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BCBSNM/HMONM Therapeutic Class Drug List (Formulary) 2004

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BCBSNM/HMONM Therapeutic Class Drug List (Formulary) 2004 BCBSNM/HMONM Therapeutic Class Drug List (Formulary) 2004 I. Antineoplastics and Immunosuppressants A. Antineoplastics B. Immunosuppressants II. Blood Modifiers A. Anticoagulants B. Platelet 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. Calcium Channel Blockers G. Diuretics H. Lipid Lowering Agents I. Nitrates J. Miscellaneous IV. Central Nervous System A. Alzheimer’s Disease B. Analgesics C. Migraine D. Parkinson’s Disease E. Seizures V. Dermatology A. Acne B. Bacterial Infections C. Corticosteroids 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 Page 1 of 35 web\web documents\drug formularies\print formulary\print_tc_formulary_2004.doc BCBSNM / HMONM Therapeutic Class Drug List 2004 VII. Endocrinology A. Adrenal Corticosteroids B. Diabetes Mellitus C. Osteoporosis D. Paget's Disease E. Thyroid Modifiers F. Miscellaneous VIII. Gastrointestinal A. Diarrhea B. Emesis C. Inflammatory Bowel Disease D. Pancreatic Enzymes E. Reflux (GERD) F. Spasm G. Ulcers H. Miscellaneous IX. Infectious Diseases A. Antimicrobials B. Antifungals C. Antivirals D. Miscellaneous E. Web site reference X. Musculoskeletal A. Gout B. Rheumatoid and Osteoarthritis C. Skeletal Muscle Relaxants XI. OB-GYN A. Contraceptives B. Endometriosis C. Menopausal/Postmenopausal Symptoms D. Vaginal Infections E. Miscellaneous Page 2 of 35 web\web documents\drug formularies\print formulary\print_tc_formulary_2004.doc BCBSNM / HMONM Therapeutic Class Drug List 2004 XII. Ophthalmic A. Allergy B. Anti-inflammatories C. Infections D. Glaucoma E. Miscellaneous XIII. Psychiatric A. Alcohol Deterrents B. Anxiety C. Attention Deficit Hyperactivity Disorder D. Bipolar Disorders E. Depression F. Insomnia G. Narcolepsy H. Psychoses XIV. Respiratory A. Asthma/COPD B. Antihistamines and Decongestants 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 Page 3 of 35 web\web documents\drug formularies\print formulary\print_tc_formulary_2004.doc BCBSNM / HMONM Therapeutic Class Drug List 2004 I. Antineoplastics and Immunosuppressants A. Antineoplastics Generic Name Relative Cost Brand Name procarbazine hcl $$$$ MATULANE® busalfan $$$$$ MYLERAN® megestral acetate $$$$$ MEGACE® melphalan $$$$$ ALKERAN® leucovorin calcium (adjunctive) $$$$$$ LEUCOVORIN CALCIUM toremifene citrate $$$$$$$ FARESTON® hydroxyurea $$$$$$$ HYDREA® tamoxifen $$$$$$$ NOLVADEX® hydroxyurea $$$$$$$ MYLOCEL® letrozole $$$$$$$ FEMARA® anastrozole $$$$$$$ ARIMIDEX® exemestane $$$$$$$ AROMOSIN® chlorambucil $$$$$$$$ LEUKERAN® methotrexate, 2.5mg only $$$$$$$$ METHOTREXATE nilutamide $$$$$$$$ NILANDRON® thioguanine $$$$$$$$ THIOGUANINE mercaptopurine $$$$$$$$ PURINETHOL® flutamide $$$$$$$$ EULEXIN® bicalutanamide $$$$$$$$ CASODEX® cyclophosphamide $$$$$$$$ CYTOXAN® etoposide $$$$$$$$$ VEPESID® estramustine phosphate sodium $$$$$$$$$ EMCYT® testolactone $$$$$$$$$ TESLAC® thalidomide $$$$$$$$$$ THALOMID® temozolomide $$$$$$$$$$ TEMODAR® capecitabine $$$$$$$$$$ XELODA® altretamine $$$$$$$$$$ HEXALEN® bexarotene $$$$$$$$$$ TARGRETIN® lomustine $$$$$$$$$$ CEENU® mitotane $$$$$$$$$$ LYSODREN® tretinoin $$$$$$$$$$ VESANOID® B. Immunosuppressants Generic Name Relative Cost Brand Name azathioprine $$$$ IMURAN® sirolimus $$$$$$$$ RAPAMUNE® mycophenolate mofetil $$$$$$$$$ CELLCEPT® tacrolimus anhydrous $$$$$$$$$ PROGRAF® cyclosporine $$$$$$$$$ NEORAL® cyclosporine $$$$$$$$$$ SANDIMMUNE® Page 4 of 35 web\web documents\drug formularies\print formulary\print_tc_formulary_2004.doc BCBSNM / HMONM Therapeutic Class Drug List 2004 II. Blood Modifiers A. Anticoagulants Generic Name Relative Cost Brand Name warfarin $$$ COUMADIN® heparin sodium $$$ HEPARIN enoxaparin sodium (MDL) $$$$$$$$$$ LOVENOX® (MDL) B. Platelet Aggregation Inhibitors Generic Name Relative Cost Brand Name dipyridamole $$$ PERSANTINE® clopidogrel $$$$$$$$ PLAVIX® C. Miscellaneous Generic Name Relative Cost Brand Name pentoxifylline ext-rel $$$$ TRENTAL® anagrelide $$$$$$$$$$ AGRYLIN™ Hematopoietic injectable drugs are available at the nonformulary copay. See Prior Authorization (PA) Criteria for information. III. Cardiovascular Agents A. ACE Inhibitors Generic Name Relative Cost Brand Name captopril $ CAPOTEN® enalapril $$ 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 $$$$$$ HYTRIN® Page 5 of 35 web\web documents\drug formularies\print formulary\print_tc_formulary_2004.doc BCBSNM / HMONM Therapeutic Class Drug List 2004 C. Angiotensin II Receptor Blockers Generic Name Relative Cost Brand Name olmesartan $$$$ BENICAR® olmesartan/hydrochlorothiazide $$$$ BENICAR HCT™ losartan $$$$$ COZAAR® losartan/hydrochlorothiazide $$$$$ HYZAAR® valsartan $$$$$$ DIOVAN® valsartan/hydrochlorothiazide $$$$$$ DIOVAN HCT® D. Antirrhythmics and Cardiac Glycosides Generic Name Relative Cost Brand Name digoxin $ LANOXIN® quinidine sulfate $$$$ QUINIDINE SULFATE quinidine gluconate ext-rel $$$$$ QUINAGLUTE® disopyramide $$$$$$ NORPACE® quinidine sulfate ext-rel $$$$$$ QUINIDEX® mexiletine $$$$$$$ MEXITIL® disopyramide ext-rel $$$$$$$ NORPACE CR® amiodarone $$$$$$$$ CORDARONE® procainamide ext-rel (6 hr) $$$$$$$$ PROCAINAMIDE EXT-REL propafenone $$$$$$$$ RYTHMOL® sotalol $$$$$$$$$ BETAPACE® procainamide $$$$$$$$$$ PRONESTYL® E. Beta Blockers Generic Name Relative Cost Brand Name Cardioselective atenolol $ TENORMIN® metoprolol $ LOPRESSOR® atenolol/chlorthalidone $ TENORETIC® betaxolol $$$$ KERLONE® metoprolol ext-rel $$$$ TOPROL-XL® metoprolol/hydrochlorothiazide $$$$$$ LOPRESSOR HCT® Noncardioselective propranolol $ INDERAL® pindolol $$ VISKEN® timolol $$ BLOCADREN® penbutolol $$ LEVATOL® nadolol $$$ CORGARD® propranolol ext-rel $$$$ INNOPRAN XL™ propranolol ext-rel $$$$$ INDERAL® LA Beta and Alpha Blockers labetalol $$$$ NORMODYNE® carvedilol $$$$$$$$ COREG® Page 6 of 35 web\web documents\drug formularies\print formulary\print_tc_formulary_2004.doc BCBSNM / HMONM Therapeutic Class Drug List 2004 F. Calcium Channel Blockers Generic Name Relative Cost Brand Name Dihydropyridines nifedipine $$ PROCARDIA® nicardipine $$$$ CARDENE® nifedipine ext-rel $$$$ ADALAT® CC nisoldipine ext-rel $$$$ SULAR® felodipine ext-rel $$$$$ PLENDIL® amlodipine $$$$$$ NORVASC® Nondihydropyridines verapamil $ CALAN® verapamil ext-rel $$ CALAN® SR diltiazem $$ CARDIZEM® diltiazem ext-rel $$$$ DILACOR XR® diltiazem ext-rel $$$$$$ CARDIZEM® CD diltiazem ext-rel $$$$$$ CARDIZEM® SR diltiazem ext-rel $$$$$$ CARDIZEM® LA G. Diuretics Generic Name Relative Cost Brand Name hydrochlorothiazide $ HYDRODIURIL® chlorthalidone $ HYGROTON® triamterene/hydrochlorothiazide 75/50 $ MAXZIDE® amiloride/hydrochlorothiazide $ MODURETIC® furosemide $ LASIX® triamterene/hydrochlorothiazide 50/25 $ TRIAMTERENE/ HYDROCHLOROTHIAZIDE indapamide $ LOZOL® bumetanide $ BUMEX® triamterene/hydrochlorothiazide 37.5/ $ MAXZIDE®-25 25 tabs triamterene/hydrochlorothiazide 37.5/ $ DYAZIDE® 25 caps amiloride $$ MIDAMOR® spironolactone $$$ ALDACTONE® spironolactone/hydrochlorothiazide $$$ ALDACTAZIDE® metolazone $$$$$ ZAROXOLYN® Page 7 of 35 web\web documents\drug formularies\print formulary\print_tc_formulary_2004.doc BCBSNM / HMONM Therapeutic Class Drug List 2004 H. Lipid Lowering Agents Generic Name Relative Cost Brand Name gemfibrozil $$ LOPID® niacin $$$$$ NIACOR® fluvastatin $$$$$$ LESCOL® cholestyramine cans $$$$$$ QUESTRAN®/ QUESTRAN®-LIGHT cholestyramine pkt $$$$$$ QUESTRAN®/ QUESTRAN®-LIGHT rosuvastatin (MDL) $$$$$$$ CRESTOR® atorvastatin $$$$$$$ LIPITOR® fluvastatin ext-rel $$$$$$$ LESCOL XL® colestipol pkt $$$$$$$ COLESTID® pravastatin $$$$$$$$ PRAVACHOL® pravastatin/buffered aspirin $$$$$$$$ PRAVIGARD™ PAC colestipol tabs $$$$$$$$$ COLESTID® I. Nitrates Generic Name Relative Cost Brand Name isosorbide dinitrate oral $ ISORDIL® isosorbide dinitrate sublingual $ ISORDIL® S.L. nitroglycerin sublingual $$ 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 $$$$ LONITEN® guanabenz $$$$$$ WYTENSIN® clonidine transdermal $$$$$$$$ CATAPRES-TTS® midodrine $$$$$$$$$$ PROAMATINE® Page 8 of 35 web\web documents\drug formularies\print formulary\print_tc_formulary_2004.doc BCBSNM / HMONM Therapeutic Class Drug List 2004 IV. Central Nervous System A. Alzheimer’s Disease Generic Name Relative Cost Brand Name donepezil $$$$$$ ARICEPT® rivastigmine
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