1 1ery e-succ/sulfisoxazole (Pediazole) 1B1 1erythromycin base (Erythromycin Base) 1B1 1erythromycin ethylsuccinate (Erythromycin) 1B1 1erythromycin stearate (Erythromycin Stearate) 1B3 3Biaxin XL 33 3Dificid 33 3Eryped 33 3Ery-Tab 33 3Ketek 33 3PCE 33 3Zmax 3


1E. Quinolones

Drug

BCBSM BCN

1 1ciprofloxacin hcl (Cipro) 1B1 1ciprofloxacin/ciprofloxa hcl (Cipro XR) 1B1 1levofloxacin (Levaquin) 1B1 1ofloxacin (Floxin) 1B2 2Avelox, ABC 22 2Cipro solution 23 3Factive 33 3Noroxin 33 3Proquin XR 3


1F. Sulfonamides and Combinations

Drug

BCBSM BCN

1 1sulfamethoxazole/trimethoprim (Bactrim, DS, Septra, DS) 1A1 1ery e-succ/sulfisoxazole (Pediazole) 1B1 1sulfadiazine (Sulfadiazine) 1B1 1sulfamethoxazole/trimethoprim (Bactrim, DS, Septra, DS susp) 1B




1G. Urinary Tract Agents

Drug

BCBSM BCN

1 1methen/m-blue/sal/na phos/hyos (Urelle) 1B1 1methen/sod phos/meth blue/hyos (Urogesic) 1B1 1methenam/me blue/ba/salicy/hyo (Hyophen) 1B1 1methenamine hippurate (Hiprex/Urex) 1B1 1methenamine mandelate (Mandelamine) 1B1 1mth/me blue/sod phos/phen/hyos (Phosphasal) 1B1 1nitrofurantoin (Furadantin) 1B1 1nitrofurantoin macrocrystal (Macrodantin) 1B1 1nitrofurantoin monohyd/m-cryst (Macrobid) 1B1 1phenazopy hcl/hyoscy/butabarb (Pyridium Plus) 1B1 1phenazopyridine hcl (Pyridium) 1B1 1trimethoprim (Trimethoprim) 1B3 3Macrodantin 33 3Monurol 33 3Primsol 33 3Prosed-DS 33 3Urelle 33 3Uribel 3


1H. Antifungals

Drug

BCBSM BCN

1 1clotrimazole (Mycelex Troche) 1B1 1fluconazole (Diflucan) 1B1 1flucytosine (Ancobon) 1B1 1griseofulvin ultramicrosize (Gris-Peg) 1B1 1griseofulvin;microsize (Grifulvin V susp) 1B1 1itraconazole (Sporanox caps) 1B1 1ketoconazole (Nizoral) 1B1 1nystatin (Nystatin) 1B1 1terbinafine hcl (Lamisil tablets) 1B1 1voriconazole (Vfend) 1B2 2Noxafil 22 2Sporanox solution 22 2Vfend susp 23 3Lamisil Granules 33 3Oravig 3




1I. Antivirals

Drug

BCBSM BCN

1 1acyclovir (Zovirax) 1B1 1amantadine hcl (Symmetrel) 1B1 1famciclovir (Famvir) 1B1 1ganciclovir (Cytovene) 1B1 1rimantadine hcl (Flumadine) 1B1 1valacyclovir hcl (Valtrex) 1B2 2Epivir HBV 22 2Relenza 22 2Tamiflu cap, susp 22 2Valcyte 22 2Virazole 2

<s> 1 4ribavirin (Ribapak) 4<s> 1 4ribavirin (Copegus) 4<s> 1 4ribavirin (Rebetol) 4<s> 2 4Baraclude 4<s> 2 4 Incivek 4<s> 2 4Rebetol solution 4<s> 2 4 Victrelis 4<s> 4 4Hepsera (g) 4<s> 3 5Tyzeka 5




1J. Antiretrovirals

Drug

BCBSM BCN

1 1abacavir sulfate (Ziagen) 1B1 1didanosine (Videx EC) 1B1 1lamivudine (Epivir) 1B1 1lamivudine/zidovudine (Combivir) 1B1 1nevirapine (Viramune) 1B1 1stavudine (Zerit) 1B1 1zidovudine (Retrovir) 1B2 2Aptivus (Must Be Used With Norvir) 22 2Atripla 22 2Complera 22 2Crixivan 22 2Edurant 22 2Emtriva 22 2Epivir solution 22 2Epzicom 22 2Intelence 22 2Invirase 22 2Isentress 22 2Kaletra 22 2Lexiva 22 2Norvir 22 2Prezista (Must Be Used With Norvir) 22 2Rescriptor 22 2Reyataz 22 2Selzentry 22 2Stribild 22 2Sustiva 22 2Trizivir 22 2Truvada 22 2Videx 22 2Viracept 22 2Viread 22 2Ziagen 23 3Viramune XR 33 3Zerit 3

<s> 2 4Fuzeon 4


1K. Antimalarials

Drug

BCBSM BCN

1 1atovaquone/proguanil hcl (Malarone) 1B1 1chloroquine phosphate (Aralen) 1B1 1hydroxychloroquine sulfate (Plaquenil) 1B1 1mefloquine hcl (Lariam) 1B1 1quinine sulfate (Qualaquin) 1B2 2Coartem 22 2Daraprim 22 2Primaquine 2




1L. Antituberculars

Drug

BCBSM BCN

1 1ethambutol hcl (Ethambutol) 1B1 1isoniazid (Isoniazid) 1B1 1pyrazinamide (Pyrazinamide) 1B1 1rifampin (Rifadin) 1B1 1rifampin/isoniazid (Rifamate) 1B2 2Dapsone 22 2Mycobutin 22 2Seromycin 22 2 Sirturo 23 3Paser 33 3Priftin 33 3Rifater 33 3Trecator 3


1M. Antiparasitics/Anthelmintics

Drug

BCBSM BCN

1 1mebendazole (Vermox) 1B1 1metronidazole (Flagyl) 1B1 1paromomycin sulfate (Humatin) 1B1 1tinidazole (Tindamax) 1B2 2Alinia 22 2Biltricide 22 2Flagyl ER 22 2Mepron 22 2Nebupent aerosol 22 2Stromectrol - Single Dose 22 2Yodoxin 23 3Albenza 3


1N. Miscellaneous Anti-infectives

Drug

BCBSM BCN

1 1clindamycin hcl (Cleocin) 1B1 1clindamycin palmitate hcl (Cleocin solution) 1B1 1neomycin sulfate (Neomycin) 1B1 1vancomycin hcl (Vancocin) 1B2 2Zyvox 23 3Xifaxan 200mg 3

<s> 2 4Tobi 4<s> 2 4Tobi podhaler 4<s> 3 5 Cayston 5



2. CARDIOVASCULAR, HYPERTENSION, CHOLESTEROL


2A. Lipid-lowering Agents

Drug

BCBSM BCN

1 1atorvastatin calcium (Lipitor) 1A1 1fenofibrate;micronized (Lofibra) 1A1 1gemfibrozil (Lopid) 1A1 1lovastatin (Mevacor) 1A1 1pravastatin sodium (Pravachol) 1A1 1simvastatin (Zocor) 1A1 1amlodipine/atorvastatin (Caduet) 1B1 1cholestyramine (with sugar) (Questran, Questran Light) 1B1 1colestipol hcl (Colestid) 1B1 1fenofibrate nanocrystallized (Tricor) 1B1 1fenofibric acid (Fibricor) 1B1 1fenofibric acid (choline) (Trilipix) 1B1 1fluvastatin sodium (Lescol) 1B2 2Niaspan 22 2Welchol 22 2Zetia 23 3Antara 33 3Colestid Flavored 33 3 Crestor 33 3Fenoglide 33 3Juvisync 33 3 Lescol XL 33 3 Livalo 33 3 Lovaza 33 3Niacor 33 3Triglide 33 3 Vytorin 3

<s> 2 4 Kynamro 4<s> 5 5 Ravicti 5




2B. Beta Blockers and Combinations

Drug

BCBSM BCN

1 1acebutolol hcl (Sectral) 1A1 1atenolol (Tenormin) 1A1 1atenolol/chlorthalidone (Tenoretic) 1A1 1betaxolol hcl (Kerlone) 1A1 1bisoprolol fumarate (Zebeta) 1A1 1bisoprolol fumarate/hctz (Ziac) 1A1 1carvedilol (Coreg) 1A1 1labetalol hcl (Normodyne) 1A1 1metoprolol succinate (Toprol XL) 1A1 1metoprolol tartrate (Lopressor) 1A1 1metoprolol/hydrochlorothiazide (Lopressor HCT) 1A1 1nadolol (Corgard) 1A1 1nadolol/bendroflumethiazide (Corzide) 1A1 1pindolol (Pindolol) 1A1 1pindolol (Pindolol) 1A1 1propranolol hcl (Inderal) 1A1 1propranolol hcl (Inderal LA) 1A1 1propranolol/hydrochlorothiazid (Inderide) 1A1 1sotalol hcl (Betapace, AF) 1A1 1timolol maleate (Blocadren) 1A3 3Bystolic 33 3Coreg CR 33 3Dutoprol 33 3Innopran XL 33 3Levatol 3


2C. ACE-Inhibitors and Combinations

Drug

BCBSM BCN

1 1amlodipine besylate/benazepril (Lotrel) 1A1 1benazepril hcl (Lotensin) 1A1 1benazepril/hydrochlorothiazide (Lotensin HCT) 1A1 1captopril (Capoten) 1A1 1captopril/hydrochlorothiazide (Capozide) 1A1 1enalapril maleate (Vasotec) 1A1 1enalapril/hydrochlorothiazide (Vaseretic) 1A1 1fosinopril sodium (Monopril) 1A1 1fosinopril/hydrochlorothiazide (Monopril HCT) 1A1 1lisinopril (Prinivil, Zestril) 1A1 1lisinopril/hydrochlorothiazide (Prinzide, Zestoretic) 1A1 1moexipril hcl (Univasc) 1A1 1moexipril/hydrochlorothiazide (Uniretic) 1A1 1quinapril hcl (Accupril) 1A1 1quinapril/hydrochlorothiazide (Accuretic) 1A1 1ramipril (Altace) 1A1 1trandolapril (Mavik) 1A1 1amlodipine besylate/benazepril (Lotrel 5/40,10/40mg) 1B1 1perindopril erbumine (Aceon) 1B3 3Tarka 3




2D. Angiotensin II Receptor Blockers and Combinations

Drug

BCBSM BCN

1 1candesartan/hydrochlorothiazid (Atacand HCT) 1A1 1eprosartan mesylate (Teveten) 1A1 1losartan potassium (Cozaar) 1A1 1losartan/hydrochlorothiazide (Hyzaar) 1A1 1valsartan/hydrochlorothiazide (Diovan HCT) 1A1 1candesartan cilexetil (Atacand) 1B1 1irbesartan (Avapro) 1B1 1irbesartan/hydrochlorothiazide (Avalide) 1B2 2 Benicar 22 2 Benicar HCT 23 3Azor 33 3 Diovan 33 3 Edarbi 33 3Edarbyclor 33 3Exforge 33 3Exforge HCT 33 3 Micardis 33 3 Micardis HCT 33 3Teveten 400mg 33 3 Teveten HCT 33 3Tribenzor 33 3Twynsta 3


2E. Calcium Channel Blockers and Combinations

Drug

BCBSM BCN

1 1amlodipine besylate (Norvasc) 1A1 1amlodipine besylate/benazepril (Lotrel) 1A1 1amlodipine besylate/benazepril (Lotrel 5/40,10/40mg) 1B1 1amlodipine/atorvastatin (Caduet) 1B1 1diltiazem hcl (Cardizem CD) 1B1 1diltiazem hcl (Cardizem LA) 1B1 1diltiazem hcl (Cardizem, SR, CD) 1B1 1diltiazem hcl (Tiazac) 1B1 1felodipine (Plendil) 1B1 1isradipine (Dynacirc) 1B1 1nicardipine hcl (Cardene) 1B1 1nifedipine (Procardia, XL;Adalat CC) 1B1 1nisoldipine (Sular) 1B1 1verapamil hcl (Calan SR/Isoptin SR) 1B1 1verapamil hcl (Verelan PM) 1B3 3Azor 33 3Cardene SR 33 3Cardizem LA 120mg 33 3Dynacirc CR 33 3Exforge 33 3Exforge HCT 33 3Tarka 33 3Tekamlo 33 3Tribenzor 33 3Twynsta 3




2F. Diuretics

Drug

BCBSM BCN

1 1amiloride hcl (Midamor) 1A1 1amiloride/hydrochlorothiazide (Moduretic) 1A1 1bumetanide (Bumex) 1A1 1chlorothiazide (Diuril) 1A1 1chlorthalidone (Hygroton, Thalitone) 1A1 1eplerenone (Inspra) 1A1 1furosemide (Lasix) 1A1 1hydrochlorothiazide (Hydrodiuril, Microzide) 1A1 1indapamide (Lozol) 1A1 1metolazone (Zaroxolyn) 1A1 1spironolact/hydrochlorothiazid (Aldactazide) 1A1 1spironolactone (Aldactone) 1A1 1torsemide (Demadex) 1A1 1triamterene/hydrochlorothiazid (Maxzide, Dyazide) 1A1 1acetazolamide (Diamox) 1B1 1acetazolamide (Diamox Sequels) 1B1 1furosemide (Lasix solution) 1B1 1methazolamide (Neptazane) 1B1 1methyclothiazide (Enduron) 1B2 2Dyrenium 22 2Edecrin 23 3Aldactazide 50/50mg 33 3Diuril susp 33 3Dutoprol 33 3Edarbyclor 3


2G. Cardiovascular Treatment

Drug

BCBSM BCN

1 1digoxin (Digoxin) 11 1sotalol hcl (Betapace, AF) 1A1 1amiodarone hcl (Cordarone) 1B1 1digoxin (Digoxin elixir) 1B1 1disopyramide phosphate (Norpace) 1B1 1flecainide acetate (Tambocor) 1B1 1mexiletine hcl (Mexitil) 1B1 1midodrine hcl (Proamatine) 1B1 1propafenone hcl (Rythmol) 1B1 1propafenone hcl (Rythmol SR) 1B1 1quinidine gluconate (Quinidine Gluconate) 1B1 1quinidine sulfate (Quinidex) 1B2 2Multaq 22 2Norpace CR 22 2Tikosyn 23 3Ranexa 3




2H. Nitrates and Combinations

Drug

BCBSM BCN

1 1isosorbide dinitrate (Isordil) 1B1 1isosorbide mononitrate (Ismo, Monoket) 1B1 1nitroglycerin (Nitro-Bid ointment) 1B1 1nitroglycerin (Nitroglycerin Patch) 1B1 1nitroglycerin (Nitroglycerin SA cap) 1B1 1nitroglycerin (Nitroglycerin spray) 1B2 2Bidil 22 2Dilatrate-Sr 23 3Isordil 40mg 33 3Minitran 33 3Nitro-Dur 33 3Nitromist 3


2I. Anticoagulants and Hemostasis Agents

Drug

BCBSM BCN

1 1clopidogrel bisulfate (Plavix) 1A1 1warfarin sodium (Coumadin) 1A1 1aminocaproic acid (Amicar) 1B1 1anagrelide hcl (Agrylin) 1B1 1cilostazol (Pletal) 1B1 1dipyridamole (Persantine) 1B1 1pentoxifylline (Trental) 1B1 1phytonadione (Vitamin K) 1B1 1ticlopidine hcl (Ticlid) 1B2 2Brilinta 22 2Effient 22 2Mephyton 22 2Pradaxa 22 2Xarelto 23 3Aggrenox 3

<s> 1 4enoxaparin sodium (Lovenox) 4<s> 1 4fondaparinux sodium (Arixtra) 4<s> 1 4heparin sodium;porcine (Heparin) 4<s> 3 5Fragmin 5<s> 3 5Innohep 5<s> 3 5Iprivask 5


2J. Alpha-adrenergic Agents

Drug

BCBSM BCN

1 1clonidine (Catapres-TTS) 1B1 1clonidine hcl (Catapres) 1B1 1clonidine hcl/chlorthalidone (Clorpres) 1B1 1doxazosin mesylate (Cardura) 1B1 1guanfacine hcl (Tenex) 1B1 1methyldopa (Aldomet) 1B1 1methyldopa/hydrochlorothiazide (Aldoril) 1B1 1prazosin hcl (Minipress) 1B1 1reserpine (Reserpine) 1B1 1terazosin hcl (Hytrin) 1B2 2Dibenzyline 23 3Clorpres 0.3-15mg 3




2K. Miscellaneous Antihypertensives

Drug

BCBSM BCN

1 1ergoloid mesylates (Ergoloid Mesylates) 1B1 1hydralazine hcl (Apresoline) 1B1 1isoxsuprine hcl (Vasodilan) 1B1 1minoxidil (Loniten) 1B1 1papaverine hcl (Papaverine caps) 1B3 3Amturnide 33 3Demser 33 3Tekamlo 33 3 Tekturna 33 3Tekturna HCT 3



3. CENTRAL NERVOUS SYSTEM


3A. Antidepressants

Drug

BCBSM BCN

1 1amitriptyline hcl (Elavil) 1A1 1bupropion hcl (Wellbutrin XL) 1A1 1bupropion hcl (Wellbutrin, SR) 1A1 1citalopram hydrobromide (Celexa) 1A1 1clomipramine hcl (Anafranil) 1A1 1desipramine hcl (Norpramin) 1A1 1doxepin hcl (Sinequan, Adapin) 1A1 1fluoxetine hcl (Prozac, Sarafem) 1A1 1fluvoxamine maleate (Luvox) 1A1 1imipramine hcl (Tofranil) 1A1 1maprotiline hcl (Maprotiline hcl) 1A1 1mirtazapine (Remeron, Soltab) 1A1 1nortriptyline hcl (Pamelor, Aventyl) 1A1 1paroxetine hcl (Paxil) 1A1 1sertraline hcl (Zoloft) 1A1 1trazodone hcl (Desyrel) 1A1 1venlafaxine hcl (Effexor) 1A1 1venlafaxine hcl (Effexor XR) 1A1 1amitrip hcl/chlordiazepoxide (Limbitrol, DS) 1B1 1amoxapine (Asendin) 1B1 1bupropion hcl (Wellbutrin XL 300mg) 1B1 1escitalopram oxalate (Lexapro) 1B1 1imipramine pamoate (Tofranil-PM) 1B1 1nefazodone hcl (Serzone) 1B1 1paroxetine hcl (Paxil CR) 1B1 1perphenazine/amitriptyline hcl (Etrafon) 1B1 1phenelzine sulfate (Nardil) 1B1 1protriptyline hcl (Vivactil) 1B1 1tranylcypromine sulfate (Parnate) 1B1 1trimipramine maleate (Surmontil) 1B3 3 Aplenzin 33 3 Cymbalta 33 3 Desvenlafaxine ER 33 3Emsam 33 3Marplan 33 3Paxil susp 33 3 Pexeva 33 3 Pristiq 33 3Sarafem tablet 33 3 Viibryd 3


PREVN - Prevent drugs may be covered at $0 if criteria are met



3B. Antipsychotics

Drug

BCBSM BCN

1 1chlorpromazine hcl (Thorazine) 1A1 1clozapine (Clozaril) 1A1 1fluphenazine hcl (Prolixin) 1A1 1haloperidol (Haldol) 1A1 1risperidone (Risperdal) 1A1 1risperidone (Risperdal M-Tab) 1A1 1thioridazine hcl (Mellaril) 1A1 1trifluoperazine hcl (Stelazine) 1A1 1clozapine (Clozapine) 1B1 1clozapine (Fazaclo 25, 100mg) 1B1 1haloperidol lactate (Haldol liquid) 1B1 1loxapine succinate (Loxitane) 1B1 1olanzapine (Zyprexa, Zydis) 1B1 1olanzapine/fluoxetine hcl (Symbyax) 1B1 1perphenazine (Perphenazine) 1B1 1quetiapine fumarate (Seroquel) 1B1 1thiothixene (Navane) 1B1 1ziprasidone hcl (Geodon) 1B2 2 Abilify 22 2Orap 23 3 Abilify Discmelt, solution 33 3 Fanapt 33 3Fazaclo 33 3 Invega 33 3 Latuda 33 3 Saphris 3


3C. Anxiolytics

Drug

BCBSM BCN

1 1alprazolam (Niravam) 1B1 1alprazolam (Xanax Intensol) 1B1 1alprazolam (Xanax, XR) 1B1 1buspirone hcl (Buspar) 1B1 1chlordiazepoxide hcl (Librium) 1B1 1clorazepate dipotassium (Tranxene) 1B1 1diazepam (Valium) 1B1 1lorazepam (Ativan) 1B1 1lorazepam (Ativan Intensol) 1B1 1meprobamate (Miltown, Equanil) 1B1 1oxazepam (Serax) 1B





3D. Sedative/Hypnotics

Drug

BCBSM BCN

1 1chloral hydrate (Chloral Hydrate) 1B1 1estazolam (Prosom) 1B1 1flurazepam hcl (Dalmane) 1B1 1midazolam hcl (Versed) 1B1 1temazepam (Restoril) 1B1 1triazolam (Halcion) 1B1 1zaleplon (Sonata) 1B1 1zolpidem tartrate (Ambien) 1B1 1 zolpidem tartrate (Ambien CR) 1B3 3 Lunesta 33 3 Rozerem 3


3E. CNS Stimulants

Drug

BCBSM BCN

1 1amphet asp/amphet/d-amphet (Adderall) 1B1 1amphet asp/amphet/d-amphet (Adderall XR) 1B1 1dexmethylphenidate hcl (Focalin) 1B1 1dextroamphetamine sulfate (Dexedrine) 1B1 1dextroamphetamine sulfate (Procentra) 1B1 1methamphetamine hcl (Desoxyn) 1B1 1methylphenidate hcl (Metadate CD) 1B1 1methylphenidate hcl (Methylin solution) 1B1 1methylphenidate hcl (Ritalin LA) 1B1 1methylphenidate hcl (Ritalin, SR; Methylin, ER) 1B1 1modafinil (Provigil) 1B3 3Daytrana 33 3 Nuvigil 33 3Strattera 33 3Zenzedi 3





3F. Nonsteroidal Anti-inflammatory Drugs

Drug

BCBSM BCN

1 1naproxen (Naprosyn) 1A1 1diclofenac potassium (Cataflam) 1B1 1diclofenac sodium (Voltaren-XR) 1B1 1etodolac (Lodine) 1B1 1fenoprofen calcium (Nalfon) 1B1 1flurbiprofen (Ansaid) 1B1 1ibuprofen (Motrin) 1B1 1indomethacin (Indocin, SR) 1B1 1ketoprofen (Ketoprofen) 1B1 1ketorolac tromethamine (Toradol) 1B1 1meclofenamate sodium (Meclomen) 1B1 1meloxicam (Mobic) 1B1 1nabumetone (Relafen) 1B1 1naproxen (EC-Naprosyn) 1B1 1naproxen sodium (Anaprox, DS) 1B1 1oxaprozin (Daypro) 1B1 1piroxicam (Feldene) 1B1 1sulindac (Clinoril) 1B1 1tolmetin sodium (Tolectin, DS) 1B2 2Indocin Suppository 23 3Nalfon 400mg 3


3G. Salicylates

Drug

BCBSM BCN

PREVN 1 1aspirin (Aspirin) 01 1choline sal/mag salicylate (Trilisate) 1B1 1diflunisal (Dolobid) 1B1 1sal-amide/acetaminophn/p-tlox (Anabar) 1B1 1salsalate (Disalcid, Salflex) 1B3 3Frenadol 3


3H. Narcotics

Drug

BCBSM BCN

1 1codeine sulfate (Codeine Sulfate) 1B1 1fentanyl (Duragesic) 1B1 1 fentanyl citrate (Actiq) 1B1 1hydromorphone hcl (Dilaudid) 1B1 1levorphanol tartrate (n/a) 1B1 1meperidine hcl (Demerol) 1B1 1methadone hcl (Methadone) 1B1 1morphine sulfate (MS Contin/Oramorph SR) 1B1 1morphine sulfate (MSIR) 1B1 1nalbuphine hcl (Nubain) 1B3 3Embeda 33 3 Exalgo 33 3 Nucynta 33 3 Nucynta ER 33 3 Oxycontin 3





3I. Narcotic/Analgesic Combinations

Drug

BCBSM BCN

1 1acetaminophen with codeine (Tylenol w/codeine) 1B1 1butalb/acetaminophen/caffeine (Fioricet;Esgic, Plus) 1B1 1butalbit/acetamin/caff/codeine (Fioricet w/codeine) 1B1 1butalbital/acetaminophen (Phrenilin) 1B1 1butalbital/aspirin/caffeine (Fiorinal) 1B1 1codeine/butalbital/asa/caffein (Fiorinal w/codeine) 1B1 1hydrocodone bit/acetaminophen (Norco) 1B1 1hydrocodone bit/acetaminophen (Xodol) 1B1 1hydrocodone/ibuprofen (Ibudone) 1B1 1hydrocodone/ibuprofen (Vicoprofen) 1B1 1oxycodone hcl/acetaminophen (Percocet) 1B1 1oxycodone hcl/aspirin (Percodan) 1B3 3Capital w/codeine 33 3Hycodan 33 3Ibudone 5/200mg 33 3Orbivan 33 3Synalgos-DC 3


3J. Narcotic Mixed Agonist/Antagonist

Drug

BCBSM BCN

1 1buprenorphine hcl/naloxone hcl (Suboxone) 1B1 1butorphanol tartrate (Stadol NS) 1B1 1pentazocine hcl/naloxone hcl (Talwin NX) 1B1 1tramadol hcl (Ryzolt) 1B1 1tramadol hcl (Ultram) 1B1 1tramadol hcl (Ultram ER) 1B1 1tramadol hcl/acetaminophen (Ultracet) 1B2 2Suboxone Film 23 3 Zubsolv 33 3Zubsolv 3


3K. Narcotic Antagonists

Drug

BCBSM BCN

1 1naltrexone hcl (Revia) 1B2 2 Relistor 2





3M. Migraine Therapy

Drug

BCBSM BCN

1 1butalb/acetaminophen/caffeine (Fioricet;Esgic, Plus) 1B1 1butalbital/acetaminophen (Phrenilin) 1B1 1butalbital/aspirin/caffeine (Fiorinal) 1B1 1butorphanol tartrate (Stadol NS) 1B1 1codeine/butalbital/asa/caffein (Fiorinal w/codeine) 1B1 1dihydroergotamine mesylate (D.H.E.45) 1B1 1dihydroergotamine mesylate (Migranal) 1B1 1ergotamine tartrate/caffeine (Cafergot) 1B1 1isomethept/acetaminop/dichlphn (Midrin) 1B1 1naratriptan hcl (Amerge) 1B1 1rizatriptan benzoate (Maxalt, MLT) 1B1 1sumatriptan (Imitrex nasal spray) 1B1 1sumatriptan succinate (Imitrex injection) 1B1 1sumatriptan succinate (Imitrex tablets) 1B1 1 zolmitriptan (Zomig, ZMT) 1B2 2Ergomar 23 3 Axert 33 3 Frova 33 3Orbivan 33 3 Relpax 33 3 Zomig nasal spray 3


3O. Parkinsons Disease and Related Disorders

Drug

BCBSM BCN

1 1amantadine hcl (Symmetrel) 1B1 1benztropine mesylate (Cogentin) 1B1 1bromocriptine mesylate (Parlodel) 1B1 1cabergoline (Dostinex) 1B1 1carbidopa/levodopa (Sinemet, CR) 1B1 1carbidopa/levodopa/entacapone (Stalevo) 1B1 1entacapone (Comtan) 1B1 1pramipexole di-hcl (Mirapex) 1B1 1ropinirole hcl (Requip) 1B1 1ropinirole hcl (Requip XL) 1B1 1selegiline hcl (Eldepryl) 1B1 1trihexyphenidyl hcl (Artane) 1B2 2Azilect 23 3Lodosyn 33 3 Neupro 33 3Tasmar 33 3Zelapar 3

<s> 2 4Apokyn 4





3P. Anticonvulsants

Drug

BCBSM BCN

1 1acetazolamide (Diamox) 1B1 1carbamazepine (Carbatrol) 1B1 1carbamazepine (Tegretol) 1B1 1carbamazepine (Tegretol XR) 1B1 1clonazepam (Klonopin, Wafer) 1B1 1divalproex sodium (Depakote) 1B1 1divalproex sodium (Depakote ER) 1B1 1ethosuximide (Zarontin) 1B1 1felbamate (Felbatol) 1B1 1gabapentin (Neurontin) 1B1 1lamotrigine (Lamictal tabs) 1B1 1lamotrigine (Lamictal XR) 1B1 1levetiracetam (Keppra) 1B1 1oxcarbazepine (Trileptal) 1B1 1phenobarbital (Phenobarbital) 1B1 1phenytoin (Dilantin chew tabs) 1B1 1phenytoin sodium extended (Dilantin) 1B1 1primidone (Mysoline) 1B1 1secobarbital sodium (Seconal) 1B1 1tiagabine hcl (Gabitril 2, 4mg) 1B1 1topiramate (Topamax) 1B1 1valproate sodium (Depakene) 1B1 1zonisamide (Zonegran) 1B2 2Banzel 22 2Dilantin 30mg 22 2Gabitril 22 2Lamictal Dosepak 22 2Peganone 22 2Tegretol XR 100mg 22 2Vimpat 23 3Banzel susp 33 3Celontin 33 3Equetro 33 3Lamictal ODT 33 3 Lyrica 33 3 Onfi 33 3Potiga 33 3Stavzor 3

<s> 2 4Sabril 4





3Q. Skeletal Muscle Relaxants

Drug

BCBSM BCN

1 1baclofen (Lioresal) 1B1 1carisoprodol (Soma) 1B1 1chlorzoxazone (Paraflex, Parafon Forte DSC) 1B1 1cyclobenzaprine hcl (Flexeril) 1B1 1dantrolene sodium (Dantrium) 1B1 1diazepam (Valium) 1B1 1metaxalone (Skelaxin) 1B1 1methocarbamol (Robaxin) 1B1 1orphenadrine citrate (Norflex) 1B1 1orphenadrine/aspirin/caffeine (Norgesic, Forte) 1B1 1tizanidine hcl (Zanaflex tabs) 1B3 3Lorzone 3


3R. Myesthenia Gravis

Drug

BCBSM BCN

1 1pyridostigmine bromide (Mestinon) 1B2 2Mestinon Timespan, syrup 22 2Prostigmin 23 3Mytelase 3


3S. Miscellaneous CNS

Drug

BCBSM BCN

1 1donepezil hcl (Aricept, ODT) 1B1 1galantamine hbr (Razadyne solution) 1B1 1lithium carbonate (Eskalith CR) 1B1 1lithium citrate (Lithium Citrate) 1B1 1nimodipine (Nimotop) 1B1 1riluzole (Rilutek) 1B1 1rivastigmine tartrate (Exelon caps) 1B2 2Exelon patch, solution 22 2Namenda, solution 22 2 Nuedexta 22 2Rilutek 23 3 Kapvay 33 3Nymalize 33 3 Savella 33 3 Xyrem 3




4. GASTROINTESTINAL AGENTS


4A. H2-Receptor Antagonists

Drug

BCBSM BCN

1 1cimetidine (Tagamet [RX Only]) 1B1 1famotidine (Pepcid [RX Only]) 1B1 1nizatidine (Axid [RX Only]) 1B1 1ranitidine hcl (Zantac [RX Only]) 1B3 3Zantac Efferdose 3


4B. Proton Pump Inhibitors

Drug

BCBSM BCN

1 1lansoprazole (Prevacid) 1B1 1omeprazole (Prilosec) 1B1 1pantoprazole sodium (Protonix) 1B


4C. Other Ulcer Therapy

Drug

BCBSM BCN

1 1misoprostol (Cytotec) 1B1 1sucralfate (Carafate, susp) 1B3 3Pylera 3


4D. Antidiarrheals and Antispasmodics

Drug

BCBSM BCN

1 1chlordiazepoxide/clidinium br (Librax) 1B1 1dicyclomine hcl (Bentyl) 1B1 1diphenoxylate hcl/atropine (Lomotil) 1B1 1glycopyrrolate (Robinul, Forte) 1B1 1hyosc sul/phenyltoloxamine cit (Digex NF) 1B1 1hyoscyamine sulfate (Levbid) 1B1 1hyoscyamine sulfate (Levsin, SL) 1B1 1methscopolamine bromide (Pamine, Forte) 1B1 1paregoric (Paregoric) 1B1 1phenobarb/hyoscy/atropine/scop (Donnatal) 1B1 1propantheline bromide (Pro-Banthine 15mg) 1B3 3Cantil 33 3Cuvposa 33 3Digex NF 33 3Symax Duotab 3




4E. Antiemetics

Drug

BCBSM BCN

1 1dronabinol (Marinol) 1B1 1granisetron hcl (Kytril) 1B1 1ondansetron (Zofran, ODT) 1B1 1prochlorperazine maleate (Compazine) 1B1 1promethazine hcl (Phenergan) 1B1 1trimethobenzamide hcl (Tigan) 1B2 2Emend 80,125mg capsules 22 2Transderm-Scop 23 3Anzemet 33 3Cesamet 33 3 Sancuso 3


4F. Bile Acids

Drug

BCBSM BCN

1 1ursodiol (Urso) 1B3 3 Chenodal 3


4G. Digestive Enzymes

Drug

BCBSM BCN

1 1lipase/protease/amylase (Pancrelipase) 1B2 2Creon 22 2Pancreaze 22 2Viokace 22 2Viokase 22 2Zenpep 23 3Pertzye 3




4H. Miscellaneous Gastrointestinal Agents

Drug

BCBSM BCN

1 1balsalazide disodium (Colazal) 1B1 1cromolyn sodium (Gastrocrom) 1B1 1hydrocortisone (Cortenema) 1B1 1hydrocortisone ac/lidocaine (Anamantle HC) 1B1 1hydrocortisone acetate (Proctocort Suppository) 1B1 1hydrocortisone/pramoxine (Pramosone cream) 1B1 1lactulose (Lactulose) 1B1 1mesalamine (Rowasa Enema) 1B1 1metoclopramide hcl (Reglan tab, solution) 1B1 1sulfasalazine (Azulfidine EN-Tab) 1B1 1sulfasalazine (Azulfidine tab) 1B2 2Analpram HC Lotion 22 2Asacol HD 22 2Canasa 22 2Cortifoam 22 2Pentasa 22 2Proctofoam-HC 22 2 Relistor 23 3 Amitiza 33 3Apriso 33 3Dipentum 33 3Epifoam 33 3 Giazo 33 3Kristalose 33 3Lialda 33 3 Linzess 33 3 Lotronex 33 3Pramosone 33 3Rectiv 33 3Sucraid 33 3Xifaxan 550mg 3

<s> 3 5 Cimzia syringe 5



5. OBSTETRICS AND GYNECOLOGY


5A. Contraceptives-Monophasic

Drug

BCBSM BCN

PREVN 1 1desogestrel-ethinyl estradiol (Desogen, Ortho-Cept) 0PREVN 1 1ethinyl estradiol/drospirenone (Yasmin) 0PREVN 1 1ethinyl estradiol/drospirenone (Yaz) 0PREVN 1 1ethynodiol d-ethinyl estradiol (Demulen) 0PREVN 1 1levonorgestrel-eth estradiol (Alesse, Levlite) 0PREVN 1 1levonorgestrel-eth estradiol (Lybrel) 0PREVN 1 1levonorgestrel-eth estradiol (Nordette, Levlen) 0PREVN 1 1levonorgestrel-eth estradiol (Seasonale) 0PREVN 1 1noreth-ethinyl estradiol/iron (Femcon Fe) 0PREVN 1 1norethindrone a-e estradiol (Loestrin, Fe) 0PREVN 1 1norethindrone-ethinyl estrad (Modicon) 0PREVN 1 1norethindrone-ethinyl estrad (Ovcon 35) 0PREVN 1 1norethindrone-mestranol (Norinyl 1/35, Ortho-Novum 1/35) 0PREVN 1 1norgestimate-ethinyl estradiol (Ortho-Cyclen) 0PREVN 1 1norgestrel-ethinyl estradiol (Lo/Ovral) 0PREVN 1 1norgestrel-ethinyl estradiol (Ovral) 0

3 3Generess Fe 33 3Lo Minastrin Fe 33 3Lo Minastrin Fe 33 3Loestrin 24 Fe 33 3Minastrin 24 Fe 33 3Natazia 33 3Ovcon-50, Fe 3


5B. Contraceptives-Biphasic

Drug

BCBSM BCN

PREVN 1 1desog-et estra/ethin estra (Mircette) 0PREVN 1 1l-norgest-eth estr/ethin estra (Loseasonique) 0PREVN 1 1l-norgest-eth estr/ethin estra (Seasonique) 0PREVN 1 1norethindrone-ethinyl estrad (Necon 10/11) 0

3 3Lo Loestrin Fe 3


5C. Contraceptives-Triphasic

Drug

BCBSM BCN

PREVN 1 1desogestrel-ethinyl estradiol (Cyclessa) 0PREVN 1 1levonorgestrel-eth estradiol (Triphasil, Trilevlen) 0PREVN 1 1noreth a-et estra/fe fumarate (Estrostep Fe) 0PREVN 1 1norethindrone-ethinyl estrad (Ortho-Novum 7/7/7) 0PREVN 1 1norethindrone-ethinyl estrad (Tri-Norinyl) 0PREVN 1 1norgestimate-ethinyl estradiol (Ortho Tri-Cyclen) 0

2 2Ortho Tri-Cyclen Lo 2





5D. Contraceptives-Misc.

Drug

BCBSM BCN

PREVN 1 1condoms, female (FC Condom, Female) 0PREVN 1 1nonoxynol 9 (Today Contraceptive Sponge) 0PREVN 1 1nonoxynol 9 (VCF) 0PREVN 1 1norethindrone (Ortho Micronor, Nor-QD) 0PREVN 2 2Ortho Evra 2

3 3Beyaz 3PREVN 3 3 Nuvaring 3

3 3Quartette 33 3Safyral 3


5E. Contraceptives-Postcoital

Drug

BCBSM BCN

PREVN 1 1levonorgestrel (Plan B) 0PREVN 1 1levonorgestrel (Plan B One-Step) 0

3 3Ella 3


5F. Progestins

Drug

BCBSM BCN

PREVN 1 1medroxyprogesterone acetate (Depo-Provera 150mg) 01 1medroxyprogesterone acetate (Provera) 1B1 1norethindrone acetate (Aygestin) 1B1 1progesterone (Progesterone in oil [inj]) 1B1 1progesterone;micronized (Prometrium) 1B2 2Depo-subQ Provera 104 2


5G. Estrogens

Drug

BCBSM BCN

1 1estradiol (Estrace) 1B1 1estradiol valerate (Delestrogen) 1B1 1estropipate (Ogen, Ortho-EST) 1B2 2Alora 22 2Enjuvia 22 2Estring 22 2Minivelle 22 2Premarin cream 22 2Premarin, Premarin Low Dose 22 2Vagifem 22 2Vivelle-Dot 23 3Cenestin 33 3Divigel 33 3Elestrin 33 3Estrace Vaginal cream 33 3Estrasorb 33 3Estrogel 33 3Evamist 33 3Femring 33 3Femtrace 33 3Menest 33 3Menostar 33 3Minivelle 3





5H. Estrogen/Progestin Combinations

Drug

BCBSM BCN

1 1estradiol/noreth ac (Activella) 1B1 1estrogen;ester/me-testosterone (Estratest, H.S.) 1B1 1norethind ac/ethinyl estradiol (FemHRT) 1B2 2FemHRT 0.5mg-2.5mcg 22 2Prempro, Low Dose/Premphase 23 3Climara Pro 33 3Combipatch 33 3Ortho-Prefest 3


5J. Infertility Treatment

Drug

BCBSM BCN

1 1 clomiphene citrate (Clomid) 1B<s> 1 4 chorionic gonadotropin; human (Novarel, Pregnyl, Profasi) 4<s> 1 4leuprolide acetate (Lupron) 4<s> 2 4 Gonal-F, RFF 4<s> 2 4 Ovidrel 4<s> 3 5 Follistim AQ 5


5K. Vaginal Anti-infective/Antifungal

Drug

BCBSM BCN

1 1clindamycin phosphate (Cleocin Vaginal cream) 1B1 1metronidazole (Metrogel-Vaginal) 1B1 1miconazole nitrate (Monostat-3) 1B1 1nystatin (Nystatin) 1B1 1terconazole (Terazol-3, 7) 1B3 3AVC 33 3Cleocin Vaginal ovules 33 3Clindesse 33 3Gynazole-1 3


5L. Miscellaneous OB-GYN

Drug

BCBSM BCN

1 1methylergonovine maleate (Methergine) 1B1 1tranexamic acid (Lysteda) 1B2 2Synarel 2

<s> 2 4Lupron Depot 4




6. RHEUMATOLOGY AND MUSCULOSKELETAL


6A. Salicylates

Drug

BCBSM BCN

1 1see chapters 3f & 3g (SALICYLATES AND NSAIDS) 1B


6B. Gout Therapy

Drug

BCBSM BCN

1 1allopurinol (Zyloprim) 1B1 1probenecid (Probenecid) 1B2 2Colcrys 22 2 Uloric 2


6C. Corticosteroids

Drug

BCBSM BCN

1 1see chapter 7c (CORTICOSTEROIDS) 1B


6D. Miscellaneous Rheumatologic Agents

Drug

BCBSM BCN

1 1azathioprine (Imuran) 1B1 1colchicine/probenecid (Colbenemid) 1B1 1hydroxychloroquine sulfate (Plaquenil) 1B1 1leflunomide (Arava) 1B1 1methotrexate sodium (Methotrexate) 1B1 1sulfasalazine (Azulfidine EN-Tab) 1B1 1sulfasalazine (Azulfidine tab) 1B2 2Cuprimine 22 2Ridaura 22 2Trexall 23 3Depen 33 3Rheumatrex 3

<s> 2 4 Enbrel 4<s> 2 4 Humira 4<s> 3 5 Cimzia syringe 5<s> 3 5 Kineret 5<s> 3 5 Orencia sub-q 5<s> 3 5 Simponi 5<s> 3 5 Xeljanz 5<s> 5 5 Simponi subq 5




6E. Osteoporosis/Hormonal Treatment

Drug

BCBSM BCN

1 1estradiol (Estrace) 1B1 1estrogen;ester/me-testosterone (Estratest, H.S.) 1B1 1estropipate (Ogen, Ortho-EST) 1B1 1norethind ac/ethinyl estradiol (FemHRT) 1B2 2Alora 22 2Enjuvia 22 2FemHRT 0.5mg-2.5mcg 22 2Premarin cream 22 2Premarin, Premarin Low Dose 22 2Prempro, Low Dose/Premphase 22 2Vivelle-Dot 23 3Cenestin 33 3Menest 33 3Minivelle 3

<s> 3 5 Forteo 5


6F. Osteoporosis/Bone Resorption

Drug

BCBSM BCN

1 1alendronate sodium (Fosamax) 1A1 1calcitonin;salmon;synthetic (Miacalcin nasal spray) 1B1 1etidronate disodium (Didronel) 1B1 1ibandronate sodium (Boniva) 1B2 2 Actonel, Weekly, 150mg 22 2Evista 22 2Miacalcin injection 23 3 Atelvia 33 3Skelid 3



7. ENDOCRINOLOGY


7A. Antithyroid Agents

Drug

BCBSM BCN

1 1methimazole (Tapazole) 1B1 1potassium iodide/iodine (Strong Iodine) 1B1 1propylthiouracil (Propylthiouracil) 1B3 3SSKI 3


7B. Thyroid Hormones

Drug

BCBSM BCN

1 1levothyroxine sodium (Levothyroxine) 1A1 1liothyronine sodium (Cytomel) 1B1 1thyroid,pork (Westhroid-p) 1B1 1thyroid;pork (Nature-Throid) 1B1 1thyroid;pork (NP Thyroid) 1B1 1thyroid;pork (Westhroid) 1B2 2Thyrolar 23 3Tirosint 3


7C. Corticosteroids

Drug

BCBSM BCN

1 1prednisone (Prednisone) 1A1 1budesonide (Entocort EC) 1B1 1cortisone acetate (Cortisone Acetate) 1B1 1dexamethasone (Decadron) 1B1 1fludrocortisone acetate (Florinef) 1B1 1hydrocortisone (Cortef, Hydrocortisone) 1B1 1methylprednisolone (Medrol, Dosepak) 1B1 1prednisolone (Prednisolone, tabs, syrup) 1B1 1prednisolone sod phosphate (Orapred) 1B1 1prednisolone sod phosphate (Prednisolone Sodium Phosphate) 1B3 3Celestone 33 3Dexpak 33 3Flo-Pred, Millipred 33 3Medrol 3


7D. Androgens

Drug

BCBSM BCN

1 1danazol (Danocrine) 1B1 1fluoxymesterone (Androxy 10mg) 1B1 1 oxandrolone (Oxandrin) 1B2 2 Androderm 22 2 Androgel, 1.62% 23 3 Anadrol-50 33 3Methitest 33 3Testred, Android 3




7E. Miscellaneous Endocrine

Drug

BCBSM BCN

1 1cabergoline (Dostinex) 1B1 1calcitonin;salmon;synthetic (Miacalcin nasal spray) 1B1 1calcitriol (Rocaltrol) 1B1 1desmopressin (nonrefrigerated) (DDAVP spray) 1B1 1desmopressin acetate (DDAVP solution) 1B1 1desmopressin acetate (DDAVP tabs) 1B1 1ergocalciferol (vitamin d2) (Calciferol) 1B1 1finasteride (Proscar) 1B2 2Glucagon, Emergency Kit 22 2Miacalcin injection 22 2Stimate 22 2Synarel 23 3DDAVP solution 33 3Glucagen Vial 33 3Hectorol 33 3Proglycem 33 3Zemplar 3

<s> 1 4 octreotide acetate (Sandostatin) 4<s> 2 4 Carbaglu 4<s> 2 4Cystagon 4<s> 2 4 Korlym 4<s> 2 4Lupron Depot-PED 4<s> 2 4 Sandostatin LAR 4<s> 2 4Sensipar 4<s> 2 4Somatuline Depot 4<s> 2 4 Somavert 4


7F. Insulins

Drug

BCBSM BCN

2 2Apidra, Solostar 22 2Humalog, MIX 22 2Humulin 70/30 22 2Humulin N 22 2Humulin R 22 2Lantus, Solostar 22 2Levemir 22 2Novolin 70-30 22 2Novolin N 22 2Novolin R 22 2Novolog, MIX 2




7G. Non-insulin Hypoglycemic Agents

Drug

BCBSM BCN

1 1glimepiride (Amaryl) 1A1 1glipizide (Glucotrol) 1A1 1glipizide (Glucotrol XL) 1A1 1glipizide/metformin hcl (Metaglip) 1A1 1glyburide (Diabeta, Micronase) 1A1 1glyburide/metformin hcl (Glucovance) 1A1 1glyburide;micronized (Glynase) 1A1 1metformin hcl (Fortamet) 1A1 1metformin hcl (Glucophage) 1A1 1metformin hcl (Glucophage XR) 1A1 1acarbose (Precose) 1B1 1chlorpropamide (Diabinese) 1B1 1nateglinide (Starlix) 1B1 1pioglitazone hcl (Actos) 1B1 1pioglitazone hcl/metformin hcl (Actoplus MET) 1B1 1pioglitazone/glimepiride (Duetact) 1B1 1repaglinide (Prandin) 1B1 1tolazamide (Tolinase) 1B1 1tolbutamide (Orinase) 1B2 2Janumet 22 2Januvia 22 2Kombiglyze XR 22 2Onglyza 23 3Actoplus MET XR 33 3Avandamet 33 3Avandaryl 33 3Avandia 33 3 Byetta 33 3 Cycloset 33 3Glyset 33 3 Invokana 33 3Juvisync 33 3Prandimet 33 3Symlin 33 3 Tradjenta 33 3 Victoza 3


7H. Growth Hormone and Related Products

Drug

BCBSM BCN

<s> 2 4 Genotropin 4<s> 2 4 Nutropin AQ NuSpin 4<s> 2 4 Nutropin, AQ 4<s> 3 5 Humatrope 5<s> 3 5 Increlex 5<s> 3 5 Norditropin NordiFlex 5<s> 3 5 Omnitrope 5<s> 3 5 Saizen 5<s> 3 5 Serostim 5<s> 3 5 Tev-Tropin 5<s> 3 5 Zorbtive 5



8. ANTINEOPLASTICS AND IMMUNOSUPPRESANTS


8A. Alkylating Agents

Drug

BCBSM BCN

1 1cyclophosphamide (Cytoxan) 1B2 2Alkeran 22 2Ceenu 22 2Leukeran 22 2Myleran 2

<s> 2 4Temodar 4


8B. Antimetabolites

Drug

BCBSM BCN

1 1mercaptopurine (Purinethol) 1B1 1methotrexate sodium (Methotrexate) 1B2 2Thioguanine 2

<s> 2 4Oforta 4<s> 2 4Xeloda 4


8C. Immunomodulators

Drug

BCBSM BCN

1 1prednisone (Prednisone) 1A1 1azathioprine (Imuran) 1B

<s> 1 4cyclosporine; modified (Neoral) 4<s> 1 4mycophenolate mofetil (Cellcept) 4<s> 1 4tacrolimus (Prograf) 4<s> 2 4 Arcalyst 4<s> 2 4Cellcept suspension 4<s> 2 4Rapamune tabs, solution 4<s> 2 4Sandimmune 4<s> 2 4Thalomid 4<s> 3 5 Kineret 5<s> 3 5Myfortic 5<s> 3 5Neoral 5<s> 3 5Revlimid 5<s> 5 5 Pomalyst 5




8D. Hormonal Agents

Drug

BCBSM BCN

1 1 anastrozole (Arimidex) 1B1 1bicalutamide (Casodex) 1B1 1 exemestane (Aromasin) 1B1 1flutamide (Eulexin) 1B1 1 letrozole (Femara) 1B1 1megestrol acetate (Megace) 1B1 1tamoxifen citrate (Tamoxifen) 1B2 2Depo-Provera 400mg 22 2Fareston 22 2Nilandron 23 3Faslodex 33 3Megace ES 33 3Soltamox 3

<s> 1 4leuprolide acetate (Lupron) 4<s> 2 4Lupron Depot 4<s> 2 4Trelstar Depot, LA 4<s> 2 4 Xtandi 4<s> 2 4Zoladex 4<s> 2 4Zytiga 4<s> 3 5Eligard 5<s> 3 5Trelstar 5


8E. Miscellaneous Antineoplastic Agents

Drug

BCBSM BCN

1 1etoposide (Vepesid) 1B1 1hydroxyurea (Hydrea) 1B2 2Droxia 22 2Emcyt 22 2Hexalen 22 2Lysodren 22 2Matulane 2

<s> 1 4 octreotide acetate (Sandostatin) 4<s> 2 4Hycamtin 4<s> 2 4 Jakafi 4<s> 2 4 Sandostatin LAR 4<s> 2 4Zolinza 4<s> 3 5Sylatron 5<s> 3 5 Targretin oral 5


8F. Adjuvant Therapy

Drug

BCBSM BCN

1 1leucovorin calcium (Leucovorin) 1B2 2Mesnex tabs 2

<s> 2 4Leukine 4<s> 2 4Neupogen 4<s> 2 4 Procrit 4<s> 3 5 Aranesp 5<s> 3 5 Epogen 5<s> 3 5Neulasta 5




8G. Kinase Inhibitors and Molecular Target Inhibitors

Drug

BCBSM BCN

3 3Azasan 3<s> 2 4Afinitor, Disperz 4<s> 2 4 Bosulif 4<s> 2 4Caprelsa 4<s> 2 4 Erivedge 4<s> 2 4Gleevec 4<s> 2 4 Inlyta 4<s> 2 4Iressa 4<s> 2 4Mekinist 4<s> 2 4Nexavar 4<s> 2 4Sprycel 4<s> 2 4 Stivarga 4<s> 2 4Sutent 4<s> 2 4Tafinlar 4<s> 2 4Tarceva 4<s> 2 4Tasigna 4<s> 2 4Tykerb 4<s> 2 4Votrient 4<s> 2 4 Xalkori 4<s> 2 4 Zelboraf 4<s> 3 5Zortress 5



9. IMMUNOLOGY AND HEMATOLOGY


9A. Immunoglobulins

Drug

BCBSM BCN

<s> 3 5 GAMMAGARD S-D MB<s> 3 5 GAMUNEX MB<s> 3 5 GAMUNEX-C MB<s> 3 5 HIZENTRA MB


9B. Hematopoietic Agents

Drug

BCBSM BCN

<s> 2 4Leukine 4<s> 2 4Neumega 4<s> 2 4Neupogen 4<s> 2 4 Procrit 4<s> 2 4 Promacta 4<s> 3 5 Aranesp 5<s> 3 5 Epogen 5<s> 3 5Neulasta 5


9C. Interferons and MS Therapy

Drug

BCBSM BCN

2 2Alferon N 2<s> 1 4ribavirin (Rebetol) 4<s> 2 4Actimmune 4<s> 2 4Avonex 4<s> 2 4Copaxone 4<s> 2 4Infergen 4<s> 2 4Intron A 4<s> 2 4Pegasys, Proclick 4<s> 2 4Peg-Intron, Redipen 4<s> 2 4Rebif 4<s> 3 5 Ampyra 5<s> 3 5 Aubagio 5<s> 3 5 Betaseron 5<s> 3 5 Extavia 5<s> 3 5 Gilenya 5<s> 3 5 Tecfidera 5


MB - May be covered under medical benefit


10. DERMATOLOGY


10A. Very High Potency Corticosteriods

Drug

BCBSM BCN

1 1betamet diprop/prop gly (Diprolene ointment) 1B1 1clobetasol propionate (Temovate, Clobevate) 1B1 1diflorasone diacetate (Psorcon, Florone) 1B1 1halobetasol propionate (Ultravate) 1B3 3Clobex, spray 33 3Vanos 0.1% cream 3


10B. High Potency Corticosteroids

Drug

BCBSM BCN

1 1amcinonide (Cyclocort) 1B1 1betamet diprop/prop gly (Diprolene AF, gel, cream, lotion) 1B1 1betamethasone dipropionate (Diprosone, Maxivate) 1B1 1betamethasone valerate (Valisone cream, lotion, oint) 1B1 1diflorasone diacetate (Psorcon, Florone) 1B1 1fluocinonide (Lidex, E) 1B1 1triamcinolone acetonide (Aristocort, Kenalog 0.05% cream) 1B3 3Halog 3


10C. Medium Potency Corticosteroids

Drug

BCBSM BCN

1 1betamethasone valerate (Valisone cream, lotion, oint) 1B1 1clobetasol propionate (Clobex shampoo, lotion) 1B1 1fluocinolone acetonide (Synalar 0.025% cream, oint) 1B1 1fluticasone propionate (Cutivate) 1B1 1fluticasone propionate (Cutivate lotion) 1B1 1hc/mineral oil/petrolat;wht (Hydrocortisone) 1B1 1hydrocortisone acetate/aloe v (Nuzon) 1B1 1hydrocortisone butyrate (Locoid cream, oint, solution) 1B1 1hydrocortisone valerate (Westcort) 1B1 1mometasone furoate (Elocon) 1B1 1triamcinolone acetonide (Aristocort, Kenalog) 1B2 2Cloderm 22 2Cordran, tape, SP 23 3Kenalog 33 3Locoid Lipocream 33 3Pandel 3


10D. Low Potency Corticosteroids

Drug

BCBSM BCN

1 1alclometasone dipropionate (Aclovate) 1B1 1desonide (Desowen, Tridesilon) 1B1 1fluocinolone acetonide (Synalar cream, solution) 1B1 1hydrocortisone (Dermacort, Hytone [RX Only]) 1B2 2Capex shampoo 23 3Desonate 3




10E. Topical Anesthetics

Drug

BCBSM BCN

1 1lidocaine (Lidocaine) 1B1 1lidocaine hcl (Xylocaine viscous) 1B1 1lidocaine/prilocaine (Emla) 1B


10F. Acne Treatment

Drug

BCBSM BCN

1 1adapalene (Differin 0.1% cream, gel) 1B1 1clindamycin phos/benzoyl perox (Duac) 1B1 1erythromycin/benzoyl peroxide (Benzamycin) 1B1 1tretinoin (Retin-A) 1B2 2Tazorac 23 3Ziana Gel 3


10G. Topical Antibacterials

Drug

BCBSM BCN

1 1gentamicin sulfate (Gentamicin cream, oint) 1B1 1mupirocin (Bactroban ointment) 1B2 2Bactroban cream, nasal 23 3Centany 3


10H. Topical Antifungals

Drug

BCBSM BCN

1 1ciclopirox (Penlac) 1B1 1ciclopirox olamine (Loprox cream, lotion) 1B1 1clotrimazole (Lotrimin) 1B1 1clotrimazole/betamethasone dip (Lotrisone cream, lotion) 1B1 1econazole nitrate (Spectazole) 1B1 1ketoconazole (Extina) 1B1 1ketoconazole (Nizoral cream) 1B1 1nystatin (Mycostatin) 1B1 1nystatin/triamcin (Nystatin-triamcinolone) 1B3 3Ertaczo 33 3Exelderm solution, cream 33 3Naftin 33 3Oxistat 33 3Vusion 33 3Xolegel 3


10I. Topical Antivirals

Drug

BCBSM BCN

1 1acyclovir (Zovirax ointment) 1B3 3Denavir 33 3Xerese 3




10J. Wound and Burn Therapy

Drug

BCBSM BCN

2 2Santyl 23 3Regranex 3


10K. Antipsoriatic/Antiseborrheic

Drug

BCBSM BCN

1 1anthralin (Drithocreme HP) 1B1 1calcipotriene (Dovonex) 1B1 1selenium sulfide (Selsun [RX Only]) 1B2 2Dritho-Scalp 22 2Oxsoralen, Ultra 22 2Soriatane 23 3Taclonex, Scalp 33 3Vectical 33 3Zithranol-RR 3

<s> 2 4 Enbrel 4<s> 2 4 Humira 4


10L. Scabicides/Pediculicides

Drug

BCBSM BCN

1 1lindane (Lindane) 1B1 1malathion (Ovide) 1B1 1permethrin (Elimite) 1B1 1spinosad (Natroba) 1B2 2Eurax 23 3Eurax lotion 33 3Sklice 33 3Ulesfia 3


10M. Miscellaneous Dermatologicals

Drug

BCBSM BCN

1 1ammonium lactate (Lac-Hydrin) 1B1 1fluorouracil (Efudex) 1B1 1imiquimod (Aldara) 1B1 1lactic acid (Lactic Acid) 1B1 1podofilox (Condylox solution) 1B2 2Condylox gel 22 2Elidel 22 2Oxsoralen 22 2Panretin 22 2Phisohex 23 3Carac 33 3 Picato 33 3Protopic 33 3 Solaraze 33 3Veregen 33 3Zonalon, Prudoxin 33 3Zyclara 3

<s> 3 5Targretin gel 5



11. OPHTHALMOLOGY


11A. Ophthalmic Beta Blockers

Drug

BCBSM BCN

1 1betaxolol hcl (Betoptic solution) 1B1 1carteolol hcl (Ocupress) 1B1 1levobunolol hcl (Betagan) 1B1 1metipranolol (Optipranolol) 1B1 1timolol maleate (Timoptic) 1B2 2Betoptic S 2


11B. Other Glaucoma Agents

Drug

BCBSM BCN

1 1apraclonidine hcl (Iopidine drops) 1B1 1brimonidine tartrate (Alphagan, P) 1B1 1dorzolamide hcl (Trusopt) 1B1 1dorzolamide hcl/timolol maleat (Cosopt) 1B1 1latanoprost (Xalatan) 1B1 1pilocarpine hcl (Pilocar, Isopto-Carpine) 1B1 1travoprost (benzalkonium) (Travatan) 1B2 2Alphagan P 0.1% 22 2Azopt 22 2Isopto Carbachol 22 2Lumigan 22 2Phospholine Iodide 22 2Pilopine HS 22 2Travatan, Z 23 3Cosopt PF 33 3Iopidine Droperette 33 3Zioptan 3


11C. Cycloplegic Mydriatics

Drug

BCBSM BCN

1 1atropine sulfate (Isopto Atropine) 1B1 1cyclopentolate hcl (Cyclogyl) 1B1 1homatropine hbr (Isopto Homatropine 5%) 1B1 1tropicamide (Mydriacyl) 1B3 3Cyclogyl 33 3Cyclomydril 33 3Isopto Homatropine 2% 33 3Isopto Hyoscine 33 3Paremyd 3


11D. Ophthalmic Anti-inflammatory Agents

Drug

BCBSM BCN

1 1bromfenac sodium (Xibrom) 1B1 1diclofenac sodium (Voltaren) 1B1 1flurbiprofen sodium (Ocufen) 1B1 1ketorolac tromethamine (Acular, LS) 1B3 3Nevanac 3




11E. Ophthalmic Anti-infectives

Drug

BCBSM BCN

1 1bacitracin (Bacitracin) 1B1 1bacitracin/polymyxin b sulfate (Polysporin) 1B1 1ciprofloxacin hcl (Ciloxan drops) 1B1 1erythromycin base (Ilotycin) 1B1 1gentamicin sulfate (Garamycin) 1B1 1levofloxacin (Quixin) 1B1 1neomy sulf/bacitra/polymyxin b (Neosporin opth oint) 1B1 1neomycin/polymyxn b/gramicidin (Neosporin opth solution) 1B1 1ofloxacin (Ocuflox) 1B1 1polymyxin b sulfate/tmp (Polytrim) 1B1 1sulfacetamide sodium (Bleph-10, Sodium Sulamyde) 1B1 1tobramycin sulfate (Tobrex) 1B1 1trifluridine (Viroptic) 1B2 2Ciloxan oint 22 2Moxeza 22 2Natacyn 22 2Vigamox 22 2Zirgan 23 3Azasite 33 3Besivance 33 3Iquix 33 3Tobrex 33 3Zymar 33 3Zymaxid 3


11F. Ophthalmic Steroids

Drug

BCBSM BCN

1 1dexamethasone sod phosphate (Decadron opth) 1B1 1fluorometholone (FML) 1B1 1prednisolone acetate (Pred Forte) 1B1 1prednisolone sod phosphate (Inflamase, Forte) 1B2 2FML Forte, S.O.P. 22 2Pred Mild 22 2Vexol 23 3Alrex 33 3Durezol 33 3Lotemax 33 3Maxidex 3




11G. Ophthalmic Anti-infective/Steroid Combinations

Drug

BCBSM BCN

1 1neo/polymyx b sulf/dexameth (Maxitrol) 1B1 1neomy sulf/bacitrac zn/poly/hc (Cortisporin) 1B1 1sulfacetamide/prednisolone sp (Vasocidin) 1B1 1tobramycin/dexamethasone (Tobradex susp) 1B2 2Blephamide drops, oint 22 2Poly-Pred 22 2Tobradex oint 23 3Bleph-10 33 3Pred-G 33 3Tobradex ST 33 3Zylet 3


11H. Miscellaneous Ophthalmic Agents

Drug

BCBSM BCN

1 1azelastine hcl (Optivar) 1B1 1benoxinate hcl/fluorescein na (Fluress) 1B1 1cromolyn sodium (Opticrom) 1B1 1epinastine hcl (Elestat) 1B1 1naphazoline hcl (Albalon) 1B1 1phenylephrine hcl (Neo-Synephrine) 1B1 1proparacaine hcl (Alcaine) 1B1 1tetracaine hcl (Tetcaine) 1B2 2Alocril 22 2Alomide 22 2Lacrisert 22 2Patanol 22 2Restasis 23 3Alamast 33 3Bepreve 33 3Emadine 33 3Lastacaft 33 3Pataday 33 3Tetravisc 33 3Tetravisc Forte 3

<s> 2 4 Cystaran 4



12. OTIC & NASAL PREPARATIONS


12A. Nasal Preparations

Drug

BCBSM BCN

1 1fluticasone propionate (Flonase) 1B1 1triamcinolone acetonide (Nasacort AQ) 1B3 3Tyzine 3


12B. Otic Preparations

Drug

BCBSM BCN

1 1acetic acid (Acetasol, HC/Vosol, HC) 1B1 1acetic acid/aluminum acetate (Domeboro Otic) 1B1 1ciprofloxacin hcl (Cetrexal) 1B1 1ofloxacin (Floxin Otic) 1B2 2Ciprodex 23 3Cetraxal 33 3Cortisporin 33 3Cortisporin-TC 3



13. RESPIRATORY, COUGH & COLD


13A. Antihistamines

Drug

BCBSM BCN

1 1cetirizine hcl (Zyrtec syrup [RX Only]) 1B1 1clemastine fumarate (Tavist) 1B1 1cyproheptadine hcl (Periactin) 1B1 1dexchlorpheniramine maleate (Polaramine) 1B1 1diphenhydramine hcl (Benadryl) 1B1 1hydroxyzine hcl (Atarax, Vistaril) 1B1 1levocetirizine dihydrochloride (Xyzal) 1B1 1promethazine hcl (Phenergan) 1B


13B. Antihistamine/Decongestant Combinations

Drug

BCBSM BCN

3 3Tyzine 3


13F. Oral Beta-Agonists

Drug

BCBSM BCN

1 1albuterol sulfate (Proventil solution) 1B1 1metaproterenol sulfate (Alupent) 1B1 1terbutaline sulfate (Brethine) 1B


13G. Inhaled Beta-Agonists

Drug

BCBSM BCN

1 1albuterol sulfate (Albuterol Nebulizer solution) 1B1 1levalbuterol hcl (Xopenex) 1B2 2Foradil 22 2Proair HFA, Ventolin HFA, 22 2Serevent Diskus 23 3Arcapta Neohaler 33 3Brovana 33 3Maxair Autohaler 33 3Perforomist 33 3Proventil HFA 3


13H. Inhaled Steroids

Drug

BCBSM BCN

1 1budesonide (Pulmicort 0.25mg, 0.5mg/2ml) 1A2 2Alvesco 22 2Asmanex 22 2Flovent 22 2Pulmicort 1mg/2ml 22 2Pulmicort Flexhaler 22 2Qvar 23 3Aerobid, M 3




13I. Intranasal Steroids

Drug

BCBSM BCN

1 1fluticasone propionate (Flonase) 1B1 1triamcinolone acetonide (Nasacort AQ) 1B


13J. Theophyllines

Drug

BCBSM BCN

1 1caffeine citrated (Cafcit) 1B1 1dyphylline (Dilor) 1B1 1theophylline anhydrous (Theophylline Anhydrous) 1B2 2Theo-24 23 3Elixophyllin 33 3Lufyllin 3


13K. Epinephrine

Drug

BCBSM BCN

2 2Epipen, Jr. 23 3Adrenaclick 33 3Adrenalin Chloride 33 3Auvi-Q 33 3Twinject 3


13L. Miscellaneous Pulmonary Agents

Drug

BCBSM BCN

1 1acetylcysteine (Mucomyst) 1B1 1cromolyn sodium (Intal solution) 1B1 1guaifenesin/dyphylline (Difil-G) 1B1 1ipratropium bromide (Atrovent solution) 1B1 1ipratropium/albuterol sulfate (Duoneb) 1B1 1montelukast sodium (Singulair) 1B1 1sodium chloride for inhalation (Sodium Chloride) 1B1 1zafirlukast (Accolate) 1B2 2Advair 22 2Atrovent Inhaler 22 2Combivent Respimat 22 2Dulera 22 2Spiriva 22 2Symbicort 23 3Broncomar-1 33 3 Daliresp 33 3Hyper-Sal 33 3Nebusal 33 3Tudorza Pressair 33 3Zyflo, CR 3

<s> 1 4 sildenafil citrate (Revatio) 4<s> 2 4Letairis 4<s> 2 4Pulmozyme 4<s> 2 4Tracleer 4<s> 2 4Tyvaso 4<s> 2 4Ventavis 4<s> 3 5 Adcirca 5<s> 3 5Remodulin 5



14. UROLOGY


14A. Urinary Antispasmodics

Drug

BCBSM BCN

1 1dicyclomine hcl (Bentyl) 1B1 1flavoxate hcl (Urispas) 1B1 1hyosc sul/phenyltoloxamine cit (Digex NF) 1B1 1hyoscyamine sulfate (Levbid) 1B1 1hyoscyamine sulfate (Levsin, SL) 1B1 1oxybutynin chloride (Ditropan) 1B1 1oxybutynin chloride (Ditropan XL) 1B1 1propantheline bromide (Pro-Banthine 15mg) 1B1 1tolterodine tartrate (Detrol) 1B1 1trospium chloride (Sanctura) 1B2 2Detrol LA 23 3Digex NF 33 3Enablex 33 3 Myrbetriq 33 3Symax Duotab 33 3Toviaz 33 3Vesicare 3


14B. Miscellaneous Urologicals

Drug

BCBSM BCN

1 1bethanechol chloride (Urecholine) 1B1 1guanidine hcl (n/a) 1B1 1phenazopy hcl/hyoscy/butabarb (Pyridium Plus) 1B1 1phenazopyridine hcl (Pyridium) 1B1 1potassium citrate (Urocit-K) 1B1 1potassium citrate/citric acid (Cytra-2, 3, K) 1B2 2Elmiron 22 2Renacidin 2


14C. BPH Treatment

Drug

BCBSM BCN

1 1alfuzosin hcl (Uroxatral) 1B1 1doxazosin mesylate (Cardura) 1B1 1finasteride (Proscar) 1B1 1tamsulosin hcl (Flomax) 1B1 1terazosin hcl (Hytrin) 1B2 2Avodart 22 2Jalyn 23 3Cardura XL 33 3Rapaflo 3



15. VITAMINS AND SUPPLEMENTS


15A. Vitamins and Minerals

Drug

BCBSM BCN

PREVN 1 1cholecalciferol (vitamin d3) (Vitamin D3) 0PREVN 1 1ferrous sulfate (Fer-In-Sol) 0PREVN 1 1sodium fluoride (Fluoride) 0

1 1calcitriol (Rocaltrol) 1B1 1cyanocobalamin (vitamin b-12) (Cyanocobalamin injection) 1B1 1ergocalciferol (vitamin d2) (Calciferol) 1B1 1fe fumarate/fa/mv; min comb#15 (Centratex) 1B1 1fe fumarate/vit c/b12-if/fa (Trinsicon) 1B1 1ferrous fumarate/folic acid (Hematinic with Folic Acid) 1B1 1ferrous sulfate/vit c/fa (Tl-Fol 500) 1B

PREVN 1 1folic acid (Folic Acid [OTC]) 1B1 1folic acid (Folvite) 1B1 1folic acid/vitamin b comp w-c (Nephrocaps) 1B1 1folic acid/vitamin b comp w-c (Vitaplex, B-Plex) 1B1 1hydroxocobalamin (Cyanokit) 1B1 1iron ag&fum/c/fa/mv cmb11/ca-t (Ferrex 28) 1B1 1iron aspgly&ps/c/b12/fa/ca/suc (Ferrex 150 Forte Plus) 1B1 1iron bg&ps/vit c/b12/fa/ca thr (Taron Forte) 1B1 1iron fum & ag/c/b12/fa/ca/succ (Multigen Plus) 1B1 1iron fum & p/fa/vit b & c no.9 (Folivane-Plus) 1B1 1iron fum & ps cmp/fa/vit c/b3 (Folivane-F) 1B1 1iron ps cmplx/vit b12/fa (Niferex-150 Forte) 1B1 1iron ps/iron hem poly/fa/b12 (Hemetab) 1B1 1iron/fa/b12/c/docusate sodium (Ferraplus 90) 1B1 1iron/fa/vitamin b comp w-c/min (Ferrocite Plus) 1B1 1iron; carbonyl/fa/c/b-6/b12/zn (Corvita) 1B1 1iron;carbonyl/vit c/vit b12/fa (Fe C) 1B1 1mv comb18/fefm-fepol cb1/fa (Tandem Plus) 1B1 1phytonadione (Vitamin K) 1B1 1vit b cmplx 3/fa/vit c/biotin (Nephro-Vite RX) 1B1 1vit b cplx #11/fa/c/biot/zn ox (Dailyvite) 1B1 1zinc sulfate (Zinc Sulfate) 1B2 2Foltrate 22 2Hematron-AF 22 2Mephyton 23 3Dailyvite 33 3Enlyte 33 3Ferralet 90 33 3Fetrin 33 3Fluor-A-Day 33 3Galzin 33 3Hectorol 33 3Hematron 3

PREVN 3 3Ironup 33 3Irospan 33 3Macutek 33 3Martinic 33 3Nascobal spray 33 3Nephron FA 3





15A-C. Vitamins and Minerals (Cont.)

Drug

BCBSM BCN

3 3Neurin-SL 33 3Niferex Gold 33 3Pamine FQ 33 3Potaba 33 3Proferrin-Forte 33 3Siderol 33 3Supervite 33 3Vital-D RX 33 3Zemplar 3


15B. Potassium Replacement

Drug

BCBSM BCN

1 1potassium chloride (Kayciel, Kaon-Cl, Kaon liquid) 1B1 1potassium chloride (K-Tab, K-Dur, Slow-K, Kaon CL) 1B2 2K-Tab 2




16. DIAGNOSTIC AND OTHER MISCELLANEOUS


16A. Diagnostics and Other Miscellaneous

Drug

BCBSM BCN

1 1acamprosate calcium (Campral) 1B1 1calcium acetate (Phoslo) 1B1 1cevimeline hcl (Evoxac) 1B1 1deferoxamine mesylate (Desferal) 1B1 1disulfiram (Antabuse) 1B1 1levocarnitine (Carnitor) 1B1 1naltrexone hcl (Revia) 1B1 1peg 3350/na sulf;bicarb;cl/kcl (Colyte) 1B1 1peg 3350/na sulf;bicarb;cl/kcl (Golytely) 1B1 1pilocarpine hcl (Salagen) 1B1 1sodium chloride/nahco3/kcl/peg (Nulytely) 1B1 1sodium polystyrene sulfonate (Kayexalate) 1B1 1triamcinolone acetonide (Oralone) 1B2 2Chemet 22 2Cuprimine 22 2Golytely 22 2Renagel 22 2Renvela tablet 23 3Aphthasol 33 3Carnitor SF 33 3Colyte 33 3Fosrenol 33 3Lithostat 33 3Magnebind 400 RX 33 3Moviprep 33 3Osmoprep, Visicol 33 3Phoslyra 33 3Prepopik 33 3Renvela Packet 0.8G 33 3Suclear 33 3Suprep 33 3Thiola 33 3Zavesca 3

<s> 2 4Buphenyl 4<s> 2 4 Kalydeco 4<s> 2 4Kuvan 4<s> 2 4Samsca 4<s> 2 4 Xenazine 4<s> 3 5Cystadane 5<s> 3 5Exjade 5<s> 3 5 Ferriprox 5<s> 3 5 Firazyr 5<s> 3 5Orfadin 5<s> 3 5Syprine 5



Index

Trade Name Page Trade Name Pageabacavir sulfate (Ziagen) 53

Abilify 62

Abilify Discmelt, solution 62

acamprosate calcium (Campral) 96

acarbose (Precose) 79

acebutolol hcl (Sectral) 56

acetaminophen with codeine (Tylenol w/codeine) 65

acetazolamide (Diamox Sequels) 58

acetazolamide (Diamox) 58

acetazolamide (Diamox) 67

acetic acid (Acetasol, HC/Vosol, HC) 90

acetic acid/aluminum acetate (Domeboro Otic) 90

acetylcysteine (Mucomyst) 92

Actimmune 83

Actonel, Weekly, 150mg 76

Actoplus MET XR 79

acyclovir (Zovirax ointment) 85

acyclovir (Zovirax) 52

adapalene (Differin 0.1% cream, gel) 85

Adcirca 92

Adrenaclick 92

Adrenalin Chloride 92

Advair 92

Aerobid, M 91

Aerobid, M 91

Afinitor 82

Afinitor, Disperz 82

Aggrenox 59

Alamast 89

Albenza 54

albuterol sulfate (Albuterol Nebulizer solution) 91

albuterol sulfate (Proventil solution) 91

alclometasone dipropionate (Aclovate) 84

Aldactazide 50/50mg 58

alendronate sodium (Fosamax) 76

Alferon N 83

alfuzosin hcl (Uroxatral) 93

Alinia 54

Alkeran 80

allopurinol (Zyloprim) 75

Alocril 89

Alomide 89

Alora 76

Alora 73

Alphagan P 0.1% 87

alprazolam (Niravam) 62

alprazolam (Xanax Intensol) 62

alprazolam (Xanax, XR) 62

Alrex 88

Alvesco 91

amantadine hcl (Symmetrel) 66

amantadine hcl (Symmetrel) 52

amcinonide (Cyclocort) 84

amiloride hcl (Midamor) 58

amiloride/hydrochlorothiazide (Moduretic) 58

aminocaproic acid (Amicar) 59

amiodarone hcl (Cordarone) 58

Amitiza 71

amitrip hcl/chlordiazepoxide (Limbitrol, DS) 61

amitriptyline hcl (Elavil) 61

amlodipine besylate (Norvasc) 57

amlodipine besylate/benazepril (Lotrel 5/40,10/40mg) 57

amlodipine besylate/benazepril (Lotrel 5/40,10/40mg) 56

amlodipine besylate/benazepril (Lotrel) 57

amlodipine besylate/benazepril (Lotrel) 56

amlodipine/atorvastatin (Caduet) 57

amlodipine/atorvastatin (Caduet) 55

ammonium lactate (Lac-Hydrin) 86

amoxapine (Asendin) 61

amoxicillin (Amoxil) 49

amoxicillin/potassium clav (Augmentin, ES, XR) 49

amoxicillin/potassium clavulanate (Augmentin XR) 49

amoxicillin/potassium clavulanate (Augmentin, ES) 49

amphet asp/amphet/d-amphet (Adderall XR) 63

amphet asp/amphet/d-amphet (Adderall) 63

ampicillin trihydrate (Ampicillin) 49

Ampyra 83

Amturnide 60

Anadrol-50 77

anagrelide hcl (Agrylin) 59

Analpram HC Lotion 71

anastrozole (Arimidex) 81

Androderm 77

Androgel, 1.62% 77

Angeliq 74

Antara 55

anthralin (Drithocreme HP) 86

Anzemet 70

Aphthasol 96

Apidra, Solostar 78

Aplenzin 61

Apokyn 66

apraclonidine hcl (Iopidine drops) 87

Apriso 71

Aptivus (Must Be Used With Norvir) 53

Aranesp 81

Aranesp 83

Arcalyst 80

Arcapta Neohaler 91

Asacol 71

Asacol HD 71

Asmanex 91

aspirin (Aspirin E.C.) 64

aspirin (Aspirin) 64

aspirin (Halfprin) 64

Astagraf XL 80

Atelvia 76

atenolol (Tenormin) 56

atenolol/chlorthalidone (Tenoretic) 56

atorvastatin calcium (Lipitor) 55

atovaquone/proguanil hcl (Malarone) 53

Atripla 53

atropine sulfate (Isopto Atropine) 87

Atrovent Inhaler 92

Aubagio 83

Augmentin susp 49

Auvi-Q 92

Avandamet 79

Avandaryl 79

Avandia 79

Trade Name Page Trade Name PageAVC 74

Avelox, ABC 50

Avodart 93

Avonex 83

Avonex Administration Pack 83

Avonex Administration Pack 83

Avonex Pen 83

Axert 66

Azasan 82

Azasite 88

azathioprine (Imuran) 80

azathioprine (Imuran) 75

azelastine hcl (Optivar) 89

Azilect 66

azithromycin (Zithromax) 50

Azopt 87

Azor 57

Azor 57

bacitracin (Bacitracin) 88

bacitracin/polymyxin b sulfate (Polysporin) 88

baclofen (Lioresal) 68

Bactroban cream, nasal 85

balsalazide disodium (Colazal) 71

Banzel 67

Banzel susp 67

Baraclude 52

benazepril hcl (Lotensin) 56

benazepril/hydrochlorothiazide (Lotensin HCT) 56

Benicar 57

Benicar HCT 57

benoxinate hcl/fluorescein na (Fluress) 89

benztropine mesylate (Cogentin) 66

Bepreve 89

Besivance 88

betamet diprop/prop gly (Diprolene AF, gel, cream, lotion) 84

betamet diprop/prop gly (Diprolene ointment) 84

betamethasone dipropionate (Diprosone, Maxivate) 84

betamethasone valerate (Valisone cream, lotion, oint) 84

betamethasone valerate (Valisone cream, lotion, oint) 84

Betaseron 83

betaxolol hcl (Betoptic solution) 87

betaxolol hcl (Kerlone) 56

bethanechol chloride (Urecholine) 93

Betoptic S 87

Beyaz 73

Biaxin XL 50

bicalutamide (Casodex) 81

Bidil 59

Biltricide 54

bisoprolol fumarate (Zebeta) 56

bisoprolol fumarate/hctz (Ziac) 56

Bleph-10 89

Blephamide drops, oint 89

Bosulif 82

Brilinta 59

brimonidine tartrate (Alphagan, P) 87

bromfenac sodium (Xibrom) 87

bromocriptine mesylate (Parlodel) 66

Broncomar-1 92

Brovana 91

budesonide (Entocort EC) 77

budesonide (Pulmicort 0.25mg, 0.5mg/2ml) 91

bumetanide (Bumex) 58

Buphenyl 96

buprenorphine hcl/naloxone hcl (Suboxone) 65

bupropion hcl (Wellbutrin XL 300mg) 61

bupropion hcl (Wellbutrin XL) 61

bupropion hcl (Wellbutrin, SR) 61

bupropion hcl (Zyban) 97

bupropion hcl (Zyban) 97

buspirone hcl (Buspar) 62

butalb/acetaminophen/caffeine (Fioricet;Esgic, Plus) 65

butalb/acetaminophen/caffeine (Fioricet;Esgic, Plus) 66

butalbit/acetamin/caff/codeine (Fioricet w/codeine) 65

butalbital/acetaminophen (Phrenilin) 66

butalbital/acetaminophen (Phrenilin) 65

butalbital/aspirin/caffeine (Fiorinal) 66

butalbital/aspirin/caffeine (Fiorinal) 65

butorphanol tartrate (Stadol NS) 65

butorphanol tartrate (Stadol NS) 66

Byetta 79

Bystolic 56

cabergoline (Dostinex) 66

cabergoline (Dostinex) 78

Cafergot 66

caffeine citrated (Cafcit) 92

calcipotriene (Dovonex oint) 86

calcipotriene (Dovonex solution) 86

calcipotriene (Dovonex) 86

calcitonin;salmon;synthetic (Miacalcin nasal spray) 76

calcitonin;salmon;synthetic (Miacalcin nasal spray) 78

calcitriol (Rocaltrol) 94

calcitriol (Rocaltrol) 78

calcium acetate (Phoslo) 96

Canasa 71

candesartan cilexetil (Atacand) 57

candesartan/hydrochlorothiazid (Atacand HCT) 57

Cantil 69

Capex shampoo 84

Capital w/codeine 65

Caprelsa 82

captopril (Capoten) 56

captopril/hydrochlorothiazide (Capozide) 56

Carac 86

Carbaglu 78

carbamazepine (Carbatrol) 67

carbamazepine (Tegretol XR) 67

carbamazepine (Tegretol) 67

carbidopa/levodopa (Sinemet, CR) 66

carbidopa/levodopa/entacapone (Stalevo) 66

Cardene SR 57

Cardizem LA 120mg 57

Cardura XL 93

carisoprodol (Soma) 68

Carnitor SF 96

carteolol hcl (Ocupress) 87

carvedilol (Coreg) 56

Cayston 54

Cedax 49

Ceenu 80

cefaclor (Ceclor, ER) 49

cefadroxil hydrate (Duricef) 49

Trade Name Page Trade Name Pagecefdinir (Omnicef) 49

cefditoren pivoxil (Spectracef) 49

cefpodoxime proxetil (Vantin) 49

cefprozil (Cefzil) 49

Ceftin 49

Ceftin 49

Ceftin 125mg/5ml 49

Ceftin 250mg/5ml 49

cefuroxime axetil (Ceftin) 49

Celestone 77

Cellcept suspension 80

Celontin 67

Cenestin 76

Cenestin 73

Centany 85

cephalexin (Keflex) 49

Cesamet 70

cetirizine hcl (Zyrtec syrup [RX Only]) 91

Cetraxal 90

cevimeline hcl (Evoxac) 96

Chantix 97

Chemet 96

Chenodal 70

chloral hydrate (Chloral Hydrate) 63

chlordiazepoxide hcl (Librium) 62

chlordiazepoxide/clidinium br (Librax) 69

chloroquine phosphate (Aralen) 53

chlorothiazide (Diuril) 58

chlorpromazine hcl (Thorazine) 62

chlorpropamide (Diabinese) 79

chlorthalidone (Hygroton, Thalitone) 58

chlorzoxazone (Paraflex, Parafon Forte DSC) 68

cholecalciferol (vitamin d3) (Vitamin D3) 94

cholestyramine (with sugar) (Questran, Questran Light) 55

cholestyramine/aspartame (Questran, Questran Light) 55

choline sal/mag salicylate (Trilisate) 64

chorionic gonadotropin; human (Novarel, Pregnyl, Profasi) 74

ciclopirox (Loprox cream, lotion) 85

ciclopirox (Penlac) 85

ciclopirox olamine (Loprox cream, lotion) 85

cilostazol (Pletal) 59

Ciloxan oint 88

cimetidine (Tagamet [RX Only]) 69

cimetidine hcl (Tagamet (RX Only)) 69

Cimzia syringe 75

Cimzia syringe 71

Cipro solution 50

Ciprodex 90

ciprofloxacin hcl (Cetrexal) 90

ciprofloxacin hcl (Ciloxan drops) 88

ciprofloxacin hcl (Cipro) 50

ciprofloxacin/ciprofloxa hcl (Cipro XR) 50

citalopram hydrobromide (Celexa) 61

clarithromycin (Biaxin, XL) 50

clemastine fumarate (Tavist) 91

Cleocin Vaginal ovules 74

Climara Pro 74

clindamycin hcl (Cleocin) 54

clindamycin palmitate hcl (Cleocin solution) 54

clindamycin phos/benzoyl perox (Duac) 85

clindamycin phosphate (Cleocin Vaginal cream) 74

Clindesse 74

clobetasol propionate (Clobex shampoo, lotion) 84

clobetasol propionate (Temovate, Clobevate) 84

clobetasol propionate/emoll (Temovate) 84

Clobex, spray 84

Cloderm 84

clomiphene citrate (Clomid) 74

clomipramine hcl (Anafranil) 61

clonazepam (Klonopin, Wafer) 67

clonidine (Catapres-TTS) 59

clonidine hcl (Catapres) 59

clonidine hcl/chlorthalidone (Clorpres) 59

clopidogrel bisulfate (Plavix) 59

clorazepate dipotassium (Tranxene) 62

Clorpres 0.3-15mg 59

clotrimazole (Lotrimin) 85

clotrimazole (Mycelex Troche) 51

clotrimazole/betamethasone dip (Lotrisone cream, lotion) 85

clozapine (Clozapine) 62

clozapine (Clozaril) 62

clozapine (Fazaclo 25, 100mg) 62

Coartem 53

codeine sulfate (Codeine Sulfate) 64

codeine/butalbital/asa/caffein (Fiorinal w/codeine) 66

codeine/butalbital/asa/caffein (Fiorinal w/codeine) 65

colchicine/probenecid (Colbenemid) 75

Colcrys 75

Colestid Flavored 55

colestipol hcl (Colestid) 55

colestipol hcl;micronized (Colestid) 55

Colyte 96

Combipatch 74

Combivent 92

Combivent Respimat 92

Complera 53

condoms, female (FC Condom, Female) 73

Condylox gel 86

Copaxone 83

Cordran, tape, SP 84

Coreg CR 56

Cortifoam 71

cortisone acetate (Cortisone Acetate) 77

Cortisporin 90

Cortisporin-TC 90

Cosopt PF 87

Creon 70

Crestor 55

Crixivan 53

cromolyn sodium (Gastrocrom) 71

cromolyn sodium (Intal solution) 92

cromolyn sodium (Opticrom) 89

Cuprimine 96

Cuprimine 75

Cuvposa 69

cyanocobalamin (vitamin b-12) (Cyanocobalamin injection) 94

cyclobenzaprine hcl (Flexeril) 68

Cyclogyl 87

Cyclomydril 87

cyclopentolate hcl (Cyclogyl) 87

cyclophosphamide (Cytoxan) 80

Cycloset 79

Trade Name Page Trade Name Pagecyclosporine; modified (Neoral) 80

Cymbalta 61

cyproheptadine hcl (Periactin) 91

Cystadane 96

Cystagon 78

Cystagon 78

Cystaran 89

Dailyvite 94

Daliresp 92

danazol (Danocrine) 77

dantrolene sodium (Dantrium) 68

Dapsone 54

Daraprim 53

Daytrana 63

DDAVP solution 78

deferoxamine mesylate (Desferal) 96

demeclocycline hcl (Declomycin) 49

Demser 60

Denavir 85

Depen 75

Depo-Provera 400mg 81

Depo-subQ Provera 104 73

desipramine hcl (Norpramin) 61

desmopressin (nonrefrigerated) (DDAVP spray) 78

desmopressin acetate (DDAVP solution) 78

desmopressin acetate (DDAVP tabs) 78

desogestrel-ethinyl estradiol (Cyclessa) 72

desogestrel-ethinyl estradiol (Cyclessa) 72

desogestrel-ethinyl estradiol (Desogen, Ortho-Cept) 72

desogestrel-ethinyl estradiol (Desogen, Ortho-Cept) 72

desog-et estra/ethin estra (Mircette) 72

desog-et estra/ethin estra (Mircette) 72

Desonate 84

desonide (Desowen, Tridesilon) 84

Desvenlafaxine ER 61

Detrol LA 93

dexamethasone (Decadron) 77

dexamethasone sod phosphate (Decadron opth) 88

dexchlorpheniramine maleate (Polaramine) 91

dexmethylphenidate hcl (Focalin) 63

Dexpak 77

dextroamphetamine sulfate (Dexedrine) 63

dextroamphetamine sulfate (Procentra) 63

diazepam (Valium) 62

diazepam (Valium) 68

Dibenzyline 59

diclofenac potassium (Cataflam) 64

diclofenac sodium (Voltaren) 64

diclofenac sodium (Voltaren) 87

diclofenac sodium (Voltaren-XR) 64

dicloxacillin sodium (Dicloxacillin) 49

dicyclomine hcl (Bentyl) 69

dicyclomine hcl (Bentyl) 93

didanosine (Videx EC) 53

Dificid 50

diflorasone diacetate (Psorcon, Florone) 84

diflorasone diacetate (Psorcon, Florone) 84

diflunisal (Dolobid) 64

Digex NF 93

Digex NF 69

digoxin (Digoxin elixir) 58

digoxin (Digoxin) 58

dihydroergotamine mesylate (D.H.E.45) 66

dihydroergotamine mesylate (Migranal) 66

Dilantin 30mg 67

Dilatrate-Sr 59

diltiazem hcl (Cardizem CD) 57

diltiazem hcl (Cardizem LA) 57

diltiazem hcl (Cardizem, SR, CD) 57

diltiazem hcl (Tiazac) 57

Diovan 57

Dipentum 71

diphenhydramine hcl (Benadryl) 91

diphenoxylate hcl/atropine (Lomotil) 69

dipyridamole (Persantine) 59

disopyramide phosphate (Norpace) 58

disulfiram (Antabuse) 96

Diuril susp 58

divalproex sodium (Depakote ER) 67

divalproex sodium (Depakote) 67

Divigel 73

donepezil hcl (Aricept, ODT) 68

dorzolamide hcl (Trusopt) 87

dorzolamide hcl/timolol maleat (Cosopt) 87

doxazosin mesylate (Cardura) 93

doxazosin mesylate (Cardura) 59

doxepin hcl (Sinequan, Adapin) 61

doxycycline hyclate (Periostat) 49

doxycycline hyclate (Vibramycin, Vibratabs) 49

doxycycline monohydrate (Monodox) 49

Dritho-Scalp 86

dronabinol (Marinol) 70

Droxia 81

Dulera 92

Durezol 88

Dutoprol 56

Dutoprol 58

Dynacirc CR 57

dyphylline (Dilor) 92

Dyrenium 58

econazole nitrate (Spectazole) 85

Edarbi 57

Edarbyclor 58

Edarbyclor 57

Edecrin 58

Edurant 53

Effient 59

Elestrin 73

Elidel 86

Eligard 81

Elixophyllin 92

Ella 73

Elmiron 93

Emadine 89

Embeda 64

Emcyt 81

Emend 80,125mg capsules 70

Emsam 61

Emtriva 53

Enablex 93

enalapril maleate (Vasotec) 56

enalapril/hydrochlorothiazide (Vaseretic) 56

Trade Name Page Trade Name PageEnbrel 75

Enbrel 86

Enjuvia 73

Enjuvia 76

Enlyte 94

enoxaparin sodium (Lovenox) 59

entacapone (Comtan) 66

Epifoam 71

epinastine hcl (Elestat) 89

Epipen 92

Epipen, Jr. 92

Epivir HBV 52

Epivir solution 53

eplerenone (Inspra) 58

Epogen 83

Epogen 81

eprosartan mesylate (Teveten) 57

Epzicom 53

Equetro 67

ergocalciferol (vitamin d2) (Calciferol) 78

ergocalciferol (vitamin d2) (Calciferol) 94

ergoloid mesylates (Ergoloid Mesylates) 60

Ergomar 66

ergotamine tartrate/caffeine (Cafergot) 66

Erivedge 82

Ertaczo 85

ery e-succ/sulfisoxazole (Pediazole) 50

ery e-succ/sulfisoxazole (Pediazole) 50

Eryped 50

Ery-Tab 50

erythromycin base (Erythromycin Base) 50

erythromycin base (Ilotycin) 88

erythromycin ethylsuccinate (Erythromycin) 50

erythromycin stearate (Erythromycin Stearate) 50

erythromycin/benzoyl peroxide (Benzamycin) 85

escitalopram oxalate (Lexapro) 61

estazolam (Prosom) 63

Estrace Vaginal cream 73

estradiol (Estrace) 76

estradiol (Estrace) 73

estradiol valerate (Delestrogen) 73

estradiol/noreth ac (Activella) 74

Estrasorb 73

Estring 73

Estrogel 73

estrogen;ester/me-testosterone (Estratest, H.S.) 76

estrogen;ester/me-testosterone (Estratest, H.S.) 74

estropipate (Ogen, Ortho-EST) 73

estropipate (Ogen, Ortho-EST) 76

ethambutol hcl (Ethambutol) 54

ethinyl estradiol/drospirenone (Yasmin) 72

ethinyl estradiol/drospirenone (Yaz) 72

ethosuximide (Zarontin) 67

ethynodiol d-ethinyl estradiol (Demulen) 72

ethynodiol d-ethinyl estradiol (Demulen) 72

etidronate disodium (Didronel) 76

etodolac (Lodine) 64

etoposide (Vepesid) 81

Eurax 86

Eurax lotion 86

Evamist 73

Evista 76

Exalgo 64

Exelderm solution, cream 85

Exelon 68

Exelon 68

Exelon patch, solution 68

exemestane (Aromasin) 81

Exforge 57

Exforge 57

Exforge HCT 57

Exforge HCT 57

Exjade 96

Extavia 83

Factive 50

famciclovir (Famvir) 52

famotidine (Pepcid [RX Only]) 69

Fanapt 62

Fareston 81

Faslodex 81

Fazaclo 62

fe fumarate/fa/mv; min comb#15 (Centratex) 94

fe fumarate/vit c/b12/stomc (Hematogen) 94

fe fumarate/vit c/b12-if/fa (Trinsicon) 94

fe fumarate/vit c/vit b12/fa (Ferrogels Forte) 94

felbamate (Felbatol) 67

felodipine (Plendil) 57

FemHRT 0.5mg-2.5mcg 74

FemHRT 0.5mg-2.5mcg 76

Femring 73

Femtrace 73

fenofibrate (Fenofibrate) 55

fenofibrate (Lofibra) 55

fenofibrate nanocrystallized (Tricor) 55

fenofibrate;micronized (Lofibra) 55

fenofibric acid (choline) (Trilipix) 55

fenofibric acid (Fibricor) 55

Fenoglide 55

fenoprofen calcium (Nalfon) 64

fentanyl (Duragesic) 64

fentanyl citrate (Actiq) 64

Ferralet 90 94

Ferriprox 96

ferrous fumarate/folic acid (Hematinic with Folic Acid) 94

ferrous sulfate (Fer-In-Sol) 94

ferrous sulfate/vit c/fa (Tl-Fol 500) 94

Fetrin 94

finasteride (Proscar) 93

finasteride (Proscar) 78

Firazyr 96

Flagyl ER 54

flavoxate hcl (Urispas) 93

flecainide acetate (Tambocor) 58

Flo-Pred, Millipred 77

Flovent 91

fluconazole (Diflucan) 74

fluconazole (Diflucan) 51

flucytosine (Ancobon) 51

fludrocortisone acetate (Florinef) 77

fluocinolone acetonide (Synalar 0.025% cream, oint) 84

fluocinolone acetonide (Synalar cream, solution) 84

fluocinonide (Lidex, E) 84

Trade Name Page Trade Name Pagefluocinonide/emollient (Lidex, E) 84

Fluor-A-Day 94

fluorometholone (FML) 88

fluorouracil (Efudex) 86

fluoxetine hcl (Prozac, Sarafem) 61

fluoxymesterone (Androxy 10mg) 77

fluphenazine hcl (Prolixin) 62

flurazepam hcl (Dalmane) 63

flurbiprofen (Ansaid) 64

flurbiprofen sodium (Ocufen) 87

flutamide (Eulexin) 81

fluticasone propionate (Cutivate lotion) 84

fluticasone propionate (Cutivate) 84

fluticasone propionate (Flonase) 90

fluticasone propionate (Flonase) 92

fluvastatin sodium (Lescol) 55

fluvoxamine maleate (Luvox) 61

FML Forte, S.O.P. 88

folic acid (Folic Acid [OTC]) 94

folic acid (Folvite) 94

folic acid/vitamin b comp w-c (Nephrocaps) 94

folic acid/vitamin b comp w-c (Vitaplex, B-Plex) 94

Follistim AQ 74

Foltrate 94

fondaparinux sodium (Arixtra) 59

Foradil 91

Forteo 76

fosinopril sodium (Monopril) 56

fosinopril/hydrochlorothiazide (Monopril HCT) 56

Fosrenol 96

Fragmin 59

Frenadol 64

Frova 66

furosemide (Lasix solution) 58

furosemide (Lasix) 58

Fuzeon 53

gabapentin (Neurontin) 67

gabapentin (Neurontin) 67

Gabitril 67

galantamine hbr (Razadyne solution) 68

Galzin 94

GAMMAGARD S-D 83

GAMUNEX 83

GAMUNEX-C 83

ganciclovir (Cytovene) 52

gemfibrozil (Lopid) 55

Generess Fe 72

Genotropin 79

gentamicin sulfate (Garamycin) 88

gentamicin sulfate (Gentamicin cream, oint) 85

Giazo 71

Gilenya 83

Gleevec 82

glimepiride (Amaryl) 79

glipizide (Glucotrol XL) 79

glipizide (Glucotrol) 79

glipizide/metformin hcl (Metaglip) 79

Glucagen Vial 78

Glucagon Emergency Kit 78

Glucagon, Emergency Kit 78

glyburide (Diabeta, Micronase) 79

glyburide/metformin hcl (Glucovance) 79

glyburide;micronized (Glynase) 79

glycopyrrolate (Robinul, Forte) 69

Glyset 79

Golytely 96

Gonal-F, RFF 74

granisetron hcl (Kytril) 70

griseofulvin ultramicrosize (Gris-Peg) 51

griseofulvin;microsize (Grifulvin V susp) 51

guaifenesin/dyphylline (Difil-G) 92

guanfacine hcl (Tenex) 59

guanidine hcl (n/a) 93

Gynazole-1 74

halobetasol propionate (Ultravate) 84

Halog 84

haloperidol (Haldol) 62

haloperidol lactate (Haldol liquid) 62

hc/mineral oil/petrolat;wht (Hydrocortisone) 84

Hectorol 94

Hectorol 78

Hematron 94

Hematron-AF 94

heparin sodium;porcine (Heparin) 59

heparin sodium;porcine/pf (Heparin) 59

Hepsera 52

Hexalen 81

HIZENTRA 83

homatropine hbr (Isopto Homatropine 5%) 87

Humalog, MIX 78

Humalog, Mix (Vial) 78

Humatrope 79

Humira 86

Humira 75

Humulin 70/30 78

Humulin N 78

Humulin R 78

Hycamtin 81

Hycodan 65

hydralazine hcl (Apresoline) 60

hydrochlorothiazide (Hydrodiuril, Microzide) 58

hydrocodone bit/acetaminophen (Norco) 65

hydrocodone bit/acetaminophen (Xodol) 65

hydrocodone/ibuprofen (Ibudone) 65

hydrocodone/ibuprofen (Vicoprofen) 65

hydrocortisone (Cortef, Hydrocortisone) 77

hydrocortisone (Cortenema) 71

hydrocortisone (Dermacort, Hytone [RX Only]) 84

hydrocortisone ac/lidocaine (Anamantle HC) 71

hydrocortisone acetate (Proctocort Suppository) 71

hydrocortisone acetate/aloe v (Nuzon) 84

hydrocortisone butyrate (Locoid cream, oint, solution) 84

hydrocortisone valerate (Westcort) 84

hydrocortisone/pramoxine (Pramosone cream) 71

hydrocortisone/pramoxine (Pramosone) 71

hydromorphone hcl (Dilaudid) 64

hydroxocobalamin (Cyanokit) 94

hydroxychloroquine sulfate (Plaquenil) 53

hydroxychloroquine sulfate (Plaquenil) 75

hydroxyurea (Hydrea) 81

hydroxyzine hcl (Atarax, Vistaril) 91

hyosc sul/phenyltoloxamine cit (Digex NF) 69

Trade Name Page Trade Name Pagehyosc sul/phenyltoloxamine cit (Digex NF) 93

hyoscyamine sulfate (Levbid) 93

hyoscyamine sulfate (Levbid) 69

hyoscyamine sulfate (Levsin, SL) 93

hyoscyamine sulfate (Levsin, SL) 69

Hyper-Sal 92

ibandronate sodium (Boniva) 76

Ibudone 5/200mg 65

ibuprofen (Motrin) 64

imipramine hcl (Tofranil) 61

imipramine pamoate (Tofranil-PM) 61

imiquimod (Aldara) 86

Incivek 52

Increlex 79

indapamide (Lozol) 58

Indocin Suppository 64

indomethacin (Indocin, SR) 64

Infergen 83

Inlyta 82

Innohep 59

Innopran XL 56

Intelence 53

Intron A 83

Invega 62

Invirase 53

Invokana 79

Iopidine Droperette 87

ipratropium bromide (Atrovent solution) 92

ipratropium/albuterol sulfate (Duoneb) 92

Iprivask 59

Iquix 88

irbesartan (Avapro) 57

irbesartan/hydrochlorothiazide (Avalide) 57

Iressa 82

iron ag&fum/c/fa/mv cmb11/ca-t (Ferrex 28) 94

iron aspgly&ps/c/b12/fa/ca/suc (Ferrex 150 Forte Plus) 94

iron bg&ps/vit c/b12/fa/ca thr (Taron Forte) 94

iron fum & ag/c/b12/fa/ca/succ (Multigen Plus) 94

iron fum & p/fa/vit b & c no.9 (Folivane-Plus) 94

iron fum & ps cmp/fa/vit c/b3 (Folivane-F) 94

iron ps cmplx/vit b12/fa (Niferex-150 Forte) 94

iron ps/iron hem poly/fa/b12 (Hemetab) 94

iron/fa/b12/c/docusate sodium (Ferraplus 90) 94

iron/fa/vitamin b comp w-c/min (Ferrocite Plus) 94

iron; carbonyl/fa/c/b-6/b12/zn (Corvita) 94

iron;carbonyl/vit c/vit b12/fa (Fe C) 94

Ironup 94

Irospan 94

Isentress 53

isomethept/acetaminop/dichlphn (Midrin) 66

isoniazid (Isoniazid) 54

Isopto Carbachol 87

Isopto Homatropine 2% 87

Isopto Hyoscine 87

Isordil 40mg 59

isosorbide dinitrate (Isordil) 59

isosorbide mononitrate (Ismo, Monoket) 59

isoxsuprine hcl (Vasodilan) 60

isradipine (Dynacirc) 57

itraconazole (Sporanox caps) 51

Jakafi 81

Jalyn 93

Janumet 79

Januvia 79

Juvisync 79

Juvisync 55

Kaletra 53

Kalydeco 96

Kapvay 68

Kenalog 84

Ketek 50

ketoconazole (Extina) 85

ketoconazole (Nizoral cream) 85

ketoconazole (Nizoral) 51

ketoprofen (Ketoprofen) 64

ketorolac tromethamine (Acular, LS) 87

ketorolac tromethamine (Toradol) 64

Kineret 80

Kineret 75

Kombiglyze XR 79

Korlym 78

Kristalose 71

K-Tab 95

Kuvan 96

Kynamro 55

labetalol hcl (Normodyne) 56

Lacrisert 89

lactic acid (Lactic Acid) 86

lactulose (Lactulose) 71

Lamictal Dosepak 67

Lamictal ODT 67

Lamictal XR 67

Lamisil Granules 51

lamivudine (Epivir) 53

lamivudine/zidovudine (Combivir) 53

lamotrigine (Lamictal tabs) 67

lamotrigine (Lamictal XR) 67

lansoprazole (Prevacid) 69

Lantus, Solostar 78

Lastacaft 89

latanoprost (Xalatan) 87

Latuda 62

leflunomide (Arava) 75

Lescol XL 55

Letairis 92

letrozole (Femara) 81

leucovorin calcium (Leucovorin) 81

Leukeran 80

Leukine 83

Leukine 81

leuprolide acetate (Lupron) 81

leuprolide acetate (Lupron) 74

levalbuterol hcl (Xopenex) 91

Levatol 56

Levemir 78

levetiracetam (Keppra) 67

levobunolol hcl (Betagan) 87

levocarnitine (Carnitor) 96

levocarnitine (with sugar) (Carnitor) 96

levocetirizine dihydrochloride (Xyzal) 91

levofloxacin (Levaquin) 50

levofloxacin (Quixin) 88

Trade Name Page Trade Name Pagelevonorgestrel (Plan B One-Step) 73

levonorgestrel (Plan B) 73

levonorgestrel (Plan B) 73

levonorgestrel-eth estradiol (Alesse, Levlite) 72

levonorgestrel-eth estradiol (Alesse, Levlite) 72

levonorgestrel-eth estradiol (Lybrel) 72

levonorgestrel-eth estradiol (Nordette, Levlen) 72

levonorgestrel-eth estradiol (Nordette, Levlen) 72

levonorgestrel-eth estradiol (Seasonale) 72

levonorgestrel-eth estradiol (Seasonale) 72

levonorgestrel-eth estradiol (Triphasil, Trilevlen) 72

levonorgestrel-eth estradiol (Triphasil, Trilevlen) 72

levorphanol tartrate (n/a) 64

levothyroxine sodium (Levothyroxine) 77

Lexiva 53

Lialda 71

lidocaine (Lidocaine) 85

lidocaine hcl (Xylocaine viscous) 85

lidocaine/prilocaine (Emla) 85

lindane (Lindane) 86

Linzess 71

liothyronine sodium (Cytomel) 77

lipase/protease/amylase (Pancrelipase) 70

lisinopril (Prinivil, Zestril) 56

lisinopril/hydrochlorothiazide (Prinzide, Zestoretic) 56

lithium carbonate (Eskalith CR) 68

lithium citrate (Lithium Citrate) 68

Lithostat 96

Livalo 55

l-norgest-eth estr/ethin estra (Loseasonique) 72

l-norgest-eth estr/ethin estra (Loseasonique) 72

l-norgest-eth estr/ethin estra (Seasonique) 72

l-norgest-eth estr/ethin estra (Seasonique) 72

Lo Loestrin Fe 72

Lo Minastrin Fe 72

Locoid Lipocream 84

Lodosyn 66

Loestrin 24 Fe 72

lorazepam (Ativan Intensol) 62

lorazepam (Ativan) 62

Lorzone 68

losartan potassium (Cozaar) 57

losartan/hydrochlorothiazide (Hyzaar) 57

Lotemax 88

Lotronex 71

lovastatin (Mevacor) 55

Lovaza 55

loxapine succinate (Loxitane) 62

Lufyllin 92

Lumigan 87

Lunesta 63

Lupron Depot 74

Lupron Depot 81

Lupron Depot-PED 78

Lyrica 67

Lysodren 81

Macrodantin 51

Macutek 94

Magnebind 400 RX 96

malathion (Ovide) 86

maprotiline hcl (Maprotiline hcl) 61

Marplan 61

Martinic 94

Matulane 81

Maxair Autohaler 91

Maxidex 88

mebendazole (Vermox) 54

meclofenamate sodium (Meclomen) 64

Medrol 77

medroxyprogesterone acetate (Depo-Provera 150mg) 73

medroxyprogesterone acetate (Provera) 73

mefloquine hcl (Lariam) 53

Megace ES 81

megestrol acetate (Megace) 81

Mekinist 82

meloxicam (Mobic) 64

Menest 73

Menest 76

Menostar 73

meperidine hcl (Demerol) 64

Mephyton 59

Mephyton 94

meprobamate (Miltown, Equanil) 62

Mepron 54

mercaptopurine (Purinethol) 80

mesalamine (Rowasa Enema) 71

Mesnex tabs 81

Mestinon Timespan, syrup 68

metaproterenol sulfate (Alupent) 91

metaxalone (Skelaxin) 68

metformin hcl (Fortamet) 79

metformin hcl (Glucophage XR) 79

metformin hcl (Glucophage) 79

methadone hcl (Methadone) 64

methamphetamine hcl (Desoxyn) 63

methazolamide (Neptazane) 58

methen/m-blue/sal/na phos/hyos (Urelle) 51

methen/sod phos/meth blue/hyos (Urogesic) 51

methenam/me blue/ba/salicy/hyo (Hyophen) 51

methenamine hippurate (Hiprex/Urex) 51

methenamine mandelate (Mandelamine) 51

methimazole (Tapazole) 77

Methitest 77

methocarbamol (Robaxin) 68

methotrexate sodium (Methotrexate) 80

methotrexate sodium (Methotrexate) 75

methotrexate sodium/pf (Methotrexate) 80

methotrexate sodium/pf (Methotrexate) 75

methscopolamine bromide (Pamine, Forte) 69

methyclothiazide (Enduron) 58

methyldopa (Aldomet) 59

methyldopa/hydrochlorothiazide (Aldoril) 59

methylergonovine maleate (Methergine) 74

methylphenidate hcl (Metadate CD) 63

methylphenidate hcl (Methylin solution) 63

methylphenidate hcl (Ritalin LA) 63

methylphenidate hcl (Ritalin, SR; Methylin, ER) 63

methylprednisolone (Medrol, Dosepak) 77

metipranolol (Optipranolol) 87

metoclopramide hcl (Reglan tab, solution) 71

metolazone (Zaroxolyn) 58

metoprolol succinate (Toprol XL) 56

Trade Name Page Trade Name Pagemetoprolol tartrate (Lopressor) 56

metoprolol/hydrochlorothiazide (Lopressor HCT) 56

metronidazole (Flagyl) 54

metronidazole (Metrogel-Vaginal) 74

mexiletine hcl (Mexitil) 58

Miacalcin injection 78

Miacalcin injection 76

Micardis 57

Micardis HCT 57

miconazole nitrate (Monostat-3) 74

midazolam hcl (Versed) 63

midodrine hcl (Proamatine) 58

Minastrin 24 Fe 72

Minitran 59

Minivelle 73

Minivelle 76

Minivelle 73

minocycline hcl (Minocin, Dynacin) 49

minoxidil (Loniten) 60

mirtazapine (Remeron, Soltab) 61

misoprostol (Cytotec) 69

modafinil (Provigil) 63

moexipril hcl (Univasc) 56

moexipril/hydrochlorothiazide (Uniretic) 56

mometasone furoate (Elocon) 84

montelukast sodium (Singulair) 92

Monurol 51

morphine sulfate (MS Contin/Oramorph SR) 64

morphine sulfate (MSIR) 64

Moviprep 96

Moxatag 49

Moxeza 88

mth/me blue/sod phos/phen/hyos (Phosphasal) 51

Multaq 58

mupirocin (Bactroban ointment) 85

mv comb18/fefm-fepol cb1/fa (Tandem Plus) 94

Mycobutin 54

mycophenolate mofetil (Cellcept) 80

Myfortic 80

Myleran 80

Myrbetriq 93

Mytelase 68

nabumetone (Relafen) 64

nadolol (Corgard) 56

nadolol/bendroflumethiazide (Corzide) 56

Naftin 85

nalbuphine hcl (Nubain) 64

Nalfon 400mg 64

naltrexone hcl (Revia) 96

naltrexone hcl (Revia) 65

Namenda, solution 68

naphazoline hcl (Albalon) 89

naproxen (EC-Naprosyn) 64

naproxen (Naprosyn) 64

naproxen sodium (Anaprox, DS) 64

naratriptan hcl (Amerge) 66

Nascobal spray 94

Natacyn 88

Natazia 72

nateglinide (Starlix) 79

Nebupent aerosol 54

Nebusal 92

nefazodone hcl (Serzone) 61

neo/polymyx b sulf/dexameth (Maxitrol) 89

neomy sulf/bacitra/polymyxin b (Neosporin opth oint) 88

neomy sulf/bacitrac zn/poly/hc (Cortisporin) 89

neomycin sulfate (Neomycin) 54

neomycin/polymyxin b sulf/hc (Cortisporin) 90

neomycin/polymyxin b sulf/hc (Cortisporin) 89

neomycin/polymyxn b/gramicidin (Neosporin opth soln) 88

neomycin/polymyxn b/gramicidin (Neosporin opth solution) 88

Neoral 80

Nephron FA 94

Neulasta 83

Neulasta 81

Neumega 83

Neupogen 81

Neupogen 83

Neupro 66

Nevanac 87

nevirapine (Viramune) 53

Nexavar 82

Niacor 55

Niaspan 55

nicardipine hcl (Cardene) 57

nicotine (Nicotine Patch) 97

nicotine (Nicotine Patch) 97

nicotine polacrilex (Commit Lozenge OTC) 97

nicotine polacrilex (Nicotine Gum, Nicorette) 97

nicotine polacrilex (Nicotine Gum, Nicorette) 97

Nicotrol, NS 97

Nicotrol, NS 97

nifedipine (Procardia, XL;Adalat CC) 57

Nilandron 81

nimodipine (Nimotop) 68

nisoldipine (Sular) 57

Nitro-Dur 59

nitrofurantoin (Furadantin) 51

nitrofurantoin macrocrystal (Macrodantin) 51

nitrofurantoin monohyd/m-cryst (Macrobid) 51

nitroglycerin (Nitro-Bid ointment) 59

nitroglycerin (Nitroglycerin Patch) 59

nitroglycerin (Nitroglycerin SA cap) 59

nitroglycerin (Nitroglycerin spray) 59

Nitromist 59

Nitrostat 59

nizatidine (Axid [RX Only]) 69

nonoxynol 9 (Today Contraceptive Sponge) 73

nonoxynol 9 (VCF) 73

Norditropin NordiFlex 79

noreth a-et estra/fe fumarate (Estrostep Fe) 72

noreth a-et estra/fe fumarate (Estrostep Fe) 72

noreth a-et estra/fe fumarate (Loestrin, Fe) 72

noreth-ethinyl estradiol/iron (Femcon Fe) 72

noreth-ethinyl estradiol/iron (Femcon Fe) 72

norethind ac/ethinyl estradiol (FemHRT) 74

norethind ac/ethinyl estradiol (FemHRT) 76

norethindrone (Ortho Micronor, Nor-QD) 73

norethindrone (Ortho Micronor, Nor-QD) 73

norethindrone acetate (Aygestin) 73

norethindrone a-e estradiol (Loestrin, Fe) 72

norethindrone a-e estradiol (Loestrin, Fe) 72

Trade Name Page Trade Name Pagenorethindrone-ethinyl estrad (Modicon) 72

norethindrone-ethinyl estrad (Modicon) 72

norethindrone-ethinyl estrad (Necon 10/11) 72

norethindrone-ethinyl estrad (Norinyl 1/50, Ortho-Novum 1/50)

72

norethindrone-ethinyl estrad (Ortho-Novum 7/7/7) 72

norethindrone-ethinyl estrad (Ortho-Novum 7/7/7) 72

norethindrone-ethinyl estrad (Ovcon 35) 72

norethindrone-ethinyl estrad (Ovcon 35) 72

norethindrone-ethinyl estrad (Tri-Norinyl) 72

norethindrone-mestranol (Norinyl 1/35, Ortho-Novum 1/35) 72

norgestimate-ethinyl estradiol (Ortho Tri-Cyclen) 72

norgestimate-ethinyl estradiol (Ortho Tri-Cyclen) 72

norgestimate-ethinyl estradiol (Ortho-Cyclen) 72

norgestimate-ethinyl estradiol (Ortho-Cyclen) 72

norgestrel-ethinyl estradiol (Lo/Ovral) 72

norgestrel-ethinyl estradiol (Lo/Ovral) 72

norgestrel-ethinyl estradiol (Ovral) 72

Noroxin 50

Norpace CR 58

nortriptyline hcl (Pamelor, Aventyl) 61

Norvir 53

Novolin 70-30 78

Novolin N 78

Novolin R 78

Novolog, MIX 78

Noxafil 51

Nucynta 64

Nucynta ER 64

Nuedexta 68

Nutropin 79

Nutropin AQ 79

Nutropin AQ NuSpin 79

Nutropin, AQ 79

Nuvaring 73

Nuvigil 63

Nymalize 68

nystatin (Mycostatin) 85

nystatin (Nystatin) 74

nystatin (Nystatin) 51

nystatin/triamcin (Nystatin-triamcinolone) 85

octreotide acetate (Sandostatin) 81

octreotide acetate (Sandostatin) 78

ofloxacin (Floxin Otic) 90

ofloxacin (Floxin) 50

ofloxacin (Ocuflox) 88

Oforta 80

olanzapine (Zyprexa, Zydis) 62

olanzapine/fluoxetine hcl (Symbyax) 62

omeprazole (Prilosec) 69

Omnitrope 79

ondansetron (Zofran, ODT) 70

Onfi 67

Onglyza 79

opium/belladonna alkaloids (Donnatal) 69

Orap 62

Oravig 51

Orbivan 66

Orbivan 65

Orencia sub-q 75

Orfadin 96

orphenadrine citrate (Norflex) 68

orphenadrine/aspirin/caffeine (Norgesic, Forte) 68

Ortho Evra 73

Ortho Tri-Cyclen Lo 72

Ortho-Prefest 74

Osmoprep, Visicol 96

Osphena 74

Ovcon-50, Fe 72

Ovidrel 74

oxandrolone (Oxandrin) 77

oxaprozin (Daypro) 64

oxazepam (Serax) 62

oxcarbazepine (Trileptal) 67

Oxistat 85

Oxsoralen 86

Oxsoralen, Ultra 86

oxybutynin chloride (Ditropan XL) 93

oxybutynin chloride (Ditropan) 93

oxycodone hcl/acetaminophen (Percocet) 65

oxycodone hcl/aspirin (Percodan) 65

Oxycontin 64

Pancreaze 70

Pandel 84

Panretin 86

pantoprazole sodium (Protonix) 69

papaverine hcl (Papaverine caps) 60

paregoric (Paregoric) 69

Paremyd 87

paromomycin sulfate (Humatin) 54

paroxetine hcl (Paxil CR) 61

paroxetine hcl (Paxil) 61

Paser 54

Pataday 89

Patanol 89

Paxil susp 61

PCE 50

peg 3350/na sulf;bicarb;cl/kcl (Colyte) 96

peg 3350/na sulf;bicarb;cl/kcl (Golytely) 96

Pegasys, Proclick 83

Peg-Intron, Redipen 83

penicillin v potassium (Penicillin VK) 49

Pentasa 71

pentazocine hcl/naloxone hcl (Talwin NX) 65

pentoxifylline (Trental) 59

Perforomist 91

perindopril erbumine (Aceon) 56

permethrin (Elimite) 86

perphenazine (Perphenazine) 62

perphenazine/amitriptyline hcl (Etrafon) 61

Pertzye 70

Pexeva 61

phenazopy hcl/hyoscy/butabarb (Pyridium Plus) 93

phenazopy hcl/hyoscy/butabarb (Pyridium Plus) 51

phenazopyridine hcl (Pyridium) 93

phenazopyridine hcl (Pyridium) 51

phenelzine sulfate (Nardil) 61

phenobarb/hyoscy/atropine/scop (Donnatal) 69

phenobarbital (Phenobarbital) 67

phenylephrine hcl (Neo-Synephrine) 89

phenytoin (Dilantin chew tabs) 67

phenytoin sodium extended (Dilantin) 67

Phisohex 86

Trade Name Page Trade Name PagePhoslyra 96

Phospholine Iodide 87

phytonadione (Vitamin K) 59

phytonadione (Vitamin K) 94

Picato 86

pilocarpine hcl (Pilocar, Isopto-Carpine) 87

pilocarpine hcl (Salagen) 96

Pilopine HS 87

pindolol (Pindolol) 56

pioglitazone hcl (Actos) 79

pioglitazone hcl/metformin hcl (Actoplus MET) 79

pioglitazone/glimepiride (Duetact) 79

piroxicam (Feldene) 64

podofilox (Condylox solution) 86

polymyxin b sulfate/tmp (Polytrim) 88

Poly-Pred 89

Pomalyst 80

potassium chloride (Kayciel, Kaon-Cl, Kaon liquid) 95

potassium chloride (K-Tab, K-Dur, Slow-K, Kaon CL) 95

potassium citrate (Urocit-K) 93

potassium citrate/citric acid (Cytra-2, 3, K) 93

potassium iodide/iodine (Strong Iodine) 77

Potiga 67

Pradaxa 59

pramipexole di-hcl (Mirapex) 66

Pramosone 71

Prandimet 79

pravastatin sodium (Pravachol) 55

prazosin hcl (Minipress) 59

Pred Mild 88

Pred-G 89

prednisolone (Prednisolone, tabs, syrup) 77

prednisolone acetate (Pred Forte) 88

prednisolone sod phosphate (Inflamase, Forte) 88

prednisolone sod phosphate (Orapred) 77

prednisolone sod phosphate (Prednisolone Sodium Phosphate)

77

prednisone (Prednisone) 77

prednisone (Prednisone) 80

Premarin cream 76

Premarin cream 73

Premarin, Premarin Low Dose 73

Premarin, Premarin Low Dose 76

Prempro, Low Dose/Premphase 76

Prempro, Low Dose/Premphase 74

Prepopik 96

Prezista (Must Be Used With Norvir) 53

Priftin 54

Primaquine 53

primidone (Mysoline) 67

Primsol 51

Pristiq 61

Proair HFA, Ventolin HFA, 91

probenecid (Probenecid) 75

prochlorperazine maleate (Compazine) 70

Procrit 81

Procrit 83

Proctofoam-HC 71

Procysbi 96

progesterone (Progesterone in oil [inj]) 73

progesterone;micronized (Prometrium) 73

Proglycem 78

Promacta 83

promethazine hcl (Phenergan) 70

promethazine hcl (Phenergan) 91

propafenone hcl (Rythmol SR) 58

propafenone hcl (Rythmol) 58

propantheline bromide (Pro-Banthine 15mg) 69

propantheline bromide (Pro-Banthine 15mg) 93

proparacaine hcl (Alcaine) 89

propranolol hcl (Inderal LA) 56

propranolol hcl (Inderal) 56

propranolol/hydrochlorothiazid (Inderide) 56

propylthiouracil (Propylthiouracil) 77

Proquin XR 50

Prosed-DS 51

Prostigmin 68

Protopic 86

protriptyline hcl (Vivactil) 61

Proventil HFA 91

Proventil HFA 91

Pulmicort 1mg/2ml 91

Pulmicort Flexhaler 91

Pulmozyme 92

Pylera 69

pyrazinamide (Pyrazinamide) 54

pyridostigmine bromide (Mestinon) 68

Quartette 73

quetiapine fumarate (Seroquel) 62

quinapril hcl (Accupril) 56

quinapril/hydrochlorothiazide (Accuretic) 56

quinidine gluconate (Quinidine Gluconate) 58

quinidine sulfate (Quinidex) 58

quinine sulfate (Qualaquin) 53

Qvar 91

ramipril (Altace) 56

Ranexa 58

ranitidine hcl (Zantac [RX Only]) 69

Rapaflo 93

Rapamune tabs, solution 80

Ravicti 55

Rebetol solution 52

Rebif 83

Rectiv 71

Regranex 86

Relenza 52

Relistor 65

Relistor 71

Relpax 66

Remodulin 92

Renacidin 93

Renagel 96

Renvela Packet 0.8G 96

Renvela tablet 96

repaglinide (Prandin) 79

Rescriptor 53

reserpine (Reserpine) 59

Restasis 89

Revlimid 80

Reyataz 53

Rheumatrex 75

ribavirin (Copegus) 52

ribavirin (Rebetol) 52

Trade Name Page Trade Name Pageribavirin (Rebetol) 83

ribavirin (Ribapak) 52

Ridaura 75

rifampin (Rifadin) 54

rifampin/isoniazid (Rifamate) 54

Rifater 54

Rilutek 68

riluzole (Rilutek) 68

rimantadine hcl (Flumadine) 52

risperidone (Risperdal M-Tab) 62

risperidone (Risperdal) 62

rivastigmine tartrate (Exelon caps) 68

rizatriptan benzoate (Maxalt, MLT) 66

ropinirole hcl (Requip XL) 66

ropinirole hcl (Requip) 66

Rozerem 63

Sabril 67

Safyral 73

Saizen 79

Saizen 79

sal-amide/acetaminophn/p-tlox (Anabar) 64

salsalate (Disalcid, Salflex) 64

Samsca 96

Sancuso 70

Sandimmune 80

Sandostatin LAR 78

Sandostatin LAR 81

Santyl 86

Saphris 62

Sarafem tablet 61

Savella 68

secobarbital sodium (Seconal) 67

see chapter 7c (CORTICOSTEROIDS) 75

see chapters 3f & 3g (SALICYLATES AND NSAIDS) 75

selegiline hcl (Eldepryl) 66

selenium sulfide (Selsun [RX Only]) 86

Selzentry 53

Sensipar 78

Serevent Diskus 91

Seromycin 54

Serostim 79

sertraline hcl (Zoloft) 61

sildenafil citrate (Revatio) 92

Simponi 75

Simponi subq 75

simvastatin (Zocor) 55

Sirturo 54

Skelid 76

Sklice 86

sodium chloride for inhalation (Sodium Chloride) 92

sodium chloride/nahco3/kcl/peg (Nulytely) 96

sodium fluoride (Fluoride) 94

sodium fluoride (Luride) 94

sodium polystyrene sulfonate (Kayexalate) 96

Solaraze 86

Soltamox 81

Somatuline Depot 78

Somavert 78

Soriatane 86

sotalol hcl (Betapace, AF) 56

sotalol hcl (Betapace, AF) 58

spinosad (Natroba) 86

Spiriva 92

spironolact/hydrochlorothiazid (Aldactazide) 58

spironolactone (Aldactone) 58

Sporanox solution 51

Sprycel 82

SSKI 77

stavudine (Zerit) 53

Stavzor 67

Stimate 78

Stivarga 82

Strattera 63

Stribild 53

Stromectrol - Single Dose 54

Suboxone Film 65

Suclear 96

Sucraid 71

sucralfate (Carafate, susp) 69

sulfacetamide sodium (Bleph-10, Sodium Sulamyde) 88

sulfacetamide/prednisolone sp (Vasocidin) 89

sulfadiazine (Sulfadiazine) 50

sulfamethoxazole/trimethoprim (Bactrim, DS, Septra, DS susp)

50

sulfamethoxazole/trimethoprim (Bactrim, DS, Septra, DS) 50

sulfasalazine (Azulfidine EN-Tab) 71

sulfasalazine (Azulfidine EN-Tab) 75

sulfasalazine (Azulfidine tab) 75

sulfasalazine (Azulfidine tab) 71

sulindac (Clinoril) 64

sumatriptan (Imitrex nasal spray) 66

sumatriptan succinate (Imitrex injection) 66

sumatriptan succinate (Imitrex tablets) 66

Suprax 49

Suprax susp 49

Suprep 96

Sustiva 53

Sutent 82

Sylatron 81

Symax Duotab 93

Symax Duotab 69

Symbicort 92

Symlin 79

Synalgos-DC 65

Synarel 74

Synarel 78

Syprine 96

Taclonex, Scalp 86

tacrolimus (Prograf) 80

Tafinlar 82

Tamiflu cap, susp 52

tamoxifen citrate (Tamoxifen) 81

tamsulosin hcl (Flomax) 93

Tarceva 82

Targretin gel 86

Targretin oral 81

Tarka 56

Tarka 57

Tasigna 82

Tasmar 66

Tazorac 85

Tecfidera 83

Tegretol XR 100mg 67

Trade Name Page Trade Name PageTekamlo 60

Tekamlo 57

Tekturna 60

Tekturna HCT 60

temazepam (Restoril) 63

Temodar 80

terazosin hcl (Hytrin) 59

terazosin hcl (Hytrin) 93

terbinafine hcl (Lamisil tablets) 51

terbutaline sulfate (Brethine) 91

terconazole (Terazol-3, 7) 74

Testred, Android 77

tetracaine hcl (Tetcaine) 89

tetracycline hcl (Tetracycline) 49

Tetravisc 89

Tetravisc Forte 89

Teveten 57

Teveten 400mg 57

Teveten HCT 57

Tev-Tropin 79

Thalomid 80

Theo-24 92

theophylline anhydrous (Theophylline Anhydrous) 92

Thioguanine 80

Thiola 96

thioridazine hcl (Mellaril) 62

thiothixene (Navane) 62

thyroid,pork (Westhroid-p) 77

thyroid;pork (Nature-Throid) 77

thyroid;pork (NP Thyroid) 77

thyroid;pork (Westhroid) 77

Thyrolar 77

tiagabine hcl (Gabitril 2, 4mg) 67

ticlopidine hcl (Ticlid) 59

Tikosyn 58

timolol maleate (Blocadren) 56

timolol maleate (Timoptic) 87

tinidazole (Tindamax) 54

Tirosint 77

tizanidine hcl (Zanaflex tabs) 68

Tobi 54

Tobi podhaler 54

Tobradex oint 89

Tobradex ST 89

tobramycin sulfate (Tobrex) 88

tobramycin/dexamethasone (Tobradex susp) 89

Tobrex 88

tolazamide (Tolinase) 79

tolbutamide (Orinase) 79

tolmetin sodium (Tolectin, DS) 64

tolterodine tartrate (Detrol) 93

topiramate (Topamax) 67

torsemide (Demadex) 58

Toviaz 93

Tracleer 92

Tradjenta 79

tramadol hcl (Ryzolt) 65

tramadol hcl (Ultram ER) 65

tramadol hcl (Ultram) 65

tramadol hcl/acetaminophen (Ultracet) 65

trandolapril (Mavik) 56

tranexamic acid (Lysteda) 74

Transderm-Scop 70

tranylcypromine sulfate (Parnate) 61

Travatan, Z 87

travoprost (benzalkonium) (Travatan) 87

trazodone hcl (Desyrel) 61

Trecator 54

Trelstar 81

Trelstar Depot, LA 81

tretinoin (Retin-A) 85

Trexall 75

triamcinolone acetonide (Aristocort, Kenalog 0.05% cream)

84

triamcinolone acetonide (Aristocort, Kenalog) 84

triamcinolone acetonide (Nasacort AQ) 90

triamcinolone acetonide (Nasacort AQ) 92

triamcinolone acetonide (Oralone) 96

triamterene/hydrochlorothiazid (Maxzide, Dyazide) 58

triazolam (Halcion) 63

Tribenzor 57

Tribenzor 57

trifluoperazine hcl (Stelazine) 62

trifluridine (Viroptic) 88

Triglide 55

trihexyphenidyl hcl (Artane) 66

trimethobenzamide hcl (Tigan) 70

trimethoprim (Trimethoprim) 51

trimipramine maleate (Surmontil) 61

Trizivir 53

tropicamide (Mydriacyl) 87

trospium chloride (Sanctura) 93

Truvada 53

Tudorza Pressair 92

Twinject 92

Twynsta 57

Twynsta 57

Tykerb 82

Tyvaso 92

Tyvaso 92

Tyvaso 92

Tyzeka 52

Tyzine 91

Tyzine 90

Ulesfia 86

Uloric 75

Urelle 51

Uribel 51

ursodiol (Urso) 70

Vagifem 73

valacyclovir hcl (Valtrex) 52

Valcyte 52

valproate sodium (Depakene) 67

valproic acid (Depakene) 67

valsartan/hydrochlorothiazide (Diovan HCT) 57

vancomycin hcl (Vancocin) 54

Vanos 0.1% cream 84

Vectical 86

venlafaxine hcl (Effexor XR) 61

venlafaxine hcl (Effexor) 61

Ventavis 92

verapamil hcl (Calan SR/Isoptin SR) 57

verapamil hcl (Verelan PM) 57

Trade Name Page Trade Name PageVeregen 86

Vesicare 93

Vexol 88

Vfend susp 51

Vibramycin suspension 49

Vibramycin syrup 49

Victoza 79

Victrelis 52

Videx 53

Vigamox 88

Viibryd 61

Vimpat 67

Viokace 70

Viokase 70

Viracept 53

Viramune XR 53

Virazole 52

Viread 53

vit b cmplx 3/fa/vit c/biotin (Nephro-Vite RX) 94

vit b cplx #11/fa/c/biot/zn ox (Dailyvite) 94

Vivelle-Dot 76

Vivelle-Dot 73

voriconazole (Vfend) 51

Votrient 82

Vusion 85

Vytorin 55

warfarin sodium (Coumadin) 59

Welchol 55

Xalkori 82

Xarelto 59

Xeljanz 75

Xeloda 80

Xenazine 96

Xerese 85

Xifaxan 200mg 54

Xifaxan 550mg 71

Xolegel 85

Xtandi 81

Xyrem 68

Yodoxin 54

zafirlukast (Accolate) 92

zaleplon (Sonata) 63

Zantac Efferdose 69

Zavesca 96

Zelapar 66

Zelboraf 82

Zemplar 78

Zenpep 70

Zenzedi 63

Zerit 53

Zetia 55

Ziagen 53

Ziana Gel 85

zidovudine (Retrovir) 53

zinc sulfate (Zinc Sulfate) 94

Zioptan 87

ziprasidone hcl (Geodon) 62

Zirgan 88

Zithranol-RR 86

Zmax 50

Zoladex 81

Zolinza 81

zolmitriptan (Zomig, ZMT) 66

zolpidem tartrate (Ambien CR) 63

zolpidem tartrate (Ambien) 63

Zomig nasal spray 66

Zonalon, Prudoxin 86

zonisamide (Zonegran) 67

Zorbtive 79

Zortress 82

Zubsolv 65

Zyclara 86

Zyflo, CR 92

Zylet 89

Zymar 88

Zymaxid 88

Zytiga 81

Zyvox 54

R020677CB 13546 SEP 13

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Documents

BCBSM/BCN Custom Select Drug ListPage 5 BCBSM and BCN Custom Select Drug List The BCBSM and BCN Custom Select Drug List is a useful reference and educational tool for prescribers,