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2006 Effective April 1, 2006 Blue Cross and Blue Shield of Oklahoma Drug Formulary D r u g L i s t b y therapeuti c c l a s s

Blue Cross and Blue Shield of Oklahoma members are requested to talk to their physicians about prescribing included on the Drug List.

This document reflects the Blue Cross and Blue Shield of Oklahoma and BlueLincs HMO Drug Formulary as of April 1, 2006. The Drug List is updated quarterly. Please visit www.bcbsok.com for recent updates.

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

TA B l e o f C o n t e n t s k e y Introduction...... 2 caps...... capsules Member Prescription Benefit...... 2 conc ...... concentrate Pharmacy and Therapeutics (P&T) Committee. . . 2 crm...... cream How to use this Drug List...... 2 delayed-release. . . . enteric-coated Cost Index...... 3 ext-release ...... extended-release Generic Substitution...... 3 inj ...... injection liq ...... liquid Quantity Limits (QL)...... 4 oint...... ointment Step Therapy (ST) ...... 5 QL...... quantity limit Pharmacologic and Therapeutic Categories. . . . . 6 SL ...... sublingual Anti-infective Drugs...... 6 soln...... solution Cancer Drugs...... 6 ST...... step therapy Hormones, Diabetes and Related Drugs...... 7 supp...... suppositories Heart and Circulatory Drugs...... 8 susp...... suspension tabs...... tablets Respiratory Drugs ...... 9 Gastrointestinal Drugs...... 10 C o n ta c t I n f o r m at i o n Genitourinary Drugs ...... 11 Central Nervous System Drugs ...... 11 If you have any questions regarding the Blue Cross and Blue Shield of Oklahoma Drug Formulary, or if you have Pain Relief Drugs...... 12 comments or suggestions that can improve the useful- Neuromuscular Drugs...... 13 ness of this publication, please direct them to: Supplements ...... 13 Ronald C. White, D.Ph. Blood Modifying Drugs...... 14 Manager Pharmacy Programs Topical Drugs...... 14 1400 South Boston Miscellaneous Categories ...... 15 Tulsa, OK 74119-3612

Phone: 918-561-9906 Fax: 918-561-9963 E-mail: [email protected]

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, 2 9 2 0 A © P rime T herape u tics L L C 3 / 0 6 an Independent Licensee of the Blue Cross and Blue Shield Association

Blue Cross and Blue Shield of Oklahoma 2006 Drug list by therapeutic class –  of 15 i n t r o d u C t i o n p h a r m a C Y a n d t h e r a p e u t i C S ( P & T ) C o m m i t t e e Blue Cross and Blue Shield of Oklahoma is pleased to present the 2006 Blue Cross and Blue Shield of Oklahoma The Prime Therapeutics P&T Committee includes and BlueLincs HMO Drug Formulary. The formulary listing physicians and pharmacists from throughout the country, and includes all Tier II Preferred Brand drugs and a partial listing includes a voting member from Blue Cross and Blue Shield of Tier I generic drugs and Tier III Brand drugs. The formulary of Oklahoma. Prime Therapeutics does not have voting only lists drugs recommended by Blue Cross and Blue Shield privileges on this committee. of Oklahoma based upon clinical recommendations of the Prime Therapeutics National Pharmacy and Therapeutics Blue Cross and Blue Shield of Oklahoma also works with (P&T) Committee. Drugs are recommended for addition to the Health Care Service Corporation (HCSC) Preferred the formulary after considering safety, efficacy, uniqueness and Drug Committee. They consider the P&T Committee’s cost. Physicians are encouraged to prescribe drugs listed in this recommendations before making the final determination formulary. Members are encouraged to show this formulary to regarding drug changes to the formulary. Members and their physicians and pharmacists. physicians can view the most up-to-date version of the formulary at www.bcbsok.com. The formulary is multi-tiered, placing prescription drugs into one of three copayment levels; generic, Preferred Brand, h o W t o u s e t h i s f o r m u l a r y or Brand. The drug beneft includes almost all prescription drugs, although some exclusions do apply. For example, drugs The formulary is organized into broad therapeutic categories. indicated for cosmetic purposes, e.g., Propecia, for hair growth, Within most categories, drugs are grouped based upon drug are not covered. Copayment levels vary depending on your class, e.g. Macrolides, or use for a specific medical condition, plan. When you have a prescription flled, prescription costs e.g. diabetes. All the drugs listed, whether generic, Preferred will be lower if you choose generic drugs. Preferred Brand drugs Brand or Brand, are recommended drugs. cost less than Brand drugs, which have the highest copayment. The majority of Brand drugs have a generic or Preferred Brand Generic drugs are shown in lowercase boldface type in the alternative. Generic drugs, including those that are unlisted, left-hand column. Most generic drugs are followed by a are available to members at a lower copayment. All Preferred reference brand drug (in parentheses) to assist in product Brand drugs are listed in this formulary. Brand drugs not listed recognition. Some generic products have no brand reference. in this formulary are available to members and, depending Brand reference drugs usually take the highest copayment. on the plan, may have the highest copayment. Some drugs, generic and brand, have a quantity limit per month and are Example: ibuprofen (Motrin) listed on pages 4-5. Preferred Brand and Brand drugs are noted in capital letters M e m b e r P r e s c ription Benefit in the center and right-hand columns.

Generally, prescription drugs are available to members at one Example: LIPITOR of three copayment levels. However, coverage and cost sharing may vary depending on the member’s group benefits: Generic versions of immediate-release dosage forms and strengths of reference brand drugs (shown in parentheses) Tier I – Lowest copay: Generic drugs – listed and unlisted and all strengths and dosage forms of the Preferred Brand generic drugs and Brand drugs (shown in capital letters) usually apply to Tier II – Middle copay: Preferred Brand drugs – all are listed in the entry in the formulary. Exceptions are noted. this formulary Tier III – Highest copay: Brand drugs – listed and unlisted Example: atenolol (Tenormin) brand drugs Tenormin is marketed as 25 mg, 50 mg and 100 mg tablets. Each strength is available generically. Generic atenolol is recommended for use. Tenormin is noted for reference only and is not on the formulary.

Example: sucralfate tabs (Carafate)

Blue Cross and Blue Shield of Oklahoma 2006 Drug list by therapeutic class –  of 15 Carafate is marketed as 1 g tablets and 500 mg/5 mL oral C o s t i n d e X suspension. The tablets have generic versions available; the oral suspension is only available as brand Carafate. The Dollar signs are based $. . . . $20.00 or less formulary entry includes generic tablets. Carafate suspension upon Average Wholesale $$. . . $20.01 to $40 would require a separate entry to be included. Because the Price (AWP) or Maximum $$$. . $40.01 to $80 suspension is not listed, it would take the highest copayment. Allowable Cost (MAC) and $$$$. $80.01 to $160 range from one ($) to five $$$$$ More than $160 • Individual formulary entries are required for specific dosage ($$$$$), ranking the drugs forms including oral immediate-release, extended-release, from least to most expensive. delayed-release, rectal, injectable, otic, ophthalmic, vaginal, Typically, dollar signs assigned to maintenance drugs are nasal, orally disintegrating tablets, transdermal, and topical. based upon a 30-day supply at the most commonly prescribed strength and dosage. For drugs that are not for maintenance Example: estradiol patches (Climara) conditions, other more appropriate quantities are used to estradiol tabs (Estrace) determine dollar signs.

Oral immediate-release and transdermal dosage forms of g e n e r i C s u B s t i t u t i o n estradiol require separate entries in the formulary. Blue Cross and Blue Shield of Oklahoma encourages generic • The category where a product is listed determines which utilization as a way to provide high-quality drugs at a reduced dosage form(s) are in the formulary. cost. Generic drugs are as safe and effective as their brand- name counterparts, but are usually less expensive. Generic Example: VOLTAREN drugs are manufactured under the same strict standards of When listed in the Eye category, this entry indicates that FDA’s Good Manufacturing Practice regulations that are Voltaren ophthalmic solution is a Preferred Brand. Voltaren required for brand products including batch requirements for tablets would require a separate entry in Rheumatoid and identity, strength, purity and quality. Osteoarthritis category to be included in the formulary. An FDA-approved generic drug may be substituted for the • The brand reference drug (shown in parentheses) defines the brand counterpart because it: extended-release or combination product listed in the formulary. • Contains the same active ingredient(s) as the brand-name drug Example: verapamil ext-release (Verelan) • Is identical in strength, dosage form and route of administration • Is therapeutically equivalent and can be expected to have The generic version of Verelan is recommended for use based the same clinical effects and safety profle upon this entry. Other extended-release verapamil products such as Verelan PM or Calan SR would require a separate entry. To encourage use of generic drugs, Preferred Brand and Brand drugs typically are removed from the formulary book after a Example: sulfacetamide/sulfur (Sulfacet-R) generic version becomes available.

Based upon this entry, the generic version of Sulfacet-R is In determining the brand or generic classifcation for covered recommended for use. Brand Sulfacet-R and other strengths prescription drugs, Blue Cross and Blue Shield of Oklahoma and formulations of sulfacetamide/sulfur brand products would utilizes the generic/brand status assigned by a nationally require a separate entry to be included in the formulary. recognized provider of drug product data base information. The brand/generic status of a drug from a specifc marketer is subject to change.

Blue Cross and Blue Shield of Oklahoma 2006 Drug list by therapeutic class –  of 15 Q u a n t i t y L i m i t s ( Q L )

Quantity limits identify the maximum quantity that can be dispensed over a specific period of time. Limits are in place to encourage appropriate drug utilization, enhance member outcomes, and reduce drug benefit costs. Limits are typically developed based upon FDA-approved drug labeling.

The following brand drugs, and generic versions if available (noted in boldface), have quantity limits as of January 1, 2006. This list is subject to change.

BRAND DOSAGE FORM/STRENGTH DISPENSING LIMITS (generic name),or generic name per 30-day supply

Actiq (fentanyl citrate) ...... transmucosal, all strengths ...... 120 units Advair Diskus (salmeterol/) ...... inhalers, 100/50, 250/50, 500/50 mcg ...... 60 powder disks (1 inhaler) Aerobid, Aerobid M () ...... inhaler ...... 21 g (3 inhalers) albuterol ...... inhaler ...... 34 g (2 inhalers) Albuterol Sulfate HFA (albuterol sulfate) ...... inhaler, 8.5 g ...... 17 g (2 inhalers) Alora (estradiol) ...... patch ...... 8 patches Alupent (metaproterenol) ...... inhaler ...... 28 g (2 inhalers) Amerge (naratriptan) ...... tablets, 1 mg, 2.5 mg ...... 18 tablets Anzemet (dolesetron) ...... tablets, 50 mg, 100 mg ...... 10 tablets Astelin (azelastine) ...... nasal solution ...... 30 mL (1 bottle) Atrovent (ipratropium) ...... nasal solution, 0.03% ...... 30 mL (1 bottle) Atrovent (ipratropium) ...... nasal solution, 0.06% ...... 30 mL (2 bottles) Atrovent HFA (ipratropium) ...... inhaler ...... 25.8 g (2 inhalers) Avonex (interferon beta-1a) ...... vial or syringe ...... 1 pkg (4 doses) Axert (almotriptan) ...... tablets, 6.25 mg, 12.5 mg ...... 12 tablets Azmacort ( acetonide) ...... inhaler ...... 40 g (2 inhalers) Bactroban Nasal (mupirocin) ...... ointment, 2% ...... 10 - 1 g single use tubes Beconase AQ (beclomethasone dipropionate) ...... nasal suspension ...... 50 g (2 bottles) Betaseron (interferon beta-1b) ...... vial ...... 1 pkg (15 vials) Caverject (alprostadil) ...... injection, all strengths ...... 8 vials Cialis (tadalafil) ...... tablets, all strengths ...... 8 tablets Climara (estradiol) ...... patch ...... 8 patches Combivent (albuterol/ipratropium) ...... inhaler ...... 29.4 g (2 inhalers) Copaxone (glatiramer acetate) ...... syringe ...... 1 pkg (30 syringes) Diflucan fluconazole( ) ...... tablets, 150 mg ...... 3 tablets Duoneb (albuterol sulfate/ipratropium) ...... nebulization solution ...... 540 mL (3 - pkg of 60) Duragesic (fentanyl) ...... patch ...... 15 patches Edex (alprostadil) ...... injection, all strengths ...... 8 cartridges Emend (aprepitant) ...... capsules, 80 mg, 125 mg ...... 6 capsules Emend Therapy Pack (aprepitant) ...... capsules, 2 - 80 mg + 1 - 125 mg ...... 6 capsules (2 Therapy Packs) Esclim (estradiol) ...... patch ...... 8 patches Estraderm (estradiol) ...... patch ...... 8 patches Flonase (fluticasone) ...... nasal solution ...... 16 g (1 bottle) Flovent HFA (fluticasone) ...... inhaler, 44 mcg ...... 53 g (5 inhalers) Flovent HFA (fluticasone) ...... inhaler, 110 mcg ...... 24 g (2 inhalers) Flovent HFA (fluticasone) ...... inhaler, 220 mcg ...... 12 g (1 inhaler) flunisolide ...... nasal solution, 0.025% ...... 75 mL (3 bottles) Foradil Aerolizer (fomoterol) ...... inhaler ...... 1 pkg (60 caps) Frova (frovatriptan) ...... tablets, 2.5 mg ...... 12 tablets Golytely (PEG-electrolytes) ...... powder for solution ...... 4000 mL (1 bottle) Imitrex (sumatriptan) ...... tablets, 25, 50, 100 mg ...... 18 tablets Imitrex (sumatriptan) ...... nasal solution, 5 mg, 20 mg ...... 6 units (1 box) Imitrex (sumatriptan) ...... syringe, vial, 6 mg/0.5 mL ...... 4 mL (8 injections) Intal (cromolyn) ...... inhaler ...... 28.4 g (2 inhalers) Kadian (morphine sulfate) ...... extended-release capsules ...... 120 capsules Kytril (granisetron) ...... tablets, 1 mg ...... 12 tablets Levitra (vardenafil) ...... tablets, all strengths ...... 8 tablets

Blue Cross and Blue Shield of Oklahoma 2006 Drug list by therapeutic class –  of 15 BRAND DOSAGE FORM/STRENGTH DISPENSING LIMITS (generic name),or generic name per 30-day supply

Lovenox (enoxaparin) ...... syringe, all strengths ...... 12 syringes Maxair Autohaler (pirbuterol) ...... inhaler ...... 14 g (1 inhaler) Maxalt, Maxalt-MLT (rizatriptan) ...... tablets, 5 mg, 10 mg ...... 12 tablets Muse (alprostadil) ...... suppository, all strengths ...... 8 suppositories Nasacort AQ () ...... nasal suspension ...... 33 g (2 bottles) Nasarel (flunisolide) ...... nasal solution ...... 50 mL (2 bottles) Nasonex () ...... nasal suspension ...... 17 g (1 bottle) Ortho Evra (norelgestromin/ethinyl estradiol) ...... patch ...... 8 patches OxyContin (oxycodone) ...... extended-release tablets, all strengths ...... 90 tablets Pulmicort Turbuhaler () ...... inhaler ...... 2 inhalers Proventil (albuterol) ...... inhaler, 17 g ...... 34 g (2 inhalers) Proventil HFA (albuterol sulfate) ...... inhaler, 6.7 g ...... 13.4 g (2 inhalers) Qvar (beclomethasone dipropionate) ...... inhaler, 7.3 g ...... 14.6 g (2 inhalers) Rebif (interferon beta-1A) ...... syringe, 22 mcg, 44 mcg ...... 12 syringes Relpax (eletriptan) ...... tablets, 20 mg, 40 mg ...... 12 tablets Rhinocort Aqua (budesonide) ...... nasal suspension ...... 18 g (2 bottles) Serevent Diskus (salmeterol) ...... inhaler ...... 60 blisters (1 inhaler) Spiriva Handihaler (tiotropium) ...... inhaler ...... 60 capsules (2 boxes) Tilade (nedocromil) ...... inhaler ...... 32.4 g (2 inhalers) Ventolin HFA (albuterol sulfate) ...... inhaler, 18 g ...... 36 g (2 inhalers) Viagra (sildenafil) ...... tablets, all strengths ...... 8 tablets Vivelle, Vivelle-Dot (estradiol) ...... patch ...... 8 patches Xopenex HFA (levalbuterol) ...... inhaler, 15 g ...... 30 g (2 inhalers) Zofran (ondansetron) ...... oral solution ...... 100 mL (2 bottles) Zofran (ondansetron) ...... tablets, 4 mg, 8 mg, 24 mg ...... 18 tablets Zofran ODT (ondansetron) ...... tablets, 4 mg, 8 mg ...... 18 tablets Zomig (zolmitriptan) ...... nasal solution ...... 12 units (2 boxes) Zomig, Zomig ZMT (zolmitriptan) ...... tablets, 2.5 mg, 5 mg ...... 12 tablets

s t e p t h e r a p y ( s t )

The step therapy program helps ensure member safety while managing the cost of specifc medications. Step therapy typically targets high-cost drugs and drug classes or drugs which should have careful assessment of patient selection or prior treatment before providing the drug. Drugs included in this program require that a prerequisite drug be tried before the step therapy drug will be approved for coverage. If the member meets the initial step therapy criteria, then the requested will be covered automatically under the member’s current prescription beneft. Drug groups subject to step therapy as of January 1, 2006: proton-pump inhibitors and drugs used to treat attention defcit hyperactivity disorder (ADHD) and narcolepsy. This list is subject to change.

Blue Cross and Blue Shield of Oklahoma 2006 Drug list by therapeutic class –  of 15 P h a r m a c o l o g i c and therapeuti c c at e g o r i e s

generic drugs – TIER I preferred brand drugs brand drugs (Brand names in parentheses are provided for reference only) tier II tier III ANTI-INFECTIVE DRUGS PENICILLINS $ amoxicillin $$$$ AUGMENTIN – 8 hr dosing $ ampicillin $$$$ AUGMENTIN XR $ penicillin v potassium $$ dicloxacillin $$$ amoxicillin/potassium clavulanate (Augmentin) CEPHALOSPORINS $ cephalexin (Keflex) $$$ OMNICEF $$$$ VANTIN $$ cefadroxil (Duricef) $$$ cefuroxime axetil tabs (Ceftin) MACROLIDES $ erythromycin delayed-release caps (Eryc) $ ERY-TAB $$$ BIAXIN XL $ erythromycin ethylsuccinate $$ ZITHROMAX susp $ erythromycin stearate $ erythromycin/sulfisoxazole (Pediazole) $$$ azithromycin (Zithromax) TETRACYCLINES $ doxycycline hyclate $ tetracycline $$ minocycline caps, tabs (Minocin, Dynacin) $$$$$ demeclocycline (Declomycin) FLUOROQUINOLONES $ ciprofloxacin tabs (Cipro) $$$$ LEVAQUIN $$$$ AVELOX AMINOGLYCOSIDES $$ neomycin sulfate $$$$$ TOBI SULFONAMIDES $ sulfamethoxazole/trimethoprim (Bactrim, Septra) TUBERCULOSIS $ isoniazid tabs $$$$$ MYCOBUTIN $$$$ pyrazinamide $$$$ rifampin (Rifadin) $$$$$ ethambutol (Myambutol) FUNGAL INFECTIONS $ fluconazole (Diflucan) –Q L – 150 mg tabs $$$$ GRIFULVIN V tabs $ (Nizoral) $$$$ griseofulvin microsize susp (Grifulvin V) $$$$$ itraconazole caps (Sporanox) VIRAL INFECTIONS • Cytomegalovirus $$$$$ ganciclovir (Cytovene) • Hepatitis $$$$$ ribavirin caps (Rebetol) $$$$$ HEPSERA $$$$$ INFERGEN $$$$$ ribavirin tabs (Copegus) $$$$$ INTRON A $$$$$ PEG-INTRON $$$$$ ROFERON-A • Herpes $$ acyclovir (Zovirax) $$$$$ VALTREX • HIV/AIDS $$$$$ didanosine delayed-release (Videx EC) $$$$$ ALL BRANDS FOR HIV $$$$$ zidovudine soln, tabs (Retrovir) • Influenza $$$ rimantadine tabs (Flumadine) $$ FLUMADINE syrup MALARIA $ hydroxychloroquine (Plaquenil) $ FANSIDAR $$ chloroquine phosphate (Aralen) $ PRIMAQUINE $$ mefloquine (Lariam) $$$$ MALARONE WORM INFECTIONS $ mebendazole $ MINTEZOL OTHER ANTI-INFECTIVES $ clindamycin (Cleocin) $$ CLEOCIN PEDIATRIC soln $ metronidazole tabs (Flagyl) $$$ KETEK $ trimethoprim (Proloprim) CANCER DRUGS cyclophosphamide tabs (Cytoxan) ALKERAN HYDREA etoposide caps (Vepesid) AROMASIN

Blue Cross and Blue Shield of Oklahoma 2006 Drug list by therapeutic class –  of 15 generic drugs – TIER I preferred brand drugs brand drugs (Brand names in parentheses are provided for reference only) tier II tier III flutamide (Eulexin) CASODEX hydroxyurea (Hydrea) CEENU leucovorin calcium 5 mg, 25 mg LEUKERAN megestrol (Megace) MATULANE mercaptopurine (Purinethol) TARGRETIN caps methotrexate 2.5 mg TEMODAR tamoxifen (Nolvadex) HORMONES, DIABETES AND RELATED DRUGS $ acetate $$$$$ ENTOCORT EC $ (Decadron) $ (Florinef) $ tabs, 20 mg (Cortef) $ (Medrol) $ sodium phosphate soln (Orapred, Pediapred) $ prednisolone syrup (Prelone) $ prednisolone tabs $ MALE HORMONES $$$$$ 200 mg $$$$ ANDROID $$$$$ ANDROGEL $$$$$ TESTIM ESTROGENS $ estradiol patches (Climara) – QL $$ ACTIVELLA $ estradiol tabs (Estrace) $$ CENESTIN $ estropipate (Ogen) $$ ESTRADERM – QL $$$ esterified estrogens/methyltestosterone $$ PREMARIN tabs (Estratest, Estratest HS) $$ VIVELLE – QL $$ VIVELLE-DOT – QL $$$ ESTROGEL $$$ PREMPHASE $$$ PREMPRO PROGESTINS $ medroxyprogesterone acetate (Provera) $$ PROMETRIUM $ norethindrone acetate (Aygestin) BIRTH CONTROL $$ /ethinyl estradiol (Mircette) $$ OGESTREL $$ desogestrel/ethinyl estradiol (Ortho-Cept) $$ ORTHO EVRA – QL $$ ethynodiol/ethinyl estradiol (Demulen) $$ ORTHO TRI-CYCLEN LO $$ levonorgestrel/ethinyl estradiol (Alesse) $$ PLAN B $$ levonorgestrel/ethinyl estradiol (Levlite) $$ YASMIN $$ levonorgestrel/ethinyl estradiol (Nordette) $$$ NUVARING $$ levonorgestrel/ethinyl estradiol (Triphasil) $$ norethindrone (Nor-QD) $$ norethindrone (Ortho Micronor) $$ norethindrone acetate/ethinyl estradiol (Loestrin) $$ norethindrone acetate/ethinyl estradiol/Fe (Loestrin Fe) $$ norethindrone/ethinyl estradiol (Modicon) $$ norethindrone/ethinyl estradiol (Ortho-Novum 1/35) $$ norethindrone/ethinyl estradiol (Ortho-Novum 10/11) $$ norethindrone/ethinyl estradiol (Ortho-Novum 7/7/7) $$ norethindrone/mestranol (Ortho-Novum 1/50) $$ norgestimate/ethinyl estradiol (Ortho-Cyclen) $$ norgestimate/ethinyl estradiol, triphasic (Ortho Tri-Cyclen) $$ norgestrel/ethinyl estradiol (Lo/Ovral) DIABETES $ glipizide (Glucotrol) $$$$ AVANDAMET $$$$ GLUCAGON EMERGENCY KIT $ glyburide (Diabeta, Micronase) $$$$ AVANDIA $ metformin (Glucophage) $$$$ STARLIX $$ glimepiride (Amaryl) $$$$$ ACTOPLUS MET $$ glipizide ext-release (Glucotrol XL) $$$$$ ACTOS $$ glyburide/metformin (Glucovance) $$ metformin ext-release (Glucophage XR)

Blue Cross and Blue Shield of Oklahoma 2006 Drug list by therapeutic class –  of 15 generic drugs – TIER I preferred brand drugs brand drugs (Brand names in parentheses are provided for reference only) tier II tier III INSULIN Rapid-Acting Insulins $$$$ HUMALOG $$$$ NOVOLOG Short-Acting Insulins $$ HUMULIN R $$ NOVOLIN R Intermediate-Acting Insulins $$ HUMULIN 50/50 $$ HUMULIN 70/30 $$ HUMULIN N $$ NOVOLIN 70/30 $$ NOVOLIN N $$$$ HUMALOG MIX 50/50 $$$$ HUMALOG MIX 75/25 $$$$ NOVOLOG MIX 70/30 Basal Insulins $$$ LANTUS THYROID REGULATION $ levothyroxine – includes Levoxyl (Synthroid) $$ THYROLAR $ propylthiouracil $$ methimazole, 5 mg, 10 mg (Tapazole) OXYTOCICS $ METHERGINE OTHER HORMONES AND RELATED DRUGS $$ clomiphene (Clomid) $$$$ ACTONEL $$$$$ SANDOSTATIN $$$$ calcitonin-salmon nasal – Fortical $$$$ ACTONEL with CALCIUM $$$$ desmopressin nasal soln, spray (DDAVP) $$$$ FOSAMAX $$$$$ cabergoline (Dostinex) $$$$ FOSAMAX PLUS D $$$$$ desmopressin tabs (DDAVP) $$$$ MIACALCIN nasal $$$$$ HECTOROL $$$$$ SENSIPAR $$$$$ STIMATE HEART AND CIRCULATORY DRUGS ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS AND COMBINATIONS $ benazepril (Lotensin) $$$ ALTACE $$$ TARKA $ benazepril/hydrochlorothiazide (Lotensin HCT) $ captopril (Capoten) $ captopril/hydrochlorothiazide (Capozide) $ enalapril (Vasotec) $ enalapril/hydrochlorothiazide (Vaseretic) $ lisinopril (Prinivil) $ lisinopril/hydrochlorothiazide (Prinzide) $$ quinapril (Accupril) $$ quinapril/hydrochlorothiazide (Accuretic) ANGIOTENSIN II RECEPTOR BLOCKERS (ARBs) AND COMBINATIONS $$$ COZAAR $$$ DIOVAN $$$ DIOVAN HCT $$$ HYZAAR BETA BLOCKERS AND COMBINATIONS $ acebutolol (Sectral) $$ TOPROL XL $ atenolol (Tenormin) $$$$ COREG $ atenolol/chlorthalidone (Tenoretic) $ bisoprolol/hydrochlorothiazide (Ziac) $ metoprolol (Lopressor) $ nadolol (Corgard) $ pindolol $ propranolol (Inderal) $ propranolol/hydrochlorothiazide (Inderide) $ timolol (Blocadren) $$ labetalol (Trandate) CALCIUM CHANNEL BLOCKERS AND COMBINATIONS $ diltiazem (Cardizem) $ verapamil (Calan) $$$ NORVASC $ verapamil ext-release (Calan SR) $$$$ LOTREL $ verapamil ext-release (Verelan) $$ diltiazem ext-release (Dilacor XR) $$ nifedipine ext-release (Adalat CC) $$ nifedipine ext-release (Procardia XL) $$$ diltiazem ext-release (Cardizem CD)

Blue Cross and Blue Shield of Oklahoma 2006 Drug list by therapeutic class –  of 15 generic drugs – TIER I preferred brand drugs brand drugs (Brand names in parentheses are provided for reference only) tier II tier III CHEST PAIN (angina) $ isosorbide dinitrate (Isordil) $$$$ NITROLINGUAL $ isosorbide mononitrate ext-release (Imdur) $ nitroglycerin SL tabs (Nitrostat) $$ isosorbide mononitrate (Monoket) $$ nitroglycerin patches (Nitro-Dur) CHOLESTEROL LOWERING $ gemfibrozil (Lopid) $$$ COLESTID $$$ LESCOL $$ lovastatin (Mevacor) $$$$ LIPITOR $$$$ PRAVACHOL $$$ cholestyramine (Questran, Questran Light) $$$$ NIASPAN $$$$ ADVICOR $$$$ TRICOR $$$$ VYTORIN $$$$ ZETIA $$$$$ ZOCOR FLUID REDUCTION $ acetazolamide (Diamox) $$$$ DIAMOX SEQUELS $ amiloride (Midamor) $ amiloride/hydrochlorothiazide (Moduretic) $ bumetanide (Bumex) $ chlorothiazide (Diuril) $ chlorthalidone 25 mg, 50 mg $ furosemide soln, 10 mg/mL; tabs (Lasix) $ hydrochlorothiazide caps (Microzide) $ hydrochlorothiazide tabs $ indapamide (Lozol) $ spironolactone (Aldactone) $ spironolactone/hydrochlorothiazide 25/25 (Aldactazide) $ triamterene/hydrochlorothiazide caps, 37.5/25 (Dyazide) $ triamterene/hydrochlorothiazide caps, 50/25 $ triamterene/hydrochlorothiazide tabs, 37.5/25 (Maxzide-25) $ triamterene/hydrochlorothiazide tabs, 75/50 (Maxzide) $$ methazolamide $$ metolazone (Zaroxolyn) HEART RHYTHM $ quinidine sulfate $$$$$ PACERONE 100, 300, 400 mg $ sotalol (Betapace) $$$ amiodarone (Cordarone) $$$ disopyramide (Norpace) $$$ flecainide (Tambocor) $$$ mexiletine $$$$ disopyramide ext-release caps, 150 mg (Norpace CR) $$$$ propafenone (Rythmol) $$$$ quinidine gluconate ext-release $$$$ sotalol (Betapace AF) OTHER HEART RELATED DRUGS $ clonidine (Catapres) $$$$ CADUET $$$ EPIPEN $ digoxin (Lanoxin) $$$$$ DIBENZYLINE $ doxazosin (Cardura) $$$$$ TRACLEER $ guanfacine (Tenex) $ methyldopa $ terazosin (Hytrin) $$ minoxidil $$ prazosin (Minipress) $$$ hydralazine $$$$$ midodrine (Proamatine) RESPIRATORY DRUGS ANTIHISTAMINES $ cyproheptadine tabs $$ CYPROHEPTADINE syrup $$$ CLARINEX syrup $ promethazine supp (Phenergan) $$$ DEXCHLORPHENIRAMINE MALEATE syrup $ promethazine syrup, tabs (Phenergan) $$$ ZYRTEC $$$ fexofenadine (Allegra) NASAL PRODUCTS $$$ flunisolide 25 mcg/spray– QL $$$ ASTELIN – QL $$$ BECONASE AQ – QL $$$ fluticasone (Flonase) – QL $$$ BACTROBAN nasal – QL $$$ ipratropium bromide (Atrovent) – QL $$$ FLONASE – QL $$$ NASACORT AQ – QL $$$$ NASONEX – QL

Blue Cross and Blue Shield of Oklahoma 2006 Drug list by therapeutic class –  of 15 generic drugs – TIER I preferred brand drugs brand drugs (Brand names in parentheses are provided for reference only) tier II tier III COUGH/COLD/ALLERGY $ carbinoxamine/pseudoephedrine ext-release tabs, $$$ ZYRTEC-D $$$ TRINALIN 8/120 (Rondec-TR) $$$$ ALLEGRA-D $$$ TUSSIONEX $ carbinoxamine/pseudoephedrine syrup, 2/25 per 5 mL (Palgic DS) $ carbinoxamine/pseudoephedrine tabs, 4/60 (Rondec) $ chlorpheniramine/pseudoephedrine/codeine soln, 2/30/10 per 5 mL (Novahistine DH) $ codeine/guaifenesin soln, 10/100 per 5 mL (Tussi-Organidin) $ codeine/guaifenesin syrup, 10/100 per 5 mL $ codeine/guaifenesin tabs, 10/300 (Brontex) $ hydrocodone/guaifenesin syrup, 5/100 per 5 mL (Hycotuss) $ hydrocodone/guaifenesin syrup, 2.5/200 per 5 mL (Pneumotussin) $ pseudoephedrine/guaifenesin ext-release caps, 60/300; ext-release tabs, 45/600, 60/600 $ pseudoephedrine/guaifenesin ext-release tabs, 120/600 (Zephrex LA) $$ carbinoxamine/pseudoephedrine soln, 1/15 per mL (Rondec) $$$$ acetylcysteine (Mucomyst) ASTHMA/COPD $ albuterol inhaler (Proventil) – QL $$$ ATROVENT HFA – QL $$$$ MAXAIR AUTOHALER – QL $ albuterol sulfate neb soln (Proventil) $$$ METAPROTERENOL tabs $ albuterol sulfate syrup, tabs $$$ TILADE – QL $$ terbutaline (Brethine) $$$$ COMBIVENT – QL $$ theophylline ext-release caps – 12 hr dosing $$$$ FLOVENT HFA – QL $$ theophylline ext-release tabs – 12 hr dosing – $$$$ FORADIL AEROLIZER – QL Theochron $$$$ INTAL INHALER – QL $$$ cromolyn sodium neb soln (Intal) $$$$ QVAR – QL $$$ ipratropium bromide neb soln $$$$ SEREVENT DISKUS – QL $$$$ SINGULAIR $$$$$ ADVAIR DISKUS – QL $$$$$ DUONEB – QL $$$$$ PULMICORT RESPULES $$$$$ PULMICORT TURBUHALER – QL OTHER RESPIRATORY DRUGS $$$$$ PULMOZYME GASTROINTESTINAL DRUGS LAXATIVES $ lactulose – Constulose $ PEG-electrolytes for soln (Colyte) $ PEG-electrolytes for soln (Nulytely) $$ polyethylene glycol 3350 (Miralax) ULCER/GERD $ cimetidine (Tagamet) $$$$ ACIPHEX $ dicyclomine (Bentyl) $$$$ PROTONIX $ famotidine (Pepcid) $ hyoscyamine (Levsin) $ hyoscyamine ext-release caps (Levsinex) $ hyoscyamine ext-release tabs (Levbid) $ ranitidine (Zantac) $$$ omeprazole delayed-release (Prilosec) $$$ sucralfate tabs (Carafate) $$$$ misoprostol (Cytotec) NAUSEA AND VOMITING $ trimethobenzamide/benzocaine supp (Tigan) $$$$$ EMEND – QL $$ TRANSDERM-SCOP $$ trimethobenzamide caps (Tigan) $$$$$ ZOFRAN – QL $$$ ANZEMET – QL $$$$$ ZOFRAN ODT – QL DIGESTIVE ENZYMES $$$$$ CREON $$$$$ LIPRAM CR/PN/UL $$$$$ PANCREASE MT $$$$$ PANCREASE IR caps, 20-4-25 $$$$$ PANCRELIPASE IR tabs, 30-8-30 – various tradenames $$$$$ PANOKASE-16 $$$$$ ULTRASE/MT $$$$$ VIOKASE

Blue Cross and Blue Shield of Oklahoma 2006 Drug list by therapeutic class – 10 of 15 generic drugs – TIER I preferred brand drugs brand drugs (Brand names in parentheses are provided for reference only) tier II tier III OTHER GASTROINTESTINAL DRUGS $ lactulose – Enulose $$$ PHOSLO $$$$$ ZELNORM $ metoclopramide (Reglan) $$$$$ ASACOL $ sulfasalazine (Azulfidine) $$$$$ CANASA $$$$ ursodiol (Actigall) $$$$$ mesalamine enema (Rowasa) GENITOURINARY DRUGS URINARY TRACT INFECTIONS $ nitrofurantoin monohydrate/macrocrystals (Macrobid) $$ nitrofurantoin macrocrystals (Macrodantin) URINARY TRACT SPASMS $ oxybutynin (Ditropan) $$$$ DETROL $$$$ DETROL LA VAGINAL PRODUCTS $ amino acid/urea crm (Amino-Cerv) $$ ESTRACE crm $$ acetic acid gel $$ PREMARIN crm $$$ clindamycin crm (Cleocin) $$$ CLEOCIN supp $$$ TERAZOL 3 supp $$$$ METROGEL VAGINAL OTHER GENITOURINAY DRUGS $$$ potassium citrate/citric acid powder, soln (Polycitra K) $$$ FLOMAX $$$ sodium citrate/citric acid soln (Bicitra) $$$$ AVODART $$$ tricitrates soln (Polycitra) $$$$ PROSCAR CENTRAL NERVOUS SYSTEM DRUGS ANXIETY $ alprazolam (Xanax) $ DIAZEPAM soln, 1 mg/mL $ buspirone (Buspar) $ diazepam (Valium) $ hydroxyzine pamoate (Vistaril) $ lorazepam (Ativan) $$ hydroxyzine hcl DEPRESSION $ amitriptyline $$$$ EFFEXOR $$$$ CYMBALTA $ doxepin (Sinequan) $$$$ EFFEXOR XR $$$$ PARNATE $ fluoxetine (Prozac) $$$$ NARDIL $$$$ VIVACTIL $ nortriptyline (Pamelor) $$$$ PAXIL CR $ trazodone (Desyrel) $$$$ PAXIL susp $$ bupropion (Wellbutrin) $$$$ WELLBUTRIN XL $$ citalopram (Celexa) $$$$ ZOLOFT $$ clomipramine (Anafranil) $$ desipramine (Norpramin) $$ imipramine hcl (Tofranil) $$ mirtazapine (Remeron) $$ paroxetine hcl (Paxil) $$$$ bupropion ext-release (Wellbutrin SR) PSYCHOTIC AND BIPOLAR DISORDERS $ fluphenazine hcl(Prolixin) $$$$$ GEODON $ haloperidol lactate oral soln $$$$$ RISPERDAL $ haloperidol tabs, 0.5 mg, 1 mg, 2 mg, 5 mg $$$$$ RISPERDAL M-TAB $ lithium carbonate caps $$$$$ SEROQUEL $ prochlorperazine supp (Compazine) $ prochlorperazine tabs (Compazine) $ thiothixene (Navane) $$ lithium carbonate ext-release (Eskalith CR) $$ lithium carbonate ext-release (Lithobid) $$ perphenazine tabs $$ thioridazine $$ trifluoperazine $$$ chlorpromazine hcl $$$ clozapine 25 mg, 100 mg (Clozaril) $$$ lithium citrate syrup $$$$ loxapine (Loxitane) SLEEP AIDS $ chloral hydrate syrup $ CHLORAL HYDRATE supp $ estazolam (Prosom) $$$ RESTORIL 7.5 mg $ phenobarbital $$$$ AMBIEN $ temazepam (Restoril) HYPERACTIVITY/NARCOLEPSY $$ dextroamphetamine (Dexedrine) $$$$ RITALIN LA $$ methylphenidate (Ritalin) $$$$ ADDERALL XR

Blue Cross and Blue Shield of Oklahoma 2006 Drug list by therapeutic class – 11 of 15 generic drugs – TIER I preferred brand drugs brand drugs (Brand names in parentheses are provided for reference only) tier II tier III $$ methylphenidate ext-release (Metadate ER, Ritalin SR) $$$$ CONCERTA $$$ amphetamine/dextroamphetamine mixed salts (Adderall) $$$ dextroamphetamine ext-release (Dexedrine Spansule) MISC. PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS $$$$ bupropion ext-release (Zyban) $$$ ANTABUSE $$$$$ ARICEPT $$$ ORAP $$$$$ AVONEX – QL $$$$$ BETASERON – QL $$$$$ COPAXONE – QL $$$$$ EXELON $$$$$ NAMENDA PAIN RELIEF DRUGS NON-NARCOTIC DRUGS $ butalbital/acetaminophen tabs, 50/325 (Phrenilin) $ butalbital/acetaminophen tabs, 50/650 (Sedapap) $ butalbital/acetaminophen/caffeine caps, 50/325/40 (Esgic) $ butalbital/acetaminophen/caffeine tabs, 50/325/40 (Fioricet) $ butalbital/aspirin/caffeine tabs, 50/325/40 $ salsalate $$ butalbital/aspirin/caffeine caps, 50/325/40 (Fiorinal) $$$ butalbital/acetaminophen/caffeine tabs, 50/500/40 (Esgic Plus) NARCOTIC DRUGS $ codeine/acetaminophen elixir, tabs $ CODEINE PHOSPHATE soln (Tylenol w/Codeine) $ CODEINE SULFATE $ codeine/aspirin tabs $$ CODEINE PHOSPHATE soluble tabs $ hydrocodone/acetaminophen caps, 5/500 $$$$$ SUBOXONE (Bancap HC) $$$$$ SUBUTEX $ hydrocodone/acetaminophen tabs, 2.5/500, 5/500, 7.5/500, 10/500 (Lortab) $ hydrocodone/acetaminophen tabs, 5/500, 7.5/750, 10/660 (Vicodin, Vicodin ES, Vicodin HP) $ hydrocodone/acetaminophen tabs, 7.5/650, 10/650 (Lorcet, Lorcet Plus) $ hydromorphone soln, tabs (Dilaudid) $ methadone conc, tabs $ morphine sulfate supp (RMS) $ oxycodone caps (OxyIR) $ oxycodone/acetaminophen caps, 5/500 (Tylox) $ oxycodone/acetaminophen tabs, 5/325, 7.5/325, 7.5/500, 10/325, 10/650 (Percocet) $ propoxyphene hcl (Darvon) $ propoxyphene napsylate/acetaminophen (Darvocet-N) $ propoxyphene hcl/acetaminophen tabs, 65/650 $ tramadol (Ultram) $$ hydrocodone/acetaminophen elixir, 7.5/500 per 15 mL (Lortab) $$ hydrocodone/acetaminophen tabs, 5/325, 7.5/325, 10/325 (Norco) $$ morphine sulfate conc, soln, tabs (MSIR) $$ oxycodone conc, soln, tabs (Roxicodone) $$ pentazocine/naloxone (Talwin NX) $$$ butalbital/aspirin/caffeine/codeine (Fiorinal w/Codeine) $$$ hydrocodone/acetaminophen tabs, 10/750 (Maxidone) $$$ hydromorphone supp (Dilaudid) $$$ morphine sulfate ext-release (MS Contin) $$$ oxycodone/aspirin tabs, 5/325 (Percodan) $$$$$ fentanyl patches (Duragesic) – QL $$$$$ oxycodone ext-release (OxyContin) – QL RHEUMATOID AND OSTEOARTHRITIS $ etodolac $$$$$ ENBREL $ ibuprofen (Motrin) $$$$$ RIDAURA $ indomethacin caps (Indocin) $ naproxen (Naprosyn) $ piroxicam (Feldene) $$ diclofenac sodium delayed-release (Voltaren) $$ ketoprofen $$ naproxen sodium (Anaprox)

Blue Cross and Blue Shield of Oklahoma 2006 Drug list by therapeutic class – 12 of 15 generic drugs – TIER I preferred brand drugs brand drugs (Brand names in parentheses are provided for reference only) tier II tier III $$ sulindac (Clinoril) $$$ diclofenac sodium ext-release (Voltaren XR) $$$ nabumetone (Relafen) $$$$$ leflunomide(Arava) MIGRAINE HEADACHES $ acetaminophen/isometheptene/dichloralphenazone $$$$ DEPAKOTE ER $$$$$ AXERT – QL (Midrin) $$$$ MIGRANAL $$$$$ IMITREX inj – QL $$$$$ IMITREX nasal spray – QL $$$$$ IMITREX tabs – QL $$$$$ ZOMIG nasal spray – QL $$$$$ ZOMIG tabs – QL $$$$$ ZOMIG ZMT – QL GOUT $ allopurinol $ colchicine $$ probenecid $$$ probenecid/colchicine NEUROMUSCULAR DRUGS SEIZURES $ carbamazepine (Tegretol) $$ PHENYTEK $ clonazepam (Klonopin) $$$ CELONTIN $$ phenytoin sodium extended (Dilantin) $$$ DILANTIN INFATABS, caps, 30 mg, susp $$ phenytoin susp (Dilantin) $$$$ NEURONTIN soln $$$ primidone (Mysoline) $$$$ TEGRETOL XR $$$$ ethosuximide (Zarontin) $$$$$ DEPAKOTE $$$$ gabapentin caps, tabs (Neurontin) $$$$$ DIASTAT $$$$ gabapentin tabs (Gabarone) $$$$$ KEPPRA $$$$ valproic acid (Depakene) $$$$$ LAMICTAL $$$$ zonisamide (Zonegran) $$$$$ TOPAMAX PARKINSON'S DISEASE $ benztropine $$$$ PARCOPA $ trihexyphenidyl $$$$$ COMTAN $$ amantadine $$$$$ MIRAPEX $$ selegiline caps (Eldepryl) $$$$$ REQUIP $$ selegiline tabs $$$ carbidopa/levodopa (Sinemet) $$$$ bromocriptine (Parlodel) $$$$ carbidopa/levodopa ext-release (Sinemet CR) $$$$$ pergolide (Permax) MUSCLE RELAXANTS $ cyclobenzaprine (Flexeril) $$ baclofen $$ methocarbamol (Robaxin) $$ orphenadrine citrate ext-release (Norflex) $$ orphenadrine/aspirin/caffeine $$ tizanidine (Zanaflex) $$$$ dantrolene (Dantrium) OTHER NEUROMUSCULAR DRUGS $$$$ pyridostigmine tabs (Mestinon) $$ MESTINON syrup $$$ MESTINON TIMESPAN $$$$$ RILUTEK SUPPLEMENTS VITAMINS $$ ergocalciferol 50,000 units (Drisdol) $ MEPHYTON $$$ calcitriol (Rocaltrol) MULTIVITAMINS $ pediatric multivitamins/fluoride (Poly-Vi-Flor) $ pediatric multivitamins/fluoride + iron (Poly-Vi-Flor + iron) $ pediatric vitamins ADC/fluoride (Tri-Vi-Flor) $ pediatric vitamins ADC/fluoride + iron (Tri-Vi-Flor + iron) $ prenatal multivitamins/folic acid 1 mg MINERALS & ELECTROLYTES $ potassium bicarbonate/chloride effervescent tabs, 25 mEq (K-Lyte/Cl) $ potassium chloride ext-release caps, 10 mEq (Micro-K 10) $ potassium chloride ext-release tabs, 10 mEq (K-Tabs)

Blue Cross and Blue Shield of Oklahoma 2006 Drug list by therapeutic class – 13 of 15 generic drugs – TIER I preferred brand drugs brand drugs (Brand names in parentheses are provided for reference only) tier II tier III $ potassium chloride ext-release tabs, 10 mEq, 20 mEq (K-Dur) $ potassium chloride ext-release tabs, 8 mEq $ potassium chloride liq, 10%, 20% $ potassium chloride packets, 20 mEq (K-Lor) $ potassium phosphate/sodium phosphates (K-Phos Neutral) $ sodium fluoride chew tabs, soln, tabs BLOOD MODIFYING DRUGS $ folic acid tabs, 1 mg $$$$ PLAVIX $$$$$ EPOGEN $ pentoxifylline ext-release (Trental) $$$$$ LEUKINE $ warfarin (Coumadin) $$$$$ LOVENOX – QL $$$ anagrelide (Agrylin) $$$$$ NEUMEGA $$$ cilostazol (Pletal) $$$$$ NEUPOGEN $$$$$ PROCRIT TOPICAL DRUGS EYE • Anti-infectives $ bacitracin/polymyxin B oint (Polysporin) $$$ CILOXAN oint $ ciprofloxacin soln(Ciloxan) $$$ VIGAMOX $ erythromycin oint $ gentamicin oint, soln $ neomycin/polymyxin B/bacitracin oint (Neosporin) $ neomycin/polymyxin B/gramicidin soln (Neosporin) $ polymyxin B/trimethoprim soln (Polytrim) $ sulfacetamide sodium soln (Bleph-10) $ tobramycin soln (Tobrex) $$$ ofloxacin soln (Ocuflox) $$$ trifluridine soln(Viroptic) • and Combination Products $ neomycin/polymyxin B/bacitracin/hydrocortisone $$ LOTEMAX oint (Cortisporin) $$$ ALREX $ dexamethasone sodium phosphate soln $$$ BLEPHAMIDE $ susp (FML) $$$ BLEPHAMIDE S.O.P. $ neomycin/polymyxin B/dexamethasone oint, $$$ TOBRADEX susp (Maxitrol) $$$ ZYLET $ susp (Pred Forte) $ prednisolone sodium phosphate soln (Inflamase Forte) $ sulfacetamide sodium/prednisolone soln • Glaucoma $ carteolol soln (Ocupress) $$ AZOPT $ levobunolol soln (Betagan) $$ BETIMOL $ metipranolol soln (Optipranolol) $$ TRUSOPT $ pilocarpine soln (Isopto Carpine) $$$ ALPHAGAN P $ timolol maleate gel-forming soln (Timoptic-XE) $$$ BETOPTIC-S $ timolol maleate soln (Timoptic) $$$ COSOPT $$ carbachol soln (Isopto Carbachol) $$$ TRAVATAN $$$ brimonidine soln 0.2% $$$ XALATAN • Other Eye Products $ atropine sulfate oint, soln (Isopto Atropine) $$$ ACULAR $$ CYCLOGYL $ cyclopentolate soln, 1% (Cyclogyl) $$$ ACULAR LS $$$ LACRISERT $ homatropine soln (Isopto Homatropine) $$$ ACULAR PF $$ cromolyn sodium soln (Crolom) $$$ OPTIVAR $$$ PATANOL $$$ VOLTAREN $$$ ZADITOR EAR $ benzocaine/antipyrine $$$ FLOXIN OTIC $ hydrocortisone/acetic acid $$$$ CIPRO HC $ neomycin/polymyxin B/hydrocortisone (Cortisporin) $$$$ CIPRODEX $$$ acetic acid MOUTH & THROAT (local) $ lidocaine viscous $$$$$ SALAGEN $ sodium fluoride dental crm, gel (Prevident) $ triamcinolone acetonide paste (Kenalog in Orabase) $$$ chlorhexidine oral rinse (Peridex) $$$ nystatin susp $$$$$ pilocarpine hcl tabs, 5 mg (Salagen) ANORECTAL $ supp, 25 mg (Anusol-HC)

Blue Cross and Blue Shield of Oklahoma 2006 Drug list by therapeutic class – 14 of 15 generic drugs – TIER I preferred brand drugs brand drugs (Brand names in parentheses are provided for reference only) tier II tier III $ hydrocortisone crm, 2.5% (Anusol-HC) $$$$$ hydrocortisone enema SKIN CONDITIONS/PRODUCTS • Acne $ clindamycin (Cleocin T) $$$ FINACEA $ erythromycin gel (Erygel) $$$$ METROGEL $ erythromycin pads, soln, 2% $$$$ METROLOTION $$$ metronidazole crm, 0.75% (Metrocream) $$$ sulfacetamide/sulfur (Sulfacet-R) $$$ tretinoin (Retin-A) $$$$ erythromycin/benzoyl peroxide (Benzamycin) $$$$$ isotretinoin caps (Accutane) • Anti-infectives $ econazole (Spectazole) $$$ OXISTAT $ gentamicin $$$ ZOVIRAX $ nystatin $$$$$ CONDYLOX $ nystatin/triamcinolone $ silver sulfadiazine (Silvadene) $$ ketoconazole crm $$ ketoconazole 2% shampoo (Nizoral) $$$ ciclopirox crm, lotn (Loprox) $$$ mupirocin oint (Bactroban) $$$$ podofilox soln (Condylox) • Corticosteroids $ dipropionate (Diprosone) $ $ (Temovate) $ (Desowen) $ (Topicort) $ acetonide(Synalar) $ (Lidex) $ hydrocortisone 2.5% (Hytone) $ (Westcort) $ triamcinolone acetonide (Kenalog) $$ betamethasone dipropionate, augmented, crm, gel, oint (Diprolene) $$ diacetate (Psorcon) $$ mometasone (Elocon) $$$ hydrocortisone acetate/pramoxine 2.5%/1% crm (Pramosone) • Other Skin Products $ aluminum chloride soln (Drysol) $$$ ELIDEL $ lidocaine crm 3%, lotn, 3% (LidaMantle) $$$$ CARAC $ lidocaine jelly 2%, oint, 5%; soln 4% (Xylocaine) $$$$ DOVONEX $ selenium sulfide 2.5% (Selsun) $$$$ OVIDE $$ permethrin crm, 5% (Elimite) $$$$ PROTOPIC $$$ anthralin crm (Psoriatec) $$$$$ ALDARA $$$ doxepin crm (Zonalon) $$$$$ OXSORALEN $$$ fluorouracil soln, 2%, 5%(Efudex) $$$$$ OXSORALEN ULTRA $$$ lidocaine/prilocaine crm (Emla) $$$$$ TARGRETIN gel $$$$ lindane shampoo MISCELLANEOUS CATEGORIES Antidotes $$$$$ CHEMET Diagnostic Products FREESTYLE TEST STRIPS ONE TOUCH II/BASIC/PROFILE TEST STRIPS ONE TOUCH FASTTAKE TEST STRIPS ONE TOUCH SURESTEP TEST STRIPS ONE TOUCH ULTRA TEST STRIPS PRECISION QID TEST STRIPS PRECISION XTRA TEST STRIPS Medical Devices B-D INSULIN SYRINGES B-D LANCETS LIFESCAN LANCETS MISCELLANEOUS DRUGS $$$ azathioprine (Imuran) $$$$ CUPRIMINE $$$$$ CELLCEPT $$$ sodium polystyrene sulfonate $$$$$ MYFORTIC $$$$$ cyclosporine (Sandimmune) $$$$$ PROGRAF $$$$$ cyclosporine modified caps 25 mg, 100 mg; soln $$$$$ RAPAMUNE (Neoral)

Blue Cross and Blue Shield of Oklahoma 2006 Drug list by therapeutic class – 15 of 15