2015 Three Tier Formulary Reference Guide
A list of medications that may lower your patients’ costs
TABLE OF CONTENTS
INTRODUCTION ...... ii
Product Selection Criteria ...... ii Member Copayment Contributions ...... ii Pharmacy and Therapeutics (P&T) Committee ...... iii Generic Substitution ...... iii DESI Drugs ...... iv Legend ...... iv Prior Authorization (PA) ...... v Prior Authorization Drug List ...... v Drugs with Quantity Limitations (QL) ...... vi Step Therapy (ST) ...... vii Drugs with Step Therapy ...... vii Specialty Pharmacy Products ...... viii Excluded Drugs - Alternatives ...... x 2015 Preventive Drug List ...... xi Affordable Care Act Requirements ...... xiii Editor's Note ...... xiv Pharmacy Appeals ...... xiv Notice ...... xiv Clinical References ...... xv
THERAPEUTIC CHAPTER INDEX ...... 1
BLUECROSS BLUESHIELDOF TENNESSEE THREE TIER FORMULARY ...... 4
INDEX ...... 58
i INTRODUCTION BlueCross BlueShield of Tennessee is pleased to provide a Three Tier Formulary. This formulary was reviewed and approved by the BlueCross Pharmacy and Therapeutics (P&T) Committee and can assist practitioners in selecting drugs for members whose drug benefits are administered through BlueCross BlueShield of Tennessee.
Product Selection Criteria
The BlueCross P&T Committee considers U.S. Food and Drug Administration (FDA) approved drugs for inclusion in the formulary. The evaluation includes a literature review, and expert opinion may be sought. Formal reviews are prepared and typically address the following information:
• Effectiveness • Contraindications • Safety • Pharmacokinetics • Comparison studies • Patient administration/compliance considerations • Approved indications • Medical outcome and pharmacoeconomic studies • Adverse effects • Cost
When a new drug is considered for formulary inclusion, an attempt will be made to examine the drug relative to similar drugs currently on formulary. Drugs reviewed by the P&T Committee are typically assigned to either Tier 2 or Tier 3, considering cost and clinical usefulness of the product. In addition, entire therapeutic classes are periodically reviewed. The class review process may result in a tier change for a specific drug(s).
All the material in the Three Tier Formulary is provided as a reference for drug therapy selection. The final choice of specific drug selection for an individual member rests solely with the prescriber.
Member Copayment Contributions
Each therapeutic group is designated by disease state or drug class. Drug lists are a part of each therapeutic group. They show an assigned copay tier for each drug, reflecting the level of member share of the prescription cost. Please note that some restrictions and exclusions may apply due to a plan's specific benefit design.
For example, smoking deterrents, e.g., nicotine patches, are excluded from coverage for some plans. In addition, over-the-counter (OTC) products are not covered, with the exception of insulin and glucose monitoring products. Investigational drugs are excluded from plans.
The Three Tier Formulary is separated in the following manner:
Tier 1: Lowest member copayment: Includes generic prescription drugs. Tier 2: Reduced member copayment: Includes selected branded products that are more cost-effective than similar drugs within a common drug class. All Tier 2 drugs are shown in this formulary. Tier 3: Highest member copayment: Includes branded products listed in this formulary not selected for Tier 2 and all covered branded products not listed. In many cases there is a reasonable alternative drug in Tier 1 or Tier 2 for the Tier 3 products.
ii To assist in the understanding of how the tiers are assigned, the following guidelines apply: • All generic products, whether shown or not, are in Tier 1. • The equivalent brand product for a listed generic is in Tier 3. • Extended-release and delayed-release products are listed separately from the immediate-release form of the same drug. These modified release forms may appear in a different tier or an excluded benefit. • Drugs shown in a drug list include dosage forms and strengths appropriate to that therapeutic category. A drug name representing different dosage forms and uses, and therefore shown in different categories, may have different copays or an excluded benefit. • Oral liquids and suppositories will be in the same tier as the immediate-release entry.
Some member groups are served in a dual copay plan. This formulary may be used as a guide for their drug selection. These members' copay plan is separated in the following manner: • Lowest copay: all generic drugs • Highest copay: all branded products
Pharmacy and Therapeutics (P&T) Committee
The BlueCross P&T Committee consists of pharmacists and physicians, some of whom are community practitioners. The decisions of the Committee may be communicated after each meeting in the BlueCross BlueShield of Tennessee newsletter, BlueAlert, specialized mailings or on http://www.bcbst.com. Drug classification, availability, and tier placement are subject to change.
Generic Substitution
Generic substitution is a pharmacy action whereby a generic version is dispensed rather than the prescribed brand-name product. Products designated in the formulary drug lists by boldface type have generic availability or the brand name cited is a generic drug. Examples of the latter include Levoxyl and Avita.
The generic products selected for substitution are commonly prescribed and dispensed and have gone through the FDA's review and approval process. This FDA process assures the following requirements have been met: 1. The generic drug must contain the same active ingredient(s), be the same strength and the same dosage form as the brand-name product. 2. The FDA has given the generic an "A" rating compared to the branded product indicating bioequivalence, and has determined the generic is therapeutically equivalent to the reference brand. The ratings of generic drugs are available by referring to the FDA reference, Approved Drug Products with Therapeutic Equivalence Evaluations (Orange Book).
When the above two criteria are met, a generic can be substituted with the full expectation that the substituted product will produce the same clinical effect and safety profile as the prescribed product. Drug products that have a narrow therapeutic index (NTI) can also be guided by these principles. It is not necessary for the health care provider to approach any one therapeutic class of drug products (e.g., NTI drugs) differently from any other class, when there has been a determination of therapeutic equivalence by the FDA for the drug products under consideration. Also, additional clinical tests or examinations by the physician are not needed when a therapeutically equivalent generic drug product is substituted for the brand-name product.
Under most BlueCross plans, if a member requests a brand-name drug which is available generically, the member will likely pay the Tier 1 copayment cost plus the cost difference between brand and generic referred to as MAC Penalty.
iii It is recommended that generic substitution not be exercised by the pharmacist with multi-source products that appear in the Orange Book and carry a "B" rating, indicating that these products cannot be considered therapeutically equivalent to other products in the group. Also, state laws or regulations may dictate the ability to practice generic substitution for selected products or categories of drugs.
It is also recommended that generic substitution not be undertaken for any unrated multi-source products that might be considered narrow therapeutic index, or maintenance drugs where it is known that products from different labelers are not bioequivalent.
DESI Drugs
DESI drugs are those drugs first marketed between 1938 and 1962, which were approved as safe but required no showing of effectiveness for FDA product approval. The DESI program subsequently determined that most of these products may remain available. A few DESI products remain classified as "less than fully effective" while awaiting final administrative disposition. Also classified as DESI are many products listed as identical, similar, or related to actual DESI drugs. Certain plans may exclude the coverage of DESI drugs.
LEGEND
AGE-A Age edit is applicable. Prior Authorization for members 17 years of age and younger. AGE-B Age edit is applicable. Prior Authorization for males 30 years of age and younger; Prior Authorization required for all females. OTC Over-the-counter PA Prior Authorization required PA+ Prior Authorization required for all males 19 years of age and older; Prior Authorization required for females ages 44 years and younger QL Quantity Limitation SPRx Product is on the Specialty Drug List ST Step Therapy d DESI drug boldface Indicates generic availability ext-rel Extended-release (also known as sustained-release) delayed-rel Delayed-release (also known as enteric coated) # Some plans do not cover these medications. Check with BlueCross BlueShield of Tennessee Member Service or the Express Scripts Pharmacy Help Desk to determine coverage. † Some groups limit the quantity to 6 tablets every 30 days. ^ Gender edit is applicable. Weigh risk of birth defects or other adverse outcomes. Do not use in pregnancy.
iv Prior Authorization (PA)
Prior Authorization for the following drugs is required by most plans before BlueCross will pay for them. To request PA, the prescriber or agent should call or fax Express Scripts. Phone: 1-877-916-2271 Hours: 24 hours a day, 7 days a week Fax: 1-800-837-0959
The following information will be requested: 1. Patient name and cardholder I.D. number 2. Physician name and phone number 3. Drug and diagnosis information
Prior Authorization Drug List Anabolic steroids (e.g., Anadrol-50, Oxandrin) # Androgens (e.g., Androderm, Androgel, Testim) - PA required for males 30 years and younger; PA required for all females. Anti-obesity drugs (e.g., Belviq, orlistat, phentermine, Qsymia) Atypical antipsychotics - (e.g., Abilify, Risperdal, Seroquel, Zyprexa) - PA required for patients 17 years and younger Erectile dysfunction drugs (e.g., Cialis, Levitra, Viagra) ^ Grastek modafinil Nuvigil Ragwitek Retinoids (e.g., Avita, Retin-A, Tazorac) - PA required for patients 40 years and older Specialty Pharmacy Products: Many of these drugs also require prior authorization. See Specialty Pharmacy Products section. Xyrem This list is subject to change.
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
v Drugs with Quantity Limitations (QL)
Drug Limit Anaphylaxis agents 2 kits in a 30-day period (e.g., Auvi-Q, EpiPen/EpiPen, Jr) buprenorphine, oral: Maximum of any combination of oral buprenorphine products of #90/30 days buprenorphine SL tablet (Subutex) buprenorphine hcl/naloxone hcl SL tablet (Suboxone) Suboxone SL film Diabetic supplies 306 qty/30 days; 918 qty/90 days Fentanyl oral products: Maximum of any combination oral fentanyl products of 16 units/30 days OR single product limitations as follows: Abstral 8 units/30 days Actiq 6 lozenges/30 days fentanyl lozenges 6 lozenges/30 days Fentora 8 tablets/30 days Onsolis 8 buccal films/30 days Low molecular weight heparins 42 day supply/365 days (e.g., Arixtra, Fragmin, Lovenox) Migraine drug, injections and nasal spray: Migranal Up to 1 kit in a 30-day period sumatriptan (Imitrex, Alsuma) injection Up to 8 syringes or vials/4 kits in a 30-day period sumatriptan (Imitrex) nasal spray Up to 12 devices in a 30-day period Sumavel Dosepro Up to 8 syringes or vials/4 kits in a 30-day period Zomig nasal spray Up to 2 cartons (40mg) in a 30-day period Migraine drugs, tablets: 18 tablets in a 30-day period Axert Frova naratriptan (Amerge) Relpax rizatriptan (Maxalt/MLT) sumatriptan (Imitrex) Treximet zolmitriptan (Zomig/Zomig ZMT) morphine sulfate er, caps (Avinza) 120 capsules/30 days (max 480mg/day) Nucynta/Nucynta ER 180 tablets/30 days Opana ER 120 tablets/30 days (max 160mg/day) OxyContin 120 tablets/30 days Relenza One treatment course in a 180-day period Specialty Pharmacy Products Limited to one month's supply Tamiflu One treatment course per 180-day period Zyvox 14 days of therapy, then PA required Some plans do not cover the following medications. Check with customer or provider services to determine coverage. Erectile dysfunction: Caverject ^ 8 injections/30 days Cialis ^ 8 tablets/30 days † Edex ^ 8 injections/30 days Levitra ^ 8 tablets/30 days † MUSE ^ 8 urethral suppositories/30 days Staxyn ^ 8 tablets/30 days † Stendra ^ 8 tablets/30 days † Viagra ^ 8 tablets/30 days † This list is subject to change.
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
vi Step Therapy (ST) Step Therapy is a form of Prior Authorization that begins drug therapy for a medical condition with the most cost-effective and safest drug therapy and progresses to alternate drugs only if necessary. Prescription drugs subject to Step Therapy guidelines are: (1) used only for patients with certain conditions; (2) Covered only for patients who have failed to respond to, or have demonstrated an intolerance to, alternate Prescription Drugs, as supported by appropriate medical documentation; and (3) when used in conjunction with selected Prescription Drugs for the treatment of the patient’s condition.
Drugs with Step Therapy
Drugs Requirements Angiotensin II Receptor Blockers trial and failure of generic ARB or Benicar/Benicar HCT Edarbi/Edarbyclor Teveten/Teveten HCT Betaseron trial and failure of Avonex, Copaxone, Extavia, or Rebif Diabetic Test Strips (e.g., Accu-chek, trial and failure of preferred products made by Lifescan (One Touch) or Freestyle) Bayer (Contour or Breeze2) Glaucoma Agents trial and failure of latanoprost, travoprost, Lumigan, or Travatan Z Rescula Xalatan Zioptan Humalog/Apidra/Apidra Solostar trial and failure of Novolog Humulin trial and failure of Novolin Nasal Steroids trial and failure of budesonide, flunisolide, fluticasone or Veramyst Beconase AQ Flonase Nasonex Omnaris Rhinocort Aqua
Short-acting Beta Agonists trial and failure of ProAir HFA Proventil HFA Ventolin HFA Xopenex HFA Testim trial and failure of Androderm AGE-B or Androgel AGE-B Zyflo CR trial and failure of zafirlukast and montelukast
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
vii Specialty Pharmacy Products
BlueCross’s Specialty Pharmacy Program designates between self-administered specialty medications and provider-administered medications. http://www.bcbst.com/providers/pharmacy/specialty-pharm-detail.shtml
The physician may obtain approval and order Specialty Pharmacy Products by calling one of the Specialty Pharmacies. You may also order self-administered drugs from one of these Specialty Pharmacies: AcariaHealth, Inc.: 1-855-405-6923 fax 1-866-892-3223
Accredo Health Group: 1-888-239-0725 fax 1-866-387-1003
Acro Pharmaceutical Services: 1-800-906-7798 fax 1-877-381-3806
Amerita, Inc.: 1-855-778-2229 fax 1-877-801-1540
Axium Healthcare Pharmacy: 1-888-315-3395 fax 1-888-315-3270
BioPlus Specialty Pharmacy: 1-888-292-0744 fax 1-800-269-5493
BriovaRx: 1-866-791-8679 fax 1-888-791-7666
Caremark Specialty Pharmacy 1-800-237-2767 fax 1-800-323-2445 Services:
EntrustRx: 1-855-273-3924 fax 1-855-273-3925
HPC Specialty Pharmacy: 1-800-757-9191 fax 1-855-813-0583
NPS Pharmacy : 1-866-406-9266 fax 1-866-420-4686
Restore Rx, Inc.: 1-877-388-0507 fax 1-901-388-0407
Transcript Pharmacy, Inc.: 1-866-420-4041 fax 1-844-407-4040
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
viii Provider-Administered Specialty Drugs The following specialty drugs are provider-administered, meaning that doctor or other health care professional orders the drug and supplies its treatment in the office or facility setting. Provider- administered specialty drugs are typically covered as a medical benefit and not a prescription drug benefit. The Specialty Pharmacy Products List is subject to change. Abilify Maintena Cyramza PA Halaven PA Mirena Retisert Trisenox Abraxane Cytovene IV Herceptin mitoxantrone RiaSTAP Tysabri PA Actemra PA Dacogen Hyalgan MPC Mozobil Risperdal Consta Vantas Acthar H.P. Gel PA Dysport MPC Hycamtin inj Myobloc MPC Rituxan PA Vectibix PA Adagen Elaprase Hylenex Myozyme MPC Ruconest PA Velcade PA Adcetris PA Elelyso PA Ilaris MPC Naglazyme MPC Sandostatin LAR Vidaza MPC Aldurazyme MPC Eligard IM MPC Immune Neulasta MPC Signifor LAR PA Vimizim PA Alferon N Eloxatin Globulins MPC Neumega Simponi Aria PA Vistide Alimta PA Entyvio PA Intron A IV Neupogen MPC Skyla Visudyne Aralast NP MPC Epogen PA Istodax PA NovoSeven RT Soliris PA Vivitrol Aranesp PA epoprostenol Ixempra Nplate Somatuline Vpriv MPC Arranon (Flolan, Jetrea PA Opdivo PA Stelara PA Xeomin MPC Arzerra PA Veletri) PA Jevtana PA Orencia PA Supartz MPC Xgeva PA Avastin PA Erbitux PA Kadcyla PA Orthovisc MPC Supprelin Xiaflex MPC Beleodaq PA Erwinaze PA Krystexxa PA Ozurdex Sylvant PA Xolair PA Benlysta PA Euflexxa MPC Kyprolis PA Perjeta PA Synagis PA Yervoy PA Berinert PA Eylea MPC Lemtrada PA Prialt Synribo PA Zaltrap PA Blincyto PA Fabrazyme MPC Leukine Procrit PA Synvisc MPC Zemaira Botox MPC Firmagon Lucentis Proleukin Synvisc-One MPC Zoladex Campath MPC Folotyn PA Lumizyme MPC Prolia PA Temodar inj PA zoledronic acid Camptosar Gazyva PA Lupron Depot MPC Provenge **PA Thyrogen (Reclast, Zometa) Cerezyme MPC Gel One MPC Macugen Qutenza Torisel Cimzia vials PA Gemzar Makena Remicade PA Treanda PA Cinryze PA Granix PA Marqibo PA Remodulin PA Trelstar MPC Medical Policy Criteria must be satisfied. The criteria can be found at http://crossroads/med_policies!SSL!/WebHelp/mpm2.htm PA These drugs require prior authorization. Your network physician or specialty pharmacy vendor must call 1-800-924-7141 for prior authorization. See prior authorization details within the Prior Authorization section. ** Provenge is not available through BCBST's Preferred SP Rx Pharmacies. Information on obtaining Provenge may be found at http://www.provenge.com/contact-us.aspx To access the Medical Policies and Decision Support Trees for Provider-Administered Specialty Drugs: http://www.bcbst.com/mpmanual/!SSL!/WebHelp/Pharmacology.htm Self-Administered Specialty Drugs The following specialty drugs are self-administered, meaning that the doctor would provide a prescription, but then you would administer the drug to yourself - usually by injection. Self-administered specialty drugs are typically covered as a prescription drug benefit. The Specialty Pharmacy Products List is subject to change. Actemra SQ PA, ST Caprelsa PA Fuzeon Jakafi PA octreotide SQ ribavirin Tivicay Acthar H.P. Gel PA Cayston PA Gammagard Juxtapid PA (Sandostatin SQ) (Copegus, Rebetol, TOBI PA Actimmune PA Cerdelga PA liquid PA Kalydeco PA Ofev PA Ribasphere) PA TOBI Podhaler PA Adcirca PA Cimzia syringes Gamunex-C PA Kineret PA, ST Opsumit PA Sabril Tracleer PA Adempas PA PA, ST Gattex PA Koate-DVI Oralair PA Samsca Tretten Advate Cinryze PA Gilenya PA Kogenate FS Orencia SQ PA, ST Sensipar Triumeq Advate H Cometriq Gilotrif PA Korlym PA Orenitram PA Signifor PA Tykerb PA Advate L Complera Gleevec Kuvan Orfadin silendafil (Revatio) Tyvaso PA Advate M Copaxone Growth Hormone Kynamro PA Otezla PA, ST PA Valchlor PA Advate UH Corifact (Norditropin) PA Lenvima PA Pegasys PA Simponi PA, ST Ventavis PA Afinitor PA Cystadane Harvoni PA Letairis PA PegIntron PA Somavert Vitekta Alphanate Cystaran Helixate FS leuprolide SQ Plegridy Sovaldi PA Votrient PA Alphanate SD Duopa PA Hemofil-M (Eligard, Lupron Pomalyst PA Sprycel Wilate Ampyra PA Enbrel PA Hizentra PA SQ) Prezcobix Stimate Xalkori PA Apokyn Epogen PA Humate-P Lynparza PA Procrit PA Stivarga PA Xeljanz PA, ST Aranesp PA epoprostenol Humira PA Mekinist PA Procysbi PA Stribild Xeloda Arcalyst (Flolan, Veletri) PA Hycamtin oral Monoclate-P Profilnine SD Sutent PA Xenazine PA Astagraf XL Erivedge PA Hyqvia PA Mozobil Promacta Sylatron PA Xtandi PA Atripla Esbriet PA Ibrance PA Myalept PA Pulmozyme Tafinlar PA Zavesca PA Aubagio PA Evotaz Iclusig PA Neulasta Ravicti Tarceva PA Zelboraf PA Avonex Exjade Imbruvica PA Neumega Rebif Targretin PA Zolinza Bebulin Extavia Incivek PA Neupogen Recombinate Tasigna Zydelig PA BeneFIX Farydak PA Increlex PA Nexavar PA Remodulin PA Tecfidera PA Zykadia PA Berinert PA Ferriprox Infergen PA Northera PA Revlimid PA temozolomide Zytiga Betaseron ST Firazyr PA Inlyta PA NovoSeven RT (Temodar oral) PA Bosulif PA Forteo Intron A SQ PA Thalomid PA
PA These drugs require prior authorization. Your network physician or specialty pharmacy vendor must call 1-877-916-2271 for prior authorization. See prior authorization details within the Prior Authorization section. ST These drugs require step therapy. To have these medications covered under the prescription drug benefit, it may be required to first try an alternative or complete the prior authorization process. See step therapy details in the Step Therapy section.
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document. ix Excluded Drugs - Alternatives
Most plans exclude the following formulary products. Note the available alternative products. Some plans may cover some or all of these drugs. You may check the individual member's benefit by calling Provider Service. This list is subject to change during the plan year. Excluded Alternatives Excluded Alternatives Absorica isotretinoin Mirvaso Finacea, topical metronidazole Aciphex omeprazole 20 mg Momexin mometasone, OTC Lac-Hydrin Acticlate doxycycline Monodox doxycycline Akynzeo granisetron, ondansetron, Anzemet Morgidox doxycycline Analpram E hydrocortisone/pramoxine Movantik Amitiza Aplenzin bupropion ext-rel Moxatag amoxicillin Arnuity Ellipta Asmanex HFA, Flovent Diskus, Flovent HFA, Qvar Nalfon 400 mg fenoprofen 200 mg, 300 mg Axiron Androderm PA, Androgel PA Nasacort AQ flunisolide, fluticasone proprionate, Veramyst Belsomra eszopiclone, zaleplon, zolpidem, zolpidem ext-rel Nascobal cyanocobalamin Bethkis tobramycin, Tobi Podhaler Nesina Januvia, Tradjenta Brintellix generic SSRI Nymalize nimodipine Brisdelle paroxetine HCl Oleptro ER trazodone Bulk Powders & Select Olysio Harvoni PA, Sovaldi PA Bulk Chemicals omega-3 acid ethyl esters OTC fish oil, fenofibrate, gemfibrozil Bunavail buprenorphine/naloxone, Suboxone SL film omeprazole/sodium omeprazole 20 mg Cambia diclofenac tablets bicarbonate capsaicin/menthol patches OTC capsaicin Onexton Acanya, benzoyl peroxide/clindamycin Cetraxal ofloxacin 0.3% otic soln Onglyza Januvia, Tradjenta Clindacin Pac clindamycin topical Oracea doxycycline Comfort Pac- cyclobenzaprine Orbivan CF acetaminophen/butalbital Cyclobenzaprine Oseni Januvia or Tradjenta plus pioglitazone Comfort Pac-Ibuprofen ibuprofen Otrexup methotrexate Comfort Pac-Naproxen naproxen Oxycodone ER Oxycontin Comfort Pac-Tizanidine tizanidine Pediaderm HC OTC hydrocortisone cream Conzip tramadol or tramadol ext-rel Pennsaid oral diclofenac Deprizine ranitidine Prodrin isometheptene/apap/dichloralphenazone Desvenlafaxine ER generic SSRI, generic SNRI Provigil Nuvigil PA Dexilant omeprazole, pantoprazole, Nexium Prumyx OTC moisturizers and emollients Diclegis OTC doxylamine, OTC pyridoxine Qnasl flunisolide, fluticasone propionate, triamcinolone Dicopanol OTC diphenhydramine acetonide, Veramyst Disalcid salsalate rabeprazole omeprazole, pantoprazole, Nexium Doryx doxycycline immediate-release Rayos prednisone Duexis ibuprofen, OTC famotidine Rectiv nitroglycerin ointment Ecoza econazole nitrate Regimex diethylpropion, phendimetrazine, phentermine Edluar zolpidem tartrate oral Rytary carbidopa/levodopa ext-rel Egrifta Sancuso oral granisetron Eligen B12 cyanocobalamin Savaysa Eliquis, Pradaxa, Xarelto Esomeprazole strontium omeprazole, pantoprazole, Nexium Silenor doxepin Evzio naltrexone Single-source brand generics Exalgo hydromorphone Sitavig acyclovir, famciclovir, valacyclovir Fanatrex gabapentin Sivextro Zyvox Fentanyl patch 37.5mcg, fentanyl patch 12mcg, 25mcg, 50mcg, 75mcg, 100mcg Sklice Lindane 62.5mcg, 87.5mcg Sodium Sulfacetamide kit sulfacetamide sodium/sulfur Fetzima generic SSRI, generic SNRI Solodyn minocycline Fortesta Androderm PA, Androgel PA Subsys fentanyl lozenges QL Forfivo XL bupropion ext-rel Sumadan sulfacetamide/sulfur Gralise gabapentin Sumaxin CP sulfacetamide/sulfur Growth Hormones Norditropin (# PA) Synapryn tramadol & OTC glucosamine (other than Tabradol cyclobenzaprine & OTC MSM Norditropin # PA) Terbinex Kit terbinafine including but not Tirosint levothyroxine limited to: Genotropin, Toviaz oxybutynin, oxybutynin ER, Enablex, Vesicare Humatrope, Nutropin and Omnitrope Trezix acetaminophen/caffeine/dihydrocodeine triamcinolone acetonide flunisolide, fluticasone proprionate, Veramyst Hemangeol propranolol oral solution Trulicity Bydureon, Byetta, Victoza Hetlioz OTC melatonin Uceris rectal foam Cortifoam hydromorphone er hydromorphone UTA Urogesic-Blue, Uro-Blue Incruse Ellipta Spiriva, Tudorza Pressair Vascepa OTC fish oil, fenofibrate, gemfibrozil Intermezzo zaleplon, zolpidem, zolpidem ext-rel Vecamyl generic ACE Inhibitor, ARB, beta blocker, calcium Jardiance Farxiga, Invokana channel blocker Jublia ciclopirox topical solution Veltin clindamycin topical & tretinoin Karbinal ER carbinoxamine maleate Versacloz clozapine Kazano Janumet, Jentadueto Viekira Harvoni PA, Sovaldi PA Kerydin ciclopirox topical solution Viibryd generic SSRI Khedezla generic SSRI, generic SNRI Vimovo naproxen & OTC omeprazole Kitabis tobramycin, Tobi Podhaler Vituz hydrocodone/chlorpheniramine susp Kombiglyze XR Janumet Vogelxo Androderm PA, Androgel PA Lamisil Oral Granules terbinafine tablets Xartemis XR oxycodone/acetaminophen Latisse Xerese Zovirax & OTC hydrocortisone cream Lazanda fentanyl lozenges QL Zegerid omeprazole 20 mg Lovaza OTC fish oil, fenofibrate, gemfibrozil Zetonna flunisolide, fluticasone, triamcinolone, Veramyst Luzu econazole nitrate Ziana clindamycin topical & tretinoin Medical foods Zipsor diclofenac potassium Metozolv ODT metoclopramide Zohydro ER hydrocodone/apap Migralam isometheptene/caffeine/APAP Zolpimist zolpidem Mimyx OTC moisturizers and emollients Zorvolex diclofenac sodium Minocin Combo Pack minocycline Zuplenz ondansetron minocycline ext-rel minocycline immediate-release Zyflo, Zyflo CR montelukast, zafirlukast Zypram hydrocortisone acetate/pramoxine
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
x 2015 Preventive Drug List If your health plan includes the Preventive Drug List option, you just pay a copay for preventive care medications instead of having to meet your plan’s deductible for certain prescription drugs. Prescription drugs on the Preventive Drug List will be covered as if you already met your deductible, so you are only responsible for paying the appropriate copay. This enhanced benefit to your health plan makes it easier for you to purchase the medications you and your family need to stay healthy today – and tomorrow.
Medications on the Preventive Drug List help prevent and manage several health concerns.
Some of these conditions, if not prevented or managed, can lead to serious illnesses and complications. Following your doctor’s treatment plan, including taking prescribed medications as directed, can help you live a healthier life today, and avoid serious illness and high health care costs in the future.
This list contains some of the most commonly prescribed preventive care drugs and is not all-inclusive. This list does not guarantee coverage for preventive care drugs that are not listed. This list is subject to change throughout the year. Check bcbst.com for the current list. To ensure coverage, check your Schedule of Benefits or call Member Services at 1-800-565-9140.
COVERED GENERICS PREFERRED COVERED BRANDS COVERED GENERICS (always your lowest copay) (may have a reduced copay) (always your lowest copay) Asthma and Other Respiratory Conditions Contraception (continued) albuterol soln Advair Diskus Perforomist Microgestin FE 1/20 Ogestrel Trinessa budesonide nebulizer soln Advair HFA ProAir HFA Mono-Linyah Orsythia Tri-Previfem cromolyn sodium Arcapta Neohaler ProAir Respiclick Mononessa Philith Tri-Sprintec ipratropium bromide Asmanex QVAR Myzilra Pimtrea Trivora inhaler Asmanex HFA Serevent Diskus Necon 0.5/35 Pirmella Velivet ipratropium-albuterol Breo Ellipta Spiriva Necon 1/35 Portia Vestura levalbuterol Brovana Symbicort Necon 1/50 Previfem Viorcle metaproterenol sulfate Combivent Respimat Tudorza Pressair Necon 7/7/7 Quasense Vyfemia montelukast Dulera Nikki Reclipsen Wera terbutaline sulfate Flovent Diskus Nora-Be Sharobel Wymzya FE zafirlukast Flovent HFA norethindrone acetate 0.35 Sprintec Xulane Foradil norgestimate-ethinyl Sronyx Zarah estradiol Syeda Zenchent COVERED GENERICS PREFERRED NON-PREFERRED Norlyroc Tarina FE 1/20 Zenchent FE (always your lowest copay) COVERED BRANDS COVERED BRANDS Nortrel 0.5/35 Tilia FE Zeosa (may have a reduced copay) (always your highest copay) Nortrel 1/35 Tri-Estarylla Zovia 1/35 Nortrel 7/7/7 Tri-Legest FE Zovia 1/50 Conditions Related to Blood Clots Ocella Tri-Linyah anagrelide Brilinta Aggrenox COVERED GENERICS PREFERRED NON-PREFERRED cilostazol Effient Coumadin (always your lowest copay) COVERED BRANDS COVERED BRANDS clopidogrel Eliquis Fragmin QL (may have a reduced copay) (always your highest copay) dipyridamole Pradaxa enoxaparin QL Xarelto Diabetes fondaparinux QL Jantoven acarbose Bydureon Actoplus Met XR pentoxifylline chlorpropamide Byetta Apidra ST ticlopidine glimepiride Farxiga Apidra SoloSTAR ST warfarin sodium glipizide Invokana Avandamet glipizide ext-rel Janumet Avandaryl COVERED GENERICS glipizide-metformin Janumet XR Avandia (always your lowest copay) glyburide Januvia Glumetza glyburide micronized Jentadueto Glyset Contraception glyburide-metformin Lantus SoloSTAR Humalog (pens & vials) Altavera Delyla Junel FE 1.5/30 Lantus (vials)* Levemir (pens) ST Alyacen desogestrel-ethinyl Junel FE 1/20 Levemir (vials)* Novolin (pens) Humulin (pens & vials) Amethia estradiol Kariva metformin Novolog (pens) ST Amethia Lo drospirenone-ethyinyl Kelnor 1/35 metformin ext-rel Tradjenta Prandimet Amethyst estradiol Kurvelo nateglinide Victoza Riomet Apri Elinest Larin Novolin (vials)* SymlinPen Aranelle Emoquette Larin FE Novolog (vials)* Ashlyna Enpresse Layolis FE pioglitazone Aubra Errin Leena pioglitazone-glimepiride Aviane Enskyce Lessina pioglitazone-metformin Azurette Estarylla Levonest repaglinide Balziva Falmina levonorgestrel-est estradiol tolazamide Briellyn Gianvi Levora tolbutamide Camila Gildagia Lomedia 24 Fe Camrese Gildess Loryna Diabetic Supplies Camrese Lo Gildess FE Low-Ogestrel Caziant Gildess 24 FE Lutera Bayer Contour/Breeze2 alcohol preps and lancets Chateal Heather Lyza diabetic products* QL QL Cryselle Introvale Marlissa Lifescan One Touch BD insulin syringes QL Cyclafem Jencycla medroxyprogesterone diabetic products* QL Cyclafem 7/7/7 Jolessa acetate Dasetta Jolivette Microgestin 1.5/30 Daysee Junel 1.5/30 Microgestin 1/20 Deblitane Junel 1/20 Microgestin FE 1.5/30 *Under your plan, this brand-name product is available at the lowest copay level. The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
xi COVERED GENERICS PREFERRED COVERED COVERED GENERICS PREFERRED COVERED (always your lowest copay) BRANDS (always your lowest copay) BRANDS (may have a reduced copay) (may have a reduced copay) Emotional Health High Cholesterol amitriptyline mirtazapine Abilify PA atorvastatin lovastatin Crestor amitriptyline- nefazodone Latuda PA cholestyramine niacin Liptruzet chlordiazepoxide nortriptyline Seroquel XR PA colestipol niacin ext-rel Simcor amitriptyline- olanzapine PA fenofibrate pravastatin Vytorin perphenazine olanzapine-fluoxetine PA fenofibric acid Prevalite Zetia amoxapine paroxetine fluvastatin simvastatin bupropion paroxetine ext-rel gemfibrozil bupropion ext-rel perphenazine chlorpromazine phenelzine Multiple Sclerosis citalopram protriptyline clomipramine quetiapine PA clozapine PA risperidone PA Avonex SPRx desipramine sertraline Copaxone SPRx doxepin thioridazine Gilenya PA SPRX duloxetine thiothixene Rebif SPRx escitalopram tranylcypromine Rebif Rebidose SPRx fluoxetine trazodone Tecfidera PA SPRx fluphenazine trifluoperazine fluvoxamine venlafaxine haloperidol venlafaxine ext-rel COVERED GENERICS PREFERRED NON-PREFERRED imipramine ziprasidone PA (always your lowest copay) COVERED BRANDS COVERED BRANDS loxapine (may have a reduced copay) (always your highest copay) maprotiline Osteoporosis (a bone disease)
High Blood Pressure & Other Heart Conditions alendronate Actonel Fosamax Plus D calcitonin-salmon nasal Atelvia acebutolol Matzim LA Azor spray Miacalcin injection acetazolamide methazolamide Benicar Fortical Afeditab CR methyclothiazide Benicar HCT ibandronate amiloride methyldopa Bystolic raloxifene amiloride-hctz methyldopa-hctz Coreg CR amiodarone metolazone Lanoxin amlodipine metoprolol succinate Tribenzor amlodipine-atorvastatin ext-rel Prenatal Care (Vitamins) amlodipine-benazepril metoprolol tartrate atenolol metoprolol-hctz all generic vitamins atenolol-chlorthalidone mexiletine benazepril minoxidil Seizure Conditions benazepril-hctz moexipril betaxolol moexipril-hctz carbamazepine Dilantin Banzel bisoprolol nadolol carbamazepine ER Vimpat Celontin bisoprolol fumarate nadolol- clonazepam Diastat bisoprolol-hctz bendroflumethiazide divalproex delayed-rel Onfi bumetanide nicardipine divalproex ext-rel Oxtellar XR candesartan Nifediac CC Epitol Peganone candesartan-hctz Nifedical XL ethosuximide Potiga captopril nifedipine ext-rel felbamate Sabril SPRx captopril-hctz nimodipine gabapentin Cartia XT nisoldipine ext-rel lamotrigine carvedilol NitroBid lamotrigine ext-rel chlorothiazide nitroglycerin levetiracetam chlorthalidone Nitro-Time levetiracetam ext-rel clonidine tablets Pacerone oxcarbazepine Clorpres perindopril phenobarbital digoxin pindolol phenytoin sodium diltiazem potassium bicarbonate extended diltiazem 24 HR CD potassium chloride primidone diltiazem ext-rel prazosin tiagabine Dilt-XR propafenone Topiragen disopyramide phosphate propranolol topiramate doxazosin propranolol ext-rel valproic acid enalapril propranolol-hctz zonisamide enalapril-hctz quinapril eplerenone quinapril-hctz Thyroid Modifiers eprosartan quinidine gluconate felodipine ext-rel quinidine sulfate levothyroxine flecainide acetate ramipril Levoxyl fosinopril reserpine liothyronine fosinopril-hctz Sorine methimazole furosemide sotalol Nature-Thyroid guanfacine sotalol AF NP Thyroid hydralazine spironolactone propylthiouracil hydrochlorothiazide spironolactone-hctz Unithroid indapamide Taztia XT Westhroid irbesartan telmisartan irbesartan-hctz telmisartan-amlodipine isosorbide dinitrate/ telmisartan-hctz mononitrate terazosin isradipine timolol maleate K-effervescent torsemide Klor-Con 8mEq trandolapril Klor-Con 10mEq trandolapril-verapamil Klor-Con 20mEq ext-rel Klor-Con M triamterene-hctz Klor-Con-EF valsartan labetalol valsartan-hctz lisinopril verapamil lisinopril-hctz verapamil ER PM losartan verapamil ext-rel losartan-hctz
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
xii Affordable Care Act Requirements
The Affordable Care Act (ACA) requires certain categories of drugs and immunizations are included in preventive care services coverage based on recommendations from the U.S. Preventive Services Task Force (USPSTF). These recommendations are important in preventing diseases as well as providing additional women’s services such as contraception. The following products may be available to you at out-of-pocket cost depending on your plan. Some plans may differ, so check your Evidence of Coverage (EOC) for details.
Drug or Drug Category Coverage Criteria Reason Aspirin - Generic OTC 81mg and Males ages 45-79 years and Females ages Prevent cardiovascular disease 325mg 55 to 79 years Bowel preparation agents - Generic OTC Males and Females ages 50 to 75 years Use in cleansing bowel as and prescription products plus brand Limit 2 prescriptions filled per 365 days preparation for colonoscopy products that do not have a generic screening equivalent Breast Cancer - generic tamoxifen & Asymptomatic women age 35 years and Prevention of breast cancer raloxifene older who are at increased risk for breast in women at high-risk cancer Fluoride - Generic OTC and Children older than 6 months through Prevent dental cavities if prescription products 5 years old water source is deficient in fluoride Folic Acid - Generic OTC and Females through age 50 years Prevent birth defects prescription products 0.4mg - 0.8mg Iron Supplements - Generic OTC and Children ages 6-12 months Prevent anemia due to iron prescription products deficiency Smoking Cessation - Generic OTC and Males and Females age 18 years and older Increase in health benefits prescription products plus brand Chantix who use tobacco products from successfully quitting smoking Vaccines - all prescription vaccines Ages per Advisory Committee on Prevention of infectious Immunization Practices (ACIP) diseases recommendations Vitamin D - Generic OTC and Males and Females ages 65 and older who Prevent falls in community- prescription products (doses less than are at increased risk for falls dwelling adults who are at 1000 IU per dosage form) increased risk of falls Women's Contraceptives - Generic Females only Prevent pregnancy prescription oral contraceptives plus brand oral contraceptives that do not have a generic equivalent
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
xiii Editor's Note
Your comments and suggestions regarding this formulary are encouraged and will be reviewed and considered by the Pharmacy and Therapeutics Committee. Please send your comments to:
Manager Formularies and Specialty Pharmacy BlueCross BlueShield of Tennessee 1 Cameron Hill Circle Chattanooga, TN 37402-2555 Phone: 423-535-7528 Fax: 1-888-343-4232
Pharmacy Appeals
To appeal a denial based on Prior Authorization criteria or to request a medical exception to the quantity limit, please FAX a written request to:
Pharmacy Management Appeals BlueCross BlueShield of Tennessee 1 Cameron Hill Circle Chattanooga, TN 37402-2555 Fax: 1-888-343-4232
Notice
The information contained in this formulary and its appendices is provided by BlueCross BlueShield of Tennessee solely for the convenience of medical providers. BlueCross does not warrant or assure accuracy of such information, nor is it intended to be comprehensive in nature. This formulary is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in his or her choice of prescription drugs. BlueCross does not assume responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer's product literature or standard references for more detailed information.
The information contained in this document is proprietary information subject to a licensing agreement. The information may not be copied in whole or in part without the written permission of BlueCross BlueShield of Tennessee.
©2013. All Rights Reserved.
Trademarks are the intellectual property of the respective product owners.
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
xiv CLINICAL REFERENCES
To access the BlueCross medical policy go to: http://www.bcbst.com/mpmanual/!SSL!/WebHelp/Pharmacology.htm
ANTINEOPLASTICS AND IMMUNOSUPPRESSANTS BETA BLOCKERS Clinical practice guidelines in oncology are available at: Guidelines for the use of beta-blockers and beta-blocker http://www.asco.org http://www.nccn.org combinations in various patient populations are available at: http://www.acc.org BLOOD MODIFIERS http://www.nhlbi.nih.gov/guidelines/hypertension Guidelines of treatment and management of hemophilia are available at: LIPID LOWERING AGENTS http://www.hemophilia.org The Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult BLOOD CELL FORMATION Treatment Panel III) is available at: Guidelines for the management of neutropenia are available at: http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm http://www.asco.org CENTRAL NERVOUS SYSTEM Guidelines for the management of anemia associated with chronic kidney disease are available at: ALZHEIMER'S DISEASE http://www.kidney.org/professionals/kdoqi/guidelines_comme Practice guidelines for the management of dementia are ntaries.cfm#guidelines available at: http://www.aan.com CARDIOVASCULAR AGENTS ANALGESICS The Seventh Report of the Joint National Committee on Practice guidelines of pain management are available at: Prevention, Detection, Evaluation and Treatment of High Blood http://www.asahq.org Pressure is available at: http://www.nhlbi.nih.gov/guidelines/hypertension OPIOIDS Practice Guidelines for Cancer Pain Management (includes WHO Guidelines for the evaluation and management of cardiovascular analgesic ladder) are available at: diseases in adults are available at: http://www.asahq.org http://www.acc.org http://www.nccn.org http://www.americanheart.org http://www.heartfailureguideline.org Opioid guidelines in the management of chronic non-malignant pain are available at: ACE INHIBITORS http://www.asipp.org/Guidelines.htm Guidelines for the use of ACE inhibitors are available at: http://professional.diabetes.org MIGRAINE http://www.acc.org http://www.americanheart.org Guidelines for prevention and management of migraine headaches http://www.nhlbi.nih.gov/guidelines/hypertension are available at: http://www.aan.com ALPHA BLOCKERS Guidelines for the use of alpha blockers in various patient MULTIPLE SCLEROSIS populations are available at: Practice guidelines for multiple sclerosis are available at: http://www.nhlbi.nih.gov/guidelines/hypertension http://www.aan.com
ANGIOTENSIN II RECEPTOR BLOCKERS PARKINSON'S DISEASE Guidelines for the use of angiotensin II receptor antagonists in Practice guidelines for the diagnosis and treatment of Parkinson's various patient populations are available at: disease are available at: http://professional.diabetes.org http://www.aan.com http://www.nhlbi.nih.gov/guidelines/hypertension SEIZURES ANTIARRHYTHMICS AND CARDIAC GLYCOSIDES Practice guidelines for the treatment of epilepsy are available at: Guidelines for the use of antiarrhythmics and cardiac glycosides in http://www.aan.com various patient populations are available at: http://www.acc.org
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
xv DERMATOLOGY INFECTIOUS DISEASES
Guidelines for care of dermatological conditions are available at: Hepatitis: CDC recommendations on the treatment of hepatitis http://www.aad.org/research/guidelines are available at: http://www.cdc.gov/hepatitis/index.htm Guidelines for the treatment of atopic dermatitis are available at: http://www.aad.org Guidelines for the management of chronic hepatitis by the American Association for the Study of Liver Disease are available ACNE VULGARIS at: http://www.aasld.org Guidelines for the care and treatment of acne vulgaris are available at: HIV/AIDS: Guidelines for the treatment of HIV patients by the http://www.aad.org U.S. Department of Health and Human Services are available at: http://www.aidsinfo.nih.gov PSORIASIS Guidelines of care for the management and treatment of psoriasis Infective Endocarditis: American Heart Association with topical therapies are available at: recommendations for the prevention of bacterial endocarditis are http://www.aad.org available at: http://www.americanheart.org EAR, NOSE, AND THROAT Influenza: Recommendations of the Advisory Committee on EAR Immunization Practices are available at: Clinical practice guidelines for the treatment of otitis media are http://www.cdc.gov/ncidod/diseases/flu/fluvirus.htm available at: http://www.aap.org International Travel: CDC recommendations for international travel are available at: NOSE http://www.cdc.gov/travel The Allergy Report and guidelines for allergy-related conditions are available at: Sexually Transmitted Diseases: CDC Sexually Transmitted http://www.aaaai.org Diseases Guidelines are available at: http://www.cdc.gov/std/treatment/default.htm ENDOCRINE Respiratory Tract Infection/Antibiotic Use/Community ANDROGENS # Acquired Pneumonia/Other: Principles of appropriate antibiotic Clinical practice guidelines for the treatment of hypogonadism are use for treatment of nonspecific upper respiratory tract infection in available at: adults are available at: http://www.aace.com http://www.cdc.gov/ncidod/guidelines/guidelines_topic_ar.htm
DIABETES MELLITUS Practice guidelines and statements developed and endorsed by the Guidelines of treatment and management of diabetes are Infectious Diseases Society of America are available at: available at: http://www.idsociety.org http://professional.diabetes.org Otitis Media GROWTH HORMONE # Clinical practice guidelines for the treatment of otitis media are Guidelines for use of growth hormone are available at: available at: http://www.aace.com http://www.aap.org
OSTEOPOROSIS MUSCULOSKELETAL Guidelines of treatment and management of osteoporosis are available at: ARTHRITIS http://www.aace.com http://www.nof.org Treatment recommendations for osteoarthritis are available at: http://www.rheumatology.org GASTROINTESTINAL Disease-Modifying Antirheumatic Drugs Guidelines for the treatment and management of various Guidelines for the management of rheumatic diseases are gastrointestinal diseases/conditions are available at: available at: http://www.acg.gi.org http://www.gastro.org http://www.rheumatology.org
OBESITY # Guidelines of treatment and management of obesity are available at: http://www.aace.com http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
xvi OB-GYN INSOMNIA Practice parameters for the treatment of sleep disorders and clinical CONTRACEPTIVES guidelines for the evaluation and management of chronic insomnia Some plans exclude coverage of contraceptives. Gender edit is in adults are available at: applicable. http://www.aasmnet.org
HORMONE THERAPY/MENOPAUSE RESPIRATORY DRUGS Guidelines of treatment and management of hormone therapy and menopause are available at: ASTHMA/COPD http://www.menopause.org Guidelines to the management, prevention, or treatment of COPD and asthma are available at: OPHTHALMIC http://www.aaaai.org http://www.ginasthma.com http://www.goldcopd.com GLAUCOMA http://www.nhlbi.nih.gov Preferred Practice Pattern Guidelines for the treatment of glaucoma are available at: ANTIHISTAMINES AND DECONGESTANTS http://one.aao.org The Allergy Report and guidelines for allergy-related conditions are available at: PSYCHIATRIC http://www.aaaai.org
Practice guidelines for psychiatric disorders are available at: UROLOGICAL http://www.psych.org ERECTILE DYSFUNCTION # ^ ATTENTION DEFICIT HYPERACTIVITY DISORDER Guidelines for the management of erectile dysfunction are Guidelines for the evaluation and management of attention deficit available at: disorder are available at: http://www.auanet.org/guidelines http://www.aacap.org http://www.aap.org Prior Authorization and Quantity Limitations are required for those plans that cover these medications. BCBST prior BIPOLAR DISORDER authorization criteria are available by calling Express Scripts. Guidelines for the evaluation and management of bipolar and Phone: 1-877-916-2271. depressive disorders are available at: http://www.psych.org SYMPTOMATIC BENIGN PROSTATIC HYPERTROPHY Guidelines for the management of BPH are available at: DEPRESSION http://www.auanet.org/guidelines Guidelines for the evaluation and management of bipolar and depressive disorders are available at: http://www.psych.org
# Many plans do not cover these medications. Check with BlueCross member or provider services or the Express Scripts Pharmacy Help Desk to determine coverage.
^ Gender edit is applicable.
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
xvii THERAPEUTIC CHAPTER INDEX FORTHE BLUECROSS BLUESHIELDOF TENNESSEE THREE TIER FORMULARY CHAPTERS
1. Anti-Infectives ...... 5 3.3.1 NSAIDs/COX-2 Inhibitors ...... 11 1.1 Penicillins ...... 5 3.3.1.1 NSAIDs ...... 11 1.2 Tetracyclines ...... 5 3.3.1.2 NSAIDs-Specific COX-2 1.3 Cephalosporins ...... 5 Inhibitors ...... 11 1.3.1 First Generation Cephalosporins ...... 5 3.3.2 Salicylates ...... 11 1.3.2 Second Generation Cephalosporins ...... 5 3.3.3 Miscellaneous Analgesics ...... 11 1.3.3 Third Generation Cephalosporins ...... 5 3.3.4 Narcotic Antagonists ...... 11 1.4 Erythromycins & Other Macrolides ...... 5 3.4 Migraine & Cluster Headache Therapy ...... 12 1.4.1 Erythromycins & Other Macrolides ...... 5 3.4.1 Headache Therapy ...... 12 1.5 Quinolones ...... 5 3.4.2 Antivertigo & Antiemetic Drugs ...... 12 1.5.1 Fluoroquinolones ...... 5 3.5 Antiparkinsonism Agents ...... 12 1.6 Sulfas & Related Agents ...... 5 3.6 Anticonvulsants ...... 13 1.7 Urinary Tract Agents ...... 6 3.7 Miscellaneous Neurological Therapy ...... 13 1.8 Antivirals ...... 6 3.8 Muscle Relaxants & Antispasmodic 1.8.1 Miscellaneous Antivirals ...... 6 Therapy ...... 13 1.8.2 HIV/AIDS Therapy ...... 6 3.8.1 Muscle Relaxants & Antispasmodic 1.9 Antifungal Agents ...... 7 Agents ...... 13 1.10 Vancomycin ...... 7 3.8.2 Myasthenia Gravis ...... 14 1.11 Miscellaneous Anti-Infectives ...... 7 3.9 Psychotherapeutic Drugs ...... 14 1.11.1 Miscellaneous Anti-Infectives ...... 7 3.9.1 Hypnotic Agents ...... 14 1.11.2 Antiparasitics ...... 7 3.9.2 Antidepressant Agents ...... 14 1.11.3 Antimalarials ...... 7 3.9.2.1 Tricyclics ...... 14 1.11.4 Antimycobacterials ...... 7 3.9.2.2 Miscellaneous Antidepressants ...... 14 2. Antineoplastic & 3.9.2.3 MAO Inhibitors ...... 14 Immunosuppressant Drugs ...... 8 3.9.2.4 Selective Serotonin Reuptake Inhibitors ...... 14 2.1 Antineoplastic & Immunosuppressant Drugs ...... 8 3.9.3 Antipsychotics ...... 15 2.1.1 Alkylating Agents ...... 8 3.9.3.1 Phenothiazines ...... 15 2.1.2 Antimetabolites ...... 8 3.9.3.2 Butyrophenones ...... 15 2.1.3 Androgens, Estrogens, Hormones & 3.9.3.3 Miscellaneous Related Drugs ...... 8 Antipsychotics ...... 15 2.1.3.3 Hormones ...... 8 3.9.4 Miscellaneous Psychotherapeutic Agents ...... 15 2.1.3.4 Antiestrogens ...... 8 3.9.5 Anxiolytics ...... 15 2.1.3.5 Antiandrogens ...... 8 2.1.5 Immunosuppressant Drugs ...... 8 4. Cardiovascular, Hypertension & 2.1.6 Miscellaneous Antineoplastic Drugs ...... 9 Lipids ...... 16 2.2 Adjunctive Agents ...... 9 4.1 Antiarrhythmic Agents ...... 16 2.2.1 Adjunctive Agents ...... 9 4.2 Cardiac Glycosides ...... 16 3. Autonomic & CNS Drugs, 4.3 Nitrates ...... 16 Neurology & Psych ...... 10 4.3.1 Rapid Acting Nitrates ...... 16 4.3.2 Long Acting Nitrates ...... 16 3.1 Narcotic Analgesics ...... 10 4.4 Coagulation Therapy ...... 16 3.1.1 Narcotics ...... 10 4.4.1 Anticoagulants ...... 16 3.1.2 Combination Narcotic/Analgesics ...... 10 4.4.2 Antiplatelet Drugs ...... 16 3.3 Non-Narcotic Analgesics ...... 11 4.4.3 Heparin ...... 16 4.4.4 Vitamin K ...... 16 4.4.5 Hemostatics ...... 16 4.4.6 Miscellaneous Coagulation Agents ...... 17 4.5 Antihypertensive Therapy ...... 17 7.4.4 Gonadotropin & Related Agents ...... 25 4.5.1 Thiazide & Related Diuretics ...... 17 7.5 Diabetes Therapy ...... 25 4.5.2 Beta-Blockers ...... 17 7.5.1 Insulin Therapy ...... 25 4.5.3 Calcium Channel Blockers ...... 17 7.5.2 Non-Insulin Hypoglycemic Agents ...... 25 4.5.3.1 Calcium Channel Blockers/ 7.5.3 Glucose Elevating Agents ...... 26 Non-Dihydropyridines ...... 17 7.5.4 Insulin Syringes/Miscellaneous Durable 4.5.3.2 Calcium Channel Blockers/ Medical Equipment ...... 26 Dihydropyridines ...... 18 7.5.5 Blood Glucose Monitoring Devices 4.5.4 ACE Inhibitors ...... 18 & Supplies ...... 26 4.5.5 Adrenergic Antagonists & Related Drugs ...... 18 8. Gastroenterology ...... 27 4.5.6 Agents for Pheochromocytoma ...... 18 8.1 Ulcer Therapy ...... 27 4.5.7 Vasodilators ...... 18 8.1.1 H2 Antagonists ...... 27 4.5.8 Other Antihypertensive Combinations ...... 19 8.1.2 Prostaglandins ...... 27 4.5.9 Angiotensin II Receptor Blockers 8.1.3 Other Ulcer Therapy ...... 27 & Renin Inhibitors ...... 19 8.1.4 Proton Pump Inhibitors ...... 27 4.6 Lipid/Cholesterol Lowering Agents ...... 19 8.2 Antidiarrheals & Antispasmodics ...... 27 4.7 Miscellaneous Cardiovascular Agents ...... 19 8.2.1 Antidiarrheals ...... 27 8.2.2 Antispasmodics ...... 27 5. Dermatologicals/Topical Therapy ...... 20 8.2.3 Combination Anticholinergics ...... 27 5.1 Topical Corticosteroids ...... 20 8.3 Miscellaneous Gastrointestinal Agents ...... 27 5.1.1 Topical Corticosteroids Very High 8.3.1 Bile Acids ...... 27 Potency ...... 20 8.3.2 Digestive Enzymes ...... 28 5.1.2 Topical Corticosteroids High Potency ...... 20 8.3.3 Miscellaneous Gastrointestinal Agents ...... 28 5.1.3 Topical Corticosteroids Medium 8.3.4 Antivertigo & Antiemetic Agents ...... 28 Potency ...... 20 8.3.5 Bowel Evacuants ...... 28 5.1.4 Topical Corticosteroids Low Potency ...... 20 5.2 Topical Anesthetics ...... 20 9. Immunology, Vaccines & 5.3 Therapy for Acne ...... 21 Biotechnology ...... 29 5.4 Topical Antibacterials ...... 21 9.1 Biotechnology Drugs ...... 29 5.5 Topical Antifungals ...... 21 9.1.1 Erythroid Stimulants ...... 29 5.6 Topical Antivirals ...... 21 9.1.2 Myeloid Stimulants ...... 29 5.7 Burn Therapy ...... 21 9.1.3 Interferons ...... 29 5.8 Topical Enzymes ...... 21 9.1.4 Growth Hormones ...... 29 5.10 Antipsoriatic/Antiseborrheic ...... 21 9.1.5 Interleukins ...... 29 5.11 Topical Scabicides/Pediculicides ...... 22 5.12 Miscellaneous Dermatologicals ...... 22 10. Musculoskeletal & Rheumatology ...... 30 6. Ear, Nose & Throat Medications ...... 23 10.1 NSAID Agents ...... 30 6.1 Intranasal Steroids ...... 23 10.1.1 NSAIDs COX-2 Inhibitors ...... 30 6.2 Miscellaneous Otic Preparations ...... 23 10.1.1.1 NSAIDs ...... 30 6.3 Otic Steroid/Antibiotic ...... 23 10.1.1.2 NSAIDs-Specific COX-2 6.4 Miscellaneous Agents ...... 23 Inhibitors ...... 30 10.1.2 Salicylates ...... 30 7. Endocrine/Diabetes ...... 24 10.2 Gout Therapy ...... 30 7.1 Antithyroid Agents ...... 24 10.3 Other Rheumatologicals ...... 30 7.2 Thyroid Hormones ...... 24 10.3.1 Corticosteroids ...... 30 7.3 Adrenal Hormones ...... 24 10.3.2 Miscellaneous Rheumatological 7.4 Miscellaneous Hormones ...... 24 Agents ...... 30 7.4.1 Androgens ...... 24 10.3.3 Muscle Relaxants & Antispasmodic 7.4.2 Ovulatory Stimulants ...... 24 Therapy ...... 30 7.4.3 Miscellaneous Agents ...... 24 10.4 Osteoporosis Therapy ...... 31 11. Obstetrics & Gynecology ...... 32 13.3 Pulmonary Agents ...... 36 11.1 Oral Contraceptives & Related Agents ...... 32 13.3.1 Xanthines ...... 36 11.1.1 Monophasic/Biphasic/Triphasic 13.3.2 Beta Agonists Oral ...... 36 Agents ...... 32 13.3.3 Beta Agonist Inhalers ...... 36 11.1.2 Progestin Only ...... 32 13.3.4 Inhaled Corticosteroids ...... 37 11.2 Oxytocics ...... 32 13.3.5 Intranasal Steroids ...... 37 11.3 Estrogens & Progestins ...... 32 13.3.6 Miscellaneous Pulmonary Agents ...... 37 11.3.1 Progestins ...... 32 11.3.2 Estrogens ...... 32 14. Urologicals ...... 38 11.3.3 Estrogen Combinations ...... 33 14.1 Cholinergic Stimulants ...... 38 11.4 Miscellaneous OB/GYN ...... 33 14.2 Anticholinergic & Antispasmodics ...... 38 11.4.1 Drugs to Treat Infertility/ 14.3 Urinary Anesthetics ...... 38 IVF Agents ...... 33 14.4 Miscellaneous Urologicals ...... 38 11.4.2 Vaginal Cleanser/Anti-Infectives ...... 33 14.5 Benign Prostatic Hyperplasia (BPH) 11.4.3 Vaginal Antifungals ...... 33 Therapy ...... 38 11.4.4 Specialized OB/GYN Drugs ...... 33 11.4.5 Diaphragms & Other Non-Oral 15. Vitamins, Hematinics & Contraceptives ...... 33 Electrolytes ...... 39 15.1 Vitamins & Hematinics ...... 39 12. Ophthalmology ...... 34 15.2 Coagulation Therapy ...... 39 12.1 Beta-Blockers ...... 34 15.2.1 Anticoagulants ...... 39 12.2 Cholinesterase Inhibitor Miotics ...... 34 15.2.2 Antiplatelet Drugs ...... 39 12.3 Direct Acting Miotics ...... 34 15.2.3 Heparin ...... 39 12.4 Other Glaucoma Drugs ...... 34 15.2.4 Vitamin K ...... 39 12.5 Oral Drugs for Glaucoma ...... 34 15.2.5 Hemostatics ...... 39 12.6 Cycloplegic Mydriatics ...... 34 15.2.6 Miscellaneous Coagulation 12.7 Non-Steroidal Anti-Inflammatory Agents ...... 39 Agents ...... 34 15.3 Electrolytes ...... 39 12.8 Vasoconstrictor Decongestants ...... 34 15.3.1 Potassium ...... 39 12.9 Antibiotics ...... 35 15.3.2 Other Electrolytes ...... 39 12.10 Sulfonamides ...... 35 12.11 Steroids ...... 35 16. Diagnostics & Miscellaneous 12.12 Steroid-Antibiotic Combinations ...... 35 Agents ...... 40 12.13 Steroid-Sulfonamide Combinations ...... 35 16.1 Miscellaneous Agents ...... 40 12.14 Sympathomimetics ...... 35 16.2 Smoking Deterrents ...... 40 12.15 Miscellaneous Ophthalmologics ...... 35 16.3 Anorexiants ...... 40 12.16 Antivirals ...... 35 Index ...... 42 13. Respiratory, Allergy, Cough & Cold ...... 36 13.1 Antihistamine & Antiallergenic Agents ...... 36 13.1.1 Antihistamines ...... 36 13.1.2 Adrenergics ...... 36 13.1.3 Corticosteroids ...... 36 13.2 Cough & Cold Therapy ...... 36 13.2.1 Antitussive Combinations ...... 36 13.2.2 Expectorant Combinations ...... 36 13.2.3 Decongestant/Antihistamines ...... 36 BLUECROSS BLUESHIELDOF TENNESSEE THREE TIER FORMULARY 1. ANTI-INFECTIVES Tennesseeof BlueShield BlueCrossTier Three
1.1 Penicillins FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME TIER 1 1.3.3 THIRD GENERATION CEPHALOSPORINS amoxicillin trihydrate (Amoxil) TIER 1 amoxicillin trihydrate/potassium clavulanate (Augmentin) cefdinir (Omnicef) amoxicillin trihydrate/potassium clavulanate (Augmentin XR) TIER 3 ampicillin trihydrate (Principen) Cedax (ceftibuten) dicloxacillin sodium (Dynapen) penicillin v potassium (Pen-Vee K) TIER 3 1.4 Erythromycins & Other Macrolides Augmentin (amoxicillin trihydrate/potassium clavulanate) FORMULARY PRODUCTS Augmentin XR (amoxicillin/clavulanate er) DRUG NAME
1.4.1 ERYTHROMYCINS & OTHER MACROLIDES 1.2 Tetracyclines TIER 1 azithromycin (Zithromax) FORMULARY PRODUCTS clarithromycin (Biaxin) DRUG NAME clarithromycin er (Biaxin XL) TIER 1 erythromycin base (E-Mycin) doxycycline hyclate (Doryx) erythromycin ethylsuccinate (E.E.S.) doxycycline hyclate capsule (Vibramycin) erythromycin ethylsuccinate/sulfisoxazole acetyl (Pediazole) doxycycline hyclate tablet (Vibra-Tabs) erythromycin stearate (Erythrocin Stearate) doxycycline monohydrate (Adoxa) TIER 3 doxycycline monohydrate (Monodox) Biaxin (clarithromycin) 1 doxycycline monohydrate (Vibramycin) Biaxin XL (clarithromycin er) minocycline hcl (Dynacin) Ery-Tab (erythromycin) minocycline hcl (Minocin) E.E.S. (erythromycin ethylsuccinate) tetracycline hcl (Achromycin V) PCE (erythromycin) TIER 3 Zithromax (azithromycin) Adoxa (doxycycline monohydrate)
Dynacin (minocycline hcl) Anti-Infectives Minocin (minocycline hcl) 1.5 Quinolones Monodox (doxycycline monohydrate) FORMULARY PRODUCTS Vibramycin Syrup (doxycycline monohydrate suspension) DRUG NAME 1.5.1 FLUOROQUINOLONES 1.3 Cephalosporins TIER 1 ciprofloxacin er (Cipro XR) FORMULARY PRODUCTS
DRUG NAME ciprofloxacin hcl (Cipro) 1.3.1 FIRST GENERATION CEPHALOSPORINS levofloxacin (Levaquin) moxifloxacin hcl (Avelox) TIER 1 ofloxacin (Floxin) cefadroxil hydrate (Duricef) TIER 3 cephalexin monohydrate (Keflex) Avelox (moxifloxacin hcl) TIER 3 Cipro (ciprofloxacin hcl) Keflex (cephalexin monohydrate) Levaquin (levofloxacin) Noroxin (norfloxacin)
FORMULARY PRODUCTS DRUG NAME 1.3.2 SECOND GENERATION CEPHALOSPORINS 1.6 Sulfas & Related Agents 1 TIER 1 FORMULARY PRODUCTS cefaclor (Ceclor) DRUG NAME cefaclor extended release (Ceclor CR) TIER 1 cefprozil (Cefzil) sulfamethoxazole/trimethoprim (Bactrim DS) cefuroxime axetil (Ceftin) sulfamethoxazole/trimethoprim (Septra DS) TIER 3 TIER 3 Ceftin (cefuroxime axetil) Bactrim (sulfamethoxazole/trimethoprim) Anti-Infectives Bactrim DS (sulfamethoxazole/trimethoprim) Septra DS (sulfamethoxazole/trimethoprim)
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
5 1. ANTI-INFECTIVES (CONTINUED)
1.7 Urinary Tract Agents FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME TIER 1 1.8.2 HIV/AIDS THERAPY methenamine hippurate (Hiprex) TIER 1 methenamine mandelate (Mandelamine) didanosine (Videx EC) nitrofurantoin (Furadantin) lamivudine (Epivir) nitrofurantoin macrocrystal (Macrodantin) lamivudine/zidovudine (Combivir) nitrofurantoin/nitrofurantoin macrocrystal (Macrobid) nevirapine (Viramune XR) phenazopyridine hcl (Pyridium) stavudine (Zerit) trimethoprim (Proloprim) zidovudine (Retrovir) TIER 3 TIER 3 Macrobid (nitrofurantoin/nitrofurantoin macrocrystal) Aptivus (tipranavir) Macrodantin (nitrofurantoin macrocrystal) Atripla (efavirenz/ emtricitab/ tenofovir)
Combivir (lamivudine/zidovudine) Complera (emtrecitabine/rilpivirine/tenofovir disoproxil fumarate) SPRx BlueCross BlueShield of Tennessee Three Tier BlueCross BlueShield of Tennessee 1.8 Antivirals Crixivan (indinavir sulfate) FORMULARY PRODUCTS Edurant (rilpivirine hcl) DRUG NAME Emtriva (emtricitabine) 1.8.1 MISCELLANEOUS ANTIVIRALS Epivir Solution (lamivudine) TIER 1 Epivir Tablet (lamivudine) acyclovir (Zovirax) Epzicom (abacavir sulfate/lamivudine) amantadine hcl (Symmetrel) Evotaz (atazanavir/cobicistat) SPRx 1 famciclovir (Famvir) Fuzeon (enfuvirtide) SPRx ganciclovir (Cytovene) Intelence (etravirine) ribavirin (Rebetol) PA SPRx Invirase (saquinavir mesylate) rimantadine (Flumadine) Isentress (raltegravir potassium) valacyclovir hcl (Valtrex) Kaletra (ritonavir/lopinavir) valganciclovir hcl (Valcyte) Lexiva (fosamprenavir calcium)
TIER 2 Norvir (ritonavir) SPRx Harvoni (ledipasvir/sofosbuvir) PA SPRx Prezcobix (darunavir/cobicistat)
Incivek (telaprevir) PA SPRx Prezista (darunavir ethanolate) Rescriptor (delavirdine mesylate) Olysio (simeprevir) PA SPRx Reyataz (atazanavir sulfate) Sovaldi (sofosbuvir) PA SPRx Selzentry (maraviroc) TIER 3 Stribild (elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate) SPRx Baraclude (entecavir) Sustiva (efavirenz) Copegus (ribavirin) PA SPRx Tivicay (dolutegravir) SPRx
Epivir HBV (lamivudine) SPRx Anti-Infectives Triumeq (abacavir/dolutegravir/lamivudine) Famvir (famciclovir) Trizivir (abacavir sulfate/lamivudine/zidovudine) Flumadine (rimantadine) Truvada (emtricitabine/tenofovir disoproxil fumarate) Hepsera (adefovir dipivoxil) Tybost (cobicistat) Relenza (zanamivir) QL Videx (didanosine) Tamiflu (oseltamivir phosphate) QL Videx EC (didanosine) Tyzeka (telbivudine) Viracept (nelfinavir mesylate) Valcyte Tablet (valganciclovir hydrochloride) Viramune (nevirapine) Valtrex (valacyclovir hcl) Viramune XR (nevirapine) Zovirax (acyclovir tablets) Viread (tenofovir disoproxil fumarate) Vitekta (elvitegravir) SPRx Ziagen (abacavir sulfate) Zerit (stavudine)
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
6 1. ANTI-INFECTIVES (CONTINUED) Tennesseeof BlueShield BlueCrossTier Three
1.9 Antifungal Agents FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME TIER 1 1.11.3 ANTIMALARIALS clotrimazole (Mycelex) TIER 1 fluconazole (Diflucan) atovaquone/proguanil hcl (Malarone) flucytosine (Ancobon) chloroquine phosphate (Aralen Phosphate) griseofulvin ultramicrosize (Gris-Peg) hydroxychloroquine sulfate (Plaquenil) itraconazole (Sporanox) mefloquine hcl (Lariam) ketoconazole (Nizoral) TIER 3 nystatin (Mycostatin) Daraprim (pyrimethamine) # terbinafine hcl (Lamisil) Plaquenil (hydroxychloroquine sulfate) voriconazole (Vfend) Primaquine (primaquine phosphate) TIER 3 Diflucan (fluconazole) Grifulvin V Tablet (griseofulvin ultramicrosize) FORMULARY PRODUCTS DRUG NAME Gris-Peg (griseofulvin ultramicrosize) Lamisil Tablet (terbinafine hcl) # 1.11.4 ANTIMYCOBACTERIALS Nizoral (ketoconazole) TIER 1 Noxafil (posaconazole) ethambutol hcl (Myambutol) Sporanox (itraconazole solution, oral) isoniazid (Isoniazid) pyrazinamide (Pyrazinamide) rifabutin (Mycobutin) 1.10 Vancomycin rifampin (Rifadin) 1 FORMULARY PRODUCTS TIER 3 DRUG NAME Myambutol (ethambutol hcl) TIER 3 Mycobutin (rifabutin) Vancocin HCl (vancomycin hcl) Paser (aminosalicyclic acid) Sirturo (bedaquiline)
1.11 Miscellaneous Anti-infectives Anti-Infectives FORMULARY PRODUCTS DRUG NAME 1.11.1 MISCELLANEOUS ANTI-INFECTIVES TIER 1 clindamycin hcl (Cleocin HCl) neomycin sulfate (Neomycin Sulfate) TIER 2 Tobi Podhaler (tobramycin) PA SPRx Xifaxan 550mg (rifaximin) TIER 3 Cleocin (clindamycin hcl) Dapsone (dapsone) Ketek (telithromycin) Zyvox (linezolid) PA QL
FORMULARY PRODUCTS DRUG NAME 1.11.2 ANTIPARASITICS TIER 1 atovaquone (Mepron) mebendazole (Vermox) metronidazole (Flagyl) metronidazole (Flagyl ER) paromomycin sulfate (Humatin) TIER 3 Alinia (nitazoxanide) Flagyl (metronidazole) Flagyl ER (metronidazole) Mepron (atovaquone) Tindamax (tinidazole)
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
7 2. ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS
2.1 Antineoplastic & Immunosuppressant Drugs FORMULARY PRODUCTS DRUG NAME FORMULARY PRODUCTS DRUG NAME 2.1.3.5 ANTIANDROGENS 2.1.1 ALKYLATING AGENTS TIER 1 TIER 1 bicalutamide (Casodex) temozolomide (Temodar) flutamide (Eulexin) TIER 2 TIER 3 Alkeran (melphalan) Casodex (bicalutamide) Leukeran (chlorambucil) Nilandron (nilutamide) Xtandi (enzalutamide) PA SPRx TIER 3 CeeNu (lomustine) Cyclophosphamide (cyclophosphamide) FORMULARY PRODUCTS Myleran (busulfan) DRUG NAME Temodar (temozolomide) PA SPRx 2.1.5 IMMUNOSUPPRESSANT DRUGS
BlueCross BlueShield of Tennessee Three Tier BlueCross BlueShield of Tennessee TIER 1 FORMULARY PRODUCTS azathioprine (Imuran) DRUG NAME cyclosporine (Cyclosporine) 2.1.2 ANTIMETABOLITES cyclosporine, modified (Cyclosporine) TIER 1 mycophenolate mofetil (CellCept) sirolimus (Rapamune) capecitabine (Xeloda) SPRx tacrolimus anhydrous (Prograf) mercaptopurine (Purinethol) methotrexate sodium (Rheumatrex) TIER 3 2 Astagraf XL (tacrolimus) SPRx TIER 3 CellCept (mycophenolate mofetil) Purinethol (mercaptopurine) Gengraf (cyclosporine, modified) Purixan (mercaptopurine) Imuran (azathioprine) Thioguanine (thioguanine) Myfortic (mycophenolate sodium) Trexall (methotrexate sodium) Neoral (cyclosporine, modified) Xeloda (capecitabine) SPRx Prograf (tacrolimus anhydrous) Rapamune (sirolimus) FORMULARY PRODUCTS Sandimmune (cyclosporine) DRUG NAME 2.1.3 ANDROGENS, ESTROGENS, HORMONES & RELATED DRUGS 2.1.3.3 HORMONES TIER 1 megestrol acetate (Megace) TIER 3 Megace (megestrol acetate)
FORMULARY PRODUCTS DRUG NAME 2.1.3.4 ANTIESTROGENS
Antineoplastic & Immunosuppressant Drugs TIER 1 anastrozole (Arimidex) exemestane (Aromasin) letrozole (Femara) tamoxifen citrate (Nolvadex) TIER 3 Arimidex (anastrozole) Aromasin (exemestane) Fareston (toremifene citrate) Femara (letrozole)
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
8 2. ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS (CONTINUED) Tennesseeof BlueShield BlueCrossTier Three
2.2 Adjunctive Agents FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 2.1.6 MISCELLANEOUS ANTINEOPLASTIC DRUGS 2.2.1 ADJUNCTIVE AGENTS TIER 1 TIER 1 etoposide (VePesid) leucovorin calcium (Leucovorin Calcium) hydroxyurea (Hydrea) medroxyprogesterone acetate (Depo-Provera) octreotide acetate vial (Sandostatin) SPRx TIER 3 TIER 3 Depo-Provera (medroxyprogesterone acetate) Droxia (hydroxyurea) Leukine (sargramostim) SPRx Emcyt (estramustine phosphate sodium) Neulasta (pegfilgrastim) SPRx Farydak (panobinostat) PA SPRx Neupogen (filgrastim) SPRx Gleevec (imatinib mesylate) SPRx Procrit (epoetin alfa) PA SPRx Hexalen (altretamine) Hydrea (hydroxyurea) Iclusig (ponatinib) PA SPRx Ibrance (palbociclib) PA SPRx Imbruvica (ibrutinib) PA SPRx Iressa (gefitinib) SPRx Lenvima (lenvatinib) PA SPRx Lynparza (olaparib) PA SPRx Lysodren (mitotane) Matulane (procarbazine hcl) Mekinist (trametinib) PA SPRx 2
Nexavar (sorafenib tosylate) PA SPRx Drugs Immunosuppressant & Antineoplastic Revlimid (lenalidomide) PA SPRx Sprycel (dasatinib) SPRx Stivarga (regorafenib) PA SPRx Sutent (sunitinib malate) PA SPRx Tafinlar (dabrafenib) PA SPRx Targretin Capsule (bexarotene) SPRx Tarceva (erlotinib hcl) PA SPRx Tasigna (nilotinib hcl) SPRx Thalomid (thalidomide) PA SPRx Tykerb (lapatinib ditosylate) PA SPRx Valchlor (mechlorethamine) PA SPRx Votrient (pazopanib hcl) PA SPRx Zoladex (goserelin acetate) Zolinza (vorinostat) SPRx Zydelig (idelalisibt) PA SPRx Zykadia (ceritinib) PA SPRx
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
9 3. AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH
3.1 Narcotic Analgesics FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 3.1.1 NARCOTICS 3.1.2 COMBINATION NARCOTIC/ANALGESICS TIER 1 TIER 1 buprenorphine hcl (Subutex) # QL acetaminophen/butalbital (Phrenilin) codeine sulfate (Codeine Sulfate) acetaminophen/caffeine/butalbital (Fioricet) fentanyl (Duragesic) aspirin/caffeine/butalbital (Fiorinal) fentanyl citrate (Actiq) QL codeine phosphate/acetaminophen (Tylenol w/Codeine) hydromorphone hcl (Dilaudid) codeine phosphate/acetaminophen/caffeine/butalbital (Fioricet w/Codeine) meperidine hcl (Demerol) codeine phosphate/aspirin (Aspirin w/Codeine) methadone hcl (Dolophine HCl) codeine phosphate/aspirin/caffeine/butalbital (Fiorinal w/Codeine) morphine sulfate (Kadian) hydrocodone bit/acetaminophen (Lortab) morphine sulfate (MS Contin) hydrocodone bit/acetaminophen (Vicodin) morphine sulfate (RMS-Suppository) oxycodone hcl/acetaminophen (Percocet) morphine sulfate er caps (Avinza) QL oxycodone hcl/acetaminophen (Tylox)
BlueCross BlueShield of Tennessee Three Tier BlueCross BlueShield of Tennessee oxycodone hcl (Roxicodone) oxycodone hcl/ibuprofen (Combunox) oxycodone hcl concentrate, oral (OxyFAST) oxycodone/aspirin (Percodan) TIER 2 TIER 3 Opana ER (oxycodone hcl) QL Esgic (butalbital/apap/caffeine) OxyContin (oxycodone hcl) QL Esgic-Plus (butalbital/apap/caffeine) TIER 3 Fioricet (acetaminophen/caffeine/butalbital) Abstral (fentanyl citrate) QL Fiorinal (aspirin/caffeine/butalbital) 3 Actiq (fentanyl citrate) QL Lorcet (hydrocodone w/acetaminophen) Avinza (morphine sulfate) QL Lortab (hydrocodone bit/acetaminophen) Butrans (buprenorphine) Percocet (oxycodone hcl/acetaminophen) Demerol (meperidine hcl) Percodan (oxycodone/aspirin) Dilaudid (hydromorphone hcl liquid) Phrenilin (acetaminophen/butalbital) Duragesic (fentanyl) Tylenol w/Codeine (codeine phosphate/acetaminophen) Fentora (fentanyl citrate) QL Tylox (oxycodone hcl/acetaminophen) Kadian (morphine sulfate) Vicodin (hydrocodone bit/acetaminophen) MS Contin (morphine sulfate) Vicoprofen (hydrocodone bit-ibuprofen)
Onsolis (fentanyl citrate) QL Opana (oxycodone hcl) Roxicodone (oxycodone hcl) Subutex (buprenorphine hcl) # QL
Autonomic & CNS Drugs, Neurology & Psych
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
10 3. AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH (CONTINUED) Tennesseeof BlueShield BlueCrossTier Three
3.3 Non-narcotic Analgesics FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 3.3.1 NSAIDS/COX II INHIBITORS 3.3.3 MISCELLANEOUS ANALGESICS 3.3.1.1 NSAIDS TIER 1 TIER 1 butorphanol tartrate aerosol, spray (Stadol) diclofenac sodium/misoprostol (Arthrotec) pentazocine hcl/acetaminophen (Talacen) etodolac (Lodine) pentazocine hcl/naloxone hcl (Talwin NX) etodolac (Lodine XL) tramadol hcl (Ryzolt) flurbiprofen (Ansaid) tramadol hcl (Ultram) ibuprofen (Motrin) tramadol hcl (Ultram ER) indomethacin (Indocin) tramadol hcl/acetaminophen (Ultracet) indomethacin (Indocin SR) TIER 2 ketoprofen (Orudis) Nucynta (tapentadol) QL meclofenamate sodium (Meclofenamate Sodium) Nucynta ER (tapentadol) QL meloxicam (Mobic) TIER 3 nabumetone (Relafen) Ultracet (tramadol hcl/acetaminophen) naproxen (Naprosyn) Ultram (tramadol hcl) naproxen sodium (Anaprox) Ultram ER (tramadol hcl) naproxen sodium (Anaprox DS) naproxen sodium (Naprelan) oxaprozin (Daypro) FORMULARY PRODUCTS DRUG NAME piroxicam (Feldene) 3.3.4 NARCOTIC ANTAGONISTS sulindac (Clinoril) 3 tolmetin sodium (Tolectin) TIER 1 Psych & Neurology Drugs, CNS & Autonomic # QL TIER 3 buprenophrine hcl/naloxone hcl, tablet (Suboxone Tablet) # Anaprox DS (naproxen sodium) naltrexone hcl (ReVia) Arthrotec (diclofenac sodium/misoprostol) TIER 2 Cataflam (diclofenac potassium) Suboxone (buprenorphine hcl/naloxone hcl) # QL Clinoril (sulindac) TIER 3 Daypro (oxaprozin) Zubsolv (buprenorphine hcl/naloxone hcl) # QL EC-Naprosyn (naproxen) Feldene (piroxicam) Mobic (meloxicam) Motrin (ibuprofen) Nalfon (fenoprofen) Naprelan (naproxen sodium) Naprosyn (naproxen) Ponstel (mefenamic acid) Sprix (ketorolac tromethamine) Voltaren (diclofenac sodium) Voltaren-XR (diclofenac sodium, extended-release)
FORMULARY PRODUCTS DRUG NAME 3.3.1.2 NSAIDS- SPECIFIC COX-II INHIBITORS TIER 1 celecoxib (Celebrex) TIER 3 Celebrex (celecoxib)
FORMULARY PRODUCTS DRUG NAME 3.3.2 SALICYLATES TIER 1 diflunisal (Dolobid) salsalate (Salsalate)
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
11 3. AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH (CONTINUED)
3.4 Migraine & Cluster Headache Therapy 3.5 Antiparkinsonism Agents FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 3.4.1 HEADACHE THERAPY TIER 1 TIER 1 amantadine hcl (Symmetrel) acetaminophen/butalbital (Phrenilin) benztropine mesylate (Cogentin) acetaminophen/caffeine/butalbital (Fioricet) bromocriptine mesylate (Parlodel) aspirin/caffeine/butalbital (Fiorinal) carbidopa/levodopa (Sinemet) dihydroergotamine mesylate (D.H.E.45) carbidopa/levodopa (Sinemet CR) ergotamine tartrate/caffeine (Cafergot) pramipexole di-hcl (Mirapex) isometheptene mucate/acetaminophen/dichloralphenazone (Midrin) d ropinirole hcl (Requip) naratriptan hcl (Amerge) QL selegiline hcl (Eldepryl) rizatriptan benzoate (Maxalt) QL trihexyphenidyl hcl (Artane) rizatriptan benzoate (Maxalt MLT) QL TIER 3 sumatriptan succinate (Alsuma) QL Apokyn (apomorphine hcl) SPRx sumatriptan succinate (Imitrex) QL Azilect (rasagiline mesylate)
BlueCross BlueShield of Tennessee Three Tier BlueCross BlueShield of Tennessee zolmitriptan (Zomig) QL Comtan (entacapone) zolmitriptan (Zomig ZMT) QL Duopa (carbidopa/levodopa) PA SPRx TIER 2 Eldepryl (selegiline hcl) Relpax (eletriptan hydrobromide) QL Mirapex (pramipexole di-hcl) Treximet (sumatriptan succinate/naproxen) QL Mirapex ER (pramipexole di-hcl) TIER 3 Neupro (rotigotine) Alsuma (sumatriptan succinate) QL Requip (ropinirole hcl) Requip XL (ropinirole hcl) 3 Amerge (naratriptan hcl) QL Axert (almotriptan malate) QL Sinemet (carbidopa/levodopa) Frova (frovatriptan succinate) QL Sinemet CR (carbidopa/levodopa) Imitrex (sumatriptan succinate) QL Stalevo (carbidopa/levodopa/entacapone) QL Zelapar (selegiline hcl) Maxalt (rizatriptan benzoate) Maxalt MLT (rizatriptan benzoate) QL Midrin (isometheptene mucate/acetaminophen/dichloralphenazone) d Migranal (dihydroergotamine mesylate) QL Sumavel Dosepro (sumatriptan succinate) QL Zomig (zolmitriptan) QL Zomig ZMT (zolmitriptan) QL
FORMULARY PRODUCTS DRUG NAME 3.4.2 ANTIVERTIGO & ANTIEMETIC DRUGS TIER 1 granisetron hcl (Kytril) ondansetron (Zofran ODT) ondansetron hcl (Zofran) prochlorperazine maleate (Compazine) promethazine hcl (Phenergan)
Autonomic & CNS Drugs, Neurology & Psych trimethobenzamide hcl (Tigan) TIER 3 Anzemet (dolasetron mesylate tablet) Emend (aprepitant) Tigan (trimethobenzamide hcl) Zofran (ondansetron hcl) Zofran ODT (ondansetron hcl)
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
12 3. AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH (CONTINUED) Tennesseeof BlueShield BlueCrossTier Three
3.6 Anticonvulsants 3.7 Miscellaneous Neurological Therapy FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME TIER 1 TIER 1 acetazolamide (Diamox) donepezil hcl (Aricept) carbamazepine (Carbatrol) donepezil hcl (Aricept ODT) carbamazepine (Tegretol, Tegretol XR) galantamine hydrobromide (Razadyne) clonazepam (Klonopin) galantamine hydrobromide (Razadyne ER) diazepam (Diastat AcuDial) rivastigmine tartrate capsules (Exelon) divalproex sodium (Depakote) TIER 2 divalproex sodium (Depakote ER) Ampyra (dalfampridine) PA SPRx divalproex sodium (Depakote Sprinkle) Copaxone (glatiramer acetate) SPRx ethosuximide (Zarontin) Copaxone 40mg/mL (glatiramer acetate) SPRx felbamate (Felbatol) Exelon (rivastigmine transdermal patch) gabapentin (Neurontin) Gilenya (fingolimod hcl) PA SPRx lamotrigine (Lamictal, Lamictal XR) Namenda XR (memantine hcl) levetiracetam (Keppra, Keppra XR) Tecfidera (dimethyl fumarate) PA SPRx mephobarbital (Mebaral) TIER 3 oxcarbazepine (Trileptal) Aricept (donepezil hcl) phenobarbital (Phenobarbital) Aubagio (teriflunomide) PA SPRx phenytoin sodium extended (Dilantin) Exelon (rivastigmine) phenytoin sodium extended (Phenytek) Horizant (gabapentin) phenytoin suspension, oral (Dilantin) Namenda (memantine hcl) phenytoin tablet, chewable (Dilantin Infatabs) Nuedexta (dextromethorphan hbr/quinidine) primidone (Mysoline) 3 Razadyne (galantamine hydrobromide) Psych & Neurology Drugs, CNS & Autonomic topiramate (Topamax) Razadyne ER (galantamine hydrobromide) valproic acid (Depakene) zonisamide (Zonegran) TIER 2 3.8 Muscle Relaxants & Antispasmodic Dilantin (phenytoin capsule) Therapy Dilantin (phenytoin suspension, oral) Dilantin Infatabs (phenytoin tablet, chewable) FORMULARY PRODUCTS DRUG NAME Lyrica (pregabalin) Oxtellar XR (oxcarbazepine) 3.8.1 MUSCLE RELAXANTS & ANTISPASMODIC AGENTS Trokendi XR (topiramate) TIER 1 Vimpat (lacosamide) baclofen (Lioresal) TIER 3 carisoprodol (Soma) Aptiom (eslicarbazepine acetate) chlorzoxazone (Parafon Forte DSC) Banzel (rufinamide tablet) cyclobenzaprine hcl (Amrix) Carbatrol (carbamazepine) cyclobenzaprine hcl (Flexeril) Depakene (valproic acid) dantrolene sodium (Dantrium) Depakote (divalproex sodium) diazepam (Valium) Depakote ER (divalproex sodium) metaxalone (Skelaxin) Depakote Sprinkle (divalproex sodium) methocarbamol (Robaxin) Diastat (diazepam) orphenadrine citrate (Norflex) Equetro (carbamazepine) oxybutynin chloride (Ditropan) Felbatol (felbamate) oxybutynin chloride (Ditropan XL) Fycompa (perampanel) tizanidine (Zanaflex) Gabitril (tiagabine hcl) tolterodine tartrate (Detrol) Keppra (levetiracetam) trospium chloride (Sanctura) Klonopin (clonazepam) TIER 2 Lamictal (lamotrigine) Enablex (darifenacin hydrobromide) Lamictal XR (lamotrigine) Gelnique (oxybutynin chloride) Mysoline (primidone) Vesicare (solifenacin succinate) Neurontin (gabapentin) TIER 3 Onfi (clobazam) Detrol (tolterodine tartrate) Phenytek (phenytoin sodium extended) Detrol LA (tolterodine tartrate) Potiga (ezogabine) Flexeril (cyclobenzaprine hcl) Tegretol (carbamazepine) Robaxin (methocarbamol) Tegretol XR (carbamazepine) Skelaxin (metaxalone) Topamax (topiramate) Soma (carisoprodol) Trileptal (oxcarbazepine) Zanaflex (tizanidine) Zarontin (ethosuximide) Zonegran (zonisamide)
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
13 3. AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH (CONTINUED)
FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 3.8.2 MYASTHENIA GRAVIS 3.9.2.2 MISCELLANEOUS ANTIDEPRESSANTS TIER 1 TIER 1 pyridostigmine bromide tablet (Mestinon) bupropion hcl (Wellbutrin) TIER 3 bupropion hcl (Wellbutrin SR) Mestinon (pyridostigmine bromide syrup) bupropion hcl (Wellbutrin XL) Mestinon (pyridostigmine bromide tablet, sustained action) duloxetine (Cymbalta) maprotiline hcl (Ludiomil) mirtazapine tablet (Remeron) 3.9 Psychotherapeutic Drugs mirtazapine tablet, rapid dissolve (Remeron Sol Tab) trazodone hcl (Desyrel) FORMULARY PRODUCTS DRUG NAME venlafaxine hcl (Effexor) 3.9.1 HYPNOTIC AGENTS venlafaxine hcl (Effexor XR) TIER 1 TIER 2 BlueCross BlueShield of Tennessee Three Tier BlueCross BlueShield of Tennessee chloral hydrate (Somnote) Pristiq ER (desvenlafaxine succinate) estazolam (ProSom) TIER 3 eszopiclone (Lunesta) Cymbalta (duloxetine hcl) flurazepam hcl (Dalmane) Effexor XR (venlafaxine hcl) temazepam (Restoril) Remeron (mirtazapine tablet) triazolam (Halcion) Remeron Sol Tab (mirtazapine tablet, rapid dissolve) zaleplon (Sonata) Wellbutrin (bupropion hcl) 3 zolpidem tartrate (Ambien) Wellbutrin SR (bupropion hcl) Wellbutrin XL (bupropion hcl) zolpidem tartrate (Ambien CR) TIER 3 Ambien (zolpidem tartrate) FORMULARY PRODUCTS Ambien CR (zolpidem tartrate) DRUG NAME Halcion (triazolam) 3.9.2.3 MAO INHIBITORS Lunesta (eszopiclone) TIER 1 Restoril (temazepam) phenelzine sulfate (Nardil) Rozerem (ramelteon) tranylcypromine sulfate (Parnate) Sonata (zaleplon) TIER 3 Emsam (selegiline patch) FORMULARY PRODUCTS Parnate (tranylcypromine sulfate) DRUG NAME 3.9.2 ANTIDEPRESSANT AGENTS FORMULARY PRODUCTS 3.9.2.1 TRICYCLICS DRUG NAME TIER 1 3.9.2.4 SELECTIVE SEROTONIN REUPTAKE INHIBITORS amitriptyline hcl (Elavil) TIER 1 amoxapine (Asendin) citalopram hydrobromide (Celexa) clomipramine hcl (Anafranil) escitalopram oxalate (Lexapro) desipramine hcl (Norpramin) fluoxetine hcl (Prozac) doxepin hcl (Sinequan) Autonomic & CNS Drugs, Neurology & Psych fluvoxamine maleate (Luvox) imipramine hcl (Tofranil) fluvoxamine maleate, extended release (Luvox CR) imipramine pamoate (Tofranil-PM) paroxetine hcl (Paxil) nortriptyline hcl (Pamelor) paroxetine hcl (Paxil CR) protriptyline hcl (Vivactil) sertraline hcl (Zoloft) TIER 3 TIER 3 Anafranil (clomipramine hcl) Celexa (citalopram hydrobromide) Norpramin (desipramine hcl) Lexapro (escitalopram oxalate) Pamelor (nortriptyline hcl) Luvox CR (fluvoxamine maleate) Tofranil (imipramine hcl) Paxil (paroxetine hcl) Tofranil-PM (imipramine pamoate) Paxil CR (paroxetine hcl) Prozac (fluoxetine hcl) Prozac Weekly (fluoxetine hcl) Sarafem (fluoxetine hcl) Zoloft (sertraline hcl)
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
14 3. AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH (CONTINUED) Tennesseeof BlueShield BlueCrossTier Three
FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 3.9.3 ANTIPSYCHOTICS 3.9.4 MISCELLANEOUS PSYCHOTHERAPEUTIC AGENTS 3.9.3.1 PHENOTHIAZINES TIER 1 TIER 1 amphetamine aspartate/amphetamine sulfate/dextroamphetamine (Adderall) chlorpromazine hcl (Thorazine) Adderall XR (amphetamine aspartate/amphetamine sulfate/dextroamphetamine) fluphenazine hcl (Prolixin) clonidine (Kapvay) perphenazine (Trilafon) dextroamphetamine sulfate (Dexedrine) thioridazine hcl (Mellaril) guanfacine hcl (Intuniv) trifluoperazine hcl (Stelazine) lithium carbonate (Eskalith) lithium citrate (Lithium Citrate) 3.9.3.2 BUTYROPHENONES methamphetamine hcl (Desoxyn) TIER 1 methylphenidate, chewable (Methylin) haloperidol (Haldol) methylphenidate hcl (Concerta) haloperidol lactate concentrate, oral (Haldol) methylphenidate hcl (Metadate ER) methylphenidate hcl (Ritalin-SR) 3.9.3.3 MISCELLANEOUS ANTIPSYCHOTICS methylphenidate hcl (Ritalin) TIER 1 modafinil (Provigil) PA clozapine (Clozaril) AGE-A TIER 2 loxapine succinate (Loxitane) Daytrana (methylphenidate) olanzapine (Zyprexa) AGE-A Intuniv (guanfacine hcl) PA olanzapine (Zyprexa Zydis) AGE-A Nuvigil (armodafinil) Quillivant XR olanzapine/fluoxetine (Symbyax) AGE-A (methylphenidate hcl) 3 quetiapine fumarate (Seroquel) AGE-A Strattera (atomoxetine hcl) Psych & Neurology Drugs, CNS & Autonomic risperidone (Risperdal) AGE-A Vyvanse (lisdexamfetamine dimesylate) thiothixene (Navane) TIER 3 ziprasidone hcl (Geodon) AGE-A Adderall (amphetamine aspartate/amphetamine sulfate/dextroamphetamine) TIER 2 Dexedrine (dextroamphetamine sulfate) Abilify (aripiprazole) AGE-A Focalin (dexmethylphenidate) Latuda (lurasidone) AGE-A Focalin XR (dexmethylphenidate) Seroquel XR (quetiapine fumarate) AGE-A Kapvay (clonidine) Lithobid (lithium carbonate) TIER 3 Metadate CD (methylphenidate hcl) Clozaril (clozapine) AGE-A Metadate ER (methylphenidate hcl) Fanapt (iloperidone) AGE-A Ritalin (methylphenidate hcl) Fazaclo (clozapine) AGE-A Ritalin LA (methylphenidate la) Geodon (ziprasidone hcl) AGE-A Ritalin-SR (methylphenidate hcl) Invega (paliperidone) AGE-A Xyrem (sodium oxybate) PA Risperdal (risperidone) AGE-A Risperdal M-Tab (risperidone) AGE-A Saphris (asenapine) AGE-A FORMULARY PRODUCTS Seroquel (quetiapine fumarate) AGE-A DRUG NAME Symbyax (olanzapine/fluoxetine) AGE-A 3.9.5 ANXIOLYTICS Zyprexa (olanzapine) AGE-A TIER 1 Zyprexa Zydis (olanzapine) AGE-A alprazolam (Niravam)
alprazolam (Xanax) alprazolam (Xanax XR) buspirone hcl (Buspar) chlordiazepoxide hcl (Librium) clorazepate dipotassium (Tranxene T-Tab) diazepam (Valium) lorazepam (Ativan) midazolam hcl (Versed) oxazepam (Serax) TIER 3 Ativan (lorazepam) Tranxene T-Tab (clorazepate dipotassium) Valium (diazepam) Xanax (alprazolam) Xanax XR (alprazolam)
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
15 4. CARDIOVASCULAR, HYPERTENSION & LIPIDS
4.1 Antiarrhythmic Agents 4.4 Coagulation Therapy FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME TIER 1 4.4.1 ANTICOAGULANTS amiodarone hcl (Cordarone) TIER 1 amiodarone hcl (Pacerone 400mg) warfarin sodium (Coumadin) disopyramide phosphate (Norpace) TIER 2 disopyramide phosphate (Norpace CR) Eliquis (apixaban) flecainide acetate (Tambocor) Pradaxa (dabigatran etexilate mesylate) mexiletine hcl (Mexitil) Xarelto (rivaroxaban) procainamide hcl (Procanbid) TIER 3 propafenone hcl (Rythmol) Coumadin (warfarin sodium) propafenone hcl (Rythmol SR) quinidine gluconate (Quinaglute) quinidine sulfate (Quinidex) FORMULARY PRODUCTS sotalol hcl (Betapace) DRUG NAME
BlueCross BlueShield of Tennessee Three Tier BlueCross BlueShield of Tennessee sotalol hcl (Betapace AF) 4.4.2 ANTIPLATELET DRUGS TIER 3 TIER 1 Betapace (sotalol hcl) cilostazol (Pletal) Betapace AF (sotalol hcl) clopidogrel bisulfate (Plavix) Cordarone (amiodarone hcl) dipyridamole (Persantine) Multaq (dronedarone hcl) ticlopidine hcl (Ticlid) Norpace (disopyramide phosphate) TIER 2 4 Norpace CR (disopyramide phosphate) Brilinta (ticagrelor) Pacerone (amiodarone hcl) Effient (prasugrel hcl) Rythmol (propafenone hcl) TIER 3 Rythmol SR (propafenone hcl) Aggrenox (aspirin/dipyridamole) Tambocor (flecainide acetate) Persantine (dipyridamole) Plavix (clopidogrel bisulfate) Pletal (cilostazol) 4.2 Cardiac Glycosides FORMULARY PRODUCTS DRUG NAME FORMULARY PRODUCTS TIER 1 DRUG NAME digoxin (Lanoxin) 4.4.3 HEPARIN TIER 1 enoxaparin sodium disposable syringe (Lovenox) QL 4.3 Nitrates fondaparinux sodium (Arixtra) QL FORMULARY PRODUCTS TIER 3 DRUG NAME Arixtra (fondaparinux sodium) QL 4.3.1 RAPID ACTING NITRATES Fragmin (dalteparin sodium,porcine) QL Lovenox (enoxaparin sodium vial) QL TIER 1 nitroglycerin (Nitrolingual) Cardiovascular, Hypertension & Lipids Cardiovascular, nitroglycerin (Nitrostat) FORMULARY PRODUCTS TIER 3 DRUG NAME Nitrolingual (nitroglycerin) 4.4.4 VITAMIN K Nitrostat (nitroglycerin) TIER 3 Mephyton (phytonadione tablet)
FORMULARY PRODUCTS DRUG NAME FORMULARY PRODUCTS 4.3.2 LONG ACTING NITRATES DRUG NAME TIER 1 4.4.5 HEMOSTATICS isosorbide dinitrate (Isordil) TIER 1 isosorbide mononitrate (Imdur) aminocaproic acid (Amicar) isosorbide mononitrate (ISMO) TIER 3 nitroglycerin capsule, sustained action (Nitroglycerin) Humate-P (ahf, human/vwf, human) SPRx nitroglycerin ointment (Nitroglycerin) NovoSeven RT (factor viia, recombinant) SPRx nitroglycerin patch, transdermal 24 hours (Transderm-Nitro) Promacta (eltrombopag olamine) SPRx TIER 3 Wilate (ahf, human/vwf, human) SPRx Nitro-Dur (nitroglycerin) Imdur (isosorbide mononitrate) Isordil (isosorbide dinitrate)
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
16 4. CARDIOVASCULAR, HYPERTENSION & LIPIDS (CONTINUED) Tennesseeof BlueShield BlueCrossTier Three
FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 4.4.6 MISCELLANEOUS COAGULATION AGENTS 4.5.2 BETA BLOCKERS TIER 1 TIER 1 pentoxifylline tablet, sustained action (Trental) acebutolol hcl (Sectral) TIER 3 atenolol (Tenormin) Advate (antihemophilic factor viii) SPRx betaxolol hcl (Kerlone) Advate H (antihemophilic factor viii) SPRx bisoprolol fumarate (Zebeta) Advate L (antihemophilic factor viii) SPRx carvedilol (Coreg) Advate M (antihemophilic factor viii) SPRx labetalol hcl (Normodyne) Advate UH (antihemophilic factor viii) SPRx labetalol hcl (Trandate) Alphanate (antihemophilic factor/vwf) SPRx metoprolol succinate (Toprol XL) Alphanate SD (antihemophilic factor ix) SPRx metoprolol tartrate (Lopressor) Bebulin (factor ix complex) SPRx nadolol (Corgard) BeneFIX (factor ix, recombinant) SPRx pindolol (Visken) Corifact (factor viii) SPRx propranolol hcl (Inderal) Helixate FS (antihemophilic factor, recombinant) SPRx propranolol hcl (Inderal LA) Hemofil-M (antihemophilic factor, human) SPRx propranolol hcl (Innopran XL) Koate-DVI (antihemophilic factor, human) SPRx timolol maleate (Blocadren) Kogenate FS (antihemophilic factor, recombinant) SPRx TIER 2 Monoclate-P (antihemophilic factor, human) SPRx Bystolic (nebivolol hcl) Profilnine SD (antihemophilic factor ix, human) SPRx Coreg CR (carvedilol phosphate) Recombinate (antihemophilic factor, recombinant) SPRx TIER 3 4 Trental (pentoxifylline tablet, sustained action) Coreg (carvedilol) Tretten (factor xiii a-subunit, recombinant) SPRx
Corgard (nadolol) Cardiovascular,Lipids & Hypertension Xyntha (antihemophilic factor viii) SPRx Inderal LA (propranolol hcl) Xyntha Solofuse (antihemophilic factor viii) SPRx Kerlone (betaxolol hcl)
Levatol (penbutolol) Sectral (acebutolol hcl) 4.5 Antihypertensive Therapy Tenormin (atenolol) FORMULARY PRODUCTS Toprol XL (metoprolol succinate) DRUG NAME Zebeta (bisoprolol fumarate) 4.5.1 THIAZIDE & RELATED DIURETICS TIER 1 FORMULARY PRODUCTS amiloride hcl (Midamor) DRUG NAME amiloride hcl/hydrochlorothiazide (Moduretic) 4.5.3 CALCIUM CHANNEL BLOCKERS bumetanide (Bumex) 4.5.3.1 CALCIUM CHANNEL BLOCKERS/NON-DIHYDROPYRIDINES chlorothiazide (Diuril) TIER 1 chlorthalidone (Hygroton) diltiazem hcl (Cardizem) eplerenone (Inspra) diltiazem hcl (Cardizem LA) furosemide (Lasix) diltiazem hcl (Tiazac) hydrochlorothiazide (HydroDIURIL) diltiazem hcl (Cardizem SR) hydrochlorothiazide (Microzide) diltiazem hcl (Cardizem CD) indapamide (Lozol) nimodipine (Nimotop) methyclothiazide (Enduron) verapamil hcl (Calan) metolazone (Zaroxolyn) verapamil hcl (Verelan) spironolactone (Aldactone) verapamil hcl (Verelan PM) spironolactone/hydrochlorothiazide (Aldactazide) verapamil hcl (Calan SR) torsemide (Demadex) verapamil hcl (Isoptin S.R.) triamterene/hydrochlorothiazide (Dyazide) triamterene/hydrochlorothiazide (Maxzide) TIER 3 TIER 3 Calan (verapamil hcl) Cardizem (diltiazem hcl) Aldactazide (spironolactone/hydrochlorothiazide) Cardizem CD (diltiazem hcl) Aldactone (spironolactone) Cardizem LA (diltiazem hcl) Demadex (torsemide) Covera-HS (verapamil hcl) Dyazide (triamterene/hydrochlorothiazide) Tiazac (diltiazem hcl) Dyrenium (triamterene) Verelan (verapamil hcl) Inspra (eplerenone) Verelan PM (verapamil hcl) Lasix (furosemide) Maxzide (triamterene/hydrochlorothiazide) Zaroxolyn (metolazone)
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
17 4. CARDIOVASCULAR, HYPERTENSION & LIPIDS (CONTINUED)
FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 4.5.3.2 CALCIUM CHANNEL BLOCKERS/DIHYDROPYRIDINES 4.5.6 AGENTS FOR PHEOCHROMOCYTOMA TIER 1 TIER 3 amlodipine besylate (Norvasc) Demser (metyrosine) felodipine extended-release (Plendil) Dibenzyline (phenoxybenzamine hcl) isradipine (DynaCirc) nifedipine (Adalat, Adalat CC) FORMULARY PRODUCTS
nifedipine (Procardia, Procardia XL) DRUG NAME nisoldipine (Sular) 4.5.7 VASODILATORS TIER 3 TIER 1 Adalat CC (nifedipine) hydralazine hcl (Apresoline) DynaCirc CR (isradipine) minoxidil (Loniten) Norvasc (amlodipine besylate) Procardia XL (nifedipine) TIER 3 BlueCross BlueShield of Tennessee Three Tier BlueCross BlueShield of Tennessee Sular (nisoldipine) BiDil (isosorbide dinitrate/hydralazine hcl)
FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 4.5.4 ACE INHIBITORS 4.5.8 OTHER ANTIHYPERTENSIVE COMBINATIONS TIER 1 TIER 1 benazepril hcl (Lotensin) amlodipine besylate/benazepril hcl (Lotrel) 4 captopril (Capoten) amlodipine/valsartan (Exforge) enalapril maleate (Vasotec) amlodipine/valsartan/hctz (Exforge HCT) fosinopril sodium (Monopril) atenolol/chlorthalidone (Tenoretic) lisinopril (Prinivil) benazepril hcl/hydrochlorothiazide (Lotensin HCT) lisinopril (Zestril) bisoprolol fumarate/hydrochlorothiazide (Ziac) moexipril hcl (Univasc) captopril/hydrochlorothiazide (Capozide) perindopril erbumine (Aceon) enalapril maleate/hydrochlorothiazide (Vaseretic) quinapril hcl (Accupril) fosinopril sodium/hydrochlorothiazide (Monopril HCT) ramipril (Altace) lisinopril/hydrochlorothiazide (Prinzide) trandolapril (Mavik) lisinopril/hydrochlorothiazide (Zestoretic) methyldopa/hydrochlorothiazide (Aldoril) TIER 3 metoprolol tartrate/hydrochlorothiazide (Lopressor HCT) Accupril (quinapril hcl) moexipril/hydrochlorothiazide (Uniretic) Aceon (perindopril erbumine) propranolol hcl/hydrochlorothiazide (Inderide) Altace (ramipril) quinapril hcl/hydrochlorothiazide (Accuretic) Epaned (enalapril maleate) telmisartan/amlodipine (Twynsta) Lotensin (benazepril hcl) trandolapril/verapamil (Tarka) Mavik (trandolapril) Prinivil (lisinopril) TIER 2 Univasc (moexipril hcl) Azor (amlodipine besylate/olmesartan) Vasotec (enalapril maleate) Tribenzor (olmesartan medoxomil/amlodipine/hctz) Cardiovascular, Hypertension & Lipids Cardiovascular, Zestril (lisinopril) TIER 3 Accuretic (quinapril hcl/hydrochlorothiazide) Exforge (amlodipine/valsartan) FORMULARY PRODUCTS Exforge HCT (amlodipine/valsartan/hctz) DRUG NAME Lopressor HCT (metoprolol tartrate/hydrochlorothiazide) 4.5.5 ADRENERGIC ANTAGONISTS & RELATED DRUGS Lotensin HCT (benazepril hcl/hydrochlorothiazide) TIER 1 Lotrel (amlodipine besylate/benazepril hcl) clonidine hcl (Catapres, Catapres-TTS) Prinzide (lisinopril/hydrochlorothiazide) doxazosin mesylate (Cardura) Tarka (trandolapril/verapamil) guanfacine hcl (Tenex) Tenoretic (atenolol/chlorthalidone) methyldopa (Aldomet) Twynsta (telmisartan/amlodipine) prazosin hcl (Minipress) Vaseretic (enalapril maleate/hydrochlorothiazide) reserpine (Reserpine) Zestoretic (lisinopril/hydrochlorothiazide) terazosin hcl (Hytrin) Ziac (bisoprolol fumarate/hydrochlorothiazide) TIER 3 Cardura (doxazosin mesylate) Catapres (clonidine hcl) Catapres-TTS (clonidine hcl) Minipress (prazosin hcl) Tenex (guanfacine hcl)
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
18 4. CARDIOVASCULAR, HYPERTENSION & LIPIDS (CONTINUED) Tennesseeof BlueShield BlueCrossTier Three
4.6 Lipid/Cholesterol Lowering Agents FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 4.5.9 ANGIOTENSIN II RECEPTOR BLOCKERS & RENIN TIER 1 INHIBITORS atorvastatin calcium (Lipitor) TIER 1 cholestyramine/aspartame (Questran Light) candesartan cilexetil (Atacand) cholestyramine/sucrose (Questran) candesartan/hydrochlorothiazide (Atacand HCT) fenofibrate, micronized (Antara, Lofibra) eprosartan mesylate (Teveten 600mg) fenofibrate, nanocrystallized (Tricor) irbesartan (Avapro) fenofibric acid (Trilipix) irbesartan/hydrochlorothiazide (Avalide) gemfibrozil (Lopid) losartan potassium (Cozaar) lovastatin (Mevacor) losartan potassium/hydrochlorothiazide (Hyzaar) niacin ext-rel (Niaspan) telmisartan (Micardis) pravastatin sodium (Pravachol) telmisartan/hydrochlorothiazide (Micardis HCT) simvastatin (Zocor) valsartan (Diovan) TIER 2 valsartan/hydrochlorothiazide (Diovan HCT) Crestor (rosuvastatin calcium) TIER 2 Liptruzet (ezetimibe/atorvastatin) Benicar (olmesartan medoxomil) Simcor (niacin/simvastatin) Benicar HCT (olmesartan medoxomil/hydrochlorothiazide) Vytorin (ezetimibe/simvastatin) Zetia (ezetimibe) TIER 3 Amturnide (aliskiren/amlodipine/hydrochlorothiazide) TIER 3 Atacand (candesartan cilexetil) Advicor (niacin/lovastatin) Altoprev Atacand HCT (candesartan cilexetil/hydrochlorothiazide) (lovastatin) 4 Avalide (irbesartan/hydrochlorothiazide) Antara (fenofibrate, micronized) Caduet (amlodipine/atorvastatin) Avapro (irbesartan) Cardiovascular,Lipids & Hypertension Cozaar (losartan potassium) Colestid (colestipol) Diovan (valsartan) Fenoglide (fenofibrate) Diovan HCT (valsartan/hydrochlorothiazide) Fibricor (fenofibrate) Edarbi (aliskiren) ST Lescol (fluvastatin) Edarbyclor (azilsartan/chlorthalidone) ST Lescol XL (fluvastatin) Hyzaar (losartan potassium/hydrochlorothiazide) Lipitor (atorvastatin calcium) Micardis (telmisartan) Lipofen (fenofibrate) Micardis HCT (telmisartan/hydrochlorothiazide) Livalo (pitavastatin calcium) Tekturna (aliskiren hemifumarate) Lofibra (fenofibrate, micronized) Tekturna HCT (aliskiren/hydrochlorothiazide) Lopid (gemfibrozil) Teveten (eprosartan mesylate) ST Mevacor (lovastatin) Teveten HCT (eprosartan mesylate/hydrochlorothiazide) ST Niaspan (niacin) Pravachol (pravastatin sodium) Questran (cholestyramine/sucrose) Questran Light (cholestyramine/aspartame) Tricor (fenofibrate, nanocrystallized) Triglide (fenofibrate) Trilipix (fenofibric acid) Welchol (colesevelam hcl) Zocor (simvastatin)
4.7 Miscellaneous Cardiovascular Agents FORMULARY PRODUCTS DRUG NAME TIER 3 Ranexa (ranolazine)
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
19 5. DERMATOLOGICALS/TOPICAL THERAPY
5.1 Topical Corticosteroids FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 5.1.1 TOPICAL CORTICOSTEROIDS VERY HIGH POTENCY 5.1.4 TOPICAL CORTICOSTEROIDS LOW POTENCY TIER 1 TIER 1 clobetasol propionate (Olux) alclometasone dipropionate (Aclovate) clobetasol propionate (Temovate) desonide (DesOwen) clobetasol propionate/emollient (Temovate-E) fluocinolone acetonide (Derma-Smoothe FS) diflorasone diacetate (Psorcon) fluocinolone acetonide (Synalar) halobetasol propionate (Ultravate) hydrocortisone 2.5% (Hytone) TIER 3 TIER 3 Diprolene (betamethasone dipropionate) Aclovate (alclometasone dipropionate) Temovate (clobetasol propionate) Derma-Smoothe FS (fluocinolone acetonide) Ultravate (halobetasol propionate) Dermasorb HC (hydrocortisone) DesOwen (desonide)
BlueCross BlueShield of Tennessee Three Tier BlueCross BlueShield of Tennessee FORMULARY PRODUCTS DRUG NAME 5.2 Topical Anesthetics 5.1.2 TOPICAL CORTICOSTEROIDS HIGH POTENCY TIER 1 FORMULARY PRODUCTS DRUG NAME amcinonide (Cyclocort) TIER 1 betamethasone dipropionate (Diprolene, Diprosone) lidocaine (Lidoderm) betamethasone valerate (Betatrex) lidocaine hcl (Lida Mantle) desoximetasone (Topicort) lidocaine hcl (Xylocaine) 5 diflorasone diacetate (Psorcon) fluocinonide (Lidex) TIER 3 fluocinonide/emollient (Lidex-E) Emla Cream (lidocaine-prilocaine) triamcinolone acetonide (Aristocort) Lidoderm (lidocaine)
TIER 3 Apexicon E (diflorasone diacetate) Diprolene (betamethasone dipropionate) Diprolene AF (betamethasone dipropionate) Topicort (desoximetasone)
FORMULARY PRODUCTS DRUG NAME 5.1.3 TOPICAL CORTICOSTEROIDS MEDIUM POTENCY TIER 1 betamethasone valerate (Betatrex) betamethasone valerate (Luxiq) desoximetasone (Topicort LP) fluocinolone acetonide (Synalar) Dermatologicals/Topical Therapy Dermatologicals/Topical fluticasone propionate (Cutivate) hydrocortisone butyrate (Locoid) hydrocortisone valerate (Westcort) mometasone furoate (Elocon) triamcinolone acetonide (Kenalog) TIER 3 Cordran (flurandrenolide tape, medicated) Cordran Lotion (flurandrenolide tape, medicated) Cutivate (fluticasone propionate) Dermasorb TA (triamcinolone) Elocon (mometasone furoate) Locoid (hydrocortisone butyrate) Luxiq (betamethasone valerate) Westcort (hydrocortisone valerate)
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
20 5. DERMATOLOGICALS/TOPICAL THERAPY (CONTINUED) Tennesseeof BlueShield BlueCrossTier Three
5.3 Therapy For Acne 5.5 Topical Antifungals FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME TIER 1 TIER 1 adapalene (Differin) PA ciclopirox (Loprox) Amnesteem ciclopirox (Penlac) Avita (tretinoin) PA clotrimazole/betamethasone dipropionate (Lotrisone) benzoyl peroxide (Benzagel) econazole nitrate (Spectazole) Claravis ketoconazole (Extina) clindamycin phosphate (Cleocin T) ketoconazole (Nizoral) clindamycin phosphate/benzoyl peroxide (Duac) nystatin (Mycostatin) erythromycin base/benzoyl peroxide (Benzamycin) nystatin/triamcinolone acetonide (Mycolog II) erythromycin base/ethyl alcohol (A/T/S) TIER 3 erythromycin base/ethyl alcohol (Erycette) Ciclodan Kit (ciclopirox kit) metronidazole (Metrocream) Loprox (ciclopirox) metronidazole (Metrolotion) Oxistat (oxiconazole nitrate) sulfacetamide sodium/sulfur (Sulfacet-R) Xolegel (ketoconazole) tretinoin (Retin-A) PA Retin-A Micro (tretinoin microsphere) PA TIER 2 5.6 Topical Antivirals Acanya (clindamycin phosphate/benzoyl peroxide) FORMULARY PRODUCTS Atralin (tretinoin) PA DRUG NAME Epiduo (adapalene/benzoyl peroxide) TIER 1 TIER 3 Zovirax Ointment (acyclovir ointment) 5 Azelex (azelaic acid) Zovirax Cream (acyclovir cream) Benzaclin (clindamycin phosphate/benzoyl peroxide) TIER 3 Benzaclin (clindamycin phosphate/benzoyl peroxide/hyaluronate sodium) Denavir
(penciclovir) Dermatologicals/TopicalTherapy Benzamycin (erythromycin base/benzoyl peroxide) Lidovir (acyclovir/lidocaine) Cleocin T (clindamycin phosphate) Differin (adapalene) PA Duac (clindamycin phosphate/benzoyl peroxide) 5.7 Burn Therapy Fabior (tazarotene) PA FORMULARY PRODUCTS
Finacea (azelaic acid) DRUG NAME Metrocream (metronidazole) TIER 1 Metrogel 1% (metronidazole) silver sulfadiazine (Silvadene) Metrolotion (metronidazole) Noritate (metronidazole) TIER 3 Silvadene (silver sulfadiazine) Plexion (sulfacetamide) Retin-A (tretinoin) PA Riax (benzoyl peroxide) 5.8 Topical Enzymes Tazorac (tazarotene) PA FORMULARY PRODUCTS DRUG NAME 5.4 Topical Antibacterials TIER 1 FORMULARY PRODUCTS trypsin/balsam peru/castor oil (Granulex) DRUG NAME TIER 3 TIER 1 Santyl (collagenase clostridium hist.) gentamicin sulfate (Garamycin) mupirocin cream (Bactroban Cream) mupirocin ointment (Bactroban Ointment) 5.10 Antipsoriatic/Antiseborrheic sulfacetamide sodium (Klaron) FORMULARY PRODUCTS TIER 3 DRUG NAME Altabax (retapamulin) TIER 1 Bactroban Cream (mupirocin calcium cream) calcipotriene (Dovonex) Bactroban Ointment (mupirocin ointment) hydrocortisone acetate/pramoxine hcl (Pramosone) selenium sulfide (Selsun Rx) sulfacetamide sodium (Ovace) TIER 3 Dovonex (calcipotriene cream) Dovonex Solution (calcipotriene solution) SelRx (selenium sulfide) Soriatane (acitretin) Tazorac (tazarotene)
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
21 5. DERMATOLOGICALS/TOPICAL THERAPY (CONTINUED)
5.11 Topical Scabicides/Pediculicides FORMULARY PRODUCTS DRUG NAME TIER 1 malathion (Ovide) permethrin (Elimite) TIER 3 Eurax (crotamiton) Natroba (spinosad) Ovide (malathion)
5.12 Miscellaneous Dermatologicals FORMULARY PRODUCTS DRUG NAME TIER 1 BlueCross BlueShield of Tennessee Three Tier BlueCross BlueShield of Tennessee aluminum chloride (Drysol) fluorouracil (Efudex) hydroquinone (Eldoquin Forte) # hydroquinone (Lustra) imiquimod (Aldara) methoxsalen, rapid (Oxsoralen-Ultra) # podofilox (Condylox) 5 tacrolimus (Protopic) urea (Carmol 40) imiquimod (Aldara) TIER 2 Elidel (pimecrolimus) TIER 3 Carac (fluorouracil) Condylox (podofilox) Eldoquin Forte (hydroquinone) # Loutrex (emollient combination) # Lustra (hydroquinone) # Oxsoralen-Ultra (methoxsalen, rapid) # Panretin (alitretinoin) Picato (fluorouracil) Protopic (tacrolimus) Utopic (urea) Zonalon (doxepin hydrochloride cream) Zyclara (imiquimod)
Dermatologicals/Topical Therapy Dermatologicals/Topical
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
22 6. EAR, NOSE & THROAT MEDICATIONS Tennesseeof BlueShield BlueCrossTier Three
6.1 Intranasal Steroids FORMULARY PRODUCTS DRUG NAME TIER 1 budesonide (Rhinocort Aqua) flunisolide (Nasalide) fluticasone propionate (Flonase) TIER 2 Dymista (azelastine/fluticasone) Veramyst (fluticasone furoate) TIER 3 Beconase AQ (beclomethasone) ST Flonase (fluticasone propionate) Nasonex (mometasone furoate) ST Omnaris (ciclesonide) ST Rhinocort Aqua (budesonide) ST
6.2 Miscellaneous Otic Preparations FORMULARY PRODUCTS DRUG NAME TIER 1 acetic acid (VoSol) acetic acid/aluminum acetate (Domeboro) 6 acetic acid/hydrocortisone (VoSol HC) antipyrine/benzocaine/glycerin (Otogesic) benzocaine (Otocain) fluocinolone acetonide oil (DermOtic) Medications Ear,Throat & Nose ofloxacin (Floxin)
6.3 Otic Steroid/Antibiotic FORMULARY PRODUCTS DRUG NAME TIER 1 neomycin sulfate/polymyxin b sulfate/hydrocortisone (Cortisporin) TIER 3 Ciprodex (ciprofloxacin hcl/dexamethasone) Cipro HC (ciprofloxacin/hydrocortisone)
6.4 Miscellaneous Agents FORMULARY PRODUCTS DRUG NAME TIER 1 azelastine hcl (Astelin) chlorhexidine gluconate (Peridex) ipratropium bromide (Atrovent) lidocaine hcl (Xylocaine) lidocaine hcl (Lida Mantle) olopatadine (Patanase) triamcinolone acetonide (Kenalog in Orabase) TIER 2 Astepro (azelastine hcl) TIER 3 Astelin (azelastine hcl) Atrovent (ipratropium bromide) Patanase (olopatadine) Peridex (chlorhexidine gluconate)
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
23 7. ENDOCRINE/DIABETES
7.1 Antithyroid Agents 7.4 Miscellaneous Hormones FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME TIER 1 7.4.1 ANDROGENS methimazole (Tapazole) TIER 1 propylthiouracil (Propylthiouracil) danazol (Danocrine) TIER 3 oxandrolone (Oxandrin) # PA Tapazole (methimazole) testosterone cypionate (Depo-Testosterone) # AGE-B testosterone enanthate (Delatestryl) # AGE-B TIER 2 7.2 Thyroid Hormones Androgel (testosterone) # AGE-B FORMULARY PRODUCTS TIER 3 DRUG NAME Androderm (testosterone) # AGE-B TIER 1 Android (methyltestosterone) # PA AGE-B Levothroid (levothyroxine sodium) Androxy (fluoxymesterone) # PA AGE-B Levoxyl (levothyroxine sodium) Oxandrin (oxandrolone) # PA BlueCross BlueShield of Tennessee Three Tier BlueCross BlueShield of Tennessee liothyronine sodium (Cytomel) Methitest (methyltestosterone) # PA AGE-B thyroid (Armour Thyroid) Striant (testosterone) # AGE-B TIER 3 Testim (testosterone) # ST AGE-B Unithroid (levothyroxine sodium) Testred (methyltestosterone) # PA AGE-B
Armour Thyroid (thyroid) Cytomel (liothyronine sodium) FORMULARY PRODUCTS Synthroid (levothyroxine sodium) DRUG NAME 7 Thyrolar (liotrix) 7.4.2 OVULATORY STIMULANTS TIER 1 7.3 Adrenal Hormones clomiphene citrate (Clomid) # TIER 3 FORMULARY PRODUCTS
DRUG NAME Serophene (clomiphene citrate) # TIER 1 Cetrotide (cetrorelix) # Clomid # cortisone acetate (Cortone Acetate) (clomiphene citrate) Follistim AQ (follitropin beta, recombinant) # dexamethasone (Decadron) Ganirelix (ganirelix acetate) # fludrocortisone acetate (Florinef Acetate) Gonal-F RFF (follitropin alfa) # hydrocortisone (Cortef) Luveris (lutropin alfa) # methylprednisolone (Medrol) Menopur (menotropins) # prednisolone sodium phosphate (Pediapred) Ovidrel (hcg alpha, recombinant) # prednisolone syrup (Prelone) Repronex (menotropins) # prednisone (Deltasone) TIER 3 Endocrine/Diabetes Cortef (hydrocortisone) FORMULARY PRODUCTS Medrol (methylprednisolone) DRUG NAME Pediapred (prednisolone sodium phosphate) 7.4.3 MISCELLANEOUS AGENTS Prelone (prednisolone syrup) TIER 1 cabergoline (Dostinex) calcitonin, salmon, synthetic (Miacalcin) calcitriol (Rocaltrol) desmopressin acetate (DDAVP) octreotide acetate vial (Sandostatin) paricalcitol (Zemplar) TIER 3 DDAVP (desmopressin acetate) Exjade (deferasirox) SPRx Hectorol (doxercalciferol) Miacalcin (calcitonin, salmon, synthetic) Samsca (tolvaptan) SPRx Sensipar (cinacalcet hcl) SPRx Somavert (pegvisomant) SPRx Stimate (desmopressin acetate) SPRx Synarel (nafarelin acetate) Zavesca (miglustat) PA SPRx Zemplar (paricalcitol)
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
24 7. ENDOCRINE/DIABETES (CONTINUED) Tennesseeof BlueShield BlueCrossTier Three
FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 7.4.4 GONADOTROPIN & RELATED AGENTS 7.5.2 NON-INSULIN HYPOGLYCEMIC AGENTS TIER 1 TIER 1 gonadotropin, chorionic, human (Novarel) # acarbose (Precose) TIER 3 chlorpropamide (Diabinese) Cetrotide (cetrorelix acetate) # glimepiride (Amaryl) Ganirelix (ganirelix acetate) # glipizide (Glucotrol) glipizide (Glucotrol XL) glipizide/metformin hcl (Metaglip) 7.5 Diabetes Therapy glyburide (DiaBeta) glyburide (Micronase) FORMULARY PRODUCTS DRUG NAME glyburide, micronized (Glynase) 7.5.1 INSULIN THERAPY glyburide/metformin hcl (Glucovance) metformin hcl (Glucophage) TIER 2 metformin hcl (Glucophage XR) Lantus (insulin glargine, human recombinant analog) nateglinide (Starlix) Lantus Solostar (insulin glargine, human recombinant analog) pioglitazone hcl/glimepiride (Duetact) Levemir Pens (insulin detemir pens) repaglinide (Prandin) Levemir Vials (insulin detemir) tolazamide (Tolinase) Novolin 70/30 OTC (insulin) tolbutamide (Orinase) Novolin N OTC (insulin) TIER 2 Novolin R OTC (insulin) Bydureon (exenatide microspheres) NovoLog (insulin aspart) 7 Byetta (exenatide) Novolog Mix 70/30 (insulin aspart protamine human/insulin aspart) Farxiga (dapagliflozin) TIER 3 Invokamet (canagliflozin/metformin) Afrezza (insulin) Invokana (canagliflozin) Apidra (insulin glulisine) ST Janumet (sitagliptin phosphate/metformin hcl) Apidra Solostar (insulin glulisine) ST Janumet XR (sitagliptin/metformin hcl) Humalog (insulin lispro) ST Endocrine/Diabetes Januvia (sitagliptin phosphate) Humalog Mix 50/50 (insulin npl/insulin lispro) ST Jentadueto (linagliptin/metformin hcl) Humalog Mix 75/25 (insulin npl/insulin lispro) ST Juvisync (sitagliptin/simvastatin) Humulin 70/30 Kwikpen (insulin) ST Tradjenta (linagliptin) Humulin 70/30 OTC (insulin) ST Victoza (liraglutide) Humulin N Kwikpen (insulin) ST Xigduo XR (dapagliflozin/metformin) Humulin N OTC (insulin) ST TIER 3 Humulin R OTC (insulin) ST Actoplus Met (pioglitazone hcl/metformin hcl) Actos (pioglitazone hcl) Amaryl (glimepiride) Avandamet (rosiglitazone maleate/metformin hcl) Avandaryl (rosiglitazone maleate/glimepiride) Avandia (rosiglitazone maleate) Cycloset (bromocriptine mesylate) DiaBeta (glyburide) Duetact (pioglitazone hcl/glimepiride) Glucophage (metformin hcl) Glucophage XR (metformin hcl) Glucotrol (glipizide) Glucotrol XR (glipizide) Glucovance (glyburide/metformin hcl) Glumetza (metformin) Glynase (glyburide, micronized) Prandimet (repaglinide/metformin hcl) Prandin (repaglinide) Precose (acarbose) Riomet (metformin hcl) Starlix (nateglinide) Symlin (pramlintide acetate)
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
25 7. ENDOCRINE/DIABETES (CONTINUED)
FORMULARY PRODUCTS DRUG NAME 7.5.3 GLUCOSE ELEVATING AGENTS TIER 2 GlucaGen (glucagon, human recombinant) Glucagon (glucagon, human recombinant)
FORMULARY PRODUCTS DRUG NAME 7.5.4 INSULIN SYRINGES/MISCELLANEOUS DURABLE MEDICAL EQUIPMENT TIER 2 All Insulin Syringes, Needles, and Alcohol Wipes V-Go Disposable Insulin Delivery Device
BlueCross BlueShield of Tennessee Three Tier BlueCross BlueShield of Tennessee
FORMULARY PRODUCTS DRUG NAME 7.5.5 BLOOD GLUCOSE MONITORING DEVICES & SUPPLIES TIER 2 Breeze 2 (blood sugar diagnostic strip) QL Contour (blood sugar diagnostic strip) QL 7 One Touch Ultra Test Strips (blood sugar diagnostic strip) QL One Touch Verio IQ Test Strips (blood sugar diagnostic strip) QL TIER 3 Accu-Chek Avita (blood sugar diagnostic strip) ST QL Accu-Chek Avita Plus (blood sugar diagnostic strip) ST QL Accu-Chek Compact (blood sugar diagnostic strip) ST QL Surestep Pro (blood sugar diagnostic strip) ST QL
Endocrine/Diabetes
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
26 8. GASTROENTEROLOGY Tennesseeof BlueShield BlueCrossTier Three
8.1 Ulcer Therapy 8.2 Antidiarrheals & Antispasmodics FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 8.1.1 H2 ANTAGONISTS 8.2.1 ANTIDIARRHEALS TIER 1 TIER 1 cimetidine tablet 300mg, 400mg and 800mg (Tagamet) diphenoxylate hcl/atropine sulfate (Lomotil) famotidine 40mg tablet (Pepcid) paregoric (Paregoric) famotidine suspension (Pepcid) TIER 3 nizatidine (Axid) Fulyzaq (crofelemer) ranitidine hcl syrup (Zantac) Lomotil (diphenoxylate hcl/atropine sulfate) ranitidine hcl 300mg tablet (Zantac Rx) TIER 3 FORMULARY PRODUCTS Axid Pulvule (nizatidine) DRUG NAME Pepcid 40mg Tablet (famotidine) 8.2.2 ANTISPASMODICS Pepcid Suspension (famotidine) Zantac 300mg Tablet (ranitidine hcl) TIER 1 Zantac Syrup (ranitidine hcl) dicyclomine hcl (Bentyl) glycopyrrolate (Robinul) hyoscyamine sulfate (Levbid) FORMULARY PRODUCTS hyoscyamine sulfate (Levsin) DRUG NAME hyoscyamine sulfate (Levsin/SL) 8.1.2 PROSTAGLANDINS hyoscyamine sulfate (Nulev) TIER 1 methscopolamine bromide (Pamine) misoprostol (Cytotec) TIER 3 TIER 3 Bentyl (dicyclomine hcl) 8 Cytotec (misoprostol) Glycate (glycopyrrolate) Levbid (hyoscyamine sulfate) Levsin (hyoscyamine sulfate) FORMULARY PRODUCTS Pamine (methscopolamine bromide) DRUG NAME 8.1.3 OTHER ULCER THERAPY TIER 1 FORMULARY PRODUCTS Gastroenterology sucralfate tablet (Carafate) DRUG NAME TIER 3 8.2.3 COMBINATION ANTICHOLINERGICS Carafate (sucralfate) TIER 1 Helidac (bismuth subsalicylate) phenobarbital/hyoscyamine/atropine/scop (Donnatal) Prevpac (lansoprazole/amoxicillin/clarithromycin) clidinium bromide/chlordiazepoxide (Librax) Pylera (bismuth/metronid/tetracycline) TIER 3 Donnatal (phenobarbital/hyoscyamine/atropine/scop) d
FORMULARY PRODUCTS DRUG NAME 8.3 Miscellaneous Gastrointestinal 8.1.4 PROTON PUMP INHIBITORS Agents TIER 1 lansoprazole 30mg (Prevacid) FORMULARY PRODUCTS Nexium (esomeprazole magnesium trihydrate) DRUG NAME omeprazole (Prilosec Rx) 8.3.1 BILE ACIDS pantoprazole sodium (Protonix) TIER 1 TIER 3 ursodiol (Actigall) Prilosec Rx (omeprazole) ursodiol (Urso) Protonix (pantoprazole sodium) ursodiol (Urso Forte) TIER 3 Actigall (ursodiol) Urso (ursodiol) Urso Forte (ursodiol)
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
27 8. GASTROENTEROLOGY (CONTINUED)
FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 8.3.2 DIGESTIVE ENZYMES 8.3.4 ANTIVERTIGO & ANTIEMETIC AGENTS TIER 2 TIER 1 Creon (amylase/lipase/protease) granisetron hcl (Kytril) Zenpep (amylase/lipase/protease) ondansetron (Zofran ODT) TIER 3 ondansetron hcl (Zofran) Pertzye (amylase/lipase/protease) prochlorperazine maleate (Compazine) Viokace (amylase/lipase/protease) promethazine hcl (Phenergan) trimethobenzamide hcl (Tigan) TIER 3 FORMULARY PRODUCTS DRUG NAME Anzemet (dolasetron mesylate tablet) 8.3.3 MISCELLANEOUS GASTROINTESTINAL AGENTS Emend (aprepitant) Zofran (ondansetron hcl) TIER 1 Zofran ODT (ondansetron hcl)
BlueCross BlueShield of Tennessee Three Tier BlueCross BlueShield of Tennessee balsalazide disodium (Colazal) budesonide (Entocort EC) cromolyn sodium (Gastrocrom) FORMULARY PRODUCTS hydrocortisone (ProctoCream-HC) DRUG NAME hydrocortisone (Cortenema) 8.3.5 BOWEL EVACUANTS hydrocortisone acetate (Anusol-HC) TIER 1 hydrocortisone acetate/lidocaine hcl (Anamantle HC) sodium sulfate/sodium/sodium bicarbonate/potassium chloride/polyethylene glycols lactulose (Cephulac) (GoLYTELY) 8 lactulose (Chronulac) sodium sulfate/sodium/sodium bicarbonate/potassium chloride/polyethylene glycols mesalamine (Asacol) (Colyte) mesalamine (Rowasa) TIER 2 metoclopramide hcl (Reglan) Prepopik (sodium picosulfate/magnesium oxide/anhydrous citric acid) sulfasalazine (Azulfidine) Suclear (sodium bicarbonate/sodium chloride/potassium chloride/polyethylene TIER 2 glycol 3350) Amitiza (lubiprostone) Suprep (sodium sulfate/potassium sulfate/magnesium sulfate) Analpram Advanced (hydrocortisone acetate/pramoxine hcl) TIER 3 Analpram HC (hydrocortisone acetate/pramoxine hcl) GoLYTELY (sodium sulfate/sodium/sodium bicarbonate/potassium Apriso (mesalamine) chloride/polyethylene glycols) Asacol (mesalamine) Halflytely-Bisacodyl (bisacodyl/sodium chloride/sodium bicarbonate/potassium Asacol HD (mesalamine) chloride/polyethylene glycol 3350) Canasa (mesalamine) NuLytely (sodium chloride/sodium bicarbonate/potassium chloride/polyethylene Delzicol (mesalamine) glycols) Kristalose (lactulose)
Gastroenterology Lialda (mesalamine) Linzess (linaclotide) Pentasa (mesalamine) Uceris (budesonide) TIER 3 Azulfidine (sulfasalazine) Cortifoam (hydrocortisone acetate) Cystadane (betaine) SPRx Dipentum (olsalazine) Entocort EC (budesonide) Lotronex (alosetron hcl) ProctoCream-HC (hydrocortisone) ProctoFoam-HC (hydrocortisone acetate/pramoxine hcl) Reglan (metoclopramide hcl) Rowasa (mesalamine)
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
28 9. IMMUNOLOGY, VACCINES & BIOTECHNOLOGY Tennesseeof BlueShield BlueCrossTier Three
9.1 Biotechnology Drugs FORMULARY PRODUCTS DRUG NAME 9.1.1 ERYTHROID STIMULANTS TIER 3 Aranesp (darbepoetin alfa in polysorbate) PA SPRx Epogen (epoetin alfa) PA SPRx Procrit (epoetin alfa) PA SPRx
FORMULARY PRODUCTS DRUG NAME 9.1.2 MYELOID STIMULANTS TIER 3 Leukine (sargramostim) SPRx Neulasta (pegfilgrastim) SPRx Neupogen (filgrastim) SPRx
FORMULARY PRODUCTS DRUG NAME 9.1.3 INTERFERONS TIER 2 Avonex Administration Pack (interferon beta-1a/albumin human) SPRx Copaxone (glatiramer acetate) SPRx 9 Copaxone 40 mg/mL (glatiramer acetate) SPRx
Pegasys (peginterferon alfa-2a) PA SPRx Immunology,Biotechnology Vaccines& Rebif (interferon beta-1a/albumin human) SPRx TIER 3 Actimmune (interferon gamma-1b,recombinant) PA SPRx Betaseron (interferon beta-1b) ST SPRx Extavia (interferon beta-1b) SPRx Infergen (interferon alfacon-1) PA SPRx Intron A (interferon alfa-2b,recombinant vial) PA SPRx Peg-Intron (peginterferon alfa-2b) PA SPRx Peg-Intron Redipen (peginterferon alfa-2b) PA SPRx Plegridy (peginterferon beta-1a) SPRx
FORMULARY PRODUCTS DRUG NAME 9.1.4 GROWTH HORMONES TIER 3 Norditropin (somatropin) # PA SPRx
FORMULARY PRODUCTS DRUG NAME 9.1.5 INTERLEUKINS TIER 3 Neumega (oprelvekin) SPRx
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
29 10. MUSCULOSKELETAL & RHEUMATOLOGY
10.1 NSAID Agents 10.3 Other Rheumatologicals FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 10.1.1 NSAIDS/COX II INHIBITORS 10.3.1 CORTICOSTEROIDS 10.1.1.1 NSAIDS TIER 1 TIER 1 cortisone acetate (Cortone Acetate) etodolac (Lodine) dexamethasone (Decadron) etodolac (Lodine XL) hydrocortisone (Cortef) flurbiprofen (Ansaid) methylprednisolone (Medrol) ibuprofen (Motrin) prednisolone sodium phosphate (Pediapred) indomethacin (Indocin) prednisolone syrup (Prelone) indomethacin (Indocin SR) prednisone (Deltasone)
ketoprofen (Orudis) ketorolac (Toradol) FORMULARY PRODUCTS meclofenamate sodium (Meclofenamate Sodium) DRUG NAME meloxicam (Mobic) 10.3.2 MISCELLANEOUS RHEUMATOLOGICAL AGENTS BlueCross BlueShield of Tennessee Three Tier BlueCross BlueShield of Tennessee nabumetone (Relafen) TIER 1 naproxen (Naprosyn) azathioprine (Imuran) naproxen sodium (Anaprox) gold sodium thiomalate (Myochrysine) naproxen sodium (Anaprox DS) hydroxychloroquine sulfate (Plaquenil) naproxen sodium (Naprelan) leflunomide (Arava) oxaprozin (Daypro) methotrexate sodium (Rheumatrex) piroxicam (Feldene) sulfasalazine (Azulfidine) 10 sulindac (Clinoril) tolmetin sodium (Tolectin) TIER 2 Savella (milnacipran) TIER 3 Sprix (ketorolac tromethamine) TIER 3 Actemra SQ (tocilizmab) PA SPRx Arava (leflunomide) FORMULARY PRODUCTS Enbrel (etanercept) PA SPRx DRUG NAME Humira (adalimumab) PA SPRx 10.1.1.2 NSAIDS- SPECIFIC COX-II INHIBITORS Kineret (anakinra) PA ST SPRx TIER 1 Orencia SQ (abatacept) PA SPRx celecoxib (Celebrex) Simponi (golimumab) PA ST SPRx TIER 3 Trexall (methotrexate sodium) Celebrex (celecoxib) Xeljanz (tofacitinib) PA SPRx
FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 10.1.2 SALICYLATES 10.3.3 MUSCLE RELAXANTS & ANTISPASMODIC THERAPY TIER 1 TIER 1 choline salicylate/magnesium salicylate (Trilisate) baclofen (Lioresal) Musculoskeletal & Rheumatology diflunisal (Dolobid) carisoprodol (Soma) salsalate (Salsalate) chlorzoxazone (Parafon Forte DSC) cyclobenzaprine hcl (Amrix) cyclobenzaprine hcl (Flexeril) 10.2 Gout Therapy dantrolene sodium (Dantrium) diazepam (Valium) FORMULARY PRODUCTS DRUG NAME metaxalone (Skelaxin) TIER 1 methocarbamol (Robaxin) allopurinol (Zyloprim) oxybutynin chloride (Ditropan) oxybutynin chloride (Ditropan XL) probenecid (Probenecid) tolterodine tartrate (Detrol) TIER 2 trospium chloride (Sanctura) Colcrys (colchicine) TIER 2 Uloric (febuxostat) Enablex (darifenacin hydrobromide) TIER 3 Gelnique (oxybutynin chloride) Zyloprim (allopurinol) Myrbetriq (mirabegron) Vesicare (solifenacin succinate) TIER 3 Detrol (tolterodine tartrate) Detrol LA (tolterodine tartrate)
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
30 10. MUSCULOSKELETAL & RHEUMATOLOGY (CONTINUED) Tennesseeof BlueShield BlueCrossTier Three
10.4 Osteoporosis Therapy FORMULARY PRODUCTS DRUG NAME TIER 1 alendronate sodium (Fosamax) calcitonin, salmon, synthetic (Miacalcin) estradiol/norethindrone acetate (Activella) estradiol patch, transdermal (Vivelle DOT) ibandronate sodium (Boniva) raloxifene hcl (Evista) TIER 2 Actonel (risedronate) Atelvia (risedronate sodium) Miacalcin Injection (calcitonin, salmon, synthetic) Premarin (estrogens, conjugated tablet) Vivelle DOT (estradiol patch, transdermal) TIER 3 Boniva (ibandronate sodium) Evista (raloxifene hcl) Forteo (teriparatide) SPRx Fosamax (alendronate sodium) Fosamax Plus D (alendronate sodium/cholecalciferol) Miacalcin Nasal Spray (calcitonin, salmon, synthetic) 10 Musculoskeletal & Rheumatology & Musculoskeletal
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
31 11. OBSTETRICS & GYNECOLOGY
11.1 Oral Contraceptives & Related Agents FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 11.1.1 MONOPHASIC/BIPHASIC/TRIPHASIC AGENTS 11.1.2 PROGESTIN ONLY TIER 1 TIER 1 levonorgestrel-ethinyl estradiol (Alesse) norethindrone (Ortho Micronor) levonorgestrel-ethinyl estradiol (Lybrel) norethindrone acetate (Aygestin)
levonorgestrel-ethinyl estradiol (Nordette) levonorgestrel-ethinyl estradiol (Seasonale) 11.2 Oxytocics levonorgestrel-ethinyl estradiol (Tri-Levlen) levonorgestrel-ethinyl estradiol (Triphasil) FORMULARY PRODUCTS levonorgestrel-ethinyl estradiol/ethinyl estradiol (LoSeasonique) DRUG NAME levonorgestrel-ethinyl estradiol/ethinyl estradiol (Seasonique) TIER 1 norethindrone a-e estradiol (Loestrin) methylergonovine maleate (Methergine) norethindrone a-e estradiol/ferrous fumarate (Loestrin Fe) TIER 3 norethindrone-ethinyl estradiol (Brevicon) Methergine (methylergonovine maleate)
BlueCross BlueShield of Tennessee Three Tier BlueCross BlueShield of Tennessee norethindrone-ethinyl estradiol (Modicon) norethindrone-ethinyl estradiol (Norinyl) norethindrone-ethinyl estradiol (Ortho-Novum) 11.3 Estrogens & Progestins norethindrone-ethinyl estradiol/ferrous fumarate (Femcon Fe) FORMULARY PRODUCTS norgestimate-ethinyl estradiol (Ortho Tri-Cyclen) DRUG NAME norgestimate-ethinyl estradiol (Ortho-Cyclen) 11.3.1 PROGESTINS norgestrel-ethinyl estradiol (Lo/Ovral) TIER 1 11 norgestrel-ethinyl estradiol (Ovral) medroxyprogesterone acetate (Provera) TIER 2 norethindrone (Ortho Micronor) Lo Loestrin Fe (norethindrone a-e estradiol/ferrous fumarate) norethindrone acetate (Aygestin) Minastrin 24 Fe (norethindrone a-e estradiol/ferrous fumarate) progesterone, micronized (Prometrium) TIER 3 TIER 3 Beyaz (drospirenone/ethinyl estradiol/levomefolate calcium) Aygestin (norethindrone acetate) Brevicon (norethindrone-ethinyl estradiol) Crinone (progesterone, micronized) Cyclessa (desogestrel-ethinyl estradiol) Depo-Provera (medroxyprogesterone acetate) Desogen (desogestrel-ethinyl estradiol) Nor-Q-D (norethindrone) Estrostep Fe (ethinyl estradiol/norethindrone acetate) Ortho Micronor (norethindrone) Loestrin (norethindrone a-e estradiol) Prometrium (progesterone, micronized) Loestrin Fe (norethindrone a-e estradiol/ferrous fumarate) Provera (medroxyprogesterone acetate)
Lo Minastrin Fe (norethindrone acetate - ethinyl estradiol - ferrous fumarate)
Lo/Ovral (norgestrel-ethinyl estradiol) FORMULARY PRODUCTS LoSeasonique (levonorgestrel-ethinyl estradiol/ethinyl estradiol) DRUG NAME Lybrel (levonorgestrel-ethinyl estradiol) 11.3.2 ESTROGENS Mircette (desogestrel-ethinyl estradiol/ethinyl estradiol) TIER 1
Obstetrics & Gynecology Modicon (norethindrone-ethinyl estradiol) estradiol patch (Estradiol) Natazia (estradiol valerate/dienogest) estradiol patch (Vivelle DOT) Nordette (levonorgestrel-ethinyl estradiol) estradiol tablet (Estrace)
Norinyl 1-0.035mg (norethindrone-ethinyl estradiol) estropipate (Ogen) Norinyl 1-0.05mg (norethindrone-ethinyl estradiol) TIER 2 Ortho-Cept (desogestrel-ethinyl estradiol) Cenestin (estrogens, conjugated, synthetic a) Ortho-Cyclen (norgestimate-ethinyl estradiol) Divigel (estradiol) Ortho-Novum (norethindrone-mestranol) Enjuvia (estrogens, conjugated synthetic b) Ortho Tri-Cyclen (norgestimate-ethinyl estradiol) Evamist (estradiol) Ortho Tri-Cyclen Lo (norgestimate-ethinyl estradiol) Premarin (estrogens, conjugated tablet) Ovcon (norethindrone-ethinyl estradiol) Vagifem (estradiol) Seasonale (levonorgestrel-ethinyl estradiol) Vivelle DOT (estradiol) Seasonique (levonorgestrel-ethinyl estradiol/ethinyl estradiol) TIER 3 Tri-Norinyl (norethindrone-ethinyl estradiol) Alora (estradiol patch) Yasmin (ethinyl estradiol/drospirenone) Climara (estradiol) YAZ (ethinyl estradiol/drospirenone) Elestrin (estradiol topical gel) Estrace (estradiol) Estraderm (estradiol) Estrasorb (estradiol topical gel) Estring (estradiol) Femring (estradiol acetate) Femtrace (estradiol) Menest (estrogen) Menostar (estradiol patch)
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
32 11. OBSTETRICS & GYNECOLOGY (CONTINUED) Tennesseeof BlueShield BlueCrossTier Three
FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 11.3.3 ESTROGEN COMBINATIONS 11.4.4 SPECIALIZED OB/GYN DRUGS TIER 1 TIER 1 estrogens, esterified/methyltestosterone (Estratest) isoxsuprine hcl (Vasodilan) estrogens, esterified/methyltestosterone (Estratest H.S.) terbutaline sulfate (Brethine) estradiol/norethindrone acetate (Activella) tranexamic acid (Lysteda) norethindrone/ethinyl estradiol (Femhrt) TIER 2 TIER 2 Osphena (ospemifene) Premphase (estrogens, conjugated/medroxyprogesterone acet) TIER 3 Prempro (estrogens, conjugated/medroxyprogesterone acet) Lysteda (tranexamic acid) TIER 3 Synarel (nafarelin acetate) Activella (estradiol/norethindrone acetate) Climara Pro (estradiol, levonorgestrel transdermal) FORMULARY PRODUCTS
Combipatch (estradiol/norethindrone acetate) DRUG NAME Duavee (conjugated estrogens/bazedoxifene) 11.4.5 DIAPHRAGMS AND OTHER NON-ORAL CONTRACEPTIVES Femhrt (norethindrone/ethinyl estradiol) Lopreeza (estradiol/norethindrone acetate) TIER 1 Prefest (estradiol/norgestimate) xulane (Ortho Evra) TIER 2 NuvaRing (etonogestrel/ethinyl estradiol) 11.4 Miscellaneous OB/GYN TIER 3 FORMULARY PRODUCTS Ortho Evra (norelgestromin/ethinyl estradiol) 11 DRUG NAME 11.4.1 DRUGS TO TREAT INFERTILITY/IVF AGENTS TIER 1 clomiphene citrate (Clomid) # gonadotropin, chorionic, human (Profasi) # Gynecology & Obstetrics TIER 3 Serophene (clomiphene citrate) Cetrotide (cetrorelix acetate) # Follistim AQ (follitropin beta, recombinant) # Ovidrel (hcg alpha, recombinant) # Repronex (menotropins) #
FORMULARY PRODUCTS DRUG NAME 11.4.2 VAGINAL CLEANSER/ANTI-INFECTIVES TIER 1 clindamycin phosphate (Clindesse) metronidazole (Metrogel) TIER 3 Metrogel (metronidazole) Nuvessa (metronidazole)
FORMULARY PRODUCTS DRUG NAME 11.4.3 VAGINAL ANTIFUNGALS TIER 1 fluconazole (Diflucan) miconazole nitrate suppository, vaginal (Monistat 3) nystatin (Nystatin) terconazole (Terazol) TIER 3 Terazol (terconazole)
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
33 12. OPHTHALMOLOGY
12.1 Beta-blockers 12.5 Oral Drugs For Glaucoma FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME TIER 1 TIER 1 betaxolol hcl (Betoptic) acetazolamide (Diamox) carteolol hcl (Ocupress) acetazolamide (Diamox Sequels) levobunolol hcl (Betagan) methazolamide (Neptazane) metipranolol (OptiPranolol) TIER 3 timolol maleate (Timoptic) Diamox Sequels (acetazolamide) timolol maleate (Timoptic-XE) TIER 2 Betimol (timolol ophthalmic) 12.6 Cycloplegic Mydriatics TIER 3 FORMULARY PRODUCTS Betagan (levobunolol hcl) DRUG NAME Betoptic S (betaxolol hcl) TIER 1 Istalol (timolol ophthalmic) atropine sulfate (Isopto Atropine) BlueCross BlueShield of Tennessee Three Tier BlueCross BlueShield of Tennessee OptiPranolol (metipranolol) cyclopentolate hcl (Cyclogyl) Timoptic (timolol maleate) homatropine hbr (Isopto Homatropine) Timoptic-XE (timolol maleate) tropicamide (Mydriacyl)
TIER 3 12.2 Cholinesterase Inhibitor Miotics Isopto Homatropine (homatropine hbr) Isopto Hyoscine (scopolamine) FORMULARY PRODUCTS 12 DRUG NAME TIER 3 12.7 Non-steroidal Anti-inflammatory Phospholine Iodide (echothiophate iodide) Agents
FORMULARY PRODUCTS 12.3 Direct Acting Miotics DRUG NAME TIER 1 FORMULARY PRODUCTS bromfenac (Bromday) DRUG NAME bromfenac sodium (Xibrom) TIER 1 diclofenac sodium (Voltaren) pilocarpine hcl (Isopto Carpine) flurbiprofen sodium (Ocufen) TIER 3 ketorolac tromethamine (Acular) Pilopine HS (pilocarpine hcl) ketorolac tromethamine (Acular LS)
TIER 2 12.4 Other Glaucoma Drugs Prolensa (bromfenac) TIER 3 Ophthalmology FORMULARY PRODUCTS Acular (ketorolac tromethamine) DRUG NAME Acular LS (ketorolac tromethamine) TIER 1 Bromday (bromfenac) dorzolamide hcl (Trusopt) Nevanac (nepafenac) dorzolamide/timolol (Cosopt) Voltaren (diclofenac sodium) latanoprost (Xalatan) travoprost (Travatan) TIER 2 12.8 Vasoconstrictor Decongestants Azopt (brinzolamide) FORMULARY PRODUCTS Lumigan (bimatoprost) DRUG NAME Travatan Z (travoprost) TIER 1 TIER 3 naphazoline hcl (Albalon) Combigan (brimonidine tartrate/timolol maleate) phenylephrine hcl (Neo-Synephrine) Cosopt (dorzolamide/timolol) Rescula (unoprostone isopropyl) ST Simbrinza (brinzolamide/brimonidine) Travatan (travoprost) Trusopt (dorzolamide hcl) Xalatan (latanoprost) ST Zioptan (tafluprost) ST
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
34 12. OPHTHALMOLOGY (CONTINUED) Tennesseeof BlueShield BlueCrossTier Three
12.9 Antibiotics 12.13 Steroid-sulfonamide Combinations FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME TIER 1 TIER 1 bacitracin (Bacitracin) sulfacetamide sodium/prednisolone sodium phosphate (Vasocidin) bacitracin/polymyxin b sulfate (Polysporin) TIER 3 ciprofloxacin hcl drops (Ciloxan) Blephamide (sulfacetamide sodium/prednisolone acetate) erythromycin base (Ilotycin) Blephamide S.O.P. (sulfacetamide sodium/prednisolone acetate) gentamicin sulfate (Garamycin) levofloxacin (Quixin) neomycin sulfate/bacitracin/polymyxin b ointment (Neosporin) 12.14 Sympathomimetics neomycin sulfate/gramicidin d/polymyxin b drops (Neosporin) FORMULARY PRODUCTS ofloxacin (Ocuflox) DRUG NAME polymyxin b sulfate/trimethoprim (Polytrim) TIER 1 tobramycin sulfate drops (Tobrex) apraclonidine hcl (Iopidine) TIER 3 brimonidine tartrate (Alphagan) AzaSite (azithromycin) brimonidine tartrate (Alphagan P 0.15%)
Ciloxan (ciprofloxacin hcl ointment) TIER 3 Ciloxan Drops (ciprofloxacin hcl drops) Alphagan P (brimonidine tartrate) Ocuflox (ofloxacin) Quixin (levofloxacin) Tobrex (tobramycin sulfate ointment) 12.15 Miscellaneous Ophthalmologics Tobrex Drops (tobramycin sulfate) Vigamox (moxifloxacin hcl) FORMULARY PRODUCTS DRUG NAME 12 TIER 1 12.10 Sulfonamides azelastine hcl (Optivar) cromolyn sodium (Opticrom) FORMULARY PRODUCTS DRUG NAME epinastine hcl (Elestat) TIER 1 TIER 2 Alrex (loteprednol etabonate)
sulfacetamide sodium (Bleph-10) Ophthalmology Bepreve (bepotastine) Pataday (olopatadine hcl) 12.11 Steroids Patanol (olopatadine hcl) Restasis (cyclosporine) FORMULARY PRODUCTS
DRUG NAME TIER 3 TIER 1 Alamast (pemirolast potassium) Alocril dexamethasone sodium phosphate (Decadron) (nedocromil) Alomide (lodoxamide) fluorometholone (FML) Elestat (epinastine hcl) prednisolone acetate (Pred Forte) Emadine (emedastine difumarate) prednisolone sodium phosphate (Inflamase Forte) Mitosol (mitomycin) TIER 3 Optivar (azelastine hcl) Flarex (fluorometholone acetate) FML (fluorometholone) Lotemax (loteprednol etabonate) 12.16 Antivirals Pred Forte (prednisolone acetate) FORMULARY PRODUCTS Pred Mild (prednisolone acetate) DRUG NAME Vexol (rimexolone) TIER 1 trifluridine (Viroptic) 12.12 Steroid-antibiotic Combinations TIER 3 Viroptic (trifluridine) FORMULARY PRODUCTS
DRUG NAME TIER 1 neomycin sulfate/bacitracin zinc/polymyxin b/hydrocortisone (Cortisporin) neomycin sulfate/polymyxin b sulfate/hydrocortisone (Cortisporin) neomycin/polymyxin b sulfate/dexamethasone (Maxitrol) tobramycin sulfate/dexamethasone drops (TobraDex) TIER 3 Maxitrol (neomycin/polymyxin b sulfate/dexamethasone) Pred-G (gentamicin/prednisolone acetate) TobraDex (tobramycin sulfate/dexamethasone) Zylet (tobramycin/loteprednol etabonate)
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
35 13. RESPIRATORY, ALLERGY, COUGH & COLD
13.1 Antihistamine & Antiallergenic Agents FORMULARY PRODUCTS DRUG NAME FORMULARY PRODUCTS DRUG NAME 13.2.2 EXPECTORANT COMBINATIONS 13.1.1 ANTIHISTAMINES TIER 1 TIER 1 guaifenesin (Liquibid) guaifenesin/phenylephrine hcl (Despec) clemastine fumarate 2.68mg (Tavist) cyproheptadine hcl (Periactin) hydroxyzine hcl (Atarax) FORMULARY PRODUCTS hydroxyzine pamoate (Vistaril) DRUG NAME levocetirizine di-hcl (Xyzal) 13.2.3 DECONGESTANT/ANTIHISTAMINES promethazine hcl (Phenergan) TIER 1 TIER 3 pseudoephedrine hcl/brompheniramine maleate (Bromfed) Clarinex (desloratadine) pseudoephedrine hcl/chlorpheniramine maleate (Deconamine SR)
Vistaril (hydroxyzine pamoate) TIER 3 Xyzal (levocetirizine di-hcl) BlueCross BlueShield of Tennessee Three Tier BlueCross BlueShield of Tennessee Clarinex-D 24 Hour (pseudoephedrine/desloratadine) Semprex-D (acrivastine/pseudoephedrine) FORMULARY PRODUCTS DRUG NAME 13.1.2 ADRENERGICS 13.3 Pulmonary Agents TIER 2 FORMULARY PRODUCTS Auvi-Q (epinephrine) QL DRUG NAME 13 EpiPen (epinephrine) QL 13.3.1 XANTHINES EpiPen Jr. (epinephrine) QL TIER 1 aminophylline (Aminophylline)
FORMULARY PRODUCTS theophylline anhydrous (Theo-Dur) DRUG NAME TIER 3 13.1.3 CORTICOSTEROIDS Elixophyllin (theophylline anhydrous) Theo-24 (theophylline anhydrous) TIER 1 cortisone acetate (Cortone Acetate) dexamethasone (Decadron) FORMULARY PRODUCTS hydrocortisone (Cortef) DRUG NAME methylprednisolone (Medrol) 13.3.2 BETA AGONISTS ORAL prednisolone sodium phosphate (Pediapred) TIER 1 prednisolone syrup (Prelone) albuterol sulfate (Proventil) prednisone (Deltasone) metaproterenol sulfate (Alupent)
terbutaline sulfate (Brethine) 13.2 Cough & Cold Therapy FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME
Respiratory, Allergy, Cough & Cold Allergy, Respiratory, 13.2.1 ANTITUSSIVE COMBINATIONS 13.3.3 BETA AGONISTS INHALERS TIER 1 TIER 1 dextromethorphan hbr/pseudoephedrine hcl/brompheniramine (Bromfed-DM) albuterol nebulizers (Proventil) albuterol sulfate (Accuneb) guaifenesin/codeine phosphate (Robitussin A-C) levalbuterol hcl (Xopenex 1.25mg/0.5) guaifenesin/codeine phosphate (Tussi-Organidin Nr) metaproterenol sulfate (Alupent) guaifenesin/codeine phosphate (Tussi-Organidin-S Nr) guaifenesin/dextromethorphan hbr (Duratuss DM) TIER 2 hydrocodone bit/homatropine (Hycodan) Albuterol Sulfate HFA phenylephrine hcl/brompheniramine maleate (Bromfed) Arcapta Neohaler (indacaterol) phenylephrine hcl/brompheniramine maleate (Bromfed-PD) Brovana (arformoterol) Foradil (formoterol fumarate) Perforomist (formoterol fumarate) ProAir HFA (albuterol sulfate) ProAir RespiClick (albuterol sulfate) Serevent Diskus (salmeterol xinafoate) TIER 3 Proventil HFA (albuterol sulfate) ST Striverdi Respimat (olodaterol) Ventolin HFA (albuterol sulfate) ST Xopenex (levalbuterol hcl) Xopenex HFA (levalbuterol tartrate) ST
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
36 13. RESPIRATORY, ALLERGY, COUGH & COLD (CONTINUED) Tennesseeof BlueShield BlueCrossTier Three
FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 13.3.4 INHALED CORTICOSTEROIDS 13.3.6 MISCELLANEOUS PULMONARY AGENTS TIER 1 TIER 1 budesonide (Pulmicort 0.25mg/2mL) acetylcysteine (Mucomyst) budesonide (Pulmicort 0.5mg/2mL) cromolyn sodium ampul for nebulization (Intal) TIER 2 ipratropium/albuterol sulfate (Duoneb) Asmanex (mometasone furoate) ipratropium bromide solution, non-oral (Atrovent) Asmanex HFA (mometasone furoate) montelukast sodium (Singulair) Flovent Diskus (fluticasone propionate) sildenafil citrate (Revatio) PA Flovent HFA (fluticasone propionate) zafirlukast (Accolate) QVAR (beclomethasone dipropionate) TIER 2 TIER 3 Adcirca (tadalafil) PA SPRx Aerospan (flunisolide) Advair Diskus (fluticasone propionate/salmeterol xinafoate) Alvesco (ciclesonide) Advair HFA (fluticasone propionate/salmeterol xinafoate) Pulmicort Flexhaler (budesonide) Anoro Ellipta (umeclidinium/vilanterol) Breo Ellipta (fluticasone furoate/vilanterol) Combivent Respimat (albuterol sulfate/ipratropium bromide) FORMULARY PRODUCTS Daliresp (roflumilast) DRUG NAME Dulera (mometasone/formoterol) 13.3.5 INTRANASAL STEROIDS Spiriva (tiotropium bromide) TIER 1 Symbicort (budesonide/formoterol fumarate) budesonide (Rhinocort Aqua) Tudorza Pressair (aclidinum bromide) 13 flunisolide (Nasalide) TIER 3 fluticasone propionate (Flonase) Accolate (zafirlukast)
TIER 2 Adempas (riociguat) PA SPRx Respiratory,Allergy,Cold & Cough Dymista (azelastine hcl/fluticasone) Atrovent HFA (ipratropium bromide) Veramyst (fluticasone furoate) Letairis (ambrisentan) PA SPRx TIER 3 Opsumit (macitentan) PA SPRx Aerospan (flunisolide) Orentram (treprostinil) PA SPRx Beconase AQ (beclomethasone dipropionate) ST Pulmozyme (dornase alfa) SPRx Flonase (fluticasone propionate) ST Revatio (sildenafil citrate) PA SPRx Nasonex (mometasone furoate) ST Singulair (montelukast sodium) Omnaris (ciclesonide) ST Tracleer (bosentan) PA SPRx Rhinocort Aqua (budesonide) ST Ventavis (iloprost) PA SPRx
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
37 14. UROLOGICALS
14.1 Cholinergic Stimulants 14.5 Benign Prostatic Hyperplasia (BPH) FORMULARY PRODUCTS Therapy DRUG NAME FORMULARY PRODUCTS TIER 1 DRUG NAME bethanechol chloride (Urecholine) TIER 1 alfuzosin hcl (Uroxatral) 14.2 Anticholinergics & Antispasmodics doxazosin mesylate (Cardura) finasteride (Proscar) FORMULARY PRODUCTS terazosin hcl (Hytrin) DRUG NAME tamsulosin hcl (Flomax) TIER 1 TIER 3 dicyclomine hcl (Bentyl) Avodart (dutasteride) flavoxate hcl (Urispas) Flomax (tamsulosin hcl) hyoscyamine sulfate (Levbid) Jalyn (dutasteride/tamsulosin hcl) hyoscyamine sulfate (Levsin) Proscar (finasteride) hyoscyamine sulfate (Levsin/SL) Rapaflo (silodosin) BlueCross BlueShield of Tennessee Three Tier BlueCross BlueShield of Tennessee hyoscyamine sulfate (Nulev) Uroxatral (alfuzosin hcl) oxybutynin chloride (Ditropan) oxybutynin chloride (Ditropan XL) trospium chloride (Sanctura) TIER 2 Enablex (darifenacin hydrobromide) Gelnique (oxybutynin chloride) 14 Myrbetriq (mirabegron) Vesicare (solifenacin succinate) TIER 3 Detrol (tolterodine tartrate) Detrol LA (tolterodine tartrate) Ditropan XL (oxybutynin chloride) Levbid (hyoscyamine sulfate)
14.3 Urinary Anesthetics FORMULARY PRODUCTS DRUG NAME TIER 1 phenazopyridine hcl (Pyridium)
Urologicals TIER 3 Pyridium (phenazopyridine hcl)
14.4 Miscellaneous Urologicals FORMULARY PRODUCTS DRUG NAME TIER 3 Caverject (alprostadil) # QL ^ Cialis (tadalafil) † # PA QL ^ Edex (alprostadil) # QL ^ Elmiron (pentosan polysulfate sodium) Levitra (vardenafil) † # PA QL ^ Muse (alprostadil) # QL ^ Staxyn (vardenafil) † # PA QL ^ Stendra (avanafil) † # PA QL ^ Viagra (sildenafil citrate) † # PA QL ^
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
38 15. VITAMINS, HEMATINICS & ELECTROLYTES Tennesseeof BlueShield BlueCrossTier Three
15.1 Vitamins & Hematinics FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME TIER 1 15.2.5 HEMOSTATICS cyanocobalamin (Vitamin B-12) TIER 1 ergocalciferol capsule (Vitamin D 50000 Unit) aminocaproic acid (Amicar) ferrous sulfate drops (Feosol) TIER 3 fluoride ion/iron/vitamins a,c,and d (Tri-Vi-Flor w/Iron) Humate-P (ahf, human/vwf, human) SPRx fluoride ion/multivitamins (Poly-Vi-Flor) NovoSeven RT (factor viia, recombinant) SPRx fluoride ion/multivitamins w-iron (Poly-Vi-Flor w/Iron) Promacta (eltrombopag olamine) SPRx fluoride ion/vitamins a,c,and d (Tri-Vi-Flor) Wilate (ahf, human/vwf, human) SPRx folic acid (Folvite) prenatal vitamin w-o vitamin a/ferrous fumarate/folic acid (Precare) FORMULARY PRODUCTS
prenatal vitamins/iron polysaccharides complex/folic acid (Niferex-PN Forte) DRUG NAME sodium fluoride (Luride) 15.2.6 MISCELLANEOUS COAGULATION AGENTS TIER 3 TIER 1 All Brand-Name Prescription Prenatal Vitamins with 1mg of Folic Acid pentoxifylline tablet, sustained action (Trental) TIER 3 15.2 Coagulation Therapy Advate (antihemophilic factor viii) SPRx Advate H (antihemophilic factor viii) SPRx FORMULARY PRODUCTS Advate L (antihemophilic factor viii) SPRx DRUG NAME Advate M (antihemophilic factor viii) SPRx 15.2.1 ANTICOAGULANTS Advate UH (antihemophilic factor viii) SPRx TIER 1 Alphanate (antihemophilic factor/vwf) SPRx 15 warfarin sodium (Coumadin) Alphanate SD (antihemophilic factor ix) SPRx TIER 2 Bebulin (factor ix complex) SPRx Eliquis (apixaban) BeneFIX (factor ix, recombinant) SPRx Electrolytes & Hematinics Vitamins, Pradaxa (dabigatran etexilate mesylate) Corifact (factor viii) SPRx Xarelto (rivaroxaban) Helixate FS (antihemophilic factor, recombinant) SPRx
Hemofil-M (antihemophilic factor, human) SPRx Koate-DVI SPRx FORMULARY PRODUCTS (antihemophilic factor, human) DRUG NAME Kogenate FS (antihemophilic factor, recombinant) SPRx 15.2.2 ANTIPLATELET DRUGS Monoclate-P (antihemophilic factor, human) SPRx TIER 1 Profilnine SD (antihemophilic factor ix, human) SPRx Recombinate (antihemophilic factor, recombinant) SPRx cilostazol (Pletal) Trental (pentoxifylline tablet, sustained action) clopidogrel bisulfate (Plavix) Tretten (factor xiii a-subunit, recombinant) SPRx dipyridamole (Persantine) Xyntha (antihemophilic factor viii) SPRx ticlopidine hcl (Ticlid) Xyntha Solofuse (antihemophilic factor viii) SPRx TIER 2 Brilinta (ticagrelor) Effient (prasugrel hcl) 15.3 Electrolytes TIER 3 FORMULARY PRODUCTS Aggrenox (aspirin/dipyridamole) DRUG NAME Persantine (dipyridamole) 15.3.1 POTASSIUM Plavix (clopidogrel bisulfate) TIER 1 Pletal (cilostazol) potassium bicarbonate/citric acid (K-Lyte) potassium chloride (K-Dur) FORMULARY PRODUCTS potassium chloride (Micro-K) DRUG NAME potassium chloride (Kay Ciel) 15.2.3 HEPARIN potassium chloride (K-Lor) TIER 1 potassium chloride (Slow-K) enoxaparin sodium disposable syringe (Lovenox) QL TIER 3 fondaparinux sodium (Arixtra) QL Klor-Con 25mEq (potassium chloride/potassium bicarbonate/citric acid) TIER 3 K-Tab (potassium chloride/potassium bicarbonate/citric acid) Arixtra (fondaparinux sodium) QL Fragmin (dalteparin sodium,porcine) QL FORMULARY PRODUCTS Lovenox (enoxaparin sodium vial) QL DRUG NAME 15.3.2 OTHER ELECTROLYTES FORMULARY PRODUCTS TIER 1 DRUG NAME calcium acetate (Phoslo) 15.2.4 VITAMIN K potassium iodide/iodine (Lugol's) TIER 3 TIER 3 Mephyton (phytonadione tablet) PhosLo (calcium acetate) The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
39 16. DIAGNOSTICS & MISCELLANEOUS AGENTS
16.1 Miscellaneous Agents FORMULARY PRODUCTS DRUG NAME TIER 1 alendronate sodium (Fosamax) disulfiram (Antabuse) PA etidronate disodium (Didronel) levocarnitine (Carnitor) midodrine hcl (ProAmatine) pilocarpine hcl (Salagen) sodium polystyrene sulfonate (Kayexalate) sodium polystyrene sulfonate enema (Sodium Polystyrene Sulfonate) TIER 2 Actonel (risedronate sodium) TIER 3 Agrylin (anagrelide) BlueCross BlueShield of Tennessee Three Tier BlueCross BlueShield of Tennessee Antabuse (disulfiram) # PA Auryxia (ferric citrate) # PA Campral (acamprosate) # PA Didronel (etidronate disodium) Evoxac (cevimeline hcl) Exjade (deferasirox) SPRx Fosamax (alendronate sodium) 16 Fosrenol (lanthanum carbonate) Grastek (timothy grass pollen allergen extract) PA Ragwitek (short ragweed pollen allergen extract) PA Renvela (sevelamer carbonate) Salagen (pilocarpine hcl) Velphoro (sucroferric oxyhydroxide)
16.2 Smoking Deterrents FORMULARY PRODUCTS DRUG NAME TIER 1 bupropion hcl (Zyban) # nicotine transdermal (Nicotine) # TIER 2 Nicotrol (nicotine) # TIER 3 Chantix (varenicline tartrate) # Zyban (bupropion hcl) #
Diagnostics & Miscellaneous Agents 16.3 Anorexiants FORMULARY PRODUCTS DRUG NAME TIER 1 diethylpropion hcl (Tenuate) # PA phendimetrazine tartrate (Bontril PDM) # PA phentermine hcl (Fastin) # PA TIER 3 Adipex-P (phentermine hcl) # PA Belviq (loracaserin) # PA Bontril PDM (phendimetrazine tartrate) # PA Contrave (bupropion hcl/naltrexone hcl) # PA Didrex (benzphetamine) # PA Qsymia (phentermine/topiramate) # PA Suprenza ODT (phentermine hcl) # PA Xenical (orlistat) # PA
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
40 BlueCross BlueShield of Tennesseeof BlueShield BlueCrossTier Three
The Legend for symbols used in this formulary can be found in the LEGEND section at the front of the document.
41 BlueCross BlueShield of Tennessee Three Tier BlueCross BlueShield of Tennessee
INDEX
42 BlueCross BlueShield of Tennesseeof BlueShield BlueCrossTier Three
A Aldara ...... 22 A/T/S ...... 21 Aldomet ...... 18 abacavir sulfate ...... 6 Aldoril ...... 18 abacavir sulfate/lamivudine ...... 6 alendronate sodium ...... 31,40 abacavir sulfate/lamivudine/zidovudine ...... 6 alendronate sodium/cholecalciferol ...... 31 abacavir/dolutegravir/lamivudine ...... 6 Alesse ...... 32 abatacept ...... 30 alfuzosin hcl ...... 38 Abilify ...... 15 Alinia ...... 7 Abstral ...... 10 aliskiren ...... 19 acamprosate ...... 40 aliskiren hemifumarate ...... 19 Acanya ...... 21 aliskiren/amlodipine/hydrochlorothiazide ...... 19 acarbose ...... 25 aliskiren/hydrochlorothiazide ...... 19 Accolate ...... 37 alitretinoin ...... 22 Accu-Chek Avita ...... 26 Alkeran ...... 8 Accu-Chek Avita Plus ...... 26 Alkylating Agents ...... 8 Accu-Chek Compact ...... 26 All Brand-Name Prescription Prenatal Accuneb ...... 36 Vitamins with 1mg of Folic Acid ...... 39 Accupril ...... 18 All Insulin Syringes, Needles, and Alcohol Accuretic ...... 18 Wipes ...... 26 Ace Inhibitors ...... 18 allopurinol ...... 30 acebutolol hcl ...... 17 almotriptan malate ...... 12 Aceon ...... 18 Alocril ...... 35 acetaminophen/butalbital ...... 10,12 Alomide ...... 35 acetaminophen/caffeine/butalbital ...... 10,12 Alora ...... 32 acetazolamide ...... 13,34 alosetron hcl ...... 28 acetic acid ...... 23 Alphagan ...... 35 acetic acid/aluminum acetate ...... 23 Alphagan P ...... 35 acetic acid/hydrocortisone ...... 23 Alphagan P 0.15% ...... 35 acetylcysteine ...... 37 Alphanate ...... 17,39 Achromycin V ...... 5 Alphanate SD ...... 17,39 acitretin ...... 21 alprazolam ...... 15 aclidinum bromide ...... 37 alprostadil ...... 38 Aclovate ...... 20 Alrex ...... 35 acrivastine/pseudoephedrine ...... 36 Alsuma ...... 12 Actemra SQ ...... 30 Altabax ...... 21 Actigall ...... 27 Altace ...... 18 Actimmune ...... 29 Altoprev ...... 19 Actiq ...... 10 altretamine ...... 9 Activella ...... 31,33 aluminum chloride ...... 22 Actonel ...... 31,40 Alupent ...... 36 Actoplus Met ...... 25 Alvesco ...... 37 Actos ...... 25 amantadine hcl ...... 6,12
Acular ...... 34 Amaryl ...... 25 INDEX Acular LS ...... 34 Ambien ...... 14 acyclovir ...... 6 Ambien CR ...... 14 acyclovir cream ...... 21 ambrisentan ...... 37 acyclovir ointment ...... 21 amcinonide ...... 20 acyclovir tablets ...... 6 Amerge ...... 12 acyclovir/lidocaine ...... 21 Amicar ...... 16,39 Adalat ...... 18 amiloride hcl ...... 17 Adalat CC ...... 18 amiloride hcl/hydrochlorothiazide ...... 17 adalimumab ...... 30 aminocaproic acid ...... 16,39 adapalene ...... 21 Aminophylline ...... 36 adapalene/benzoyl peroxide ...... 21 aminophylline ...... 36 Adcirca ...... 37 aminosalicyclic acid ...... 7 Adderall ...... 15 amiodarone hcl ...... 16 Adderall XR ...... 15 Amitiza ...... 28 adefovir dipivoxil ...... 6 amitriptyline hcl ...... 14 Adempas ...... 37 amlodipine besylate ...... 18 Adipex-P ...... 40 amlodipine besylate/benazepril hcl ...... 18 Adjunctive Agents ...... 9 amlodipine besylate/olmesartan ...... 18 Adoxa ...... 5 amlodipine/atorvastatin ...... 19 Adrenal Hormones ...... 24 amlodipine/valsartan ...... 18 Adrenergic Antagonists & Related Drugs ...... 18 amlodipine/valsartan/hctz ...... 18 Adrenergics ...... 36 Amnesteem ...... 21 Advair Diskus ...... 37 amoxapine ...... 14 Advair HFA ...... 37 amoxicillin trihydrate ...... 5 Advate ...... 17,39 amoxicillin trihydrate/potassium Advate H ...... 17,39 clavulanate ...... 5 Advate L ...... 17,39 amoxicillin/clavulanate er ...... 5 Advate M ...... 17,39 Amoxil ...... 5 Advate UH ...... 17,39 amphetamine aspartate/amphetamine sulfate/ Advicor ...... 19 dextroamphetamine ...... 15 Aerospan ...... 37 ampicillin trihydrate ...... 5 Afrezza ...... 25 Ampyra ...... 13 Agents For Pheochromocytoma ...... 18 Amrix ...... 13,30 Aggrenox ...... 16,39 Amturnide ...... 19 Agrylin ...... 40 amylase/lipase/protease ...... 28 ahf, human/vwf, human ...... 16,39 Anafranil ...... 14 Alamast ...... 35 anagrelide ...... 40 Albalon ...... 34 anakinra ...... 30 albuterol nebulizers ...... 36 Analpram Advanced ...... 28 albuterol sulfate ...... 36 Analpram HC ...... 28 Albuterol Sulfate HFA ...... 36 Anamantle HC ...... 28 albuterol sulfate/ipratropium bromide ...... 37 Anaprox ...... 11,30 alclometasone dipropionate ...... 20 Anaprox DS ...... 11,30 Aldactazide ...... 17 anastrozole ...... 8 Aldactone ...... 17 Ancobon ...... 7 43 Androderm ...... 24 aspirin/caffeine/butalbital ...... 10,12 Androgel ...... 24 aspirin/dipyridamole ...... 16,39 Androgens ...... 24 Astagraf XL ...... 8 Androgens, Estrogens, Hormones & Related Astelin ...... 23 Drugs ...... 8 Astepro ...... 23 Android ...... 24 Atacand ...... 19 Androxy ...... 24 Atacand HCT ...... 19 Angiotensin II Receptor Blockers & Renin Atarax ...... 36 Inhibitors ...... 19 atazanavir sulfate ...... 6 Anorexiants ...... 40 atazanavir/cobicistat ...... 6 Anoro Ellipta ...... 37 Atelvia ...... 31 Ansaid ...... 11,30 atenolol ...... 17 Antabuse ...... 40 atenolol/chlorthalidone ...... 18 Antara ...... 19 Ativan ...... 15 Antara, Lofibra ...... 19 atomoxetine hcl ...... 15 Antiandrogens ...... 8 atorvastatin calcium ...... 19 Antiarrhythmic Agents ...... 16 atovaquone ...... 7 Antibiotics ...... 35 atovaquone/proguanil hcl ...... 7 Anticholinergics & Antispasmodics ...... 38 Atralin ...... 21 Anticoagulants ...... 16,39 Atripla ...... 6 Anticonvulsants ...... 13 atropine sulfate ...... 34 Antidepressant Agents ...... 14 Atrovent ...... 23,37 Antidiarrheals ...... 27 Atrovent HFA ...... 37 Antidiarrheals & Antispasmodics ...... 27 Aubagio ...... 13 Antiestrogens ...... 8 Augmentin ...... 5 Antifungal Agents ...... 7 Augmentin XR ...... 5 antihemophilic factor ix ...... 17,39 Auryxia ...... 40 antihemophilic factor ix, human ...... 17,39 Auvi-Q ...... 36 antihemophilic factor viii ...... 17,39 Avalide ...... 19 antihemophilic factor, human ...... 17,39 avanafil ...... 38 antihemophilic factor, recombinant ...... 17,39 Avandamet ...... 25 antihemophilic factor/vwf ...... 17,39 Avandaryl ...... 25 Antihistamine & Antiallergenic Agents ...... 36 Avandia ...... 25 Antihistamines ...... 36 Avapro ...... 19 Antihypertensive Therapy ...... 17 Avelox ...... 5 Antimalarials ...... 7 Avinza ...... 10 Antimetabolites ...... 8 Avita ...... 21 Antimycobacterials ...... 7 Avodart ...... 38 Antineoplastic & Immunosuppressant Drugs ...... 8 Avonex Administration Pack ...... 29 Antiparasitics ...... 7 Axert ...... 12 Antiparkinsonism Agents ...... 12 Axid ...... 27 Antiplatelet Drugs ...... 16,39 Axid Pulvule ...... 27 Antipsoriatic/Antiseborrheic ...... 21 Aygestin ...... 32 Antipsychotics ...... 15 AzaSite ...... 35 antipyrine/benzocaine/glycerin ...... 23 azathioprine ...... 8,30 Antispasmodics ...... 27 azelaic acid ...... 21 Antithyroid Agents ...... 24 azelastine hcl ...... 23,35 Antitussive Combinations ...... 36 azelastine hcl/fluticasone ...... 37 Antivertigo & Antiemetic Agents ...... 28 azelastine/fluticasone ...... 23 Antivertigo & Antiemetic Drugs ...... 12 Azelex ...... 21 Antivirals ...... 6,35 Azilect ...... 12 Anusol-HC ...... 28 azilsartan/chlorthalidone ...... 19 Anxiolytics ...... 15 azithromycin ...... 5,35 Anzemet ...... 12,28 Azopt ...... 34 Apexicon E ...... 20 Azor ...... 18 Apidra ...... 25 Azulfidine ...... 28,30 Apidra Solostar ...... 25 apixaban ...... 16,39 B Apokyn ...... 12 Bacitracin ...... 35 apomorphine hcl ...... 12 bacitracin ...... 35 apraclonidine hcl ...... 35 bacitracin/polymyxin b sulfate ...... 35 aprepitant ...... 12,28 baclofen ...... 13,30 Apresoline ...... 18 Bactrim ...... 5 Apriso ...... 28 Bactrim DS ...... 5 Aptiom ...... 13 Bactroban Cream ...... 21 Aptivus ...... 6 Bactroban Ointment ...... 21 Aralen Phosphate ...... 7 balsalazide disodium ...... 28 Aranesp ...... 29 Banzel ...... 13 Arava ...... 30 Baraclude ...... 6 Arcapta Neohaler ...... 36 Bebulin ...... 17,39 arformoterol ...... 36 beclomethasone ...... 23 Aricept ...... 13 beclomethasone dipropionate ...... 37 Aricept ODT ...... 13 Beconase AQ ...... 23,37 Arimidex ...... 8 bedaquiline ...... 7 aripiprazole ...... 15 Belviq ...... 40 Aristocort ...... 20 benazepril hcl ...... 18 Arixtra ...... 16,39 benazepril hcl/hydrochlorothiazide ...... 18 armodafinil ...... 15 BeneFIX ...... 17,39 Armour Thyroid ...... 24 Benicar ...... 19 Aromasin ...... 8 Benicar HCT ...... 19 Artane ...... 12 Benign Prostatic Hyperplasia (BPH) Therapy ...... 38 Arthrotec ...... 11 Bentyl ...... 27,38 Asacol ...... 28 Benzaclin ...... 21 Asacol HD ...... 28 Benzagel ...... 21 asenapine ...... 15 Benzamycin ...... 21 Asendin ...... 14 benzocaine ...... 23 Asmanex ...... 37 benzoyl peroxide ...... 21 Asmanex HFA ...... 37 benzphetamine ...... 40 Aspirin w/Codeine ...... 10 benztropine mesylate ...... 12 44 bepotastine ...... 35 Cafergot ...... 12 Bepreve ...... 35 Calan ...... 17 Beta Agonists Inhalers ...... 36 Calan SR ...... 17 Beta Agonists Oral ...... 36 calcipotriene ...... 21 Beta Blockers ...... 17 calcipotriene cream ...... 21 Beta-blockers ...... 34 calcipotriene solution ...... 21 Betagan ...... 34 calcitonin, salmon, synthetic ...... 24,31 betaine ...... 28 calcitriol ...... 24 betamethasone dipropionate ...... 20 calcium acetate ...... 39 betamethasone valerate ...... 20 Calcium Channel Blockers ...... 17 Betapace ...... 16 Calcium Channel Blockers/Dihydropyridines ...... 18 Betapace AF ...... 16 Calcium Channel Blockers/Non- Betaseron ...... 29 Dihydropyridines ...... 17 Betatrex ...... 20 Campral ...... 40 betaxolol hcl ...... 17,34 canagliflozin ...... 25 bethanechol chloride ...... 38 canagliflozin/metformin ...... 25 Betimol ...... 34 Canasa ...... 28 Betoptic ...... 34 candesartan cilexetil ...... 19 Betoptic S ...... 34 candesartan cilexetil/hydrochlorothiazide ...... 19 bexarotene ...... 9 candesartan/hydrochlorothiazide ...... 19 Beyaz ...... 32 capecitabine ...... 8 Biaxin ...... 5 Capoten ...... 18 Biaxin XL ...... 5 Capozide ...... 18 bicalutamide ...... 8 captopril ...... 18 BiDil ...... 18 captopril/hydrochlorothiazide ...... 18 Bile Acids ...... 27 Carac ...... 22 bimatoprost ...... 34 Carafate ...... 27 Biotechnology Drugs ...... 29 carbamazepine ...... 13 bisacodyl/sodium chloride/sodium Carbatrol ...... 13 bicarbonate/potassium chloride/ carbidopa/levodopa ...... 12 polyethylene glycol 3350 ...... 28 carbidopa/levodopa/entacapone ...... 12 bismuth subsalicylate ...... 27 Cardiac Glycosides ...... 16 bismuth/metronid/tetracycline ...... 27 Cardizem ...... 17 bisoprolol fumarate ...... 17 Cardizem CD ...... 17 bisoprolol fumarate/hydrochlorothiazide ...... 18 Cardizem LA ...... 17 Bleph-10 ...... 35 Cardizem SR ...... 17 Blephamide ...... 35 Cardura ...... 18,38 Blephamide S.O.P...... 35 carisoprodol ...... 13,30 Blocadren ...... 17 Carmol 40 ...... 22 Blood Glucose Monitoring Devices & Carnitor ...... 40 Supplies ...... 26 carteolol hcl ...... 34 blood sugar diagnostic strip ...... 26 carvedilol ...... 17 Boniva ...... 31 carvedilol phosphate ...... 17 Bontril PDM ...... 40 Casodex ...... 8 bosentan ...... 37 Cataflam ...... 11 Bowel Evacuants ...... 28 Catapres ...... 18 Breeze 2 ...... 26 Catapres-TTS ...... 18 Breo Ellipta ...... 37 Caverject ...... 38 Brethine ...... 33,36 Ceclor ...... 5 Brevicon ...... 32 Ceclor CR ...... 5 Brilinta ...... 16,39 Cedax ...... 5 brimonidine tartrate ...... 35 CeeNu ...... 8 brimonidine tartrate/timolol maleate ...... 34 cefaclor ...... 5 brinzolamide ...... 34 cefaclor extended release ...... 5 brinzolamide/brimonidine ...... 34 cefadroxil hydrate ...... 5 Bromday ...... 34 cefdinir ...... 5 Bromfed ...... 36 cefprozil ...... 5 Bromfed-DM ...... 36 ceftibuten ...... 5 Bromfed-PD ...... 36 Ceftin ...... 5 bromfenac ...... 34 cefuroxime axetil ...... 5 bromfenac sodium ...... 34 Cefzil ...... 5 bromocriptine mesylate ...... 12,25 Celebrex ...... 11,30 Brovana ...... 36 celecoxib ...... 11,30 budesonide ...... 23,28,37 Celexa ...... 14 budesonide/formoterol fumarate ...... 37 CellCept ...... 8 bumetanide ...... 17 Cenestin ...... 32 Bumex ...... 17 cephalexin monohydrate ...... 5 buprenophrine hcl/naloxone hcl, tablet ...... 11 Cephalosporins ...... 5 buprenorphine ...... 10 Cephulac ...... 28 buprenorphine hcl ...... 10 ceritinib ...... 9 buprenorphine hcl/naloxone hcl ...... 11 cetrorelix ...... 24 bupropion hcl ...... 14,40 cetrorelix acetate ...... 25,33 bupropion hcl/naltrexone hcl ...... 40 Cetrotide ...... 24,25,33 Burn Therapy ...... 21 cevimeline hcl ...... 40 Buspar ...... 15 Chantix ...... 40 buspirone hcl ...... 15 chloral hydrate ...... 14 busulfan ...... 8 chlorambucil ...... 8 butalbital/apap/caffeine ...... 10 chlordiazepoxide hcl ...... 15 butorphanol tartrate aerosol, spray ...... 11 chlorhexidine gluconate ...... 23 Butrans ...... 10 chloroquine phosphate ...... 7 Butyrophenones ...... 15 chlorothiazide ...... 17 Bydureon ...... 25 chlorpromazine hcl ...... 15 Byetta ...... 25 chlorpropamide ...... 25 Bystolic ...... 17 chlorthalidone ...... 17 chlorzoxazone ...... 13,30 cholestyramine/aspartame ...... 19 C cholestyramine/sucrose ...... 19 cabergoline ...... 24 choline salicylate/magnesium salicylate ...... 30 Caduet ...... 19 Cholinergic Stimulants ...... 38 45 Cholinesterase Inhibitor Miotics ...... 34 conjugated estrogens/bazedoxifene ...... 33 Chronulac ...... 28 Contour ...... 26 Cialis ...... 38 Contrave ...... 40 ciclesonide ...... 23,37 Copaxone ...... 13,29 Ciclodan Kit ...... 21 Copaxone 40 mg/mL ...... 29 ciclopirox ...... 21 Copaxone 40mg/mL ...... 13 ciclopirox kit ...... 21 Copegus ...... 6 cilostazol ...... 16,39 Cordarone ...... 16 Ciloxan ...... 35 Cordran ...... 20 Ciloxan Drops ...... 35 Cordran Lotion ...... 20 cimetidine tablet 300mg, 400mg and 800mg ...... 27 Coreg ...... 17 cinacalcet hcl ...... 24 Coreg CR ...... 17 Cipro ...... 5 Corgard ...... 17 Cipro HC ...... 23 Corifact ...... 17,39 Cipro XR ...... 5 Cortef ...... 24,30,36 Ciprodex ...... 23 Cortenema ...... 28 ciprofloxacin er ...... 5 Corticosteroids ...... 30,36 ciprofloxacin hcl ...... 5 Cortifoam ...... 28 ciprofloxacin hcl drops ...... 35 cortisone acetate ...... 24,30,36 ciprofloxacin hcl ointment ...... 35 Cortisporin ...... 23,35 ciprofloxacin hcl/dexamethasone ...... 23 Cortone Acetate ...... 24,30,36 ciprofloxacin/hydrocortisone ...... 23 Cosopt ...... 34 citalopram hydrobromide ...... 14 Cough & Cold Therapy ...... 36 Claravis ...... 21 Coumadin ...... 16,39 Clarinex ...... 36 Covera-HS ...... 17 Clarinex-D 24 Hour ...... 36 Cozaar ...... 19 clarithromycin ...... 5 Creon ...... 28 clarithromycin er ...... 5 Crestor ...... 19 clemastine fumarate 2.68mg ...... 36 Crinone ...... 32 Cleocin ...... 7 Crixivan ...... 6 Cleocin HCl ...... 7 crofelemer ...... 27 Cleocin T ...... 21 cromolyn sodium ...... 28,35 clidinium bromide/chlordiazepoxide ...... 27 cromolyn sodium ampul for nebulization ...... 37 Climara ...... 32 crotamiton ...... 22 Climara Pro ...... 33 Cutivate ...... 20 clindamycin hcl ...... 7 cyanocobalamin ...... 39 clindamycin phosphate ...... 21,33 Cyclessa ...... 32 clindamycin phosphate/benzoyl peroxide ...... 21 cyclobenzaprine hcl ...... 13,30 clindamycin phosphate/benzoyl peroxide/ Cyclocort ...... 20 hyaluronate sodium ...... 21 Cyclogyl ...... 34 Clindesse ...... 33 cyclopentolate hcl ...... 34 Clinoril ...... 11,30 Cyclophosphamide ...... 8 clobazam ...... 13 cyclophosphamide ...... 8 clobetasol propionate ...... 20 Cycloplegic Mydriatics ...... 34 clobetasol propionate/emollient ...... 20 Cycloset ...... 25 Clomid ...... 24,33 Cyclosporine ...... 8 clomiphene citrate ...... 24,33 cyclosporine ...... 8,35 clomipramine hcl ...... 14 cyclosporine, modified ...... 8 clonazepam ...... 13 Cymbalta ...... 14 clonidine ...... 15 cyproheptadine hcl ...... 36 clonidine hcl ...... 18 Cystadane ...... 28 clopidogrel bisulfate ...... 16,39 Cytomel ...... 24 clorazepate dipotassium ...... 15 Cytotec ...... 27 clotrimazole ...... 7 Cytovene ...... 6 clotrimazole/betamethasone dipropionate ...... 21 clozapine ...... 15 D Clozaril ...... 15 D.H.E.45 ...... 12 Coagulation Therapy ...... 16,39 dabigatran etexilate mesylate ...... 16,39 cobicistat ...... 6 dabrafenib ...... 9 codeine phosphate/acetaminophen ...... 10 dalfampridine ...... 13 codeine phosphate/acetaminophen/caffeine/ Daliresp ...... 37 butalbital ...... 10 Dalmane ...... 14 codeine phosphate/aspirin ...... 10 dalteparin sodium,porcine ...... 16,39 codeine phosphate/aspirin/caffeine/ danazol ...... 24 butalbital ...... 10 Danocrine ...... 24 Codeine Sulfate ...... 10 Dantrium ...... 13,30 codeine sulfate ...... 10 dantrolene sodium ...... 13,30 Cogentin ...... 12 dapagliflozin ...... 25 Colazal ...... 28 dapagliflozin/metformin ...... 25 colchicine ...... 30 Dapsone ...... 7 Colcrys ...... 30 dapsone ...... 7 colesevelam hcl ...... 19 Daraprim ...... 7 Colestid ...... 19 darbepoetin alfa in polysorbate ...... 29 colestipol ...... 19 darifenacin hydrobromide ...... 13,30,38 collagenase clostridium hist...... 21 darunavir ethanolate ...... 6 Colyte ...... 28 darunavir/cobicistat ...... 6 Combigan ...... 34 dasatinib ...... 9 Combination Anticholinergics ...... 27 Daypro ...... 11,30 Combination Narcotic/Analgesics ...... 10 Daytrana ...... 15 Combipatch ...... 33 DDAVP ...... 24 Combivent Respimat ...... 37 Decadron ...... 24,30,35,36 Combivir ...... 6 Deconamine SR ...... 36 Combunox ...... 10 Decongestant/Antihistamines ...... 36 Compazine ...... 12,28 deferasirox ...... 24,40 Complera ...... 6 Delatestryl ...... 24 Comtan ...... 12 delavirdine mesylate ...... 6 Concerta ...... 15 Deltasone ...... 24,30,36 Condylox ...... 22 Delzicol ...... 28 46 Demadex ...... 17 Dolobid ...... 11,30 Demerol ...... 10 Dolophine HCl ...... 10 Demser ...... 18 dolutegravir ...... 6 Denavir ...... 21 Domeboro ...... 23 Depakene ...... 13 donepezil hcl ...... 13 Depakote ...... 13 Donnatal ...... 27 Depakote ER ...... 13 dornase alfa ...... 37 Depakote Sprinkle ...... 13 Doryx ...... 5 Depo-Provera ...... 9,32 dorzolamide hcl ...... 34 Depo-Testosterone ...... 24 dorzolamide/timolol ...... 34 Derma-Smoothe FS ...... 20 Dostinex ...... 24 Dermasorb HC ...... 20 Dovonex ...... 21 Dermasorb TA ...... 20 Dovonex Solution ...... 21 DermOtic ...... 23 doxazosin mesylate ...... 18,38 desipramine hcl ...... 14 doxepin hcl ...... 14 desloratadine ...... 36 doxepin hydrochloride cream ...... 22 desmopressin acetate ...... 24 doxercalciferol ...... 24 Desogen ...... 32 doxycycline hyclate ...... 5 desogestrel-ethinyl estradiol ...... 32 doxycycline hyclate capsule ...... 5 desogestrel-ethinyl estradiol/ethinyl doxycycline hyclate tablet ...... 5 estradiol ...... 32 doxycycline monohydrate ...... 5 desonide ...... 20 doxycycline monohydrate suspension ...... 5 DesOwen ...... 20 dronedarone hcl ...... 16 desoximetasone ...... 20 drospirenone/ethinyl estradiol/ Desoxyn ...... 15 levomefolate calcium ...... 32 Despec ...... 36 Droxia ...... 9 desvenlafaxine succinate ...... 14 Drugs To Treat Infertility/IVF Agents ...... 33 Desyrel ...... 14 Drysol ...... 22 Detrol ...... 13,30,38 Duac ...... 21 Detrol LA ...... 13,30,38 Duavee ...... 33 dexamethasone ...... 24,30,36 Duetact ...... 25 dexamethasone sodium phosphate ...... 35 Dulera ...... 37 Dexedrine ...... 15 duloxetine ...... 14 dexmethylphenidate ...... 15 duloxetine hcl ...... 14 dextroamphetamine sulfate ...... 15 Duoneb ...... 37 dextromethorphan hbr/pseudoephedrine hcl/ Duopa ...... 12 brompheniramine ...... 36 Duragesic ...... 10 dextromethorphan hbr/quinidine ...... 13 Duratuss DM ...... 36 DiaBeta ...... 25 Duricef ...... 5 Diabetes Therapy ...... 25 dutasteride ...... 38 Diabinese ...... 25 dutasteride/tamsulosin hcl ...... 38 Diamox ...... 13,34 Dyazide ...... 17 Diamox Sequels ...... 34 Dymista ...... 23,37 Diaphragms And Other Non-Oral Dynacin ...... 5 Contraceptives ...... 33 DynaCirc ...... 18 Diastat ...... 13 DynaCirc CR ...... 18 Diastat AcuDial ...... 13 Dynapen ...... 5 diazepam ...... 13,15,30 Dyrenium ...... 17 Dibenzyline ...... 18 diclofenac potassium ...... 11 E diclofenac sodium ...... 11,34 E-Mycin ...... 5 diclofenac sodium, extended-release ...... 11 E.E.S...... 5 diclofenac sodium/misoprostol ...... 11 EC-Naprosyn ...... 11 dicloxacillin sodium ...... 5 echothiophate iodide ...... 34 dicyclomine hcl ...... 27,38 econazole nitrate ...... 21 didanosine ...... 6 Edarbi ...... 19 Didrex ...... 40 Edarbyclor ...... 19 Didronel ...... 40 Edex ...... 38 diethylpropion hcl ...... 40 Edurant ...... 6 Differin ...... 21 efavirenz ...... 6 diflorasone diacetate ...... 20 efavirenz/ emtricitab/ tenofovir ...... 6 Diflucan ...... 7,33 Effexor ...... 14 diflunisal ...... 11,30 Effexor XR ...... 14 Digestive Enzymes ...... 28 Effient ...... 16,39 digoxin ...... 16 Efudex ...... 22 dihydroergotamine mesylate ...... 12 Elavil ...... 14 Dilantin ...... 13 Eldepryl ...... 12 Dilantin Infatabs ...... 13 Eldoquin Forte ...... 22 Dilaudid ...... 10 Electrolytes ...... 39 diltiazem hcl ...... 17 Elestat ...... 35 dimethyl fumarate ...... 13 Elestrin ...... 32 Diovan ...... 19 eletriptan hydrobromide ...... 12 Diovan HCT ...... 19 Elidel ...... 22 Dipentum ...... 28 Elimite ...... 22 diphenoxylate hcl/atropine sulfate ...... 27 Eliquis ...... 16,39 Diprolene ...... 20 Elixophyllin ...... 36 Diprolene AF ...... 20 Elmiron ...... 38 Diprosone ...... 20 Elocon ...... 20 dipyridamole ...... 16,39 eltrombopag olamine ...... 16,39 Direct Acting Miotics ...... 34 elvitegravir ...... 6 disopyramide phosphate ...... 16 elvitegravir/cobicistat/emtricitabine/ disulfiram ...... 40 tenofovir disoproxil fumarate ...... 6 Ditropan ...... 13,30,38 Emadine ...... 35 Ditropan XL ...... 13,30,38 Emcyt ...... 9 Diuril ...... 17 emedastine difumarate ...... 35 divalproex sodium ...... 13 Emend ...... 12,28 Divigel ...... 32 Emla Cream ...... 20 dolasetron mesylate tablet ...... 12,28 emollient combination ...... 22 47 Emsam ...... 14 Estrostep Fe ...... 32 emtrecitabine/rilpivirine/tenofovir eszopiclone ...... 14 disoproxil fumarate ...... 6 etanercept ...... 30 emtricitabine ...... 6 ethambutol hcl ...... 7 emtricitabine/tenofovir disoproxil ethinyl estradiol/drospirenone ...... 32 fumarate ...... 6 ethinyl estradiol/norethindrone acetate ...... 32 Emtriva ...... 6 ethosuximide ...... 13 Enablex ...... 13,30,38 etidronate disodium ...... 40 enalapril maleate ...... 18 etodolac ...... 11,30 enalapril maleate/hydrochlorothiazide ...... 18 etonogestrel/ethinyl estradiol ...... 33 Enbrel ...... 30 etoposide ...... 9 Enduron ...... 17 etravirine ...... 6 enfuvirtide ...... 6 Eulexin ...... 8 Enjuvia ...... 32 Eurax ...... 22 enoxaparin sodium disposable syringe ...... 16,39 Evamist ...... 32 enoxaparin sodium vial ...... 16,39 Evista ...... 31 entacapone ...... 12 Evotaz ...... 6 entecavir ...... 6 Evoxac ...... 40 Entocort EC ...... 28 Exelon ...... 13 enzalutamide ...... 8 exemestane ...... 8 Epaned ...... 18 exenatide ...... 25 Epiduo ...... 21 exenatide microspheres ...... 25 epinastine hcl ...... 35 Exforge ...... 18 epinephrine ...... 36 Exforge HCT ...... 18 EpiPen ...... 36 Exjade ...... 24,40 EpiPen Jr...... 36 Expectorant Combinations ...... 36 Epivir ...... 6 Extavia ...... 29 Epivir HBV ...... 6 Extina ...... 21 Epivir Solution ...... 6 ezetimibe ...... 19 Epivir Tablet ...... 6 ezetimibe/atorvastatin ...... 19 eplerenone ...... 17 ezetimibe/simvastatin ...... 19 epoetin alfa ...... 9,29 ezogabine ...... 13 Epogen ...... 29 eprosartan mesylate ...... 19 F eprosartan mesylate/hydrochlorothiazide ...... 19 Fabior ...... 21 Epzicom ...... 6 factor ix complex ...... 17,39 Equetro ...... 13 factor ix, recombinant ...... 17,39 ergocalciferol capsule ...... 39 factor viia, recombinant ...... 16,39 ergotamine tartrate/caffeine ...... 12 factor viii ...... 17,39 erlotinib hcl ...... 9 factor xiii a-subunit, recombinant ...... 17,39 Ery-Tab ...... 5 famciclovir ...... 6 Erycette ...... 21 famotidine ...... 27 Erythrocin Stearate ...... 5 famotidine 40mg tablet ...... 27 Erythroid Stimulants ...... 29 famotidine suspension ...... 27 erythromycin ...... 5 Famvir ...... 6 erythromycin base ...... 5,35 Fanapt ...... 15 erythromycin base/benzoyl peroxide ...... 21 Fareston ...... 8 erythromycin base/ethyl alcohol ...... 21 Farxiga ...... 25 erythromycin ethylsuccinate ...... 5 Farydak ...... 9 erythromycin ethylsuccinate/sulfisoxazole Fastin ...... 40 acetyl ...... 5 Fazaclo ...... 15 erythromycin stearate ...... 5 febuxostat ...... 30 Erythromycins & Other Macrolides ...... 5 felbamate ...... 13 escitalopram oxalate ...... 14 Felbatol ...... 13 Esgic ...... 10 Feldene ...... 11,30 Esgic-Plus ...... 10 felodipine extended-release ...... 18 Eskalith ...... 15 Femara ...... 8 eslicarbazepine acetate ...... 13 Femcon Fe ...... 32 esomeprazole magnesium trihydrate ...... 27 Femhrt ...... 33 estazolam ...... 14 Femring ...... 32 Estrace ...... 32 Femtrace ...... 32 Estraderm ...... 32 fenofibrate ...... 19 Estradiol ...... 32 fenofibrate, micronized ...... 19 estradiol ...... 32 fenofibrate, nanocrystallized ...... 19 estradiol acetate ...... 32 fenofibric acid ...... 19 estradiol patch ...... 32 Fenoglide ...... 19 estradiol patch, transdermal ...... 31 fenoprofen ...... 11 estradiol tablet ...... 32 fentanyl ...... 10 estradiol topical gel ...... 32 fentanyl citrate ...... 10 estradiol valerate/dienogest ...... 32 Fentora ...... 10 estradiol, levonorgestrel transdermal ...... 33 Feosol ...... 39 estradiol/norethindrone acetate ...... 31,33 ferric citrate ...... 40 estradiol/norgestimate ...... 33 ferrous sulfate drops ...... 39 estramustine phosphate sodium ...... 9 Fibricor ...... 19 Estrasorb ...... 32 filgrastim ...... 9,29 Estratest ...... 33 Finacea ...... 21 Estratest H.S...... 33 finasteride ...... 38 Estring ...... 32 fingolimod hcl ...... 13 estrogen ...... 32 Fioricet ...... 10,12 Estrogen Combinations ...... 33 Fioricet w/Codeine ...... 10 Estrogens ...... 32 Fiorinal ...... 10,12 Estrogens & Progestins ...... 32 Fiorinal w/Codeine ...... 10 estrogens, conjugated synthetic b ...... 32 First Generation Cephalosporins ...... 5 estrogens, conjugated tablet ...... 31,32 Flagyl ...... 7 estrogens, conjugated, synthetic a ...... 32 Flagyl ER ...... 7 estrogens, conjugated/medroxyprogesterone acet ...... 33 Flarex ...... 35 estrogens, esterified/methyltestosterone ...... 33 flavoxate hcl ...... 38 estropipate ...... 32 flecainide acetate ...... 16 48 Flexeril ...... 13,30 glipizide/metformin hcl ...... 25 Flomax ...... 38 GlucaGen ...... 26 Flonase ...... 23,37 Glucagon ...... 26 Florinef Acetate ...... 24 glucagon, human recombinant ...... 26 Flovent Diskus ...... 37 Glucophage ...... 25 Flovent HFA ...... 37 Glucophage XR ...... 25 Floxin ...... 5,23 Glucose Elevating Agents ...... 26 fluconazole ...... 7,33 Glucotrol ...... 25 flucytosine ...... 7 Glucotrol XL ...... 25 fludrocortisone acetate ...... 24 Glucotrol XR ...... 25 Flumadine ...... 6 Glucovance ...... 25 flunisolide ...... 23,37 Glumetza ...... 25 fluocinolone acetonide ...... 20 glyburide ...... 25 fluocinolone acetonide oil ...... 23 glyburide, micronized ...... 25 fluocinonide ...... 20 glyburide/metformin hcl ...... 25 fluocinonide/emollient ...... 20 Glycate ...... 27 fluoride ion/iron/vitamins a,c,and d ...... 39 glycopyrrolate ...... 27 fluoride ion/multivitamins ...... 39 Glynase ...... 25 fluoride ion/multivitamins w-iron ...... 39 gold sodium thiomalate ...... 30 fluoride ion/vitamins a,c,and d ...... 39 golimumab ...... 30 fluorometholone ...... 35 GoLYTELY ...... 28 fluorometholone acetate ...... 35 Gonadotropin & Related Agents ...... 25 Fluoroquinolones ...... 5 gonadotropin, chorionic, human ...... 25,33 fluorouracil ...... 22 Gonal-F RFF ...... 24 fluoxetine hcl ...... 14 goserelin acetate ...... 9 fluoxymesterone ...... 24 Gout Therapy ...... 30 fluphenazine hcl ...... 15 granisetron hcl ...... 12,28 flurandrenolide tape, medicated ...... 20 Granulex ...... 21 flurazepam hcl ...... 14 Grastek ...... 40 flurbiprofen ...... 11,30 Grifulvin V Tablet ...... 7 flurbiprofen sodium ...... 34 Gris-Peg ...... 7 flutamide ...... 8 griseofulvin ultramicrosize ...... 7 fluticasone furoate ...... 23,37 Growth Hormones ...... 29 fluticasone furoate/vilanterol ...... 37 guaifenesin ...... 36 fluticasone propionate ...... 20,23,37 guaifenesin/codeine phosphate ...... 36 fluticasone propionate/salmeterol guaifenesin/dextromethorphan hbr ...... 36 xinafoate ...... 37 guaifenesin/phenylephrine hcl ...... 36 fluvastatin ...... 19 guanfacine hcl ...... 15,18 fluvoxamine maleate ...... 14 fluvoxamine maleate, extended release ...... 14 FML ...... 35 H Focalin ...... 15 H2 Antagonists ...... 27 Focalin XR ...... 15 Halcion ...... 14 folic acid ...... 39 Haldol ...... 15 Follistim AQ ...... 24,33 Halflytely-Bisacodyl ...... 28 follitropin alfa ...... 24 halobetasol propionate ...... 20 follitropin beta, recombinant ...... 24,33 haloperidol ...... 15 Folvite ...... 39 haloperidol lactate concentrate, oral ...... 15 fondaparinux sodium ...... 16,39 Harvoni ...... 6 Foradil ...... 36 hcg alpha, recombinant ...... 24,33 formoterol fumarate ...... 36 Headache Therapy ...... 12 Forteo ...... 31 Hectorol ...... 24 Fosamax ...... 31,40 Helidac ...... 27 Fosamax Plus D ...... 31 Helixate FS ...... 17,39 fosamprenavir calcium ...... 6 Hemofil-M ...... 17,39 fosinopril sodium ...... 18 Hemostatics ...... 16,39 fosinopril sodium/hydrochlorothiazide ...... 18 Heparin ...... 16,39 Fosrenol ...... 40 Hepsera ...... 6 Fragmin ...... 16,39 Hexalen ...... 9 Frova ...... 12 Hiprex ...... 6 frovatriptan succinate ...... 12 HIV/AIDS Therapy ...... 6 Fulyzaq ...... 27 homatropine hbr ...... 34 Furadantin ...... 6 Horizant ...... 13 furosemide ...... 17 Hormones ...... 8 Fuzeon ...... 6 Humalog ...... 25 Fycompa ...... 13 Humalog Mix 50/50 ...... 25 Humalog Mix 75/25 ...... 25 Humate-P ...... 16,39 G Humatin ...... 7 gabapentin ...... 13 Humira ...... 30 Gabitril ...... 13 Humulin 70/30 Kwikpen ...... 25 galantamine hydrobromide ...... 13 Humulin 70/30 OTC ...... 25 ganciclovir ...... 6 Humulin N Kwikpen ...... 25 Ganirelix ...... 24,25 Humulin N OTC ...... 25 ganirelix acetate ...... 24,25 Humulin R OTC ...... 25 Garamycin ...... 21,35 Hycodan ...... 36 Gastrocrom ...... 28 hydralazine hcl ...... 18 gefitinib ...... 9 Hydrea ...... 9 Gelnique ...... 13,30,38 hydrochlorothiazide ...... 17 gemfibrozil ...... 19 hydrocodone bit-ibuprofen ...... 10 Gengraf ...... 8 hydrocodone bit/acetaminophen ...... 10 gentamicin sulfate ...... 21,35 hydrocodone bit/homatropine ...... 36 gentamicin/prednisolone acetate ...... 35 hydrocodone w/acetaminophen ...... 10 Geodon ...... 15 hydrocortisone ...... 20,24,28,30,36 Gilenya ...... 13 hydrocortisone 2.5% ...... 20 glatiramer acetate ...... 13,29 hydrocortisone acetate ...... 28 Gleevec ...... 9 hydrocortisone acetate/lidocaine hcl ...... 28 glimepiride ...... 25 hydrocortisone acetate/pramoxine hcl ...... 21,28 glipizide ...... 25 hydrocortisone butyrate ...... 20 49 hydrocortisone valerate ...... 20 isometheptene mucate/acetaminophen/ HydroDIURIL ...... 17 dichloralphenazone ...... 12 hydromorphone hcl ...... 10 Isoniazid ...... 7 hydromorphone hcl liquid ...... 10 isoniazid ...... 7 hydroquinone ...... 22 Isoptin S.R...... 17 hydroxychloroquine sulfate ...... 7,30 Isopto Atropine ...... 34 hydroxyurea ...... 9 Isopto Carpine ...... 34 hydroxyzine hcl ...... 36 Isopto Homatropine ...... 34 hydroxyzine pamoate ...... 36 Isopto Hyoscine ...... 34 Hygroton ...... 17 Isordil ...... 16 hyoscyamine sulfate ...... 27,38 isosorbide dinitrate ...... 16 Hypnotic Agents ...... 14 isosorbide dinitrate/hydralazine hcl ...... 18 Hytone ...... 20 isosorbide mononitrate ...... 16 Hytrin ...... 18,38 isoxsuprine hcl ...... 33 Hyzaar ...... 19 isradipine ...... 18 Istalol ...... 34 itraconazole ...... 7 I itraconazole solution, oral ...... 7 ibandronate sodium ...... 31 Ibrance ...... 9 ibrutinib ...... 9 J ibuprofen ...... 11,30 Jalyn ...... 38 Iclusig ...... 9 Janumet ...... 25 idelalisibt ...... 9 Janumet XR ...... 25 iloperidone ...... 15 Januvia ...... 25 iloprost ...... 37 Jentadueto ...... 25 Ilotycin ...... 35 Juvisync ...... 25 imatinib mesylate ...... 9 Imbruvica ...... 9 Imdur ...... 16 K imipramine hcl ...... 14 K-Dur ...... 39 imipramine pamoate ...... 14 K-Lor ...... 39 imiquimod ...... 22 K-Lyte ...... 39 Imitrex ...... 12 K-Tab ...... 39 Immunosuppressant Drugs ...... 8 Kadian ...... 10 Imuran ...... 8,30 Kaletra ...... 6 Incivek ...... 6 Kapvay ...... 15 indacaterol ...... 36 Kay Ciel ...... 39 indapamide ...... 17 Kayexalate ...... 40 Inderal ...... 17 Keflex ...... 5 Inderal LA ...... 17 Kenalog ...... 20 Inderide ...... 18 Kenalog in Orabase ...... 23 Keppra ...... 13 indinavir sulfate ...... 6 Indocin ...... 11,30 Keppra XR ...... 13 Kerlone ...... 17 Indocin SR ...... 11,30 Ketek ...... 7 ...... 11,30 indomethacin ketoconazole ...... 7,21 Infergen ...... 29 ...... 11,30 Inflamase Forte ...... 35 ketoprofen ketorolac ...... 30 Inhaled Corticosteroids ...... 37 ketorolac tromethamine ...... 11,30,34 Innopran XL ...... 17 Kineret ...... 30 Inspra ...... 17 Klaron ...... 21 insulin ...... 25 Klonopin ...... 13 insulin aspart ...... 25 Klor-Con 25mEq ...... 39 insulin aspart protamine human/insulin Koate-DVI ...... 17,39 aspart ...... 25 Kogenate FS ...... 17,39 insulin detemir ...... 25 Kristalose ...... 28 insulin detemir pens ...... 25 Kytril ...... 12,28 insulin glargine, human recombinant analog ...... 25 insulin glulisine ...... 25 insulin lispro ...... 25 L insulin npl/insulin lispro ...... 25 labetalol hcl ...... 17 Insulin Syringes/Miscellaneous Durable lacosamide ...... 13 Medical Equipment ...... 26 lactulose ...... 28 Insulin Therapy ...... 25 Lamictal ...... 13 Intal ...... 37 Lamictal XR ...... 13 Intelence ...... 6 Lamisil ...... 7 interferon alfa-2b,recombinant vial ...... 29 Lamisil Tablet ...... 7 interferon alfacon-1 ...... 29 lamivudine ...... 6 interferon beta-1a/albumin human ...... 29 lamivudine/zidovudine ...... 6 interferon beta-1b ...... 29 lamotrigine ...... 13 interferon gamma-1b,recombinant ...... 29 Lanoxin ...... 16 Interferons ...... 29 lansoprazole 30mg ...... 27 Interleukins ...... 29 lansoprazole/amoxicillin/clarithromycin ...... 27 Intranasal Steroids ...... 23,37 lanthanum carbonate ...... 40 Intron A ...... 29 Lantus ...... 25 Intuniv ...... 15 Lantus Solostar ...... 25 Invega ...... 15 lapatinib ditosylate ...... 9 Invirase ...... 6 Lariam ...... 7 Invokamet ...... 25 Lasix ...... 17 Invokana ...... 25 latanoprost ...... 34 Iopidine ...... 35 Latuda ...... 15 ipratropium bromide ...... 23,37 ledipasvir/sofosbuvir ...... 30 ipratropium bromide solution, non-oral ...... 37 leflunomide ...... 30 ipratropium/albuterol sulfate ...... 37 lenalidomide ...... 9 irbesartan ...... 19 lenvatinib ...... 9 irbesartan/hydrochlorothiazide ...... 19 Lenvima ...... 9 Iressa ...... 9 Lescol ...... 19 Isentress ...... 6 Lescol XL ...... 19 ISMO ...... 16 Letairis ...... 37 50 letrozole ...... 8 Lotensin HCT ...... 18 Leucovorin Calcium ...... 9 loteprednol etabonate ...... 35 leucovorin calcium ...... 9 Lotrel ...... 18 Leukeran ...... 8 Lotrisone ...... 21 Leukine ...... 9,29 Lotronex ...... 28 levalbuterol hcl ...... 36 Loutrex ...... 22 levalbuterol tartrate ...... 36 lovastatin ...... 19 Levaquin ...... 5 Lovenox ...... 16,39 Levatol ...... 17 loxapine succinate ...... 15 Levbid ...... 27,38 Loxitane ...... 15 Levemir Pens ...... 25 Lozol ...... 17 Levemir Vials ...... 25 lubiprostone ...... 28 levetiracetam ...... 13 Ludiomil ...... 14 Levitra ...... 38 Lugol's ...... 39 levobunolol hcl ...... 34 Lumigan ...... 34 levocarnitine ...... 40 Lunesta ...... 14 levocetirizine di-hcl ...... 36 lurasidone ...... 15 levofloxacin ...... 5,35 Luride ...... 39 levonorgestrel-ethinyl estradiol ...... 32 Lustra ...... 22 levonorgestrel-ethinyl estradiol/ethinyl lutropin alfa ...... 24 estradiol ...... 32 Luveris ...... 24 Levothroid ...... 24 Luvox ...... 14 levothyroxine sodium ...... 24 Luvox CR ...... 14 Levoxyl ...... 24 Luxiq ...... 20 Levsin ...... 27,38 Lybrel ...... 32 Levsin/SL ...... 27,38 Lynparza ...... 9 Lexapro ...... 14 Lyrica ...... 13 Lexiva ...... 6 Lysodren ...... 9 Lialda ...... 28 Lysteda ...... 33 Librax ...... 27 Librium ...... 15 M Lida Mantle ...... 20,23 macitentan ...... 37 Lidex ...... 20 Macrobid ...... 6 Lidex-E ...... 20 Macrodantin ...... 6 lidocaine ...... 20 Malarone ...... 7 lidocaine hcl ...... 20,23 malathion ...... 22 lidocaine-prilocaine ...... 20 Mandelamine ...... 6 Lidoderm ...... 20 MAO Inhibitors ...... 14 Lidovir ...... 21 maprotiline hcl ...... 14 linaclotide ...... 28 maraviroc ...... 6 linagliptin ...... 25 Matulane ...... 9 linagliptin/metformin hcl ...... 25 Mavik ...... 18 linezolid ...... 7 Maxalt ...... 12 Linzess ...... 28 Maxalt MLT ...... 12 Lioresal ...... 13,30 Maxitrol ...... 35 liothyronine sodium ...... 24 Maxzide ...... 17 liotrix ...... 24 Mebaral ...... 13 Lipid/Cholesterol Lowering Agents ...... 19 mebendazole ...... 7 Lipitor ...... 19 mechlorethamine ...... 9 Lipofen ...... 19 Meclofenamate Sodium ...... 11,30 Liptruzet ...... 19 meclofenamate sodium ...... 11,30 Liquibid ...... 36 Medrol ...... 24,30,36 liraglutide ...... 25 medroxyprogesterone acetate ...... 9,32 lisdexamfetamine dimesylate ...... 15 mefenamic acid ...... 11 lisinopril ...... 18 mefloquine hcl ...... 7 lisinopril/hydrochlorothiazide ...... 18 Megace ...... 8 lithium carbonate ...... 15 megestrol acetate ...... 8 Lithium Citrate ...... 15 Mekinist ...... 9 lithium citrate ...... 15 Mellaril ...... 15 Lithobid ...... 15 meloxicam ...... 11,30 Livalo ...... 19 melphalan ...... 8 Lo Loestrin Fe ...... 32 memantine hcl ...... 13 Lo Minastrin Fe ...... 32 Menest ...... 32 Lo/Ovral ...... 32 Menopur ...... 24 Locoid ...... 20 Menostar ...... 32 Lodine ...... 11,30 menotropins ...... 24,33 Lodine XL ...... 11,30 meperidine hcl ...... 10 lodoxamide ...... 35 mephobarbital ...... 13 Loestrin ...... 32 Mephyton ...... 16,39 Loestrin Fe ...... 32 Mepron ...... 7 Lofibra ...... 19 mercaptopurine ...... 8 Lomotil ...... 27 mesalamine ...... 28 lomustine ...... 8 Mestinon ...... 14 Long Acting Nitrates ...... 16 Metadate CD ...... 15 Loniten ...... 18 Metadate ER ...... 15 Lopid ...... 19 Metaglip ...... 25 Lopreeza ...... 33 metaproterenol sulfate ...... 36 Lopressor ...... 17 metaxalone ...... 13,30 Lopressor HCT ...... 18 metformin ...... 25 Loprox ...... 21 metformin hcl ...... 25 loracaserin ...... 40 methadone hcl ...... 10 lorazepam ...... 15 methamphetamine hcl ...... 15 Lorcet ...... 10 methazolamide ...... 34 Lortab ...... 10 methenamine hippurate ...... 6 losartan potassium ...... 19 methenamine mandelate ...... 6 losartan potassium/hydrochlorothiazide ...... 19 Methergine ...... 32 LoSeasonique ...... 32 methimazole ...... 24 Lotemax ...... 35 Methitest ...... 24 Lotensin ...... 18 methocarbamol ...... 13,30 51 methotrexate sodium ...... 8,30 mometasone furoate ...... 20,23,37 methoxsalen, rapid ...... 22 mometasone/formoterol ...... 37 methscopolamine bromide ...... 27 Monistat 3 ...... 33 methyclothiazide ...... 17 Monoclate-P ...... 17,39 methyldopa ...... 18 Monodox ...... 5 methyldopa/hydrochlorothiazide ...... 18 Monophasic/Biphasic/Triphasic Agents ...... 32 methylergonovine maleate ...... 32 Monopril ...... 18 Methylin ...... 15 Monopril HCT ...... 18 methylphenidate ...... 15 montelukast sodium ...... 37 methylphenidate hcl ...... 15 morphine sulfate ...... 10 methylphenidate la ...... 15 morphine sulfate er caps ...... 10 methylphenidate, chewable ...... 15 Motrin ...... 11,30 methylprednisolone ...... 24,30,36 moxifloxacin hcl ...... 5,35 methyltestosterone ...... 24 MS Contin ...... 10 metipranolol ...... 34 Mucomyst ...... 37 metoclopramide hcl ...... 28 Multaq ...... 16 metolazone ...... 17 mupirocin calcium cream ...... 21 metoprolol succinate ...... 17 mupirocin cream ...... 21 metoprolol tartrate ...... 17 mupirocin ointment ...... 21 metoprolol tartrate/hydrochlorothiazide ...... 18 Muscle Relaxants & Antispasmodic Agents ...... 13 Metrocream ...... 21 Muscle Relaxants & Antispasmodic Therapy ...... 13,30 Metrogel ...... 33 Muse ...... 38 Metrogel 1% ...... 21 Myambutol ...... 7 Metrolotion ...... 21 Myasthenia Gravis ...... 14 metronidazole ...... 7,21,33 Mycelex ...... 7 metyrosine ...... 18 Mycobutin ...... 7 Mevacor ...... 19 Mycolog II ...... 21 mexiletine hcl ...... 16 mycophenolate mofetil ...... 8 Mexitil ...... 16 mycophenolate sodium ...... 8 Miacalcin ...... 24,31 Mycostatin ...... 7,21 Miacalcin Injection ...... 31 Mydriacyl ...... 34 Miacalcin Nasal Spray ...... 31 Myeloid Stimulants ...... 29 Micardis ...... 19 Myfortic ...... 8 Micardis HCT ...... 19 Myleran ...... 8 miconazole nitrate suppository, vaginal ...... 33 Myochrysine ...... 30 Micro-K ...... 39 Myrbetriq ...... 30,38 Micronase ...... 25 Mysoline ...... 13 Microzide ...... 17 Midamor ...... 17 N midazolam hcl ...... 15 nabumetone ...... 11,30 midodrine hcl ...... 40 nadolol ...... 17 Midrin ...... 12 nafarelin acetate ...... 24,33 miglustat ...... 24 Nalfon ...... 11 Migraine & Cluster Headache Therapy ...... 12 naltrexone hcl ...... 11 Migranal ...... 12 Namenda ...... 13 milnacipran ...... 30 Namenda XR ...... 13 Minastrin 24 Fe ...... 32 naphazoline hcl ...... 34 Minipress ...... 18 Naprelan ...... 11,30 Minocin ...... 5 Naprosyn ...... 11,30 minocycline hcl ...... 5 naproxen ...... 11,30 minoxidil ...... 18 naproxen sodium ...... 11,30 mirabegron ...... 30,38 naratriptan hcl ...... 12 Mirapex ...... 12 Narcotic Analgesics ...... 10 Mirapex ER ...... 12 Narcotic Antagonists ...... 11 Mircette ...... 32 Narcotics ...... 10 mirtazapine tablet ...... 14 Nardil ...... 14 mirtazapine tablet, rapid dissolve ...... 14 Nasalide ...... 23,37 Miscellaneous Agents ...... 23,40 Nasonex ...... 23,37 Miscellaneous Agents ...... 24 Natazia ...... 32 Miscellaneous Analgesics ...... 11 nateglinide ...... 25 Miscellaneous Antidepressants ...... 14 Natroba ...... 22 Miscellaneous Anti-infectives ...... 7 Navane ...... 15 Miscellaneous Antineoplastic Drugs ...... 9 nebivolol hcl ...... 17 Miscellaneous Antipsychotics ...... 15 nedocromil ...... 35 Miscellaneous Antivirals ...... 6 nelfinavir mesylate ...... 6 Miscellaneous Cardiovascular Agents ...... 19 Neo-Synephrine ...... 34 Miscellaneous Coagulation Agents ...... 17,39 Neomycin Sulfate ...... 7 Miscellaneous Dermatologicals ...... 22 neomycin sulfate ...... 7 Miscellaneous Gastrointestinal Agents ...... 27,28 neomycin sulfate/bacitracin zinc/polymyxin b/ Miscellaneous Hormones ...... 24 hydrocortisone ...... 35 Miscellaneous Neurological Therapy ...... 13 neomycin sulfate/bacitracin/polymyxin b Miscellaneous OB/GYN ...... 33 ointment ...... 35 Miscellaneous Ophthalmologics ...... 35 neomycin sulfate/gramicidin d/polymyxin b Miscellaneous Otic Preparations ...... 23 drops ...... 35 Miscellaneous Psychotherapeutic Agents ...... 15 neomycin sulfate/polymyxin b sulfate/ Miscellaneous Pulmonary Agents ...... 37 hydrocortisone ...... 23,35 Miscellaneous Rheumatological Agents ...... 30 neomycin/polymyxin b sulfate/dexamethasone ...... 35 Miscellaneous Urologicals ...... 38 Neoral ...... 8 misoprostol ...... 27 Neosporin ...... 35 mitomycin ...... 35 nepafenac ...... 34 Mitosol ...... 35 Neptazane ...... 34 mitotane ...... 9 Neulasta ...... 9,29 Mobic ...... 11,30 Neumega ...... 29 Modicon ...... 32 Neupogen ...... 9,29 Moduretic ...... 17 Neupro ...... 12 modafinil ...... 15 Neurontin ...... 13 moexipril hcl ...... 18 Nevanac ...... 34 moexipril/hydrochlorothiazide ...... 18 nevirapine ...... 6 52 Nexavar ...... 9 NuvaRing ...... 33 Nexium ...... 27 Nuvessa ...... 33 niacin ...... 19 Nuvigil ...... 15 niacin ext-rel ...... 19 Nystatin ...... 33 niacin/lovastatin ...... 19 nystatin ...... 7,21,33 niacin/simvastatin ...... 19 nystatin/triamcinolone acetonide ...... 21 Niaspan ...... 19 Nicotine ...... 40 nicotine ...... 40 O nicotine transdermal ...... 40 octreotide acetate vial ...... 9,24 Nicotrol ...... 40 Ocufen ...... 34 nifedipine ...... 18 Ocuflox ...... 35 Niferex-PN Forte ...... 39 Ocupress ...... 34 Nilandron ...... 8 ofloxacin ...... 5,23,35 nilotinib hcl ...... 9 Ogen ...... 32 nilutamide ...... 8 olanzapine ...... 15 nimodipine ...... 17 olanzapine/fluoxetine ...... 15 Nimotop ...... 17 olaparib ...... 9 Niravam ...... 15 olmesartan medoxomil ...... 19 nisoldipine ...... 18 olmesartan medoxomil/amlodipine/hctz ...... 18 nitazoxanide ...... 7 olmesartan medoxomil/hydrochlorothiazide ...... 19 Nitrates ...... 16 olodaterol ...... 36 Nitro-Dur ...... 16 olopatadine ...... 23 ...... 35 nitrofurantoin ...... 6 olopatadine hcl olsalazine ...... 28 nitrofurantoin macrocrystal ...... 6 Olux ...... 20 nitrofurantoin/nitrofurantoin macrocrystal ...... 6 Olysio ...... 6 Nitroglycerin ...... 16 omeprazole ...... 27 nitroglycerin ...... 16 Omnaris ...... 23,37 nitroglycerin capsule, sustained action ...... 16 Omnicef ...... 5 nitroglycerin ointment ...... 16 ondansetron ...... 12,28 nitroglycerin patch, transdermal 24 hours ...... 16 ondansetron hcl ...... 12,28 Nitrolingual ...... 16 One Touch Ultra Test Strips ...... 26 Nitrostat ...... 16 One Touch Verio IQ Test Strips ...... 26 nizatidine ...... 27 Onfi ...... 13 Nizoral ...... 7,21 Onsolis ...... 10 Nolvadex ...... 8 Opana ...... 10 Non-Insulin Hypoglycemic Agents ...... 25 Opana ER ...... 10 Non-narcotic Analgesics ...... 11 oprelvekin ...... 29 Non-steroidal Anti-inflammatory Agents ...... 34 Opsumit ...... 37 Nor-Q-D ...... 32 Opticrom ...... 35 Nordette ...... 32 OptiPranolol ...... 34 Norditropin ...... 29 Optivar ...... 35 norelgestromin/ethinyl estradiol ...... 33 Oral Contraceptives & Related Agents ...... 32 norethindrone ...... 32 Oral Drugs For Glaucoma ...... 34 norethindrone a-e estradiol ...... 32 Orencia SQ ...... 30 norethindrone a-e estradiol/ferrous Orentram ...... 37 fumarate ...... 32 Orinase ...... 25 norethindrone acetate ...... 32 orlistat ...... 40 norethindrone acetate - ethinyl estradiol orphenadrine citrate ...... 13 ferrous fumarate ...... 32 Ortho Evra ...... 33 norethindrone-ethinyl estradiol ...... 32 Ortho Micronor ...... 32 norethindrone-ethinyl estradiol/ferrous Ortho Tri-Cyclen ...... 32 fumarate ...... 32 Ortho Tri-Cyclen Lo ...... 32 norethindrone-mestranol ...... 32 Ortho-Cept ...... 32 norethindrone/ethinyl estradiol ...... 33 Ortho-Cyclen ...... 32 Norflex ...... 13 Ortho-Novum ...... 32 norfloxacin ...... 5 Orudis ...... 11,30 norgestimate-ethinyl estradiol ...... 32 oseltamivir phosphate ...... 6 norgestrel-ethinyl estradiol ...... 32 ospemifene ...... 33 Norinyl ...... 32 Osphena ...... 33 Norinyl 1-0.035mg ...... 32 Osteoporosis Therapy ...... 31 Norinyl 1-0.05mg ...... 32 Other Antihypertensive Combinations ...... 18 Noritate ...... 21 Other Electrolytes ...... 39 Normodyne ...... 17 Other Glaucoma Drugs ...... 34 Noroxin ...... 5 Other Rheumatologicals ...... 30 Norpace ...... 16 Other Ulcer Therapy ...... 27 Norpace CR ...... 16 Otic Steroid/Antibiotic ...... 23 Norpramin ...... 14 Otocain ...... 23 nortriptyline hcl ...... 14 Otogesic ...... 23 Norvasc ...... 18 Ovace ...... 21 Norvir ...... 6 Ovcon ...... 32 Novarel ...... 25 Ovide ...... 22 Novolin 70/30 OTC ...... 25 Ovidrel ...... 24,33 Novolin N OTC ...... 25 Ovral ...... 32 Novolin R OTC ...... 25 Ovulatory Stimulants ...... 24 NovoLog ...... 25 Oxandrin ...... 24 Novolog Mix 70/30 ...... 25 oxandrolone ...... 24 NovoSeven RT ...... 16,39 oxaprozin ...... 11,30 Noxafil ...... 7 oxazepam ...... 15 NSAID Agents ...... 30 oxcarbazepine ...... 13 NSAIDS ...... 11,30 oxiconazole nitrate ...... 21 NSAIDS- Specific COX-II Inhibitors ...... 11,30 Oxistat ...... 21 NSAIDS/COX II Inhibitors ...... 11,30 Oxsoralen-Ultra ...... 22 Nucynta ...... 11 Oxtellar XR ...... 13 Nucynta ER ...... 11 oxybutynin chloride ...... 13,30,38 Nuedexta ...... 13 oxycodone hcl ...... 10 Nulev ...... 27,38 oxycodone hcl concentrate, oral ...... 10 NuLytely ...... 28 oxycodone hcl/acetaminophen ...... 10 53 oxycodone hcl/ibuprofen ...... 10 Phrenilin ...... 10,12 oxycodone/aspirin ...... 10 phytonadione tablet ...... 16,39 OxyContin ...... 10 Picato ...... 22 OxyFAST ...... 10 pilocarpine hcl ...... 34,40 Oxytocics ...... 32 Pilopine HS ...... 34 pimecrolimus ...... 22 pindolol ...... 17 P pioglitazone hcl ...... 25 Pacerone ...... 16 pioglitazone hcl/glimepiride ...... 25 Pacerone 400mg ...... 16 pioglitazone hcl/metformin hcl ...... 25 palbociclib ...... 9 piroxicam ...... 11,30 paliperidone ...... 15 pitavastatin calcium ...... 19 Pamelor ...... 14 Plaquenil ...... 7,30 Pamine ...... 27 Plavix ...... 16,39 panobinostat ...... 9 Plegridy ...... 29 Panretin ...... 22 Plendil ...... 18 pantoprazole sodium ...... 27 Pletal ...... 16,39 Parafon Forte DSC ...... 13,30 Plexion ...... 21 Paregoric ...... 27 podofilox ...... 22 paregoric ...... 27 Poly-Vi-Flor ...... 39 paricalcitol ...... 24 Poly-Vi-Flor w/Iron ...... 39 Parlodel ...... 12 Parnate ...... 14 polymyxin b sulfate/trimethoprim ...... 35 Polysporin ...... 35 paromomycin sulfate ...... 7 paroxetine hcl ...... 14 Polytrim ...... 35 Paser ...... 7 ponatinib ...... 9 Pataday ...... 35 Ponstel ...... 11 Patanase ...... 23 posaconazole ...... 7 Patanol ...... 35 Potassium ...... 39 Paxil ...... 14 potassium bicarbonate/citric acid ...... 39 Paxil CR ...... 14 potassium chloride ...... 39 pazopanib hcl ...... 9 potassium chloride/potassium bicarbonate/ PCE ...... 5 citric acid ...... 39 Pediapred ...... 24,30,36 potassium iodide/iodine ...... 39 Pediazole ...... 5 Potiga ...... 13 Peg-Intron ...... 29 Pradaxa ...... 16,39 Peg-Intron Redipen ...... 29 pramipexole di-hcl ...... 12 Pegasys ...... 29 pramlintide acetate ...... 25 pegfilgrastim ...... 9,29 Pramosone ...... 21 peginterferon alfa-2a ...... 29 Prandimet ...... 25 peginterferon alfa-2b ...... 29 Prandin ...... 25 peginterferon beta-1a ...... 29 prasugrel hcl ...... 16,39 pegvisomant ...... 24 Pravachol ...... 19 pemirolast potassium ...... 35 pravastatin sodium ...... 19 Pen-Vee K ...... 5 prazosin hcl ...... 18 penbutolol ...... 17 Precare ...... 39 penciclovir ...... 21 Precose ...... 25 penicillin v potassium ...... 5 Pred Forte ...... 35 Penicillins ...... 5 Pred Mild ...... 35 Penlac ...... 21 Pred-G ...... 35 Pentasa ...... 28 prednisolone acetate ...... 35 pentazocine hcl/acetaminophen ...... 11 prednisolone sodium phosphate ...... 24,30,35,36 pentazocine hcl/naloxone hcl ...... 11 prednisolone syrup ...... 24,30,36 pentosan polysulfate sodium ...... 38 prednisone ...... 24,30,36 pentoxifylline tablet, sustained action ...... 17,39 Prefest ...... 33 Pepcid ...... 27 pregabalin ...... 13 Pepcid 40mg Tablet ...... 27 Prelone ...... 24,30,36 Pepcid Suspension ...... 27 Premarin ...... 31,32 perampanel ...... 13 Premphase ...... 33 Percocet ...... 10 Prempro ...... 33 Percodan ...... 10 prenatal vitamin w-o vitamin a/ferrous Perforomist ...... 36 fumarate/folic acid ...... 39 Periactin ...... 36 prenatal vitamins/iron polysaccharides Peridex ...... 23 complex/folic acid ...... 39 perindopril erbumine ...... 18 Prepopik ...... 28 permethrin ...... 22 Prevacid ...... 27 perphenazine ...... 15 Prevpac ...... 27 Persantine ...... 16,39 Prezcobix ...... 6 Pertzye ...... 28 Prezista ...... 6 phenazopyridine hcl ...... 6,38 Prilosec Rx ...... 27 phendimetrazine tartrate ...... 40 Primaquine ...... 7 phenelzine sulfate ...... 14 primaquine phosphate ...... 7 Phenergan ...... 12,28,36 primidone ...... 13 Phenobarbital ...... 13 Principen ...... 5 phenobarbital ...... 13 Prinivil ...... 18 phenobarbital/hyoscyamine/atropine/scop ...... 27 Prinzide ...... 18 Phenothiazines ...... 15 Pristiq ER ...... 14 phenoxybenzamine hcl ...... 18 ProAir HFA ...... 36 phentermine hcl ...... 40 ProAir RespiClick ...... 36 phentermine/topiramate ...... 40 ProAmatine ...... 40 phenylephrine hcl ...... 34 Probenecid ...... 30 phenylephrine hcl/brompheniramine maleate ...... 36 probenecid ...... 30 Phenytek ...... 13 procainamide hcl ...... 16 phenytoin capsule ...... 13 Procanbid ...... 16 phenytoin sodium extended ...... 13 procarbazine hcl ...... 9 phenytoin suspension, oral ...... 13 Procardia ...... 18 phenytoin tablet, chewable ...... 13 Procardia XL ...... 18 Phoslo ...... 39 prochlorperazine maleate ...... 12,28 Phospholine Iodide ...... 34 Procrit ...... 9,29 54 ProctoCream-HC ...... 28 Razadyne ...... 13 ProctoFoam-HC ...... 28 Razadyne ER ...... 13 Profasi ...... 33 Rebetol ...... 6 Profilnine SD ...... 17,39 Rebif ...... 29 progesterone, micronized ...... 32 Recombinate ...... 17,39 Progestin Only ...... 32 Reglan ...... 28 Progestins ...... 32 regorafenib ...... 9 Prograf ...... 8 Relafen ...... 11,30 Prolensa ...... 34 Relenza ...... 6 Prolixin ...... 15 Relpax ...... 12 Proloprim ...... 6 Remeron ...... 14 Promacta ...... 16,39 Remeron Sol Tab ...... 14 promethazine hcl ...... 12,28,36 Renvela ...... 40 Prometrium ...... 32 repaglinide ...... 25 propafenone hcl ...... 16 repaglinide/metformin hcl ...... 25 propranolol hcl ...... 17 Repronex ...... 24,33 propranolol hcl/hydrochlorothiazide ...... 18 Requip ...... 12 Propylthiouracil ...... 24 Requip XL ...... 12 propylthiouracil ...... 24 Rescriptor ...... 6 Proscar ...... 38 Rescula ...... 34 ProSom ...... 14 Reserpine ...... 18 Prostaglandins ...... 27 reserpine ...... 18 Proton Pump Inhibitors ...... 27 Restasis ...... 35 Protonix ...... 27 Restoril ...... 14 Protopic ...... 22 retapamulin ...... 21 protriptyline hcl ...... 14 Retin-A ...... 21 Proventil ...... 36 Retin-A Micro ...... 21 Proventil HFA ...... 36 Retrovir ...... 6 Provera ...... 32 Revatio ...... 37 Provigil ...... 15 ReVia ...... 11 Prozac ...... 14 Revlimid ...... 9 Prozac Weekly ...... 14 Reyataz ...... 6 pseudoephedrine hcl/brompheniramine Rheumatrex ...... 8,30 maleate ...... 36 Rhinocort Aqua ...... 23,37 pseudoephedrine hcl/chlorpheniramine Riax ...... 21 maleate ...... 36 ribavirin ...... 6 pseudoephedrine/desloratadine ...... 36 rifabutin ...... 7 Psorcon ...... 20 Rifadin ...... 7 Psychotherapeutic Drugs ...... 14 rifampin ...... 7 Pulmicort 0.25mg/2mL ...... 37 rifaximin ...... 7 Pulmicort 0.5mg/2mL ...... 37 rilpivirine hcl ...... 6 Pulmicort Flexhaler ...... 37 rimantadine ...... 6 Pulmonary Agents ...... 36 rimexolone ...... 35 Pulmozyme ...... 37 riociguat ...... 37 Purinethol ...... 8 Riomet ...... 25 Purixan ...... 8 risedronate ...... 31 Pylera ...... 27 risedronate sodium ...... 31,40 Pyrazinamide ...... 7 Risperdal ...... 15 pyrazinamide ...... 7 Risperdal M-Tab ...... 15 Pyridium ...... 6,38 risperidone ...... 15 pyridostigmine bromide syrup ...... 14 Ritalin ...... 15 pyridostigmine bromide tablet ...... 14 Ritalin LA ...... 15 pyridostigmine bromide tablet, sustained Ritalin-SR ...... 15 action ...... 14 ritonavir ...... 6 pyrimethamine ...... 7 ritonavir/lopinavir ...... 6 rivaroxaban ...... 16,39 rivastigmine ...... 13 Q rivastigmine tartrate capsules ...... 13 Qsymia ...... 40 rivastigmine transdermal patch ...... 13 Questran ...... 19 rizatriptan benzoate ...... 12 Questran Light ...... 19 RMS-Suppository ...... 10 quetiapine fumarate ...... 15 Robaxin ...... 13,30 Quillivant XR ...... 15 Robinul ...... 27 Quinaglute ...... 16 Robitussin A-C ...... 36 quinapril hcl ...... 18 Rocaltrol ...... 24 quinapril hcl/hydrochlorothiazide ...... 18 roflumilast ...... 37 Quinidex ...... 16 ropinirole hcl ...... 12 quinidine gluconate ...... 16 rosiglitazone maleate ...... 25 quinidine sulfate ...... 16 rosiglitazone maleate/glimepiride ...... 25 Quinolones ...... 5 rosiglitazone maleate/metformin hcl ...... 25 Quixin ...... 35 rosuvastatin calcium ...... 19 QVAR ...... 37 rotigotine ...... 12 Rowasa ...... 28 Roxicodone ...... 10 R Rozerem ...... 14 Ragwitek ...... 40 rufinamide tablet ...... 13 raloxifene hcl ...... 31 Rythmol ...... 16 raltegravir potassium ...... 6 Rythmol SR ...... 16 ramelteon ...... 14 Ryzolt ...... 11 ramipril ...... 18 Ranexa ...... 19 ranitidine hcl ...... 27 S ranitidine hcl 300mg tablet ...... 27 Salagen ...... 40 ranitidine hcl syrup ...... 27 Salicylates ...... 11,30 ranolazine ...... 19 salmeterol xinafoate ...... 36 Rapaflo ...... 38 Salsalate ...... 11,30 Rapamune ...... 8 salsalate ...... 11,30 Rapid Acting Nitrates ...... 16 Samsca ...... 24 rasagiline mesylate ...... 12 Sanctura ...... 13,30,38 55 Sandimmune ...... 8 Stadol ...... 11 Sandostatin ...... 9,24 Stalevo ...... 12 Santyl ...... 21 Starlix ...... 25 Saphris ...... 15 stavudine ...... 6 saquinavir mesylate ...... 6 Staxyn ...... 38 Sarafem ...... 14 Stelazine ...... 15 sargramostim ...... 9,29 Stendra ...... 38 Savella ...... 30 Steroid-antibiotic Combinations ...... 35 scopolamine ...... 34 Steroid-sulfonamide Combinations ...... 35 Seasonale ...... 32 Steroids ...... 35 Seasonique ...... 32 Stimate ...... 24 Second Generation Cephalosporins ...... 5 Stivarga ...... 9 Sectral ...... 17 Strattera ...... 15 Selective Serotonin Reuptake Inhibitors ...... 14 Striant ...... 24 selegiline hcl ...... 12 Stribild ...... 6 selegiline patch ...... 14 Striverdi Respimat ...... 36 selenium sulfide ...... 21 Suboxone ...... 11 SelRx ...... 21 Suboxone Tablet ...... 11 Selsun Rx ...... 21 Subutex ...... 10 Selzentry ...... 6 Suclear ...... 28 Semprex-D ...... 36 sucralfate ...... 27 Sensipar ...... 24 sucralfate tablet ...... 27 Septra DS ...... 5 sucroferric oxyhydroxide ...... 40 Serax ...... 15 Sular ...... 18 Serevent Diskus ...... 36 Sulfacet-R ...... 21 Serophene ...... 24,33 sulfacetamide ...... 21 Seroquel ...... 15 sulfacetamide sodium ...... 21,35 Seroquel XR ...... 15 sulfacetamide sodium/prednisolone acetate ...... 35 sertraline hcl ...... 14 sulfacetamide sodium/prednisolone sodium sevelamer carbonate ...... 40 phosphate ...... 35 short ragweed pollen allergen extract ...... 40 sulfacetamide sodium/sulfur ...... 21 sildenafil citrate ...... 37,38 sulfamethoxazole/trimethoprim ...... 5 silodosin ...... 38 Sulfas & Related Agents ...... 5 Silvadene ...... 21 sulfasalazine ...... 28,30 silver sulfadiazine ...... 21 Sulfonamides ...... 35 Simbrinza ...... 34 sulindac ...... 11,30 Simcor ...... 19 sumatriptan succinate ...... 12 simeprevir ...... 6 sumatriptan succinate/naproxen ...... 12 Simponi ...... 30 Sumavel Dosepro ...... 12 simvastatin ...... 19 sunitinib malate ...... 9 Sinemet ...... 12 Suprenza ODT ...... 40 Sinemet CR ...... 12 Suprep ...... 28 Sinequan ...... 14 Surestep Pro ...... 26 Singulair ...... 37 Sustiva ...... 6 sirolimus ...... 8 Sutent ...... 9 Sirturo ...... 7 Symbicort ...... 37 sitagliptin phosphate ...... 25 Symbyax ...... 15 sitagliptin phosphate/metformin hcl ...... 25 Symlin ...... 25 sitagliptin/metformin hcl ...... 25 Symmetrel ...... 6,12 sitagliptin/simvastatin ...... 25 Sympathomimetics ...... 35 Skelaxin ...... 13,30 Synalar ...... 20 Slow-K ...... 39 Synarel ...... 24,33 Smoking Deterrents ...... 40 Synthroid ...... 24 sodium bicarbonate/sodium chloride/ potassium chloride/polyethylene glycol T 3350 ...... 28 tacrolimus ...... 8,22 sodium chloride/sodium bicarbonate/ tacrolimus anhydrous ...... 8 potassium chloride/polyethylene glycols ...... 28 tadalafil ...... 37,38 sodium fluoride ...... 39 Tafinlar ...... 9 sodium oxybate ...... 15 tafluprost ...... 34 sodium picosulfate/magnesium oxide/ Tagamet ...... 27 anhydrous citric acid ...... 28 Talacen ...... 11 Sodium Polystyrene Sulfonate ...... 40 Talwin NX ...... 11 sodium polystyrene sulfonate ...... 40 Tambocor ...... 16 sodium polystyrene sulfonate enema ...... 40 Tamiflu ...... 6 sodium sulfate/potassium sulfate/magnesium tamoxifen citrate ...... 8 sulfate ...... 28 tamsulosin hcl ...... 38 sodium sulfate/sodium/sodium bicarbonate/ Tapazole ...... 24 potassium chloride/polyethylene glycols ...... 28 tapentadol ...... 11 sofosbuvir ...... 6 Tarceva ...... 9 solifenacin succinate ...... 13,30,38 Targretin Capsule ...... 9 Soma ...... 13,30 Tarka ...... 18 somatropin ...... 29 Tasigna ...... 9 Somavert ...... 24 Tavist ...... 36 Somnote ...... 14 tazarotene ...... 21 Sonata ...... 14 Tazorac ...... 21 sorafenib tosylate ...... 9 Tecfidera ...... 13 Soriatane ...... 21 Tegretol ...... 13 sotalol hcl ...... 16 Tegretol XR ...... 13 Sovaldi ...... 6 Tekturna ...... 19 Specialized OB/GYN Drugs ...... 33 Tekturna HCT ...... 19 Spectazole ...... 21 telaprevir ...... 6 spinosad ...... 22 telbivudine ...... 6 Spiriva ...... 37 telithromycin ...... 7 spironolactone ...... 17 telmisartan ...... 19 spironolactone/hydrochlorothiazide ...... 17 telmisartan/amlodipine ...... 18 Sporanox ...... 7 telmisartan/hydrochlorothiazide ...... 19 Sprix ...... 11,30 temazepam ...... 14 Sprycel ...... 9 Temodar ...... 8 56 Temovate ...... 20 Topical Corticosteroids Very High Potency ...... 20 Temovate-E ...... 20 Topical Enzymes ...... 21 temozolomide ...... 8 Topical Scabicides/Pediculicides ...... 22 Tenex ...... 18 Topicort ...... 20 tenofovir disoproxil fumarate ...... 6 Topicort LP ...... 20 Tenoretic ...... 18 topiramate ...... 13 Tenormin ...... 17 Toprol XL ...... 17 Tenuate ...... 40 Toradol ...... 30 Terazol ...... 33 toremifene citrate ...... 8 terazosin hcl ...... 18,38 torsemide ...... 17 terbinafine hcl ...... 7 Tracleer ...... 37 terbutaline sulfate ...... 33,36 Tradjenta ...... 25 terconazole ...... 33 tramadol hcl ...... 11 teriflunomide ...... 13 tramadol hcl/acetaminophen ...... 11 teriparatide ...... 31 trametinib ...... 9 Testim ...... 24 Trandate ...... 17 testosterone ...... 24 trandolapril ...... 18 testosterone cypionate ...... 24 trandolapril/verapamil ...... 18 testosterone enanthate ...... 24 tranexamic acid ...... 33 Testred ...... 24 Transderm-Nitro ...... 16 tetracycline hcl ...... 5 Tranxene T-Tab ...... 15 Tetracyclines ...... 5 tranylcypromine sulfate ...... 14 Teveten ...... 19 Travatan ...... 34 Teveten 600mg ...... 19 Travatan Z ...... 34 Teveten HCT ...... 19 travoprost ...... 34 thalidomide ...... 9 trazodone hcl ...... 14 Thalomid ...... 9 Trental ...... 17,39 Theo-24 ...... 36 treprostinil ...... 37 Theo-Dur ...... 36 tretinoin ...... 21 theophylline anhydrous ...... 36 tretinoin microsphere ...... 21 Therapy For Acne ...... 21 Tretten ...... 17,39 Thiazide & Related Diuretics ...... 17 Trexall ...... 8,30 Thioguanine ...... 8 Treximet ...... 12 thioguanine ...... 8 Tri-Levlen ...... 32 thioridazine hcl ...... 15 Tri-Norinyl ...... 32 thiothixene ...... 15 Tri-Vi-Flor ...... 39 Third Generation Cephalosporins ...... 5 Tri-Vi-Flor w/Iron ...... 39 Thorazine ...... 15 triamcinolone ...... 20 thyroid ...... 24 triamcinolone acetonide ...... 20,23 Thyroid Hormones ...... 24 triamterene ...... 17 Thyrolar ...... 24 triamterene/hydrochlorothiazide ...... 17 tiagabine hcl ...... 13 triazolam ...... 14 Tiazac ...... 17 Tribenzor ...... 18 ticagrelor ...... 16,39 Tricor ...... 19 Ticlid ...... 16,39 Tricyclics ...... 14 ticlopidine hcl ...... 16,39 trifluoperazine hcl ...... 15 Tigan ...... 12,28 trifluridine ...... 35 timolol maleate ...... 17,34 Triglide ...... 19 timolol ophthalmic ...... 34 trihexyphenidyl hcl ...... 12 Timoptic ...... 34 Trilafon ...... 15 Timoptic-XE ...... 34 Trileptal ...... 13 timothy grass pollen allergen extract ...... 40 Trilipix ...... 19 Tindamax ...... 7 Trilisate ...... 30 tinidazole ...... 7 trimethobenzamide hcl ...... 12,28 tiotropium bromide ...... 37 trimethoprim ...... 6 tipranavir ...... 6 Triphasil ...... 32 Tivicay ...... 6 Triumeq ...... 6 tizanidine ...... 13 Trizivir ...... 6 Tobi Podhaler ...... 7 Trokendi XR ...... 13 TobraDex ...... 35 tropicamide ...... 34 tobramycin ...... 7 trospium chloride ...... 13,30,38 tobramycin sulfate ...... 35 Trusopt ...... 34 ...... 35 Truvada ...... 6 tobramycin sulfate drops trypsin/balsam peru/castor oil ...... 21 tobramycin sulfate ointment ...... 35 Tudorza Pressair ...... 37 tobramycin sulfate/dexamethasone ...... 35 Tussi-Organidin Nr ...... 36 tobramycin sulfate/dexamethasone drops ...... 35 Tussi-Organidin-S Nr ...... 36 tobramycin/loteprednol etabonate ...... 35 Twynsta ...... 18 Tobrex ...... 35 Tybost ...... 6 Tobrex Drops ...... 35 Tykerb ...... 9 tocilizmab ...... 30 Tylenol w/Codeine ...... 10 tofacitinib ...... 30 Tylox ...... 10 Tofranil ...... 14 Tyzeka ...... 6 Tofranil-PM ...... 14 tolazamide ...... 25 tolbutamide ...... 25 U Tolectin ...... 11,30 Uceris ...... 28 Tolinase ...... 25 Ulcer Therapy ...... 27 tolmetin sodium ...... 11,30 Uloric ...... 30 tolterodine tartrate ...... 13,30,38 Ultracet ...... 11 tolvaptan ...... 24 Ultram ...... 11 Topamax ...... 13 Ultram ER ...... 11 Topical Anesthetics ...... 20 Ultravate ...... 20 Topical Antibacterials ...... 21 umeclidinium/vilanterol ...... 37 Topical Antifungals ...... 21 Uniretic ...... 18 Topical Antivirals ...... 21 Unithroid ...... 24 Topical Corticosteroids ...... 20 Univasc ...... 18 Topical Corticosteroids High Potency ...... 20 unoprostone isopropyl ...... 34 Topical Corticosteroids Low Potency ...... 20 urea ...... 22 Topical Corticosteroids Medium Potency ...... 20 Urecholine ...... 38 57 Urinary Anesthetics ...... 38 Welchol ...... 19 Urinary Tract Agents ...... 6 Wellbutrin ...... 14 Urispas ...... 38 Wellbutrin SR ...... 14 Uroxatral ...... 38 Wellbutrin XL ...... 14 Urso ...... 27 Westcort ...... 20 Urso Forte ...... 27 Wilate ...... 16,39 ursodiol ...... 27 Utopic ...... 22 X Xalatan ...... 34 V Xanax ...... 15 V-Go Disposable Insulin Delivery Device ...... 26 Xanax XR ...... 15 Vagifem ...... 32 Xanthines ...... 36 Vaginal Antifungals ...... 33 Xarelto ...... 16,39 Vaginal Cleanser/Anti-infectives ...... 33 Xeljanz ...... 30 valacyclovir hcl ...... 6 Xeloda ...... 8 Valchlor ...... 9 Xenical ...... 40 Valcyte ...... 6 Xibrom ...... 34 Valcyte Tablet ...... 6 Xifaxan 550mg ...... 7 valganciclovir hcl ...... 6 Xigduo XR ...... 25 valganciclovir hydrochloride ...... 6 Xolegel ...... 21 Valium ...... 13,15,30 Xopenex ...... 36 valproic acid ...... 13 Xopenex 1.25mg/0.5 ...... 36 valsartan ...... 19 Xopenex HFA ...... 36 valsartan/hydrochlorothiazide ...... 19 Xtandi ...... 8 Valtrex ...... 6 xulane ...... 33 Vancocin HCl ...... 7 Xylocaine ...... 20,23 Vancomycin ...... 7 Xyntha ...... 17,39 vancomycin hcl ...... 7 Xyntha Solofuse ...... 17,39 vardenafil ...... 38 Xyrem ...... 15 varenicline tartrate ...... 40 Xyzal ...... 36 Vaseretic ...... 18 Vasocidin ...... 35 Vasoconstrictor Decongestants ...... 34 Y Vasodilan ...... 33 Yasmin ...... 32 Vasodilators ...... 18 YAZ ...... 32 Vasotec ...... 18 Velphoro ...... 40 Z venlafaxine hcl ...... 14 zafirlukast ...... 37 Ventavis ...... 37 zaleplon ...... 14 Ventolin HFA ...... 36 Zanaflex ...... 13 VePesid ...... 9 zanamivir ...... 6 Veramyst ...... 23,37 Zantac ...... 27 verapamil hcl ...... 17 Zantac 300mg Tablet ...... 27 Verelan ...... 17 Zantac Rx ...... 27 Verelan PM ...... 17 Zantac Syrup ...... 27 Vermox ...... 7 Zarontin ...... 13 Versed ...... 15 Zaroxolyn ...... 17 Vesicare ...... 13,30,38 Zavesca ...... 24 Vexol ...... 35 Zebeta ...... 17 Vfend ...... 7 Zelapar ...... 12 Viagra ...... 38 Zemplar ...... 24 Vibra-Tabs ...... 5 Zenpep ...... 28 Vibramycin ...... 5 Zerit ...... 6 Vibramycin Syrup ...... 5 Zestoretic ...... 18 Vicodin ...... 10 Zestril ...... 18 Vicoprofen ...... 10 Zetia ...... 19 Victoza ...... 25 Ziac ...... 18 Videx ...... 6 Ziagen ...... 6 Videx EC ...... 6 zidovudine ...... 6 Vigamox ...... 35 Zioptan ...... 34 Vimpat ...... 13 ziprasidone hcl ...... 15 Viokace ...... 28 Zithromax ...... 5 Viracept ...... 6 Zocor ...... 19 Viramune ...... 6 Zofran ...... 12,28 Viramune XR ...... 6 Zofran ODT ...... 12,28 Viread ...... 6 Zoladex ...... 9 Viroptic ...... 35 Zolinza ...... 9 Visken ...... 17 zolmitriptan ...... 12 Vistaril ...... 36 Zoloft ...... 14 Vitamin B-12 ...... 39 zolpidem tartrate ...... 14 Vitamin D 50000 Unit ...... 39 Zomig ...... 12 Vitamin K ...... 16,39 Zomig ZMT ...... 12 Vitamins & Hematinics ...... 39 Vitekta ...... 6 Zonalon ...... 22 Vivactil ...... 14 Zonegran ...... 13 Vivelle DOT ...... 31,32 zonisamide ...... 13 Voltaren ...... 11,34 Zovirax ...... 6 Voltaren-XR ...... 11 Zovirax Cream ...... 21 Zovirax Ointment ...... 21 voriconazole ...... 7 vorinostat ...... 9 Zubsolv ...... 11 VoSol ...... 23 Zyban ...... 40 VoSol HC ...... 23 Zyclara ...... 22 Votrient ...... 9 Zydelig ...... 9 Vytorin ...... 19 Zykadia ...... 9 Vyvanse ...... 15 Zylet ...... 35 Zyloprim ...... 30 Zyprexa ...... 15 W Zyprexa Zydis ...... 15 warfarin sodium ...... 16,39 Zyvox ...... 7 58 For Prior Authorization Medication Requests: Express Scripts Phone: 877-916-2271 Fax: 800-837-0959
Adjudication Assistance: Express Scripts Pharmacy Help Desk Phone: 800-922-1557
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