Performance Drug List Changes

Drugs Moving to a Non-Preferred Brand Level (higher out-of-pocket cost for you) Effective: January 1, 2018

Non-Preferred Generic Preferred Preferred Brand Condition Brand1 Alternative(s)2 Alternative(s)1,2 Used For $$$ $ $$

ACETAMINOPHEN/ CAFFEINE/ butalbital-acetaminophen-caffeine- DIHYDROCODEINE codeine capsule 50-325-40-30 mg, Headache N/A (acetaminophen-caffeine- butalbital-aspirin-caffeine-codeine dihdrocodeine cap 320.5-30- capsule 50-325-40-30 mg 16 mg)

AUGMENTED betamethasone dipropionate BETAMETHASONE cream, betamethasone DIPROPIONATE Topical Steroid N/A dipropionate lotion, betamethasone (betamethasone dipropionate dipropionate augmented oint augmented gel 0.05%)

BETAMETHASONE betamethasone dipropionate DIPROPIONATE cream, betamethasone Topical Steroid N/A (betamethasone dipropionate dipropionate lotion, betamethasone augmented gel 0.05%) dipropionate augmented oint

LEVONORGESTREL AND ETHINYL ESTRADIOL (levonorgestrel-ethinyl Birth Control Ashlyna, Daysee, Fayosim N/A estradiol continuous tab 90- 20 mcg

METHYLPHENIDATE HCL amphetamine-dextroamphetamine (methylphenidate hcl chew ADHD CONCERTA tablet, methylphenidate tablet tab 2.5 mg, 5 mg, 10 mg)

METOPROLOL/ HYDROCHLOROTHIAZIDE hydrochlorothiazide tablet, (metoprolol & Hypertension N/A metoprolol tablet hydrochlorothiazide tab 100- 50 mg)

1 Third-party brand names are the property of their respective owners. 2This list is not all-inclusive. Other medicines may be available in this drug class. Please note: Alternative drugs used to treat the same condition as a non-preferred brand drug(s) may have different active ingredients (i.e., work in a different way, but resolve the same problem).

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association IL 10-17 1 Drugs No Longer Covered Effective: January 1, 2018

Condition Drug1 Preferred Alternative(s)1,2 Used For There is a generic equivalent available. Please talk to ALKERAN (melphalan tab 2 mg) Cancer your doctor or pharmacist about other medications available for your condition.

There is a generic equivalent available. Please talk to AXIRON (testosterone td soln 30 mg/act) Low Testosterone your doctor or pharmacist about other medications available for your condition.

CIPRO HC (ciprofloxacin-hydrocortisone ofloxacin otic soln 0.3%, CIPRODEX (ciprofloxacin- Otic Anti-Infective otic susp 0.2-1%) dexamethasone otic susp 0.3-0.1%)

CLINDAGEL (clindamycin phosphate gel clindamycin phosphate gel 1% (generic), clindamycin Acne 1%) phosphate lotion 1%

DICLEGIS (doxylamine-pyridoxine tab Talk to your doctor or pharmacist about over-the- Nausea/Vomiting delayed release 10-10 mg) counter options This medication has been determined not safe or not EGRIFTA (tesamorelin acetate for inj 2 mg effective by Prime’s Pharmacy and Therapeutics Lipodystrophy base equiv) Committee. Please talk to your doctor or pharmacist about other medications available for your condition. There is a generic equivalent available. Please talk to LIALDA (mesalamine tab delayed release Ulcerative Colitis your doctor or pharmacist about other medications 1.2 gm) available for your condition.

MINOCYCLINE HCL ER (minocycline hcl Antibiotic minocycline capsule, tablet tab sr 24hr 45 mg) minocycline hcl tab sr 24hr 90 mg, 135 mg Antibiotic minocycline capsule, tablet

PERFOROMIST (formoterol fumarate soln Asthma/ BROVANA (arformoterol tartrate soln nebu 15 mcg/2 nebu 20 mcg/2 mL) COPD/Bronchitis mL) There is a generic equivalent available. Please talk to RENVELA (sevelamer carbonate packet Hyperphosphatemia your doctor or pharmacist about other medications 0.8 gm) available for your condition.

This medication has been determined not safe or not effective by Prime’s Pharmacy and Therapeutics rimantadine hydrochloride tab 100 mg Influenza Committee. Please talk to your doctor or pharmacist about other medications available for your condition. There is a generic equivalent available. Please talk to ROZEREM (ramelteon tab 8 mg) Insomnia your doctor or pharmacist about other medications available for your condition. There is a generic equivalent available. Please talk to SEROQUEL XR (quetiapine fumarate tab Antidepressant/Bipolar your doctor or pharmacist about other medications sr 24hr 150 mg) Disorder available for your condition.

There is a generic equivalent available. Please talk to STRATTERA (atomoxetine hcl cap 80 mg ADHD your doctor or pharmacist about other medications base equiv) available for your condition.

ZELAPAR (selegiline hcl orally Parkinson’s Disease rasagiline tablet, selegiline tablet

disintegrating tab 1.25 mg)

There is a generic equivalent available. Please talk to ZETIA (ezetimibe tab 10mg) High Cholesterol your doctor or pharmacist about other medications available for your condition.

benzonatate capsule, cheratussin ac (guaifenesin- Removal of select over-the-counter (OTC) codeine solution 100-10 mg/5 mL), virtussin a/c controlled substance schedule V products Cough & Cold (guaifenesin-codeine solution 100-10 mg/5 mL), over- (i.e., CAPCOF, CODITUSSIN AC, etc.) the-counter cough and cold products

1 Third-party brand names are the property of their respective owners. 2 This list is not all-inclusive. Other medicines may be available in this drug class. Please note: Alternative drugs used to treat the same condition as a non-preferred brand drug(s) may have different active ingredients (i.e., work in a different way, but resolve the same problem).