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Medications Exempt from BJC Mail Order Requirement for Plan Year 2021 *

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Medications Exempt from BJC Mail Order Requirement for Plan Year 2021 * Medications Exempt from BJC Mail Order Requirement for Plan Year 2021 * 1-DAY ANBESOL BESIVANCE 3 DAY VAGINAL ANESTHETIC ORAL GEL BETADINE 3-DAY VAGINAL CREAM ANTIFUNGAL BETAMETHASONE ACETATE-SOD PHOS ABSORICA APRACLONIDINE HCL BETAMETHASONE SOD PHOS-ACETATE ABSTRAL ARISTOSPAN BETAMETHASONE SOD PHOS-WATER ACETAMIN-CAFF-DIHYDROCODEINE ARIXTRA BETHANECHOL CHLORIDE ACETAMINOPHEN-CODEINE ARYMO ER BICILLIN C-R ACETIC ACID-ALUMINUM ASA-BUTALB-CAFFEINE-CODEINE BICILLIN L-A ACTIQ ASCOMP WITH CODEINE BILTRICIDE ACTISEP ASPERCREME LIDOCAINE BISACODYL ACULAR ASPIRIN-CAFFEINE-DIHYDROCODEIN BISA-LAX ACULAR LS ATHLETE'S FOOT BLEPH-10 ACYCLOVIR ATHLETIC FOOT CREAM BLEPHAMIDE ACYCLOVIR SODIUM AUGMENTIN BLEPHAMIDE S.O.P. ADDERALL XR AUGMENTIN ES-600 BRIMONIDINE TARTRATE ADHANSIA XR AUGMENTIN XR BROMFENAC SODIUM ADZENYS ER AVC BROMSITE ADZENYS XR-ODT AVELOX BROVANA AEMCOLO AVELOX IV BSS AFREZZA AVIDOXY BSS PLUS AFTERA AVYCAZ BUDESONIDE EC A-HYDROCORT AZACTAM BUDESONIDE ER AK-POLY-BAC AZACTAM-ISO-OSMOTIC DEXTROSE BUPRENEX ALAWAY AZASITE BUPRENORPHINE ALBENDAZOLE AZELASTINE HCL BUPRENORPHINE HCL ALBENZA AZITHROMYCIN BUPRENORPHINE-NALOXONE ALBUTEROL SULFATE AZO URINARY PAIN RELIEF BURN RELIEF ALBUTEROL SULFATE HFA AZO URINARY TRACT DEFENSE BUTALB-ACETAMINOPH-CAFF-CODEIN ALFENTANIL HCL AZO URINARY TRACT HEALTH BUTALB-CAFF-ACETAMINOPH-CODEIN ALLERGY EYE DROPS AZOPT BUTALBITAL COMPOUND-CODEINE ALOCANE EMERGENCY BURN AZTREONAM BUTALBITAL-ASPIRIN-CAFFEINE ALOPHEN PILLS BABY TEETHING GEL BUTORPHANOL TARTRATE ALPHAGAN P BABY TEETHING PAIN MEDICINE BYDUREON ALREX BACIGUENT BYDUREON BCISE ALTACHLORE BACIIM BYDUREON PEN ALTAFLUOR BACITRACIN BYETTA ALTAFLUOR BENOX BACITRACIN-POLYMYXIN CALCITONIN-SALMON AMNESTEEM BACTRIM CANK-OXIDE AMOXICILLIN BACTRIM DS CAPITAL W-CODEINE AMOXICILLIN-CLAVULANATE POT ER BASAGLAR KWIKPEN U-100 CARBAMOXIDE AMOXICILLIN-CLAVULANATE POTASS BAXDELA CAYSTON AMPHETAMINE SULFATE BELBUCA CEDAX AMPICILLIN SODIUM BELLADONNA-OPIUM CEFACLOR AMPICILLIN TRIHYDRATE BENZACLIN CEFACLOR ER AMPICILLIN-SULBACTAM BENZAMYCIN CEFADROXIL AMYTAL SODIUM BENZ-O-STHETIC CEFAZOLIN SODIUM ANASPAZ BEPREVE CEFAZOLIN SODIUM-DEXTROSE * This list is not all-inclusive and does not guarantee coverage Page 1 of 7 Medications Exempt from BJC Mail Order Requirement for Plan Year 2021 * CEFDINIR CLEOCIN PEDIATRIC DEBROX CEFDITOREN PIVOXIL CLEOCIN PHOSPHATE DECADRON CEFIXIME CLEOCIN PHOSPHATE IN D5W DEFERASIROX CEFOTAN CLINDAMYCIN HCL DEFERIPRONE CEFOTAXIME SODIUM CLINDAMYCIN PALMITATE HCL DELTASONE CEFOTETAN CLINDAMYCIN PEDIATRIC DEMECLOCYCLINE HCL CEFOXITIN CLINDAMYCIN PHOS-BENZOYL PEROX DEMEROL CEFOXITIN SODIUM CLINDAMYCIN PHOSPHATE DEPO-MEDROL CEFPODOXIME PROXETIL CLINDAMYCIN PHOSPHATE-D5W DERMATOP CEFPROZIL CLINDAMYCIN-0.9% NACL DERMOTIC CEFTAZIDIME CLINDAMYCIN-BENZOYL PEROXIDE DESOXYN CEFTIBUTEN CLINDESSE DEXABLISS CEFTIN CLOTRIMAZOLE DEXAMETHASONE CEFTRIAXONE CLOTRIMAZOLE AF DEXAMETHASONE ACETATE LA CEFUROXIME CLOTRIMAZOLE-3 DEXAMETHASONE ACETATE-SOD PHOS CEFUROXIME SODIUM CLOTRIMAZOLE-7 DEXAMETHASONE INTENSOL CEFUROXIME SODIUM-0.9% NACL CLOZAPINE DEXAMETHASONE SODIUM PHOSPHATE CELESTONE CLOZAPINE ODT DEXAMETHASONE-0.9% NACL CELLCEPT CLOZARIL DEXAMETHASONE-MOXIFLOXACIN CEPACOL SORE THROAT COCAINE HCL DEXEDRINE CEPHALEXIN CODEINE PHOSPHATE DEXMETHYLPHENIDATE HCL CEQUA CODEINE SULFATE DEXMETHYLPHENIDATE HCL ER CESAMET COLISTIMETHATE DEXONTO CETROTIDE COLLYRIUM DEXPAK CHEMET COLY-MYCIN M PARENTERAL DEXTENZA CHILDREN'S ALAWAY COLY-MYCIN S DEXTROAMPHETAMINE SULFATE CHLORASEPTIC SORE THROAT COMBIPATCH DEXTROAMPHETAMINE SULFATE ER CILOXAN COMPLETE LICE TREATMENT DEXTROAMPHETAMINE-AMPHET ER CIPRO CONZIP DEXTROAMPHETAMINE-AMPHETAMINE CIPRO HC COREMINO DEXYCU CIPRO I.V. CORTANE-B DICLOFENAC SODIUM CIPRODEX CORTEF DICLOXACILLIN SODIUM CIPROFLOXACIN CORTISONE ACETATE DIFLUCAN CIPROFLOXACIN ER CORTISPORIN-TC DIHYDROCODEINE BITARTRATE CIPROFLOXACIN HCL COTEMPLA XR-ODT DILATRATE-SR CIPROFLOXACIN-D5W COUMADIN DILAUDID CIPROFLOXACIN-DEXAMETHASONE CRESEMBA DISKETS CITRATE OF MAGNESIA CROMOLYN SODIUM DITROPAN XL CITROMA CROTAN DOLOPHINE HCL CLAFORAN CYCLOSPORINE DORYX CLARAVIS CYCLOSPORINE IN KLARITY DORZOLAMIDE CLARITHROMYCIN CYSTARAN DORZOLAMIDE HCL CLARITHROMYCIN ER CYSTEX PLUS DOXY 100 CLEARLAX DALVANCE DOXYCYCLINE HYCLATE CLENPIQ DARIFENACIN ER DOXYCYCLINE MONOHYDRATE CLEOCIN DAXBIA DRONABINOL CLEOCIN HCL DAYTRANA DSUVIA * This list is not all-inclusive and does not guarantee coverage Page 2 of 7 Medications Exempt from BJC Mail Order Requirement for Plan Year 2021 * DUCODYL EVEKEO ODT GAMASTAN DULCOLAX EXALGO GAMASTAN S-D DURAMORPH EYE IRRIGATING SOLUTION GANIRELIX ACETATE DUREZOL EYE ITCH RELIEF GATIFLOXACIN DVORAH EYE WASH GATIFLOXACIN-DEXAMETHASONE DXEVO EYE-STREAM GAVILAX DYANAVEL XR FACTIVE GAVILYTE-C E.E.S. 200 FALLBACK SOLO GAVILYTE-G E.E.S. 400 FAMCICLOVIR GAVILYTE-H AND BISACODYL EAR DROPS FAMOTIDINE GAVILYTE-N EAR DROPS FOR SWIMMERS FAZACLO GELNIQUE EAR DRYING AGENT FENTANYL GENTAK EAR SYSTEM FENTANYL BASE GENTAMICIN SULFATE EAR WAX REMOVAL FENTANYL CITRATE GENTLE LAXATIVE EARWAX TREATMENT DROPS FENTANYL CITRATE-0.9% NACL GENTLELAX ECONTRA EZ FENTANYL CITRATE-STERILE WATER GIALAX ECONTRA ONE-STEP FENTANYL-BUPIVACAINE-0.9% NACL GLYCOLAX ED-SPAZ FENTANYL-ROPIVACAINE-0.9% NACL GLY-OXIDE EHA FERRIPROX GOLYTELY ELESTAT FERRIPROX (2 TIMES A DAY) GONITRO ELIMITE FIORICET WITH CODEINE GOPRELTO ELLA FIORINAL WITH CODEINE #3 GYNAZOLE 1 ELURYNG FIRST-MOUTHWASH BLM GYNE-LOTRIMIN EMADINE FLAC OTIC OIL GYNE-LOTRIMIN-7 EMVERM FLAGYL HEALTHYLAX ENABLEX FLAREX HIDEX ENDOCET FLAVOXATE HCL HIPREX ENDOMETRIN FLOWTUSS HUMALOG ENOXAPARIN SODIUM FLUCONAZOLE HUMALOG JUNIOR KWIKPEN ENTOCORT EC FLUCONAZOLE IN DEXTROSE HUMALOG KWIKPEN U-100 EPINASTINE HCL FLUCONAZOLE IN SALINE HUMALOG KWIKPEN U-200 EPINEPHRINE FLUCONAZOLE-NACL HUMALOG MIX 50-50 EPIPEN FLUDROCORTISONE ACETATE HUMALOG MIX 50-50 KWIKPEN EPIPEN 2-PAK FLUOCINOLONE ACETONIDE OIL HUMALOG MIX 75-25 EPIPEN JR FLUORESCEIN-PROPARACAINE HUMALOG MIX 75-25 KWIKPEN EPIPEN JR 2-PAK FLUOROMETHOLONE HUMULIN 70/30 KWIKPEN ERYPED 200 FLURBIPROFEN SODIUM HUMULIN 70-30 ERYPED 400 FLUROX HUMULIN N ERY-TAB FML HUMULIN N KWIKPEN ERYTHROCIN LACTOBIONATE FONDAPARINUX SODIUM HUMULIN R ERYTHROCIN STEARATE FORADIL HUMULIN R U-500 ERYTHROMYCIN FORTAZ HUMULIN R U-500 KWIKPEN ERYTHROMYCIN ETHYLSUCCINATE FORTAZ IN ISO-OSMOTIC DEXTROSE HURRICAINE ERYTHROMYCIN-BENZOYL PEROXIDE FRAGMIN HYCOFENIX ETONOGESTREL-ETHINYL ESTRADIOL FURADANTIN HYDROCOD-CPM-PSEUDOEPHEDRINE EURAX FUZEON HYDROCODONE BITARTRATE EVEKEO GABAPENTIN HYDROCODONE BITARTRATE ER * This list is not all-inclusive and does not guarantee coverage Page 3 of 7 Medications Exempt from BJC Mail Order Requirement for Plan Year 2021 * HYDROCODONE-ACETAMINOPHEN KEFLEX MACROBID HYDROCODONE-CHLORPHENIRAMNE ER KENALOG-10 MACRODANTIN HYDROCODONE-GUAIFENESIN KENALOG-40 MAFENIDE ACETATE HYDROCODONE-HOMATROPINE MBR KENALOG-80 MAGNESIUM CITRATE HYDROCODONE-IBUPROFEN KETOCONAZOLE MALATHION HYDROCORTISONE KETOROLAC TROMETHAMINE MARINOL HYDROCORTISONE-ACETIC ACID KETOTIFEN FUMARATE MAXITROL HYDROMET KLARITY-A(AZITHROMYCIN-CHONDR) MEDICATED DOUCHE HYDROMORPHONE ER LANTUS MEDIWASH HYDROMORPHONE HCL LANTUS SOLOSTAR MEDI-WASH HYDROMORPHONE HCL-0.9% NACL LATANOPROST MEDROL HYDROMORPHONE HCL-WATER LAXACLEAR ME-NAPHOS-MB-HYO 1 HYDROMORPH-ROPIVA-0.9% NACL LAXATIVE MEPERIDINE HCL HYOPHEN LAXATIVE FEMININE METADATE CD HYOSCYAMINE SULFATE LAXATIVE PEG 3350 METADATE ER HYOSCYAMINE SULFATE ER LEVAQUIN METHADONE HCL HYOSCYAMINE SULFATE SR LEVBID METHADONE HCL-0.9% NACL HYOSYNE LEVEMIR METHADONE INTENSOL HYSINGLA ER LEVEMIR FLEXTOUCH METHADOSE IBUDONE LEVOFLOXACIN METHAMPHETAMINE HCL ICATIBANT LEVOFLOXACIN-D5W METHENAMINE HIPPURATE ILEVRO LEVONORGESTREL METHENAMINE MANDELATE ILUVIEN LEVORPHANOL TARTRATE METHYLIN INFUMORPH LEVSIN METHYLPHENIDATE ER INTENSE TOOTHACHE PAIN RELIEF LEVSIN-SL METHYLPHENIDATE ER (LA) INVELTYS LICE BEDDING METHYLPHENIDATE HCL IOPIDINE LICE COMPLETE KIT 1-2-3 METHYLPHENIDATE HCL CD IPRATROPIUM-ALBUTEROL LICE KILLING METHYLPHENIDATE HCL ER (CD) IPRIVASK LICE PYRINYL SHAMPOO METHYLPHENIDATE LA ISOCHRON LICE SOLUTION METHYLPREDNISOLONE ISORDIL LICE TREATMENT METHYLPREDNISOLONE ACETATE ISORDIL TITRADOSE LIDOCAINE HCL METHYLPREDNISOLONE SODIUM SUCC ISOSORBIDE DINITRATE LIDOCAINE HCL VISCOUS METHYLPREDNISOLONE-BUPIVACAINE ISOSORBIDE DINITRATE ER LIDOCAINE PLUS METRO IV ISOSORBIDE MONONITRATE LINDANE METROGEL-VAGINAL ISOSORBIDE MONONITRATE ER LOCORT METRONIDAZOLE ISOTRETINOIN LORCET MICONAZOLE 1 ITCH RELIEF LORCET HD MICONAZOLE 3 ITCHY EYE LORCET PLUS MICONAZOLE 7 ITRACONAZOLE LORTAB MICONAZOLE NITRATE IVERMECTIN LOTEMAX MICONAZOLE-7 JANTOVEN LOTEMAX SM MILK OF MAGNESIA JETREA LOTEPREDNOL ETABONATE MILLIPRED JOCK ITCH LYCELLE MILLIPRED DP JOCK ITCH RELIEF LYUMJEV MINITRAN JORNAY PM LYUMJEV KWIKPEN U-100 MINOCIN KADIAN LYUMJEV KWIKPEN U-200 MINOCYCLINE HCL * This list is not all-inclusive and does not guarantee coverage Page 4 of 7 Medications Exempt from BJC Mail Order Requirement for Plan Year 2021 * MINOCYCLINE HCL ER NEOMYCIN-POLYMYXIN-HC ORAL SALINE LAXATIVE MINOLIRA ER NEOMYCIN-POLYMYXIN-HYDROCORT ORAMAGIC PLUS MIRALAX NEO-POLYCIN ORAPRED ODT MITIGO NEO-POLYCIN HC ORASEP MONDOXYNE NL NEUAC ORAVIG MONISTAT 1 NEW DAY ORBACTIV MONISTAT 3 NEXT CHOICE ONE DOSE OSCIMIN MONISTAT 7 NITRO-BID OSCIMIN SL MONODOX NITRO-DUR OSCIMIN SR MONUROL NITROFURANTOIN OSELTAMIVIR PHOSPHATE MORGIDOX NITROFURANTOIN MONO-MACRO OTIPRIO MORPHINE SULFATE NITROGLYCERIN OTOVEL MORPHINE SULFATE ER NITROGLYCERIN IN D5W OVIDE MORPHINE SULFATE-0.9% NACL NITROGLYCERIN PATCH OVIDREL MOUTH PAIN NITROLINGUAL OXACILLIN MOXATAG NITROMIST OXACILLIN
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