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BCBSNM/HMONM Therapeutic Class Drug List (Formulary) 2004

I. Antineoplastics and Immunosuppressants A. Antineoplastics B. Immunosuppressants

II. Modifiers A. B. Aggregation Inhibitors C. Miscellaneous

III. Cardiovascular Agents A. ACE Inhibitors B. Alpha Blockers C. Angiotensin II Receptor Blockers D. Antiarrhythmics and Cardiac Glycosides E. Beta Blockers F. Channel Blockers G. Diuretics H. Lipid Lowering Agents I. Nitrates J. Miscellaneous

IV. A. Alzheimer’s Disease B. C. Migraine D. Parkinson’s Disease E. Seizures

V. Dermatology A. B. Bacterial Infections C. D. Fungal Infections E. Psoriasis F. Scabies and Pediculosis G. Viral Infections H. Miscellaneous

VI. Ear, Nose, and Throat A. Ear B. Nose C. Throat and Mouth

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VII. Endocrinology A. Adrenal Corticosteroids B. Diabetes Mellitus C. D. Paget's Disease E. Thyroid Modifiers F. Miscellaneous

VIII. Gastrointestinal A. B. Emesis C. Inflammatory Bowel Disease D. Pancreatic E. Reflux (GERD) F. Spasm G. Ulcers H. Miscellaneous

IX. Infectious Diseases A. Antimicrobials B. C. Antivirals D. Miscellaneous E. Web site reference

X. Musculoskeletal A. Gout B. Rheumatoid and Osteoarthritis C. Relaxants

XI. OB-GYN A. Contraceptives B. Endometriosis C. Menopausal/Postmenopausal Symptoms D. Vaginal Infections E. Miscellaneous

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XII. Ophthalmic A. Allergy B. Anti-inflammatories C. Infections D. Glaucoma E. Miscellaneous

XIII. Psychiatric A. Alcohol Deterrents B. C. Attention Deficit Hyperactivity Disorder D. Bipolar Disorders E. F. G. Narcolepsy H. Psychoses

XIV. Respiratory A. Asthma/COPD B. and C. Antitussives and Expectorants

XV. Supplements A. Potassium B. Vitamins and Minerals

XVI. Urological A. Symptomatic Benign Prostatic Hyperplasia B. Miscellaneous

XVII. Miscellaneous Drugs A. Anaphylaxis Emergency B. Subarachnoid Hemorrhage C. Wilson’s Disease

Legend: $ Relative cost (more $ = higher cost) MDL Managed drug limitations PA Prior authorization required ST Step therapy boldface Indicates generic availability CAPITAL Indicates brand-name drug lowercase Indicates generic drug name

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I. Antineoplastics and Immunosuppressants A. Antineoplastics Generic Name Relative Cost Brand Name hcl $$$$ MATULANE® busalfan $$$$$ MYLERAN® megestral acetate $$$$$ MEGACE® $$$$$ ALKERAN® leucovorin calcium (adjunctive) $$$$$$ LEUCOVORIN CALCIUM citrate $$$$$$$ FARESTON® hydroxyurea $$$$$$$ HYDREA® $$$$$$$ NOLVADEX® hydroxyurea $$$$$$$ MYLOCEL® $$$$$$$ FEMARA® $$$$$$$ ARIMIDEX® $$$$$$$ AROMOSIN® $$$$$$$$ LEUKERAN® , 2.5mg only $$$$$$$$ METHOTREXATE $$$$$$$$ NILANDRON® thioguanine $$$$$$$$ THIOGUANINE $$$$$$$$ PURINETHOL® $$$$$$$$ EULEXIN® bicalutanamide $$$$$$$$ CASODEX® $$$$$$$$ CYTOXAN® $$$$$$$$$ VEPESID® $$$$$$$$$ EMCYT® $$$$$$$$$ TESLAC® $$$$$$$$$$ THALOMID® $$$$$$$$$$ TEMODAR® $$$$$$$$$$ XELODA® $$$$$$$$$$ HEXALEN® $$$$$$$$$$ TARGRETIN® $$$$$$$$$$ CEENU® $$$$$$$$$$ LYSODREN® $$$$$$$$$$ VESANOID®

B. Immunosuppressants Generic Name Relative Cost Brand Name azathioprine $$$$ IMURAN® $$$$$$$$ RAPAMUNE® mycophenolate mofetil $$$$$$$$$ CELLCEPT® anhydrous $$$$$$$$$ PROGRAF® cyclosporine $$$$$$$$$ NEORAL® cyclosporine $$$$$$$$$$ SANDIMMUNE®

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II. Blood Modifiers A. Anticoagulants Generic Name Relative Cost Brand Name $$$ COUMADIN® sodium $$$ HEPARIN enoxaparin sodium (MDL) $$$$$$$$$$ LOVENOX® (MDL)

B. Platelet Aggregation Inhibitors Generic Name Relative Cost Brand Name $$$ PERSANTINE® clopidogrel $$$$$$$$ PLAVIX®

C. Miscellaneous Generic Name Relative Cost Brand Name ext-rel $$$$ TRENTAL® $$$$$$$$$$ AGRYLIN™ Hematopoietic injectable drugs are available at the nonformulary copay. See Prior Authorization (PA) Criteria for information.

III. Cardiovascular Agents A. ACE Inhibitors Generic Name Relative Cost Brand Name captopril $ CAPOTEN® enalapril $$ VASOTEC® lisinopril $$ ZESTRIL® lisinopril/hydrochlorothiazide $$$ ZESTORETIC® enalapril/hydrochlorothiazide $$$ VASERETIC® moexipril $$$ UNIVASC® quinapril/hydrochlorothiazide $$$ ACCURETIC™ quinapril $$$$ ACCUPRIL® ramipril $$$$$ ALTACE® trandolapril/verapamil ext-rel $$$$$$ TARKA®

B. Alpha Blockers Generic Name Relative Cost Brand Name prazosin $ MINIPRESS® doxazosin $$$ CARDURA® terazosin $$$$$$ HYTRIN®

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C. Angiotensin II Receptor Blockers Generic Name Relative Cost Brand Name olmesartan $$$$ BENICAR® olmesartan/hydrochlorothiazide $$$$ BENICAR HCT™ losartan $$$$$ COZAAR® losartan/hydrochlorothiazide $$$$$ HYZAAR® valsartan $$$$$$ DIOVAN® valsartan/hydrochlorothiazide $$$$$$ DIOVAN HCT®

D. Antirrhythmics and Cardiac Glycosides Generic Name Relative Cost Brand Name $ LANOXIN® sulfate $$$$ QUINIDINE SULFATE quinidine gluconate ext-rel $$$$$ QUINAGLUTE® disopyramide $$$$$$ NORPACE® quinidine sulfate ext-rel $$$$$$ QUINIDEX® mexiletine $$$$$$$ MEXITIL® disopyramide ext-rel $$$$$$$ NORPACE CR® $$$$$$$$ CORDARONE® ext-rel (6 hr) $$$$$$$$ PROCAINAMIDE EXT-REL propafenone $$$$$$$$ RYTHMOL® sotalol $$$$$$$$$ BETAPACE® procainamide $$$$$$$$$$ PRONESTYL®

E. Beta Blockers Generic Name Relative Cost Brand Name Cardioselective atenolol $ TENORMIN® metoprolol $ LOPRESSOR® atenolol/chlorthalidone $ TENORETIC® betaxolol $$$$ KERLONE® metoprolol ext-rel $$$$ TOPROL-XL® metoprolol/hydrochlorothiazide $$$$$$ LOPRESSOR HCT® Noncardioselective $ INDERAL® pindolol $$ VISKEN® $$ BLOCADREN® penbutolol $$ LEVATOL® nadolol $$$ CORGARD® propranolol ext-rel $$$$ INNOPRAN XL™ propranolol ext-rel $$$$$ INDERAL® LA Beta and Alpha Blockers labetalol $$$$ NORMODYNE® $$$$$$$$ COREG®

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F. Calcium Channel Blockers Generic Name Relative Cost Brand Name Dihydropyridines $$ PROCARDIA® $$$$ CARDENE® nifedipine ext-rel $$$$ ADALAT® CC ext-rel $$$$ SULAR® ext-rel $$$$$ PLENDIL® $$$$$$ NORVASC® Nondihydropyridines verapamil $ CALAN® verapamil ext-rel $$ CALAN® SR diltiazem $$ CARDIZEM® diltiazem ext-rel $$$$ DILACOR XR® diltiazem ext-rel $$$$$$ CARDIZEM® CD diltiazem ext-rel $$$$$$ CARDIZEM® SR diltiazem ext-rel $$$$$$ CARDIZEM® LA

G. Diuretics Generic Name Relative Cost Brand Name hydrochlorothiazide $ HYDRODIURIL® chlorthalidone $ HYGROTON® /hydrochlorothiazide 75/50 $ MAXZIDE® amiloride/hydrochlorothiazide $ MODURETIC® furosemide $ LASIX® triamterene/hydrochlorothiazide 50/25 $ TRIAMTERENE/ HYDROCHLOROTHIAZIDE indapamide $ LOZOL® bumetanide $ BUMEX® triamterene/hydrochlorothiazide 37.5/ $ MAXZIDE®-25 25 tabs triamterene/hydrochlorothiazide 37.5/ $ DYAZIDE® 25 caps amiloride $$ MIDAMOR® $$$ ALDACTONE® spironolactone/hydrochlorothiazide $$$ ALDACTAZIDE® metolazone $$$$$ ZAROXOLYN®

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H. Lipid Lowering Agents Generic Name Relative Cost Brand Name gemfibrozil $$ LOPID® $$$$$ NIACOR® fluvastatin $$$$$$ LESCOL® cholestyramine cans $$$$$$ QUESTRAN®/ QUESTRAN®-LIGHT cholestyramine pkt $$$$$$ QUESTRAN®/ QUESTRAN®-LIGHT (MDL) $$$$$$$ CRESTOR® atorvastatin $$$$$$$ LIPITOR® fluvastatin ext-rel $$$$$$$ LESCOL XL® colestipol pkt $$$$$$$ COLESTID® $$$$$$$$ PRAVACHOL® pravastatin/buffered $$$$$$$$ PRAVIGARD™ PAC colestipol tabs $$$$$$$$$ COLESTID®

I. Nitrates Generic Name Relative Cost Brand Name isosorbide dinitrate oral $ ISORDIL® isosorbide dinitrate sublingual $ ISORDIL® S.L. nitroglycerin sublingual $$ NITROSTAT® isosorbide dinitrate ext-rel tabs $$ ISOSORBIDE DINITRATE EXT-REL nitroglycerin ointment $$ NITRO-BID® isosorbide mononitrate ext-rel $$$ IMDUR® nitroglycerin transdermal $$$$$ NITREK® nitroglycerin transdermal $$$$$$$ TRANSDERM-NITRO® nitroglycerin transdermal $$$$$$$ NITRO-DUR®

J. Miscellaneous Generic Name Relative Cost Brand Name hydralazine $ HYDRALAZINE clonidine $ CATAPRES® methyldopa $$ ALDOMET® minoxidil $$$$ LONITEN® guanabenz $$$$$$ WYTENSIN® clonidine transdermal $$$$$$$$ CATAPRES-TTS® midodrine $$$$$$$$$$ PROAMATINE®

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IV. Central Nervous System A. Alzheimer’s Disease Generic Name Relative Cost Brand Name donepezil $$$$$$ ARICEPT® rivastigmine $$$$$$$ EXELON®

B. Analgesics Generic Name Relative Cost Brand Name NSAIDs ibuprofen $ MOTRIN® naproxen $ NAPROSYN® naproxen sodium $ ANAPROX® diflunisal $$$$ DOLOBID® ketoprofen $$$$ ORUDIS® etodolac $$$$ LODINE® meclofenamate $$$$$ MECLOFENAMATE rofecoxib (MDL, ST) $$$$$$ VIOXX® (MDL, ST) oxycodone/acetaminophen $ TYLOX® /aspirin $ ASPIRIN/CODEINE 3/4 hydrocodone/acetaminophen tabs 5/500 $ LORTAB® 5/500 oxycodone/acetaminophen 5/325 only $ PERCOCET® hydrocodone/acetaminophen 7.5/750 $ VICODIN ES® hydrocodone/acetaminophen 7.5/500 $ LORTAB® 7.5/500 hydrocodone/acetaminophen 7.5/650 $$ LORCET® PLUS codeine/acetaminophen $$ TYLENOL® w/CODEINE oxycodone/aspirin $$ PERCODAN® propoxyphene nap/acetaminophen $$ DARVOCET-N® oxycodone $$$$$ ROXICODONE™ oxycodone $$$$$$ OXYIR® codeine/acetaminophen susp (alcohol-free) $$$$$$ CAPITAL® w/CODEINE® hydromorphone $$$$$$$ DILAUDID® morphine $$$$$$$ MSIR® oxycodone ext-rel $$$$$$$$ OXYCONTIN® morphine ext-rel $$$$$$$$ MS CONTIN® codeine sulfate $$$$$$$$$ CODEINE meperidine $$$$$$$$$$ DEMEROL® morphine rectal supp $$$$$$$$$$ RMS® SUPPOSITORIES butorphanol (MDL) $$$$$$$$$$ STADOL NS® (MDL) Miscellaneous aspirin/butalbital/ $$$$ FIORINAL® acetaminophen/butalbital/caffeine $$$$$ FIORICET®

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C. Migraine Generic Name Relative Cost Brand Name Abortive Therapy ibuprofen $ MOTRIN® acetaminophen/dichloralphenazone/ $ MIDRIN® isometheptene ergotamine/caffeine tabs $$ CAFERGOT® ergotamine/caffeine suppositories $$ CAFERGOT® (MDL) $$$$ ZOMIG® / ZOMIG ZMT® / ZOMIG® NS (MDL) rizatriptan (MDL) $$$$ MAXALT® (MDL) rizatriptan MLT (MDL) $$$$ MAXALT-MLT® (MDL) Prophylactic Therapy $ ELAVIL® propranolol $ INDERAL® verapamil $ CALAN® propranolol ext-rel $$$$ INDERAL® LA divalproex sodium delayed-rel $$$$$$ DEPAKOTE® divalproex extended release $$$$$$ DEPAKOTE® ER

D. Parkinson’s Disease Generic Name Relative Cost Brand Name benztropine $ COGENTIN® $ DIPHENHYDRAMINE amantadine, except tabs $$ AMANTADINE trihexyphenidyl $$ ARTANE® carbidopa/levodopa $$$$ SINEMET® selegiline tabs $$$$ SELEGILINE selegiline caps $$$$$$ ELDEPRYL® pramipexole $$$$$$$ MIRAPEX® $$$$$$$$ REQUIP™ tolcapone $$$$$$$$ TASMAR® $$$$$$$$ PARLODEL® carbidopa/levodopa ext-rel $$$$$$$$ SINEMET® CR pergolide $$$$$$$$$ PERMAX®

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E. Seizures Generic Name Relative Cost Brand Name $ PHENOBARBITAL $$ TEGRETOL® sodium extended $$ DILANTIN® $$$ KLONOPIN® phenytoin $$$ DILANTIN® INFATABS® primidone $$$ MYSOLINE® carbamazepine ext-rel $$$ CARBATROL® mephobarbital $$$$ MEBARAL® carbamazepine ext-rel $$$$$ TEGRETOL®-XR valproic acid $$$$$ DEPAKENE® ethosuximide $$$$$ ZARONTIN® tiagabine $$$$$$$ GABITRIL™ $$$$$$$ NEURONTIN® felbamate $$$$$$$$ FELBATOL® divalproex sodium delayed-rel $$$$$$$$ DEPAKOTE® $$$$$$$$ LAMICTAL® topiramate $$$$$$$$ TOPAMAX®

V. Dermatology A. Acne Generic Name Relative Cost Brand Name Acne Rosacea 15% gel $$$$$$ FINACEA™ metronidazole gel/cream/lotion $$$$$$$ METROGEL® Acne Vulgaris Oral $ SUMYCIN® doxycycline hyclate $$$$ VIBRAMYCIN® delayed-rel $$$$ ERY-TAB® minocycline, except 75mg $$$$$$$$ MINOCIN® isotretinoin $$$$$$$$$$ ACCUTANE® Topical erythromycin soln $ T-STAT® gel $$ CLEOCIN T® benzoyl peroxide $$ BENZAC® AC erythromycin gel 2% $$$$ EMGEL® clindamycin lotion $$$$ CLEOCIN T® clindamycin soln $$$$$ CLEOCIN T® sulfacetamide $$$$$ KLARON® tretinoin (PA) $$$$$ AVITA® (PA) tretinoin (PA) $$$$$$ RETIN-A® (PA) tretinoin gel (PA) $$$$$$ RETIN-A® MICRO® (PA) erythromycin/benzoyl peroxide $$$$$$$$ BENZAMYCIN®

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B. Bacterial Infections Generic Name Relative Cost Brand Name gentamicin $ GARAMYCIN® silver sulfadiazine $ SILVADENE® $$$$$ BACTROBAN®

C. Corticosteroids Generic Name Relative Cost Brand Name Low lotion 1% $ NUTRACORT® hydrocortisone cream 2.5% $ HYTONE® ointment 0.05% $$ DESOWEN® cream/ointment 0.05% $$$$ ACLOVATE® Medium acetonide cream/lotion $ KENALOG® 0.025% valerate $ BETA-VAL® cream/ointment/lotion 0.1% acetonide cream/ointment $ SYNALAR® 0.025%/ 0.01% $ KENALOG® cream/ointment/lotion 0.1% cream 0.05% $$$ TOPICORT® LP propionate cream 0.05%/ $$$$ CUTIVATE® ointment 0.005% High triamcinolone acetonide cream 0.5% $ KENALOG® cream/ointment/gel 0.05% $ LIDEX® betamethasone dipropionate cream/ $ DIPROSONE® ointment/lotion 0.05% desoximetasone cream/ointment 0.25%/ $$$$ TOPICORT® gel 0.05% cream/ointment 0.1% $$$$ CYCLOCORT® Very High propionate cream/ointment $$$$ TEMOVATE® 0.05% betamethasone dipropionate augmented $$$$$ DIPROLENE® ointment 0.05% betamethasone dipropionate augmented $$$$$$ DIPROLENE® lotion/gel 0.05% betamethasone dipropionate augmented cream $$$$$$ DIPROLENE® AF 0.05%

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D. Fungal Infections Generic Name Relative Cost Brand Name nystatin/triamcinolone $ MYCOLOG®-II nystatin $ MYCOSTATIN® $$$$$ MONISTAT-DERM® econazole $$$$$$ SPECTAZOLE® $$$$$$ NIZORAL® oxiconazole $$$$$$ OXISTAT® /betamethasone $$$$$$$ LOTRISONE® ciclopirox $$$$$$$$ LOPROX®

E. Psoriasis Generic Name Relative Cost Brand Name chloroxine $$$$ CAPITROL® methotrexate, 2.5mg only $$$$$$$$ METHOTREXATE calcipotriene $$$$$$$$$ DOVONEX® acitretin $$$$$$$$$$ SORIATANE®

F. Scabies and Pediculosis Generic Name Relative Cost Brand Name lindane $$ LINDANE crotamiton $$$ EURAX® 5% $$$$$ ELIMITE® malathion $$$$$$$ OVIDE®

G. Viral Infections Generic Name Relative Cost Brand Name acyclovir $$$$$$$$ ZOVIRAX® podofilox $$$$$$$$$ CONDYLOX® imiquimod (MDL) $$$$$$$$$ ALDARA™ (MDL)

H. Miscellaneous Generic Name Relative Cost Brand Name selenium sulfide shampoo 2.5% $ SELSUN® hydrocortisone cream $$ PROCTOCREAM®-HC 2.5% aluminum chloride $$ DRYSOL® ketoconazole $$$$$ NIZORAL® SHAMPOO 1%/pramoxine cream $$$$$$$ ANALPRAM-HC® ammonium lactate $$$$$$$ LAC-HYDRIN®

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hydrocortisone acetate/pramoxine foam $$$$$$$ PROCTOFOAM® HC /prilocaine (MDL) $$$$$$$$ EMLA® (MDL) tacrolimus $$$$$$$$ PROTOPIC® $$$$$$$$ FLUOROPLEX® pimecrolimus cream $$$$$$$$ ELIDEL® fluorouracil $$$$$$$$$ CARAC™ fluorouracil $$$$$$$$$ EFUDEX® becaplermin (MDL) $$$$$$$$$$ REGRANEX® (MDL)

VI. Ear, Nose, and Throat A. Ear Generic Name Relative Cost Brand Name benzocaine/antipyrine $ AURALGAN® OTIC $ VOSOL® OTIC acetic acid/hydrocortisone $ VOSOL® HC OTIC acetic acid/aluminum acetate $$ DOMEBORO® OTIC /polymyxin B/hydrocortisone $$$$ CORTISPORIN® OTIC trolamine polypeptide oleate $$$$ CERUMENEX®

B. Nose Generic Name Relative Cost Brand Name spray $$$$$$$$ NASONEX® triamcinolone acetonide spray $$$$$$$$ NASACORT® AQ fluticasone spray $$$$$$$$ FLONASE® spray $$$$$$$$ RHINOCORT® AQUA® Others ipratropium spray $$$$$ ATROVENT® spray $$$$$$$$ ASTELIN®

C. Throat and Mouth Generic Name Relative Cost Brand Name chlorhexidine gluconate $ PERIDEX® lidocaine viscous $ XYLOCAINE® triamcinolone paste $ KENALOG® IN ORABASE® cevimeline $$$$$$$$$$ EVOXAC™ pilocarpine $$$$$$$$$$ SALAGEN®

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VII. Endocrinology A. Adrenal Corticosteroids Generic Name Relative Cost Brand Name $ DELTASONE® $ DECADRON® $ PREDNISOLONE prednisolone $$ PRELONE® SYRUP $$ FLORINEF® acetate $$$ $$$ MEDROL® hydrocortisone $$$ CORTEF® prednisolone sod. phos. $$$$$$ PEDIAPRED®

B. Diabetes Mellitus Generic Name Relative Cost Brand Name Oral Agents glipizide $ GLUCOTROL® tolazamide $ TOLINASE® chlorpropamide $ DIABINESE® $ ORINASE® glyburide $ DIABETA® glyburide $ MICRONASE® glyburide micronized $$ GLYNASE® glimepiride $$$ AMARYL® $$$$ GLUCOPHAGE® glipizide ext-rel $$$$$$ GLUCOTROL XL® acarbose $$$$$$$ PRECOSE® glyburide/metformin $$$$$$$ GLUCOVANCE™ pioglitazone $$$$$$$$ ACTOS® $$$$$$$$ AVANDIA® rosiglitazone/metformin $$$$$$$$ AVANDAMET® isophane human 70%/ $$ HUMULIN® 70/30 regular 30% (OTC) insulin human (OTC) $$ HUMULIN® R insulin isophane human 50%/ $$ HUMULIN® 50/50 regular 50% (OTC) insulin human (OTC) $$ HUMULIN® L insulin isophane human (NPH) (OTC) $$ HUMULIN® N extended insulin zinc human (OTC) $$ HUMULIN® U insulin isophane human 70%/ $$ NOVOLIN® 70/30 regular 30% (OTC) insulin human (OTC) $$ NOVOLIN® R insulin isophane human (NPH) (OTC) $$ NOVOLIN® N insulin zinc human (OTC) $$ NOVOLIN® L

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$$$$$$ LANTUS® protamine 75%/ $$$$$$ HUMALOG® MIX 75/25™ insulin lispro 25% $$$$$$ NOVALOG® insulin lispro $$$$$$ HUMALOG® Glucose Elevating Agents , human recomb. $$$$$$$$ GLUCAGON Diabetes Monitoring Products lancets $ LANCETS insulin syringes $$ BD™ INSULIN SYRINGES glucose test strips $$$$ ACCU-CHEK® ADVANTAGE glucose test strips $$$$ ACCU-CHEK® COMFORT CURVE glucose test strips $$$$ ACCU-CHEK® EASY TEST glucose test strips $$$$ ACCU-CHEK® INSTANT TEST glucose test strips $$$$ ACCU-CHEK® INSTANT PLUS glucose test strips $$$$ ACCU-CHEK® SIMPLICITY glucose test strips $$$$ ONE TOUCH® glucose test strips $$$$ ONE TOUCH® ULTRA glucose test strips $$$$ CHEMSTRIP bG® glucose test strips $$$$ CHEMSTRIP bG® VISUAL glucose test strips $$$$ FAST TAKE® glucose test strips $$$$ FREESTYLE™ glucose test strips $$$$ SURESTEP® glucose test strips $$$$ SURESTEP® PRO TEST glucose test strips $$$$ TRACER® bG™

C. Osteoporosis Generic Name Relative Cost Brand Name risedronate $$$$$$ ACTONEL® alendronate $$$$$$$ FOSAMAX® $$$$$$$ EVISTA® -salmon nasal $$$$$$$ MIACALCIN®

D. Paget’s Disease Generic Name Relative Cost Brand Name risedronate $$$$$$ ACTONEL® alendronate $$$$$$$ FOSAMAX® etidronate $$$$$$$$ DIDRONEL®

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E. Thyroid Modifiers Generic Name Relative Cost Brand Name thyroid $ ARMOUR® THYROID $ LEVOTHROID® levothyroxine $ LEVOXYL® propylthiouracil $ PROPYLTHIOURACIL levothyroxine $ SYNTHROID® liothyronine $$ CYTOMEL® methimazole $$$$$$$ TAPAZOLE®

F. Miscellaneous Generic Name Relative Cost Brand Name desmopressin nasal $$$$$$$$ DDAVP® desmopressin tabs $$$$$$$$ DDAVP®

VIII. Gastrointestinal A. Diarrhea Generic Name Relative Cost Brand Name loperamide $ IMODIUM® diphenoxylate/atropine $ LOMOTIL®

B. Emesis Generic Name Relative Cost Brand Name $ ANTIVERT® $ PHENERGAN® $ REGLAN® thiethylperazine $ TORECAN® trimethobenzamide $ TIGAN® $$ COMPAZINE® granisetron (MDL) $$$$$$$$ KYTRIL® (MDL) (MDL) $$$$$$$$$$ ZOFRAN® (MDL)

C. Inflammatory Bowel Disease Generic Name Relative Cost Brand Name sulfasalazine $$$ AZULFIDINE® sulfasalazine delayed-rel $$$$ AZULFIDINE EN-TABS® olsalazine sodium $$$$$$ DIPENTUM® mesalamine tabs delayed-rel $$$$$$ ASACOL® mesalamine caps ext-rel $$$$$$$$ PENTASA hydrocortisone acetate foam $$$$$$$$$ CORTIFOAM® hydrocortisone enema $$$$$$$$$ CORTENEMA® mesalamine rectal supp $$$$$$$$$$ ROWASA®

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D. Pancreatic Enzymes Generic Name Relative Cost Brand Name pancrelipase $$$$$$ VIOKASE® pancrelipase $$$$$$$$ PANCREASE® pancrelipase delayed-rel $$$$$$$$ PANCREASE® MT pancrelipase delayed-rel $$$$$$$$ CREON® pancrelipase delayed-rel $$$$$$$$$$ ULTRASE® pancrelipase delayed-rel $$$$$$$$$$ ULTRASE® MT

E. Reflux (GERD) Generic Name Relative Cost Brand Name $$ TAGAMET® metoclopramide $$$ REGLAN® tabs $$$ ZANTAC® , except orally disintegrating tabs $$$$ PEPCID® delayed-rel $$$$$ PROTONIX® delayed-rel $$$$$$ ACIPHEX® delayed-rel $$$$$$$$$ NEXIUM® delayed-rel (10mg and 40mg only) $$$$$$$$$$ PRILOSEC® (10mg and 40mg only)

F. Spasm Generic Name Relative Cost Brand Name atropine/hyoscyamine/scopolamine/ $ DONNATAL® phenobarbital hyoscyamine sulfate $ LEVSIN® dicyclomine $$ BENTYL® hyoscyamine sulfate ext-rel $$$ LEVSINEX® hyoscyamine sulfate ext-rel $$$$ LEVBID®

G. Ulcers Generic Name Relative Cost Brand Name Peptic Ulcer/H Pylori Treatment ranitidine tabs $ ZANTAC® cimetidine $$ TAGAMET® famotidine, except orally distintegrating $$$$ PEPCID® tabs $$$$$ CARAFATE® rabeprazole delayed-rel $$$$$$ ACIPHEX® esomeprazole delayed-rel $$$$$$$$$ NEXIUM® omeprazole delayed-rel (10mg and 40mg only) $$$$$$$$$$ PRILOSEC® (10mg and 40mg only)

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H. Miscellaneous Generic Name Relative Cost Brand Name lactulose $ CHRONULAC® peg 3350/electrolytes $$ GOLYTELY® peg 3350/sodium bicarbonate/ $$$ NULYTELY® sodium chloride/potassium chloride sodium $$$$ VISICOL™ lactulose $$$$$ CEPHULAC® bismuth subsalicylate + metronidazole + $$$$$ HELIDAC® tetracycline ursodiol $$$$$$$$ ACTIGALL® $$$$$$$$ CYTOTEC® ursodiol $$$$$$$$ URSO®

IX. Infectious Diseases A. Antimicrobials Generic Name Relative Cost Brand Name Beta-Lactam penicillin VK $ VEETIDS® , except film-coated tabs $ AMOXIL® ampicillin $ PRINCIPEN® $$ DICLOXACILLIN amoxicillin/clavulanate $$$$ AUGMENTIN® amoxicillin/clavulanate $$$$$ AUGMENTIN® ES 600 Cephalosporins First Generation cephalexin (not tabs) $ KEFLEX® cephalexin $$$ VELOSEF® Second Generation cefaclor $$$ CECLOR® cefprozil $$$$$$ CEFZIL® loracarbef $$$$$$ LORABID® Third Generation cefdinir $$$$$ OMNICEF® Fluoroquinolones norfloxacin $$$$$ NOROXIN® moxifloxacin $$$$$$ AVELOX® ciprofloxacin (not XR) $$$$$$ CIPRO® (not XR) levofloxacin $$$$$$ LEVAQUIN™

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Macrolides erythromycin stearate $ ERYTHROCIN® erythromycin $ ERYTHROMYCIN BASE FILMTAB erythromycin delayed-rel pellets $ ERYC® erythromycin ethylsuccinate $$ E.E.S.® erythromycin delayed-rel $$ ERY-TAB® erythromycin/sulfisoxazole $$ PEDIAZOLE® azithromycin (MDL) $$$$ ZITHROMAX® (MDL) clarithromycin $$$$ BIAXIN® clarithromycin ext-rel $$$$$ BIAXIN® XL Sulfonamides sulfamethoxazole/trimethoprim $ BACTRIM® sulfisoxazole $$ GANTRISIN® tetracycline $ SUMYCIN® doxycycline hyclate $ VIBRAMYCIN® minocycline, except 75 mg $$$ MINOCIN®

B. Antifungals Generic Name Relative Cost Brand Name nystatin $$ MYCOSTATIN® ultramicrosize $$$ GRIS-PEG griseofulvin microsize $$$ GRIFULVIN V® ketoconazole $$$$ NIZORAL® clotrimazole troches $$$$$$ MYCELEX® fluconazole (PA, MDL) $$$$$$$ DIFLUCAN® (PA, MDL) terbinafine (PA) $$$$$$$$ LAMISIL® (PA)

C. Antivirals Generic Name Relative Cost Brand Name Cytomegalovirus ganciclovir $$$$$$$$$$ CYTOVENE® Hepatitis Viral hepatitis treatment recommendations from the Centers for Disease Control and Prevention (CDC) are available at: www.cdc.gov/ncidod/diseases/hepatitis/index.htm. Hepatitis B $$$$$$$ EPIVIR-HBV® Herpes acyclovir $ ZOVIRAX® valacyclovir $$$ VALTREX®

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HIV/AIDS Non-nucleoside Reverse Transcriptase Inhibitors $$$$$ VIRAMUNE® $$$$$$ RESCRIPTOR® $$$$$$$$ SUSTIVA® Nucleoside Analogues zalcitabine $$$$$$$$ HIVID® didanosine $$$$$$$$ VIDEX® lamivudine $$$$$$$$ EPIVIR® emtricitabine $$$$$$$$ EMTRIVA™ stavudine $$$$$$$$ ZERIT® $$$$$$$$ RETROVIR® $$$$$$$$ ZIAGEN® lamivudine/zidovudine $$$$$$$$$ COMBIVIR® abacavir/lamivudine/zidovudine $$$$$$$$$$ TRIZIVIR® Nucleotide Analogues tenofovir $$$$$$$$$ VIREAD® Protease Inhibitors sulfate $$$$$$$$ CRIXIVAN® $$$$$$$$$ VIRACEPT® amprenavir $$$$$$$$$ AGENERASE® saquinavir $$$$$$$$$ FORTOVASE® atazanavir $$$$$$$$$ REYATAZ™ lopinavir/ $$$$$$$$$ KALETRA® ritonavir $$$$$$$$$ NORVIR® Influenza amantadine, except tabs $ AMANTADINE Tuberculosis and Mycobacterium Avium Complex isoniazid $ ISONIAZID pyrazinamide $$$$$ PYRAZINAMIDE rifampin $$$$$ RIFADIN® ethambutol $$$$$ MYAMBUTOL® rifabutin $$$$$$$ MYCOBUTIN®

D. Miscellaneous Generic Name Relative Cost Brand Name pyrimethamine $ DARAPRIM® metronidazole tabs $ FLAGYL® $ PLAQUENIL® dapsone $ DAPSONE sulfamethoxazole/trimethoprim $ BACTRIM® $$ VERMOX® doxycycline hyclate $$ VIBRAMYCIN® primaquine $$ PRIMAQUINE phosphate $$ ARALEN® clindamycin $$$ CLEOCIN®

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pentamidine $$$$$ PENTAM® pentamidine $$$$$ NEBUPENT® paromomycin $$$$$$ HUMATIN® atovaquone $$$$$$ MEPRON® vancomycin $$$$$$$$ VANCOCIN®

E. Web site reference Bacterial Endocarditis The 1997 American Association recommendations for Prevention of Bacterial Endocarditis are available at: http://216.185.112.5/presenter.jhtml?identifier=1729. International Travel Drugs used for international travel are not covered on the BCBSNM drug formulary. Current recommendations for international travel are available from the Centers for Disease Control and Prevention (CDC) at www.cdc.gov/travel. Sexually Transmitted Diseases Information on STDs is available from the Centers for Disease Control and Prevention at: www.cdc.gov/health/std.htm. Sinusitis Treatment of Acute Bacterial Sinusitis can be complex. View an evidence-based summary of how to approach Acute Bacterial Sinusitis at http://www.ahcpr.gov/clinic/epcsums/sinussum.htm.

X. Musculoskeletal A. Gout Generic Name Relative Cost Brand Name allopurinol $ ZYLOPRIM® colchicine $$$ COLCHICINE probenecid $$$$$$ PROBENECID

B. Rheumatoid and Osteoarthritis Generic Name Relative Cost Brand Name NSAIDs and Other Analgesics piroxicam $ FELDENE® indomethacin $$ INDOCIN® ibuprofen $$$ MOTRIN® naproxen $$$ NAPROSYN® salsalate $$$ DISALCID™ naproxen sodium $$$$ ANAPROX® sulindac $$$$$ CLINORIL® diclofenac sodium delayed-rel $$$$$ VOLTAREN® fenoprofen $$$$$ NALFON® etodolac $$$$$ LODINE® ketoprofen $$$$$ ORUDIS® flurbiprofen $$$$$$ ANSAID® indomethacin ext-rel $$$$$$ INDOCIN® SR diflunisal $$$$$$ DOLOBID®

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ketoprofen ext-rel $$$$$$$ ORUVAIL® rofecoxib (ST, MDL) $$$$$$$$ VIOXX® (ST, MDL) tolmetin $$$$$$$$ TOLECTIN® meclofenamate $$$$$$$$$$ MECLOFENAMATE Disease Modifying Antirheumatic Drugs (DMARDS) sulfasalazine delayed-rel $$$$ AZULFIDINE EN-TABS® sulfasalazine $$$$$ AZULFIDINE® hydroxychloroquine $$$$$ PLAQUENIL® methotrexate, 2.5 mg only $$$$$$ RHEUMATREX® azathioprine $$$$$$ IMURAN® penicillamine $$$$$$$ CUPRIMINE® auranofin $$$$$$$$$ RIDAURA® leflunomide $$$$$$$$$$ ARAVA®

C. Skeletal Muscle Relaxants Generic Name Relative Cost Brand Name Spasm $ FLEXERIL® chlorzoxazone $ PARAFON FORTE® DSC methocarbamol $$$ ROBAXIN® carisoprodol $$$ SOMA® carisoprodol/aspirin $$$$$ SOMA® COMPOUND Spasticity $ VALIUM® baclofen $$ LIORESAL® dantrolene $$$$$ DANTRIUM®

XI. OB-GYN A. Contraceptives Generic Name Relative Cost Brand Name Monophasic (EE = ethinyl , ME=) 20 mcg 20/1 EE/norethindrone acetate/ $$$ LOESTRIN® FE 1/20 20/1 EE/norethindrone acetate $$$$ LOESTRIN® 1/20 30 mcg estrogen 30/1.5 EE/norethindrone/acetate/iron $$$ LOESTRIN® FE 1.5/30 30/0.3 EE/ $$$ YASMIN® 30/0.15 EE/ $$$ LEVORA® 30/0.3 EE/ $$$$ LOW-OGESTREL® 30/0.15 EE/ $$$$$ ORTHO-CEPT® 30/1.5 EE/norethindrone acetate $$$$$ LOESTRIN® 1.5/30

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35 mcg estrogen 35/1 EE/ethynodiol diacetate $$$ ZOVIA™ 1/35 35/0.4 EE/norethindrone $$$$ OVCON® 35 35/0.25 EE/ $$$$$ ORTHO-CYCLEN® 35/1 EE/norethindrone $$$$$ ORTHO-NOVUM® 1/35 35/0.5 EE/norethindrone $$$$$ MODICON® 50 mcg estrogen 50/1 EE/ethynodiol diacetate $$$$$ ZOVIA™ 1/50 50/1 ME/norethindrone $$$$$ ORTHO-NOVUM® 1/50 50/1 EE/norethindrone $$$$$ OVCON® 50 50/0.5 EE/norgestrel $$$$$$ OGESTREL® Biphasic 20/0.15 EE/desogestrel $$$ MIRCETTE® EE/norethindrone $$$$$$ ORTHO-NOVUM® 10/11 Triphasic EE/levonorgestrel $$ TRIVORA™ EE/norethindrone acetate/iron $$$ ESTROSTEP® FE EE/norethindrone $$$ TRI-NORINYL® EE/desogestrel $$$$ CYCLESSA™ EE/norgestimate $$$$$ ORTHO TRI-CYCLEN® EE/norethindrone $$$$$ ORTHO-NOVUM® 7/7/7 Progestin norgestrel $$$$$ OVRETTE® norethindrone $$$$$$ MICRONOR® Transdermal EE/ $$$$$$$ ORTHO EVRA™ Intravaginal EE/ $$$$$$$$ NUVARING® Injectable acetate 150 mg/mL $ DEPO-PROVERA®

B. Endometriosis Generic Name Relative Cost Brand Name $$$$$$$$ DANOCRINE®

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C. /Postmenopausal Osteoporosis Generic Name Relative Cost Brand Name Systemic estradiol $ ESTRACE® $ OGEN® estrogens esterified $ ESTRATAB® estrogens, conjugated $ CENESTIN® estrogens, conjugated $ PREMARIN® estradiol transdermal $ ESCLIM® estradiol transdermal $$ ESTRADERM® estradiol transdermal $$ VIVELLE® estradiol transdermal $$ ALORA™ EE/norethindrone acetate $$ FEMHRT® estradiol transdermal $$ CLIMARA® estradiol transdermal $$$ VIVELLE-DOT® estrogens, conjugated/medroxyprogesterone $$$$$ PREMPHASE® estrogens, conjugated/medroxyprogesterone $$$$$ PREMPRO™ Vaginal estradiol vaginal tabs $$ VAGIFEM® estradiol vaginal ring $$$ FEMRING® $$$$ CRINONE™ 8% estrogens, conjugated cream $$$$ PREMARIN® estradiol vaginal ring $$$$ ESTRING™ estradiol vaginal cream $$$$$$ ESTRACE® CREAM progesterone $$$$$$$$ CRINONE™ 4% Progestins Systemic medroxyprogesterone acetate $ PROVERA® progesterone, micronized $$ PROMETRIUM®

D. Vaginal Infections Generic Name Relative Cost Brand Name metronidazole tabs $ FLAGYL® ORAL triple sulfa $ SULTRIN® fluconazole (MDL) $ DIFLUCAN® 150 ORAL (MDL) $$$$$$ TERAZOL® 3/7 clindamycin supp $$$$$$ CLEOCIN® metronizadole $$$$$$ METROGEL® VAGINAL clindamycin cream $$$$$$ CLEOCIN®

E. Miscellaneous Generic Name Relative Cost Brand Name methylergonovine $ METHERGINE®

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XII. Ophthalmic A. Allergy Generic Name Relative Cost Brand Name cromolyn sodium $$$$$ CROLOM® $$$$$$ ZADITOR™ $$$$$$$$ ALOMIDE® $$$$$$$$$$ LIVOSTIN®

B. Anti-Inflammatories Generic Name Relative Cost Brand Name neomycin/polymyxin B/dexamethasone $ MAXITROL® prednisolone phosphate 0.125% $ INFLAMASE® MILD 1% $$ PRED FORTE® flurbiprofen $$ OCUFEN® dexamethasone sodium phosphate $$$ DECADRON® prednisolone phosphate 1% $$$ INFLAMASE® FORTE neomycin/dexamethasone $$$ NEODECADRON® $$$ FML® $$$ FLAREX® sulfacetamide 10%/ $$$ VASOCIDIN® prednisolone phosphate 0.25% $$$ HMS® prednisolone acetate 0.12% $$$$ PRED MILD® sulfacetamide/fluorometholone $$$$ FML-S® gentamicin/prednisolone acetate $$$$$ PRED-G® dexamethasone $$$$$ MAXIDEX® sulfacetamide 10%/prednisolone 0.2% $$$$$$ BLEPHAMIDE® tobramycin/dexamethasone $$$$$$ TOBRADEX® diclofenac sodium $$$$$$ VOLTAREN® neomycin/polymyxin B/hydrocortisone $$$$$$$$ CORTISPORIN®

C. Infections Generic Name Relative Cost Brand Name Bacterial bacitracin $ AK-TRACIN™ erythromycin $ ILOTYCIN® gentamicin $ GARAMYCIN® sulfacetamide 10% $ BLEPH®-10 tobramycin $ TOBREX® bacitracin/polymyxin B $ POLYSPORIN® sulfacetamide/ $$ VASOSULF® polymyxin B/trimethoprim $$$ POLYTRIM® neomycin/polymyxin B/gramicidin $$$$ NEOSPORIN® ofloxacin $$$$$ OCUFLOX® ciprofloxacin $$$$$ CILOXAN®

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moxifloxacin $$$$$ VIGAMOX™ Viral vidarabine $$$$$ VIRA-A® trifluridine $$$$$$$$$$ VIROPTIC®

D. Glaucoma Generic Name Relative Cost Brand Name Oral acetazolamide $$$ DIAMOX® methazolamide $$$$$ NEPTAZANE® acetazolamide ext-rel $$$$$$ DIAMOX® SEQUELS® Topical dipivefrin $ PROPINE® timolol maleate $ TIMOPTIC® pilocarpine $ ISOPTO® CARPINE levobunolol $$ BETAGAN® timolol hemihydrate $$ BETIMOL® timolol maleate gel $$ TIMOPTIC-XE® metipranolol $$$ OPTIPRANOLOL® betaxolol $$$$ BETOPTIC® S carbachol $$$$$ ISOPTO® CARBACHOL brinzolamide $$$$$$ AZOPT® latanoprost $$$$$$ XALATAN® bimatoprost $$$$$$ LUMIGAN® pilocarpine $$$$$$ PILOPINE HS® GEL epinephrine $$$$$$$ EPIFRIN® brimonidine $$$$$$$$ ALPHAGAN® P

E. Miscellaneous Generic Name Relative Cost Brand Name $ ALBALON® atropine $ ISOPTO® ATROPINE homatropine $ ISOPTO® HOMATROPINE scopolamine $$$ ISOPTO® HYOSCINE tropicamide $$$ MYDRIACYL® cyclopentolate $$$$ CYCLOGYL® apraclonidine 0.5% $$$$$$$$$$ IOPIDINE®

XIII. Psychiatric A. Alcohol Deterrents Generic Name Relative Cost Brand Name disulfiram $$$$ ANTABUSE® naltrexone (MDL) $$$$$$$$ REVIA® (MDL)

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B. Anxiety Generic Name Relative Cost Brand Name $ XANAX® diazepam $ VALIUM® hcl $ ATARAX® hydroxyzine pamoate $ VISTARIL® chlordiazepoxide $ LIBRIUM® $$$ SERAX® lorazepam $$$ ATIVAN® buspirone $$$$$ BUSPAR® $$$$$$ PAXIL® sertraline $$$$$$ ZOLOFT® venlafaxine ext-rel $$$$$$$ EFFEXOR® XR

C. Attention Deficit Hyperactivity Disorder Generic Name Relative Cost Brand Name $$ DEXEDRINE® methylphenidate $$ RITALIN® methylphenidate ext-rel 20mg $$$ RITALIN-SR® dextroamphetamine ext-rel $$$$ DEXEDRINE® SPANSULE®

D. Bipolar Disorders Generic Name Relative Cost Brand Name lithium carbonate $ LITHIUM CARBONATE lithium carbonate ext-rel caps $$$ ESKALITH CR® lithium carbonate ext-rel tabs $$$$ LITHOBID® divalproex sodium delayed-rel $$$$$$$ DEPAKOTE® $$$$$$$$$ ZYPREXA®

E. Depression Generic Name Relative Cost Brand Name amitriptyline $ ELAVIL® $ SINEQUAN® $ DESYREL® amitriptyline/ $$ AMITRIPTYLINE/ PERPHENAZINE $$ NORPRAMIN® hcl $$ TOFRANIL® imipramine pamoate $$ TOFRANIL® PM $$ PAMELOR® fluoxetine $$$ PROZAC® $$$ LUDIOMIL® $$$ ANAFRANIL® $$$$ REMERON®

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$$$$$ ASENDIN® phenelzine $$$$$ NARDIL® paroxetine $$$$$ PAXIL® $$$$$ PARNATE® citalopram $$$$$ CELEXA™ escitalopram $$$$$ LEXAPRO™ sertraline $$$$$$ ZOLOFT® (ST) (not SR or XL tabs) $$$$$$ WELLBUTRIN® (ST) (not SR or XL tabs) amoxapine $$$$$$ AMOXAPINE paroxetine controlled release $$$$$$$ PAXIL CR™ venlafaxine ext-rel $$$$$$$ EFFEXOR® XR venlafaxine $$$$$$$$ EFFEXOR®

F. Insomnia Generic Name Relative Cost Brand Name $ HALCION® temazepam $ RESTORIL® chloral hydrate $$$$ CHLORAL HYDRATE

G. Narcolepsy Generic Name Relative Cost Brand Name methylphenidate $$$$ RITALIN® dextroamphetamine $$$$ DEXEDRINE® methylphenidate ext-rel 20mg $$$$$ RITALIN-SR® dextroamphetamine ext-rel $$$$$$$ DEXEDRINE® SPANSULE

H. Psychoses Generic Name Relative Cost Brand Name $ HALDOL® decanoate $ PROLIXIN® thiothixene $$ NAVANE® $$ MELLARIL® perphenazine $$ TRILAFON® $$$ STELAZINE® $$$$$ THORAZINE® $$$$$$$$ LOXITANE® $$$$$$$$ RISPERDAL® $$$$$$$$$ SEROQUEL® $$$$$$$$$ CLOZARIL® olanzapine $$$$$$$$$ ZYPREXA®

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XIV. Respiratory Drugs A. Asthma/COPD Generic Name Relative Cost Brand Name Asthma Information about asthma is available at: www.nlm.nih.gov. Chronic Obstructive Pulmonary Disease (COPD) Information about COPD is available at: www.health.nih.gov. Inhalers albuterol $$$ PROVENTIL® pirbuterol, autohaler $$$$ MAXAIR™ metoproteranol $$$$$ ALUPENT® formoterol $$$$$$$ FORADIL® salmeterol xinafoate $$$$$$$$ SEREVENT® DISKUS® Corticosteroids budesonide powder $$$$$ PULMICORT® TURBUHALER® beclomethasone $$$$$ QVAR™ triamcinolone acetonide $$$$$ AZMACORT® fluticasone powder (based on 100 mcg) $$$$$$ FLOVENT® ROTADISK® fluticasone (based on 110 mcg) $$$$$$$ FLOVENT® Others $$$$$$$ ATROVENT® ipratropium bromide/albuterol sulfate $$$$$$$$$ COMBIVENT® $$$$$$$$$ TILADE® cromolyn sodium $$$$$$$$$$ INTAL® salmeterol/fluticasone powder $$$$$$$$$$ ADVAIR DISKUS® (based on 250 mcg) Oral Agents Beta albuterol sulfate $$$$ PROVENTIL® metaproterenol tabs $$$$ ALUPENT® terbutaline $$$$$$ BRETHINE® Leukotriene Modifiers $$$$$$$ ACCOLATE® montelukast $$$$$$$$ SINGULAIR® Theophyllines ext-rel tabs $$$$$ THEOCHRON® theophylline liquid $$$$$ THEOPHYLLINE theophylline caps $$$$$ SLO-BID® theophylline tabs $$$$$ THEO-DUR® theophylline ext-rel caps (12 hr) $$$$$$$ THEOPHYLLINE EXT-REL theophylline ext-rel caps $$$$$$$ THEO-24® theophylline ext-rel tabs $$$$$$$ UNIPHYL® Inhalations for Nebulization albuterol sulfate soln $$$ PROVENTIL®

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cromolyn sodium soln $$$$$$ INTAL® metaproterenol soln $$$$$$$ ALUPENT® ipratropium bromide soln $$$$$$$$ ATROVENT® albuterol sulfate/ipratropium bromide soln $$$$$$$$$$ DUONEB™ budesonide susp $$$$$$$$$$ PULMICORT® RESPULES

B. Antihistamines and Decongestants Generic Name Relative Cost Brand Name First Generation Antihistamines promethazine $ PHENERGAN® diphenhydramine $$ DIPHENHYDRAMINE hydroxyzine hydrochlorothiazide $$$ ATARAX® hydroxyzine pamoate $$$$ VISTARIL® 2.68mg $$$$ TAVIST® $$$$$ PERIACTIN® / Combinations chlorpheniramine 8mg / $$$ DECONAMINE® SR 120mg ext-rel 6mg / $$$ BROMFED-PD® pseudoephedrine 60mg ext-rel brompheniramine 12mg / $$$ BROMFED® pseudoephedrine 120mg ext-rel 4mg / $$$$$$$ RONDEC® DROPS pseudoephedrine 60mg carbinoxamine 8mg / $$$$$$$ RONDEC®-TR pseudoephedrine 120mg ext-rel /pseudoephedrine ext-rel $$$$$$$$ TRINALIN® REPETABS

C. Antitussives and Expectorants Generic Name Relative Cost Brand Name guaifenesin ext-rel $ HUMIBID® L.A. dextromethorphan/carbinoxamine/ $ CARDEC®-DM pseudoephedrine drops dextromethorphan/promethazine $ PHENERGAN® DM codeine/promethazine $ PHENERGAN® w/CODEINE hydrocodone/homatropine $ HYCODAN® codeine/promethazine/phenylephrine $ PHENERGAN® VC w/CODEINE codeine/guaifenesin $ ROBITUSSIN A-C® codeine/chlorpheniramine/pseudoephedrine $ NOVAHISTINE® DH codeine/pseudoephedrine/guaifenesin $ ROBITUSSIN®-DAC benzonatate $$ TESSALON® guaifenesin/pseudoephedrine ext-rel $$ ENTEX® PSE dextromethorphan/ $$ DIMETANE®-DX brompheniramine/pseudoephedrine

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XV. Supplements A. Potassium Generic Name Relative Cost Brand Name potassium chloride liquid $ KAOCHLOR® S-F potassium chloride ext-rel tabs 8mEq $ SLOW-K® potassium chloride ext-rel caps 10mEq $ MICRO-K® potassium chloride ext-rel tabs 10mEq $$ KLOR-CON® potassium chloride ext-rel tabs 20mEq $$ K-DUR® potassium chloride ext-rel tabs 10mEq $$ K-DUR® potassium chloride ext-rel caps 8mEq $$$ MICRO-K® 8 potassium chloride packets 20mEq $$$$ K-LOR™

B. Vitamins and Minerals Generic Name Relative Cost Brand Name cyanocobalamin injection $ VITAMIN B-12 folic acid $ FOLIC ACID fluoride tablets $ LURIDE® LOZI-TABS® multivitamins/fluoride/ $ POLY-VI-FLOR® ±iron drops/tabs vitamins ADC/fluoride/±iron drops $ TRI-VI-FLOR® fluoride drops $ LURIDE® prenatal vitamins w/folic acid $ PRENATAL VITAMINS w/FOLIC ACID vitamin B complex w/vitamin C and folic $ NEPHRO-VITE® RX acid phytonadione $ MEPHYTON® ergocalciferol (D2) $$$$ DRISDOL® calcitriol (1,25-D3) $$$$ ROCALTROL®

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XVI. Urological A. Symptomatic Benign Prostatic Hyperplasia Generic Name Relative Cost Brand Name doxazosin $ CARDURA® terazosin $$$ HYTRIN® alfuzosin $$$$$ UROXATRAL® tamsulosin $$$$$$ FLOMAX® $$$$$$$$ PROSCAR®

B. Miscellaneous Generic Name Relative Cost Brand Name phenazopyridine $ PYRIDIUM® oxybutynin $ DITROPAN® propantheline $$$$ PRO-BANTHINE® oxybutynin patch $$$$$$ OXYTROL™ tolterodine ext-rel $$$$$$$ DETROL LA® tolterodine $$$$$$$$ DETROL® bethanechol $$$$$$$$ URECHOLINE® flavoxate $$$$$$$$ URISPAS®

XVII. Miscellaneous A. Anaphylaxis Emergency Generic Name Relative Cost Brand Name epinephrine $$$$$$ EPIPEN® epinephrine $$$$$$ EPIPEN® JR.

B. Subarachnoid Hemorrhage Generic Name Relative Cost Brand Name nimodipine $$$$$$$$ NIMOTOP®

C. Wilson's Disease Generic Name Relative Cost Brand Name penicillamine $$$$$$$ CUPRIMINE® zinc acetate $$$$$$$$ GALZIN™

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The Pharmacy and Therapeutics Committee meets quarterly and reviews this list for possible additions/deletions. Members are notified in the Blues Healthline newsletter, and Providers are notified in the Blues Provider newsletter of any changes to the Drug List. (Note: some drugs may require prior approval and/or may be limited to specific quantities.)

3-Tier Plan Not all members currently have the 3-Tier plan, but for those who do, the following information may be helpful in understanding this benefit.

Drug costs continue to rise faster than any other component of health care. This 3-Tier prescription drug plan allows you to make choices and helps us keep your premiums affordable. Unlike other prescription drug plans, this plan allows you to get a prescription drug even if it’s not on the list and to get a brand- name drug even when there is a generic-equivalent available. Make sure to have your prescriptions filled at either a participating pharmacy (see the Network Directory) or through the Managed Prescription Mail Service program.

Your Out-of-Pocket Costs Your copayment is based on two points: ƒ whether you are receiving a generic drug or a brand-name drug AND ƒ whether the drug is on our Drug List (formulary)

Tier 1=lowest copayment Tier 2=middle copayment Tier 3=highest copayment You pay this amount when You pay this amount when You pay this amount when you receive a generic drug you receive a brand-name you receive a drug that is not that is on our Drug List. drug that is on our Drug List on our Drug List. and no generic is available.

If you or your doctor prefer that you receive a brand-name drug when a generic equivalent is available, you’ll pay additional costs:

For a brand-name drug that is on For a brand-name drug that is NOT on our Drug List (generic is available) our Drug List (generic is available) You will pay: The Tier 1 copayment PLUS You will pay: The Tier 1 copayment PLUS the difference in cost between the generic the difference in cost between the generic and brand-name drug. and brand-name drug.

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How to save money with this plan ƒ Ask your doctor to prescribe drugs for you that are on our Drug List (formulary). ƒ When available, use generic-equivalent drugs instead of brand-name drugs. Remember that if a generic drug is not available, you will have to pay Tier 2 for a drug on our Drug List or Tier 3 for a drug that is not on our Drug List. ƒ Use the Managed Prescription Mail Service if you are on for a chronic condition such as high blood pressure. It allows you to get up to a 90-day supply of your medication for only two copayments.

What is a drug list (formulary)? The BCBSNM/HMONM Drug List (formulary) is a list of drugs that are available to members at lower copayment levels. Drugs not on the list are still covered but require a higher copayment. The BCBSNM/HMONM Pharmacy and Therapeutics Committee (made up of physicians and pharmacists) evaluates drugs for therapeutic uniqueness, safety, and cost before including them on the Drug List. Your physician has a copy of our Drug List and should consult it when making prescription drug decisions for you.

Are generics as safe as the brand-name drug? Generic drugs are evaluated by the and Drug Administration and undergo the same scrutiny as brand-name drugs. A generic-equivalent drug must have the same active ingredients and be chemically equivalent to the brand-name drug. Only generic drugs that have the same clinical effects and safety profile as the brand-name drug are covered under BCBSNM plans.

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