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BJC Emergency Fill List for Plan Year 2021 *

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BJC Emergency Fill List for Plan Year 2021 * BJC Emergency Fill List for Plan Year 2021 * In case of an emergency you and each of your covered dependents can fill up to 2 prescriptions per year from the following list of acute medications at a participating Express Scripts network pharmacy for the same copayment you would pay at a BJC or select out‐of‐area pharmacy. 1-DAY ASPERCREME LIDOCAINE BLEPH-10 3 DAY VAGINAL ASPIRIN-CAFFEINE-DIHYDROCODEIN BLEPHAMIDE 3-DAY VAGINAL CREAM ATHLETE'S FOOT BLEPHAMIDE S.O.P. ABSTRAL ATHLETIC FOOT CREAM BRIMONIDINE TARTRATE ACETAMIN-CAFF-DIHYDROCODEINE AUGMENTIN BROMFENAC SODIUM ACETAMINOPHEN-CODEINE AUGMENTIN ES-600 BROMSITE ACETIC ACID-ALUMINUM AUGMENTIN XR BSS ACTIQ AVC BSS PLUS ACTISEP AVELOX BUDESONIDE EC ACULAR AVELOX IV BUDESONIDE ER ACULAR LS AVIDOXY BUPRENEX ACYCLOVIR AVYCAZ BUPRENORPHINE ACYCLOVIR SODIUM AZACTAM BUPRENORPHINE HCL AEMCOLO AZACTAM-ISO-OSMOTIC DEXTROSE BUPRENORPHINE-NALOXONE A-HYDROCORT AZASITE BURN RELIEF AK-POLY-BAC AZELASTINE HCL BUTALB-ACETAMINOPH-CAFF-CODEIN ALAWAY AZITHROMYCIN BUTALB-CAFF-ACETAMINOPH-CODEIN ALBENDAZOLE AZO URINARY PAIN RELIEF BUTALBITAL COMPOUND-CODEINE ALBENZA AZO URINARY TRACT DEFENSE BUTALBITAL-ASPIRIN-CAFFEINE ALBUTEROL SULFATE AZO URINARY TRACT HEALTH BUTORPHANOL TARTRATE ALBUTEROL SULFATE HFA AZOPT CANK-OXIDE ALFENTANIL HCL AZTREONAM CAPITAL W-CODEINE ALLERGY EYE DROPS BABY TEETHING GEL CARBAMOXIDE ALOCANE EMERGENCY BURN BABY TEETHING PAIN MEDICINE CAYSTON ALPHAGAN P BACIGUENT CEDAX ALREX BACIIM CEFACLOR ALTACHLORE BACITRACIN CEFACLOR ER ALTAFLUOR BACITRACIN-POLYMYXIN CEFADROXIL ALTAFLUOR BENOX BACTRIM CEFAZOLIN SODIUM AMOXICILLIN BACTRIM DS CEFAZOLIN SODIUM-DEXTROSE AMOXICILLIN-CLAVULANATE POT ER BAXDELA CEFDINIR AMOXICILLIN-CLAVULANATE POTASS BELBUCA CEFDITOREN PIVOXIL AMPICILLIN SODIUM BENZ-O-STHETIC CEFIXIME AMPICILLIN TRIHYDRATE BEPREVE CEFOTAN AMPICILLIN-SULBACTAM BESIVANCE CEFOTAXIME SODIUM ANASPAZ BETADINE CEFOTETAN ANBESOL BETAMETHASONE ACETATE-SOD PHOS CEFOXITIN ANESTHETIC ORAL GEL BETAMETHASONE SOD PHOS-ACETATE CEFOXITIN SODIUM ANTIFUNGAL BETAMETHASONE SOD PHOS-WATER CEFPODOXIME PROXETIL APRACLONIDINE HCL BETHANECHOL CHLORIDE CEFPROZIL ARISTOSPAN BICILLIN C-R CEFTAZIDIME ASA-BUTALB-CAFFEINE-CODEINE BICILLIN L-A CEFTIBUTEN ASCOMP WITH CODEINE BILTRICIDE CEFTIN * This list is not all-inclusive and does not guarantee coverage Page 1 of 6 BJC Emergency Fill List for Plan Year 2021 * CEFTRIAXONE COREMINO DOXYCYCLINE HYCLATE CEFUROXIME CORTANE-B DOXYCYCLINE MONOHYDRATE CEFUROXIME SODIUM CORTEF DURAMORPH CEFUROXIME SODIUM-0.9% NACL CORTISONE ACETATE DUREZOL CELESTONE CORTISPORIN-TC DVORAH CEPACOL SORE THROAT CRESEMBA DXEVO CEPHALEXIN CROMOLYN SODIUM E.E.S. 200 CEQUA CROTAN E.E.S. 400 CHEMET CYCLOSPORINE IN KLARITY EAR DROPS CHILDREN'S ALAWAY CYSTARAN EAR DROPS FOR SWIMMERS CHLORASEPTIC SORE THROAT CYSTEX PLUS EAR DRYING AGENT CILOXAN DALVANCE EAR SYSTEM CIPRO DARIFENACIN ER EAR WAX REMOVAL CIPRO HC DAXBIA EARWAX TREATMENT DROPS CIPRO I.V. DEBROX ED-SPAZ CIPRODEX DECADRON EHA CIPROFLOXACIN DEFERASIROX ELESTAT CIPROFLOXACIN ER DEFERIPRONE ELIMITE CIPROFLOXACIN HCL DELTASONE EMADINE CIPROFLOXACIN-D5W DEMECLOCYCLINE HCL EMVERM CIPROFLOXACIN-DEXAMETHASONE DEMEROL ENABLEX CLAFORAN DEPO-MEDROL ENDOCET CLARITHROMYCIN DERMOTIC ENTOCORT EC CLARITHROMYCIN ER DEXABLISS EPINASTINE HCL CLEOCIN DEXAMETHASONE ERYPED 200 CLEOCIN HCL DEXAMETHASONE ACETATE LA ERYPED 400 CLEOCIN PEDIATRIC DEXAMETHASONE ACETATE-SOD PHOS ERY-TAB CLEOCIN PHOSPHATE DEXAMETHASONE INTENSOL ERYTHROCIN LACTOBIONATE CLEOCIN PHOSPHATE IN D5W DEXAMETHASONE SODIUM PHOSPHATE ERYTHROCIN STEARATE CLINDAMYCIN HCL DEXAMETHASONE-0.9% NACL ERYTHROMYCIN CLINDAMYCIN PALMITATE HCL DEXAMETHASONE-MOXIFLOXACIN ERYTHROMYCIN ETHYLSUCCINATE CLINDAMYCIN PEDIATRIC DEXONTO EURAX CLINDAMYCIN PHOSPHATE DEXPAK EXALGO CLINDAMYCIN PHOSPHATE-D5W DEXTENZA EYE IRRIGATING SOLUTION CLINDAMYCIN-0.9% NACL DEXYCU EYE ITCH RELIEF CLINDESSE DICLOFENAC SODIUM EYE WASH CLOTRIMAZOLE DICLOXACILLIN SODIUM EYE-STREAM CLOTRIMAZOLE AF DIFLUCAN FACTIVE CLOTRIMAZOLE-3 DILATRATE-SR FAMCICLOVIR CLOTRIMAZOLE-7 DILAUDID FENTANYL CODEINE SULFATE DISKETS FENTANYL BASE COLISTIMETHATE DITROPAN XL FENTANYL CITRATE COLLYRIUM DOLOPHINE HCL FENTANYL CITRATE-STERILE WATER COLY-MYCIN M PARENTERAL DORYX FERRIPROX COLY-MYCIN S DORZOLAMIDE FERRIPROX (2 TIMES A DAY) COMPLETE LICE TREATMENT DORZOLAMIDE HCL FIORICET WITH CODEINE CONZIP DOXY 100 FIORINAL WITH CODEINE #3 * This list is not all-inclusive and does not guarantee coverage Page 2 of 6 BJC Emergency Fill List for Plan Year 2021 * FIRST-MOUTHWASH BLM ILUVIEN LORCET HD FLAC OTIC OIL INFUMORPH LORCET PLUS FLAGYL INTENSE TOOTHACHE PAIN RELIEF LORTAB FLAREX INVELTYS LOTEMAX FLAVOXATE HCL IOPIDINE LOTEMAX SM FLUCONAZOLE ISOCHRON LOTEPREDNOL ETABONATE FLUCONAZOLE IN DEXTROSE ISORDIL LYCELLE FLUCONAZOLE IN SALINE ISORDIL TITRADOSE MACROBID FLUCONAZOLE-NACL ISOSORBIDE DINITRATE MACRODANTIN FLUDROCORTISONE ACETATE ISOSORBIDE DINITRATE ER MAFENIDE ACETATE FLUOCINOLONE ACETONIDE OIL ISOSORBIDE MONONITRATE MALATHION FLUORESCEIN-PROPARACAINE ISOSORBIDE MONONITRATE ER MAXITROL FLUOROMETHOLONE ITCH RELIEF MEDICATED DOUCHE FLURBIPROFEN SODIUM ITCHY EYE MEDIWASH FLUROX ITRACONAZOLE MEDI-WASH FML IVERMECTIN MEDROL FORTAZ JETREA ME-NAPHOS-MB-HYO 1 FORTAZ IN ISO-OSMOTIC DEXTROSE JOCK ITCH MEPERIDINE HCL FURADANTIN JOCK ITCH RELIEF METHADONE HCL GATIFLOXACIN KADIAN METHADONE INTENSOL GATIFLOXACIN-DEXAMETHASONE KEFLEX METHADOSE GELNIQUE KENALOG-10 METHENAMINE HIPPURATE GENTAK KENALOG-40 METHENAMINE MANDELATE GENTAMICIN SULFATE KENALOG-80 METHYLPREDNISOLONE GLY-OXIDE KETOCONAZOLE METHYLPREDNISOLONE ACETATE GONITRO KETOROLAC TROMETHAMINE METHYLPREDNISOLONE SODIUM SUCC GYNAZOLE 1 KETOTIFEN FUMARATE METHYLPREDNISOLONE-BUPIVACAINE GYNE-LOTRIMIN KLARITY-A(AZITHROMYCIN-CHONDR) METRO IV GYNE-LOTRIMIN-7 LEVAQUIN METROGEL-VAGINAL HIDEX LEVBID METRONIDAZOLE HIPREX LEVOFLOXACIN MICONAZOLE 1 HURRICAINE LEVOFLOXACIN-D5W MICONAZOLE 3 HYDROCODONE BITARTRATE ER LEVORPHANOL TARTRATE MICONAZOLE 7 HYDROCODONE-ACETAMINOPHEN LEVSIN MICONAZOLE NITRATE HYDROCODONE-IBUPROFEN LEVSIN-SL MICONAZOLE-7 HYDROCORTISONE LICE BEDDING MILLIPRED HYDROCORTISONE-ACETIC ACID LICE COMPLETE KIT 1-2-3 MILLIPRED DP HYDROMORPHONE ER LICE KILLING MINITRAN HYDROMORPHONE HCL LICE PYRINYL SHAMPOO MINOCIN HYOPHEN LICE SOLUTION MINOCYCLINE HCL HYOSCYAMINE SULFATE LICE TREATMENT MINOCYCLINE HCL ER HYOSCYAMINE SULFATE ER LIDOCAINE HCL MINOLIRA ER HYOSCYAMINE SULFATE SR LIDOCAINE HCL VISCOUS MITIGO HYOSYNE LIDOCAINE PLUS MONDOXYNE NL HYSINGLA ER LINDANE MONISTAT 1 IBUDONE LOCORT MONISTAT 3 ILEVRO LORCET MONISTAT 7 * This list is not all-inclusive and does not guarantee coverage Page 3 of 6 BJC Emergency Fill List for Plan Year 2021 * MONODOX NUVESSA PEDIAPRED MONUROL NUZYRA PENICILLIN G POTASSIUM MORGIDOX NYSTATIN PENICILLIN G PROCAINE MORPHINE SULFATE OCUFLOX PENICILLIN G SODIUM MORPHINE SULFATE ER OFLOXACIN PENICILLIN GK-ISO-OSM DEXTROSE MOUTH PAIN OKEBO PENICILLIN V POTASSIUM MOXATAG OMIDRIA PENTAM 300 MOXEZA OMNIPRED PENTAMIDINE ISETHIONATE MOXIFLOXACIN ONMEL PENTAZOCINE-NALOXONE HCL MOXIFLOXACIN HCL OPANA PERMETHRIN MOXIFLOXACIN HCL-BSS OPANA ER PEROXIDE SORE MOUTH CLEANSER MOXIFLOXACIN HCL-NACL ORABASE PEROXYL DENTAL RINSE MS CONTIN ORAL ANALGESIC PEROXYL ORAL CLEANSER MURINE EAR DROPS ORAL ANESTHETIC PFIZERPEN MURINE EAR WAX REMOVAL SYSTEM ORAL ANESTHETIC PASTE PHENAZOPYRIDINE HCL MURO-128 ORAL CLEANSER PHOSPHASAL MYDRIATIC4(TROP-PROP-PE-KTRLC) ORAL PAIN RELIEVER PINAWAY NAFCILLIN ORAMAGIC PLUS PINWORM MEDICINE NAFCILLIN SODIUM ORAPRED ODT PINWORM TREATMENT NALBUPHINE HCL ORASEP PIN-X NALOCET ORAVIG PIPERACILLIN-TAZOBACTAM NALOXONE HCL ORBACTIV POLYCIN NALTREXONE HCL OSCIMIN POLYMYXIN B SUL-TRIMETHOPRIM NEBUPENT OSCIMIN SL POLYTRIM NEOMYCIN-BACITRACIN-POLY-HC OSCIMIN SR POSACONAZOLE NEOMYCIN-BACITRACIN-POLYMYXIN OSELTAMIVIR PHOSPHATE POVIDONE-IODINE NEOMYCIN-POLYMYXIN-DEXAMETH OTIPRIO PRAZIQUANTEL NEOMYCIN-POLYMYXIN-GRAMICIDIN OTOVEL PRE-ATTACHED LTA KIT NEOMYCIN-POLYMYXIN-HC OVIDE PRED FORTE NEOMYCIN-POLYMYXIN-HYDROCORT OXACILLIN PRED-G NEO-POLYCIN OXACILLIN SODIUM PREDNISOLONE NEO-POLYCIN HC OXAYDO PREDNISOLONE ACETATE NITRO-BID OXYBUTYNIN CHLORIDE PREDNISOLONE ACET-GATIFLOXACIN NITRO-DUR OXYBUTYNIN CHLORIDE ER PREDNISOLONE ACET-MOXIFLOXACIN NITROFURANTOIN OXYCODONE HCL PREDNISOLONE PHOS-GATIFLOXACIN NITROFURANTOIN MONO-MACRO OXYCODONE HCL-ASPIRIN PREDNISOLONE PHOS-MOXIFLOXACIN NITROGLYCERIN OXYCODONE HCL-IBUPROFEN PREDNISOLONE SODIUM PHOS ODT NITROGLYCERIN IN D5W OXYCODONE-ACETAMINOPHEN PREDNISOLONE SODIUM PHOSPHATE NITROGLYCERIN PATCH OXYCONTIN PREDNISONE NITROLINGUAL OXYMORPHONE HCL PREDNISONE INTENSOL NITROMIST OXYMORPHONE HCL ER PRIMSOL NITROSTAT OXYTROL PROBUPHINE NITRO-TIME OXYTROL FOR WOMEN PROLATE NIX PAIN RELIEF PROLENSA NIX COMPLETE PANLOR PYRIDIUM NOXAFIL PATADAY RADIAGUARD NULEV PCE REESE'S PINWORM * This list is not all-inclusive and does not guarantee coverage Page 4 of 6 BJC Emergency Fill List for Plan Year 2021 * RELENZA TALWIN URETRON D-S REMIFENTANIL HCL TAMIFLU URIBEL REPREXAIN TAPERDEX URIMAR-T RESTASIS TARGADOX URIN D.S. RESTASIS MULTIDOSE TAZICEF URINARY PAIN RELIEF RETISERT TERAZOL 7 URISTAT RID TERCONAZOLE URO-458 RINGWORM TETRACYCLINE HCL UROGESIC-BLUE ROXICODONE TINDAMAX URO-MP ROXYBOND TINIDAZOLE UROQID-ACID NO.2 SEYSARA TIOCONAZOLE-1 URYL SILVADENE TOBRADEX USTELL SILVER SULFADIAZINE TOBRADEX ST UTA SIMBRINZA TOBRAMYCIN UTIRA-C SKLICE TOBRAMYCIN-DEXAMETHASONE VAGISTAT-3 SOCHLOR TOBREX VALACYCLOVIR SODIUM CHLORIDE TOLTERODINE TARTRATE VALACYCLOVIR HCL SOLIFENACIN SUCCINATE TOLTERODINE TARTRATE ER VANCOCIN HCL SOLODYN TOVIAZ VANCOMYCIN SOLOSEC TRAMADOL HCL VANCOMYCIN
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